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Koppenaver v. Berryhill

United States District Court, M.D. Pennsylvania

April 8, 2019

BRAD JASON KOPPENAVER, Plaintiff,
v.
NANCY BERRYHILL Acting Commissioner of Social Security, Defendant

          Mariani Judge.

          REPORT AND RECOMMENDATION

          Martin C. Carlson United States Magistrate Judge.

         I. Introduction

         In evaluating Social Security appeals we are enjoined to apply a deferential standard of review, which calls upon us simply to determine whether substantial evidence, a quantum of proof that is less than a preponderance but more than a scintilla of evidence, supports the Administrative law Judge's (ALJ's) findings. Governed by this deferential standard of review we turn to the instant case, a Social Security appeal brought by Brad Koppenhaver. Koppenhaver contends on appeal that the ALJ erred: (1) in failing to find him per se disabled; (2) in evaluating the severity of his symptoms; and (3) in framing a residual functional capacity assessment for the plaintiff. However, recognizing the equivocal nature of this medical record, and given the very deferential standard of review which applies here, for the reasons set forth below, we conclude that the ALJ's decision is supported by substantial evidence and is adequately explained in a written decision that conforms to the legal and regulatory guidelines governing Social Security claims. Accordingly we recommend that the decision be affirmed and the plaintiff's appeal be denied.

         II. Statement of Facts

          n January 15, 2015, [1] Brad Koppenhaver filed an application for supplemental security benefits, [2] alleging that he had become disabled due to the combined effects of spinal conditions, hepatitis C, diabetes, MRSA, depression, obesity, and coxa-vera, a hip deformity which caused a discrepancy in the length of his legs. (Tr. 17, 139, and 155.) At the time of this disability application, Koppenhaver was in his 30's and qualified as a younger worker under the Commissioner's regulations. (Tr. 28.) He had a high school education, (id.), and prior employment as a laborer, bricklayer and a cook. (Tr. 65.)

         Koppenhaver also had a significant polysubstance drug abuse history, spanning more than 15 years, which included an episode in 2011 in which he was found by police playing chicken with an imaginary train after ingesting bath salts. (Tr. 334, 336.) At the time of his disability hearing, Koppenhaver was undergoing methadone treatment for his addiction, (Tr. 69), but reported receiving no other treatment for what he described as chronic pain. (Tr. 71.)

         While Koppenhaver's disability application cited a series of emotional and physical impairments, before the ALJ and now on appeal the “crux” of Koppenhaver's disability claim related to his back and hip disorders. (Tr. 63.) With respect to these physical conditions, Koppenhaver's coxa-vera hip disorder had caused only a minor, ½ inch discrepancy between the length of his legs. (Tr. 67.) Further, it appeared that no medical source evidence provided by Koppenhaver relating to this condition opined that it was a disabling impairment. (Tr. 101.) Instead, the only medical opinion evidence relating to Koppenhaver's physical impairments was the opinion of a state agency medical expert, Dr. Mesaros, who stated in April of 2015 that Koppenhaver retained the residual functional capacity to perform a range of sedentary work. (Tr. 105-08.)

         Koppenhaver himself acknowledged at various times that he retained the ability to engage in some physical activity. For example, at his disability hearing Koppenhaver reported taking walks with his daughter and being able to shovel snow for brief periods of time. (Tr. 68-9.) Medical records also disclosed that in June of 2014 Koppenhaver had reported to treating doctors that he had experienced discomfort while playing basketball with his daughter, (Tr. 230), and Koppenhaver acknowledged some involvement in this sport during his disability hearing. (Tr. 74.) Further, the record revealed that Koppenhaver was not fully compliant with recommended treatment regimes. Thus, because of his history of opiate addiction, Koppenhaver's care-givers had recommended other treatment for his chronic pain, including physical therapy, but Koppenhaver had declined to follow through on this physical therapy treatment plan. (Tr. 220, 476.) While no medical source opined that Koppenhaver's physical impairments were disabling, medical treatment records disclosed that he was observed in February of 2015 walking normally, (Tr.251), and displayed no joint stiffness or restricted range of motion in the Summer and Autumn of 2015. (Tr. 441, 459.) Koppenhaver did report to his physicians, however, that he had been seeking disability since 2009. (Tr. 225, 227, 476.)

