United States District Court, N.D. Ohio, Eastern Division
C. NUGENT JUDGE
REPORT & RECOMMENDATION
M. Parker United States Magistrate Judge
Ivan Paul Ward, III, seeks judicial review of the final
decision of the Commissioner of Social Security, denying his
applications for disability insurance benefits
(“DIB”) and supplemental security income
(“SSI”) under Titles II and XIV of the Social
Security Act. This matter is before me pursuant to 42 U.S.C.
§§ 405(g), 1383(c)(3), and Local Rule 72.2(b).
Because the Administrative Law Judge (“ALJ”)
failed to apply proper legal standards in evaluating the
state agency consultants' opinions, I recommend that the
Commissioner's final decision denying Ward's
applications for disability insurance benefits and
supplemental security income be VACATED and that Ward's
case be REMANDED for further consideration.
December 17, 2015, Ward applied for DIB and SSI. (Tr.
231-39). Ward alleged that he became disabled on
July 7, 2013, due to “1-eye blind shadow on the side,
lungs-asthmatic severe was on life support in 2005,
back-stenosis and arthritis and bulging disks, PTSD,
insomnia, anxiety and panic disorder, anorexic and bulimia
disorder.” (Tr. 73, 89, 231, 233, 263). The Social
Security Administration denied Ward's applications
initially and upon reconsideration. (Tr. 73-144). Ward
requested an administrative hearing. (Tr. 184-85). ALJ
Jeffrey La Vicka heard Ward's case on January 30, 2018,
and denied his claims in a March 9, 2018, decision. (Tr.
8-72). On June 11, 2018, the Appeals Council denied further
review, rendering the ALJ's decision the final decision
of the Commissioner. (Tr. 1-5). On July 9, 2018, Ward filed a
complaint to seek judicial review of the Commissioner's
decision. ECF Doc. 1. On October 19, 2018, Ward filed a
motion for summary judgment, stating that the court should
grant summary judgment in his favor for the reasons stated in
his merits brief. ECF Doc. 11.
Personal, Educational and Vocational Evidence
was born on April 4, 1985, and he was 28 years old on the
alleged onset date. (Tr. 231, 233). Ward had a GED. (Tr.
40-41). He also had previous work experience as a stacker and
rack loader, which the ALJ determined he could no longer
perform. (Tr. 22, 69).
Relevant Medical Evidence
Physical Health Treatment Records
Ward's arguments focus on his alleged mental
health-related disability, it is unnecessary to set forth a
detailed history of how his physical health issues were
treated or evaluated. The following captures the key parts of
his physical health care records that reveal information
about his mental status and/or the consistency of his
February 22, 2013, November 18, 2013, September 15, 2014,
October 21, 2014, and March 24, 2015, Ward went to the
emergency department with “mild” to
“moderate” respiratory distress due to asthma.
(Tr. 606-09, 620-25, 655-61, 663-66, 672-77). During his
emergency department visits, Ross Lentini, MD, and Marian
Barnett-Rico, MD, noted that Ward was cooperative and
pleasant, and he improved with asthma medications. (Tr.
608-09, 622-24, 657-60, 666). On March 24, 2015, Antony
Cesario, CNP, noted that Ward had no back or joint pain, no
anxiety symptoms, normal range of motion in his extremities,
and normal mood, sleep, and appetite. (Tr. 672, 676).
March 2, 2013, Charles Payne, DO, admitted Ward to the
hospital after he complained that he had chest pain and
coughed up blood and mucous. (Tr. 389, 589). Dr. Payne noted
that Ward was pleasant and cooperative during his
examination. (Tr. 590).
6, 2013, Ward saw his primary care physician, Mumtaz Husain,
MD, for a checkup and asthma medication refills. (Tr. 912).
Dr. Husain noted that Ward had persistent tooth pain,
anxiety, insomnia, left eye blindness, panic disorder,
asthma, steroid-induced diabetes, and “very poor
compliance with treatment.” (Tr. 912). On examination,
Dr. Husain noted that Ward was conversant, his lungs were
clear, and his extremities were normal. (Tr. 912).
and July 2013, Ward twice went to the emergency department
for back pain. On June 22, 2013, Ward reported that his back
pain began after he fell out of his truck in May 2013, and on
July 11, 2013, Ward said that he hurt his back lifting
50-pound bags while working at home. (Tr. 408, 496, 498).
During his June 22 emergency department visit, Allison
Callahan, PAC, noted that Ward denied any weakness in his
lower extremities, was pleasant, had some pain in his back,
and had normal range of motion and gait. (Tr. 408-09). During
his July 2013, visit, Brian Richardson, MD, noted that Ward
had limited range of motion in his back, but he did not have
any limitations in his extremities or gait. (Tr. 499, 501).
