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Chappelle v. Berryhill

United States District Court, D. Oregon

June 2, 2017

WILLIAM E. CHAPPELLE, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          OPINION AND ORDER

          STACIE F. BECKERMAN, United States Magistrate Judge

         William Chappelle (“Chappelle”) brings this appeal challenging the Commissioner of Social Security's (“Commissioner”) denial of his applications for Social Security disability insurance benefits and Supplemental Security Income under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-34, 1381-83f. The Court has jurisdiction to hear this appeal pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons explained below, the Court affirms the Commissioner's decision because it is free of legal error and supported by substantial evidence.

         BACKGROUND

         Chappelle stands five-feet, seven-inches tall and his weight ranged from 194 to 238 pounds during the relevant time period. He was born in May 1978, making him thirty-two years old on July 8, 2010, the alleged disability onset date. Chappelle has an associate's degree, and his past relevant work includes time as a fabric home assembler, auto detailer/lot attendant, building materials attendant, auto supplies sales representative, laborer, and stock clerk. He alleges disability due primarily to lower back and hip pain. (SeeTr. 705, 711, “On the average day do you experience pain? A. Yes. Q. Where? A. In the lower back and hips. Q. Anywhere else? A. That's it. . . . Q. Is there anything else . . . important about your physical or mental health condition or your ability to work that we haven't already asked you about today? A. No, I don't believe so. My pain is basically what causes me to not be able to work.”).

         On April 8, 2010, three months before the alleged onset of disability, Chappelle's treating physician, Dr. Michael Moser (“Dr. Moser”), referred Chappelle to a neurosurgeon, Dr. Andrea Halliday (“Dr. Halliday”), based on complaints of lower back pain and tingling in his legs. Neuroimaging revealed that Chappelle had “a small right paracentral disc protrusion at ¶ 4-5” and “degenerative disc disease at ¶ 4-5 and L5-S1 with loss of disc height.” (Tr. 292.) Ultimately, Dr. Halliday opined that Chappelle's complaints stemmed from “discogenic disease and not anything radicular.” (Tr. 290.) Dr. Halliday advised Chappelle and Dr. Moser that “the best way . . . to manage this would be for [Chappelle] to see a chiropractor and to lose weight.” (Tr. 290.)

         On May 12, 2010, Chappelle presented for a follow-up visit with Dr. Moser regarding treatment of his diabetes and his consultation with Dr. Halliday. Chappelle reported that he was “doing quite well” and “work[ing] out in a gym in Cottage Grove [one] hour every night, including aerobics and weights.” (Tr. 435.) Dr. Moser noted that Chappelle exhibited “improved control” of his diabetes, “good control” of his hypertension, and “markedly improved control” of his hyperlipidemia. (Tr. 436.) He advised Chappelle to continue “with diet, exercise, and weight loss.” (Tr. 436.)

         On June 2, 2010, Chappelle visited Dr. Paul Coelho (“Dr. Coelho”) and underwent a lumbar discogram, which revealed “two levels of significant . . . concordant axial back pain[.]” (Tr. 294.)

         On July 8, 2010, Chappelle underwent a “L4-5 and L5-S1 minimally invasive fusion.” (Tr. 305.) A week later, Chappelle reported that he was “doing well” and planned to start physical therapy. (Tr. 311.) The next week, Chappelle reported “improving comfort levels although he continue[d] to have right leg numbness and mild weakness [similar] to his preoperative status.” (Tr. 309.)

         Chappelle returned to Dr. Moser's office on September 9, 2010. Chappelle reported that he was “doing fairly well other than his back, ” which made it difficult for him to exercise. (Tr. 433.) Dr. Moser noted that Chappelle exhibited fair control of his diabetes, and “emphasized to [Chappelle] the need for compliance with medication, diet, and exercise.” (Tr. 433.)

         On September 21, 2010, Chappelle presented for a postoperative visit with his surgeon, Dr. Glenn Keiper, Jr. (“Dr. Keiper”). Chappelle reported that he was “doing well, ” he was “still having difficulty at night with bilateral hip pain, ” his back pain had reduced “significantly, ” and he had not pursued “physical therapy for financial reasons.”[1] (Tr. 326.) Dr. Keiper advised Chappelle to stop taking “narcotic medications as [soon as] possible, ” noted that physical therapy was “very important, ” and added that Chappelle's x-rays looked “great for this point in his fusion process.” (Tr. 326.)

         From November 27, 2010 through December 3, 2010, Chappelle was hospitalized by Dr. Moser “with acute pancreatitis due to marked hyperlipidemia and hypertriglyceridemia.” (Tr. 426.)

         On February 7, 2011, Chappelle visited Dr. Moser and reported that he needed “some type of an excuse indicating that he is unable to participate in the gymnasium here in town since he has had his back surgery.” (Tr. 424.) Chappelle added that “he was not able to obtain his Xopenex or Tricor through the patient's assistance program, ” but continued to take Norco for back pain. (Tr. 424-25.) Dr. Moser provided Chappelle with a handwritten note, stating “Due to personal medical reasons, Mr. Chappelle cannot participate in gym work” effective July 2010. (Tr. 425.)

