Cheasebro v. Commissioner, Social Security Administration

          OPINION AND ORDER AFFIRMING THE COMMISSIONER'S DECISION

          Marcia S. Krieger Senior United States District Judge.

         THIS MATTER comes before the Court on the Plaintiff's Complaint (# 1), the Plaintiff's Opening Brief (# 20), the Defendant's Response (# 22), and the Plaintiff's Reply (#23). For the following reasons, the Commissioner's decision is affirmed.

         I. JURISDICTION

         The Court has jurisdiction over an appeal from a final decision of the Commissioner under 42 U.S.C. § 405(g).

         II. BACKGROUND

         A. Procedural History

         Plaintiff Ivan Cheasebro (“Mr. Cheasebro”) seeks judicial review of a final decision by the Defendant Commissioner (“Commissioner”) denying his application for supplemental security income (“SSI”) under the Social Security Act. In July 2014, Mr. Cheasebro filed for SSI, claiming he became disabled in December 2012.^[1] (# 16-5 at 147-52). Following a January 31, 2017 hearing before an Administrative Law Judge (“ALJ”), Mr. Cheasebro received an unfavorable decision dated June 1, 2017 (“Decision”). (# 16-2 at 19). Mr. Cheasebro appealed that Decision to the Appeals Council. However, on June 8, 2018, the Appeals Counsel denied his Request for Review. (# 16-2 at 1). Mr. Cheasebro now appeals the final agency action to this Court.

         B. Factual Background

         Mr. Cheasebro was born on September 15, 1996, thus, he was 17 years old on July 29, 2014, the date the application was filed. However, on the date of the hearing, he was 20 years old. (# 16-2 at 49-50). Mr. Cheasebro had been homeschooled and ultimately graduated from high school in December 2015. He has never worked. (# 16-2 at 51-52).

         Hearing Testimony

         At the January 31, 2017 hearing, Mr. Cheasebro was advised that he had the right to be represented by an attorney or a non-qualified attorney at his own cost. He elected to proceed without representation. (# 16-2 at 45-46). In response to the ALJ's questions, Mr. Cheasebro testified that he became disabled on December 1, 2012 when he slipped and fell at the Dollar Store and injured his back and leg. (# 16-2 at 49). Mr. Cheasebro stated that he lives with his mother in Lamar, Colorado, who is also unemployed and on disability due to both leg and back pain. (# 16-2 at 49-53).

         In July 2015, Mr. Cheasebro moved from Aurora, Colorado to Lamar, Colorado. Mr. Cheasebro stated that he started treating with his current provider, Margaret Loewen, M.D., in September 2016. Prior to that, he was treated by Augustine Obinnah, M.D., Joshua Norman, PAC, Nicholas Durst, DPT, and Sharon Headrick, LCSW, CAC-III. Ms. Cheasebro testified that the only medications he currently takes are over-the-counter Tylenol and Gabapentin. While he stated that the Tylenol works 50% of the time and the Gabapentin “works, ” he still has “very bad days.” (# 16-2 at 53-58). Mr. Cheasebro testified that he does not take any medications for mental health issues. (# 16-2 at 58). As part of a treatment plan for his pain, Mr. Cheasebro has undergone multiple back injections and physical therapy. He has had no surgeries but has sought emergent treatment at hospitals on several occasions. (# 16-2 at 58-60). Mr. Cheasebro stated that he uses a cane and just acquired a wheelchair a “couple of days ago.” (# 16-2 at 60).

         Mr. Cheasebro rated his back pain as 4.5/5 at best to a 10 at worst on a scale of 1 to 10. He stated that his back pain radiates down his legs and is “episodic” and occurs 5-6 times a day. (# 16-2 at 60-62). He also testified that due to his pain, he can only walk 20-35 feet, lift two gallons of water, and cannot hold his arms over his head without numbness. He further testified that he cannot kneel, crawl, or squat. (# 16-2 at 65-67). Mr. Cheasebro testified that he usually stays in bed at least 2 days a week due to his pain. When he does get out of bed, he stated he will prepare frozen meals, watch internet videos or movies, play video games, and build with legos. (# 16-2 at 65-82). He further stated that he has trouble sleeping and wakes up “constantly” during the night due to the pain. (# 16-2 at 71). Mr. Cheasebro tries to assist his mother with household chores but is limited by his pain. (# 16-2 at 71-77). Further, he does no volunteer work nor gets any exercise other than walking to get the mail. (# 16-2 at 77-81).

         Medical Evidence

         The Court summarizes only the medical evidence relevant to its decision. The medical records suggest that Mr. Cheasebro had a fall in December 2011. Treatment notes from 2012 to 2016 document Mr. Cheasebro's ongoing complaints of back and knee pain. From 2012 to 2015, Mr. Cheasebro's primary care doctor, Dr. Obinnah, noted “normal” examination findings, prescribed pain medications, and administered multiple steroid injections. (# 16-9 at 325-420). In April 2012, Dr. Obinnah noted that an MRI on Mr. Cheasebro's right ankle was “negative.” (# 16-9 at 416). In June 2013, Dr. Obinnah noted that an MRI on Mr. Cheasebro's right knee was “reviewed and was within normal limits.” (# 16-9 at 412). In January 2013, Dr. Obinnah reported that he “discussed the possibility of psychosomatic issues as a possible cause of the patient's pain syndrome.” (# 16-9 at 403). In April 2013, Dr. Obinnah reported that he had an “extensive discussion with [Mr. Cheasebro and his mother] regarding possible etiologies for his pain since a lot of his tests so far including the MRIs have been negative.” (# 16-9 at 395). Dr. Obinnah opined that Mr. Cheasebro “most likely has myofascial pain, possibly related to RSD, although the patient has a more generalized pain situation.” (# 16-9 at 395).

         In January 2015, Mr. Cheasebro had another MRI on his back that revealed “normal” results. (# 16-9 at 339). In July 2015, Dr. Obinnah reported that Mr. Cheasebro had “no new complaints other than having to live in his car for the moment due to being homeless.” (# 16-9 at 325). In 2016, Mr. Cheasebro attended physical therapy, but the Daily Progress Notes indicated “very poor participation.” (# 16-7 at 312). In October 2016, Mr. Cheasebro's physical therapist reported “no appreciable gains” and recommended he return to his primary care provider for “consideration of other interventions.” (# 16-10 at 531-32).

         In July 2016, Mr. Cheasebro fell in the shower and sought emergent treatment for a shoulder injury at the Prowers Medical Center. (# 16-8 at 322). X-rays were “normal, ” and Mr. Cheasebro was discharged with a diagnosis of “left shoulder pain, ” and ...