Callahan and Dr. Richardson both gave Ward Vicodin, and they
directed Ward to follow up with Dr. Husain. (Tr. 409, 501,
503). On June 25, 2016, Ward asked Dr. Thomas to refill his
Vicodin, and Dr. Thomas noted that Ward was likely
“over using the Vicodin and not using it
properly.” (Tr. 486).
16, 2013, Ward saw Dr. Husain for a follow-up related to his
back pain. (Tr. 914). On examination, Dr. Husain noted that
Ward was alert, oriented, and conversant. (Tr. 914). At
follow-ups on July 26, 2013, August 27, 2013, September 4 and
27, 2013, and October 24, 2013, Dr. Husain also noted
Ward's insomnia and anxiety were controlled through
medication. (Tr. 414-15, 421-22, 469-72, 480-81, 916-22).
25, 2013, Ward told Joel Siegal, MD, that he had constant,
throbbing back and neck pain that began after he lifted bags
at work. (Tr. 464, 475). He also complained that he had
anorexia, wheezing, difficulty walking, and anxiety. (Tr.
475). On examination, Dr. Siegal noted that Ward was in no
acute distress, was alert and oriented, and had intact
cognition. (Tr. 475-76). Dr. Siegal renewed Ward's
Vicodin prescription. (Tr. 466, 479).
September 13, 2013, Amanda Davidson, PT, evaluated Ward's
functional capacity on referral from Dr. Husain. (Tr. 508-38,
541-72). Based on her testing, Davidson stated that Ward
would be unable to return to work due to his disc derangement
throughout the spine, inability to maintain proper postures,
and weakness. (Tr. 509). Davidson noted, however, that Ward
might have magnified his pain due to frustration and not
being able to do what he would like to do. (Tr. 509).
Davidson recommended that Ward not be cleared to return to
work. (Tr. 509).
November 21, 2013, Ward told Dr. Husain that he felt
“much better” after he took his asthma
medications and antibiotics, and he also requested valium and
Vicodin refills for his chronic back pain. (Tr. 923). Dr.
Husain noted that Ward was conversant, alert, and oriented,
had an appropriate affect, and controlled his insomnia and
anxiety with treatment. (Tr. 923). On March 19, 2014, Dr.
Husain noted that he wanted to wean Ward off valium. (Tr.
February 7, 2014, Ward went to the emergency department for
abdominal pain, headache, vomiting, dizziness, and a runny
nose. (Tr. 627). On examination, Dr. Payne noted that Ward
was pleasant and cooperative. (Tr. 630).
March 22, 2014, Ward again went to the emergency department
for vomiting and abdominal pain. (Tr. 644). Ward told Ashley
Kinsey, PA, that he did not eat well or drink enough, and
Ward's wife said that he had an eating disorder. (Tr.
644). On examination, Kinsey noted that Ward was alert,
cooperative, had no pain or limitations in his extremities,
and had full muscle strength. (Tr. 646). Kinsey diagnosed
Ward with nausea, noted that he had no activity restrictions
and could return to work. (Tr. 657, 650).
16, 2015, Dr. Barnett-Rico noted that Ward was diagnosed with
anorexia. (Tr. 681). Nevertheless, on examination, Dr.
Barnett-Rico noted that Ward was well-nourished,
well-developed, and cooperative. (Tr. 681). On June 13, 2017,
Ward saw Dr. Barnett-Rico for a toe injury, and Dr.
Barnett-Rico noted that Ward had no gastrointestinal issues,
no weight loss or weakness, no decreased range of motion or
back pain, and no depression, anxiety, or sleep issues. (Tr.
August 9, 2015, Ward's wife found him unconscious after
he went out drinking with friends, said that he smoked
marijuana, and “suspected he was taking other
drugs.” (Tr. 687). Ward told Joseph Matua, DO, that he
was “a diabetic who has been at the bar doing shots and
drinking beer, ” and that he had vomited six times.
Mental Health Treatment Records
October 12, 2015, Ward saw Kathy Enterline, MSW, because the
court ordered him to go to anger management counseling after
he was arrested for domestic violence. (Tr. 714-18). Ward
told Enterline that he had social anxiety, isolation,
anhedonia, worry, feelings of guilt due to unemployment, and
nightmares about a childhood attack during which he lost his
left eye. (Tr. 714). Ward told Enterline that he helped his
parents run a bar and maintain apartments that they owned,
but he was unable to maintain employment due to his back and
eye injuries. (Tr. 715). Enterline diagnosed Ward with
anxiety disorder and PTSD, noted that he had normal weight
and a cooperative attitude, did not note any impairment to
Ward's thought processes or perception, and stated that
his therapy would focus on anger management, reduced anxiety,
and learning coping skills. (Tr. 715, 718, 724). Ward
attended two additional therapy sessions on October 28 and
December 7, 2015; however, he quit going to therapy sessions
and was discharged from services on March 28, 2016. (Tr.