         It was against this equivocal medical and factual backdrop that the ALJ conducted a hearing into Koppenhaver's disability application on March 22, 2017. (Tr. 59-80.) At this hearing Koppenhaver and a vocational expert both appeared and testified. (Id.) Following this hearing, on May 30, 2017, the ALJ issued a decision denying Koppenhaver's claim for disability benefits. (Tr.14-29.) In this decision, the ALJ first found at Step 1 of the five-step sequential process that applies to disability claims that Koppenhaver had not engaged in substantial gainful activity since January 14, 2015, the application date. (Tr. 19.) At Step 2, the ALJ concluded that Koppenhaver had the following severe impairments: coxa vera deformity, joint and degenerative disc disease, neuralgia, bursitis, hepatitis C, obesity, social anxiety disorder, anxiety, depression and an opioid disorder. (Id.) At Step 3, the ALJ concluded that none of these impairments met a listing which would define Koppenhaver as per se disabled. (Tr. 20-22.) In particular, with respect to Koppenhaver's disc and hip disorders, the ALJ found that:

Listing 1.02 lists the qualifying factors for a finding of disability due to a major dysfunction of a joint. In order for a claimant to be found to be disabled under listing 1.02, their impairment must render them unable to either (a) ambulate effectively, or (b) perform fine and gross movements using one major peripheral joint in each upper extremity. The claimant does not allege such limitation and is shown.in the record to be able to ambulate effectively and perform fine and gross movements using one major peripheral joint in each upper extremity.
(Tr. 20.)

         The ALJ then found that Koppenhaver retained the residual functional capacity to perform a limited range of sedentary work. Specifically, the ALJ found:

After careful consideration of the entire record, . . . that the claimant has the residual functional capacity to perform sedentary work as defined in 20 CFR 416.967(a) except that he can lift and carry twenty pounds occasionally and ten pounds frequently; can stand and/or walk for four hours and sit for six hours in an eight hour workday; can occasionally climb ramps and stairs, balance, stoop, kneel, and crouch; and can never climb ladders/ropes/scaffolds or crawl. Due to mental limitations, he is limited to performing simple, routine tasks.
(Tr. 22.)

         In reaching this conclusion the ALJ arrived at a residual functional capacity assessment which was consistent with the only medical opinion on record, the opinion of Dr. Mesaros, the state agency expert, who stated that Koppenhaver could perform sedentary work. (Id.) The ALJ also concluded that this residual functional capacity assessment was congruent with Koppenhaver's reported activities of daily living, and the relatively conservative treatment history in this case. (Tr. 24-26.) Thus, the ALJ gave only partial credence to Koppenhaver's claims of totally disabling pain.

         Having made these findings the ALJ concluded at Step 4 of this analytical process that Koppenhaver could not return to his past work, but concluded at Step 5 that there were significant jobs in the regional and national economy which Koppenhaver could perform. (Tr. 27-29.) The ALJ therefore found that Koppenhaver was not disabled and denied this application for disability benefits. (Id.)

         This appeal followed. (Doc. 1.) Koppenhaver contends on appeal that the ALJ erred: (1) in failing to find him per se disabled; (2) in evaluating the severity of his symptoms; and (3) in framing the plaintiff's residual functional capacity assessment. This case is now fully briefed and is, therefore, ripe for resolution.

         For the reasons set forth below, it is recommended that the decision of the Commissioner be affirmed.

         III. Discussion

         A. Evaluation of Social Security Disability Claims

         Resolution of the instant social security appeal involves an informed consideration of the respective roles of two adjudicators-the ALJ and this court. At the outset, it is the responsibility of the ALJ in the first instance to determine whether a claimant has met the statutory prerequisites for entitlement to benefits. To receive disability benefits, a claimant must present evidence which demonstrates that the claimant has an inability to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a ...


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