October 12, 2015, Ward completed a self-assessment as part of
his counseling intake process. (Tr. 720-21). Ward stated that
he did not have any physical or mental disabilities, but he
endorsed difficulty walking, difficulty breathing, arthritis,
and asthma. (Tr. 720). He stated that he had no problems with
nutrition, eating, appetite, or liquids; however, he said
that he had unexplained weight loss. (Tr. 720). Ward also
stated that he exercised. (Tr. 720).
12, 2016, Ward saw Koteswara Kaza, MD, for psychiatric
treatment. (Tr. 783-92). Ward told Dr. Kaza that he had panic
attacks, difficulty sleeping, anxiety that made him feel
sick, difficulty going anywhere, and daily anger. (Tr. 783).
Ward said that he avoided everyone, felt hopeless and
worthless, and did not do anything other than sit at his
table all day. (Tr. 783). Ward and his mother told Dr. Kaza
that he went days without eating, then would binge eat, and
make himself throw up. (Tr. 783). Ward said he drank every
day, smoked “a few” cigarettes every day, enjoyed
throwing a football around, and had trouble going places and
doing things with his kids. (Tr. 786-87). On examination, Dr.
Kaza noted that Ward was cooperative and pleasant, and he did
not note any problems with Ward's thought content,
perceptions, thought processes, or cognition. (Tr. 789-90).
Dr. Kaza prescribed medications to control Ward's anxiety
and depression. (Tr. 790-91). Dr. Kaza also ordered a drug
test, tested positive for marijuana and negative for any
other drugs. (Tr. 791, 793-94). On July 26, 2016, Ward told
Dr. Kaza that his medications were not working, and that he
had panic attacks twice a day. (Tr. 779). Dr. Kaza did not
note any significant changes on examination, adjusted
Ward's medications, and recommended psychotherapy. (Tr.
779-81). On August 13, 2016, Ward admitted to Dr. Kaza that
he used marijuana, and Dr. Kaza told Ward to stop using
marijuana because it could increase his anxiety and
depression. (Tr. 778). On November 3, 2016, Ward told Dr.
Kaza that he felt more anxious, had intolerable side effects
from his medications, stopped taking his medications, and had
some hallucinations. (Tr. 1167). Dr. Kaza noted that Ward had
logical thought processes, appropriate behavior, and changes
in his daily living activities. (Tr. 1167). He adjusted
Ward's medications, and Ward refused psychotherapy. (Tr.
September 1, 2016, through January 4, 2018, Ward saw Maria
Craig, PA, for 16 medication management sessions. (Tr.
1135-66, 1171-91). During his examinations, Craig regularly
noted that examination, Ward was alert, oriented,
cooperative, and that he had logical thought processes. (Tr.
1135-66, 1171-91). On September 1, 2016, Ward told Craig that
his medications did not help him, and he continued to have
panic attacks, anxiety, and depression. (Tr. 1164). Ward also
stated that he had not used marijuana for “a couple
weeks.” (Tr. 1164). On January 11, 2017, Ward told
Craig that his antianxiety medication worked well. (Tr.
1177). On February 16, 2017, Ward said that he felt
“horrible” after being without medications for
two days, and that he saw things and heard voices calling his
name. (Tr. 1180). On March 16, 2017, Ward said that his moods
continued to oscillate, and that he had not left his home
since his last doctor's visit. (Tr. 1183). Craig adjusted
Ward's medication. (Tr. 1185). On May 16, 2017, Ward said
that he felt much better, but he continued to have auditory
hallucinations. (Tr. 1189). Craig noted that Ward was alert,
logical, and cooperative, and she continued Ward's
medications. (Tr. 1190-91). On June 13, 2017, Ward told Craig
that he had an upset stomach and still had trouble regulating
his moods, but he had better control over his anger. (Tr.
1160). Ward had increased depression on January 11 and August
10, 2017; however, on September 7, 2017, Ward said that he
was “doing good” and his anxiety was “okay,
” so long as he kept to himself. (Tr. 1150, 1153,
1157). On October 5, 2017, Craig noted that Ward was better
able to control himself, though he continued to have some
anxiety, depression, and anger symptoms through January 4,
2018. (Tr. 1135-39, 1141-49).
Relevant Opinion Evidence
Physician Opinion-Mumtaz Husain, MD
December 13, 2013, the Industrial Commission of Ohio,
received a letter from Dr. Husain, stating:
This letter is to attest to the condition of Ivan Ward a
current patient in my practice. [Ward] has suffered two
separate injuries to his back causing multiple medical
problems including thoracic sprain and lumbar sprain. The
first injury we saw in office was due to a fall from a truck
while at his place of employment and was treated for a
compression facture. When he was released for light duty at
work he suffered another injury and went to the emergency
room he was treated for aggravation to a preexisting disc
protrusion at ¶ 3-4 as well as the ...