         Chappelle returned to Dr. Moser's office on June 8, 2011. Chappelle reported that he continued to experience back pain and noted that he was “eating the wrong stuff” at times. (Tr. 421.) Dr. Moser referred Chappelle to a neurosurgeon, Dr. Erik Hauck (“Dr. Hauck”), based on his complaints of continued back pain. Dr. Hauck “declined surgery” but noted that a “repeat” magnetic resonance imaging (“MRI”) might be necessary “if symptoms increased.” (Tr. 418, 422.)

         In February 2012, Chappelle filed his application for Supplemental Security Income benefits.

         On April 19, 2012, Chappelle visited Dr. Moser and reported that he continued “to have low back pain radiating to bilateral hips, left greater than right, and into his ‘tailbone.'” (Tr. 535.) Chappelle also reported that frequency, duration, and intensity of his pain had increased, that he needs to stop while walking to pick up the mail, and that he is unable to play with his young daughter. Dr. Moser noted that a neurosurgeon, Dr. Hauck, had “advised conservative treatment.” (Tr. 535.) Dr. Moser ordered an MRI of Chappelle's lumbar spine “in reference to spinal stenosis, ” which might “require reconsultation with Dr. Hauck pending review of MRI.” (Tr. 536.)

         On April 26, 2012, an MRI of Chappelle's lumbar spine showed signs of spinal stenosis and “[s]table” degenerative and postsurgical changes. (Tr. 548.) Around the same time, an MRI of Chappelle's hips revealed “mild osteoarthritis of the bilateral hips, ” and an MRI of his left knee was normal in appearance. (Tr. 546-47.) A subsequent MRI of the lumbar spine (taken from bending views) revealed normal alignment, “[s]table postsurgical changes of fusion at ¶ 4-L5 and L5-S1, ” and “[m]ultilevel degenerative disc disease, spondylosis and facet arthropathy.” (Tr. 545.)

         On May 17, 2012, Chappelle presented for a follow-up consultation with Dr. Hauck regarding his back pain. Dr. Hauck noted that he reviewed Chappelle's MRI, and that the MRI did “not demonstrate any significant nerve root compression, ” but it did show signs of “progressive arthritis, particularly in the L5 vertebra compare to the previous MRI from [2011].” (Tr. 528.) Dr. Hauck concluded that Chappelle's pain “is largely due to osteoarthritis, ” and the progression is “consistent with failed back syndrome, ” but not “nerve compression syndrome.”[2](Tr. 528.)

         In a treatment record dated June 27, 2012, Dr. Moser noted that Dr. Hauck offered “only conservative treatment” (a steroid used to treat inflammatory conditions), and Chappelle found minimal relief, Chappelle had “not seen Dr. Hauck again with consideration of any further treatment, such as injections into his back, ” and Chappelle reported being in constant pain, “yet only takes Percocet [twice a day].” (Tr. 520-21; see alsoTr. 645, noting on December 17, 2012, that Dr. Hauck “determined [in May 2012] that conservative treatment would be effective at this point”.)

         On July 24, 2012, Dr. William Backlund (“Dr. Backlund”), a non-examining state agency physician, completed a physical residual functional capacity assessment. (Tr. 69-70.) Based on his review of the record, Dr. Backlund found that Chappelle could lift and carry twenty pounds occasionally and ten pounds frequently; sit, stand, or walk up to six hours in an eight-hour workday; push or pull in accordance with his lift and carry restrictions; frequently stoop and climb ramps and stairs; occasionally crouch, crawl, and climb ladders, ropes, or scaffolds; and balance without limitation. He also found no evidence of manipulative, visual, communicative, or environmental limitations.

         In a treatment record dated August 17, 2012, Dr. Moser listed “continued back pain with consideration of failed back syndrome” as one of Chappelle's medical issues, and discussed with Chappelle the “need for compliance with diet, exercise, weight loss, and medication.” (Tr. 509-10.)

         On September 20, 2012, Dr. Sharon Meyers (“Dr. Meyers”), a non-examining state agency physician, completed a physical residual functional capacity assessment, adopting Dr. Backlund's findings. (Tr. 89-91.)

         On October 22, 2012, Chappelle visited Susan Grzesiak (“Grzesiak”), a qualified mental health professional, and underwent a Comprehensive Adult Mental Health Assessment.[3]Grzesiak noted that Chappelle's wife worked at the clinic and “brings in limited income, ” that Chappelle lives with his wife, mother, and two daughters, that the family is “eligible for food stamps periodically, ” and that Chappelle “will soon lose his unemployment money.”[4] (Tr. 574-75.) Grzesiak's diagnostic impressions were dysthymic disorder, health and pain issues, economic and physical stressors, and a Global Assessment of Functioning (“GAF”) score of forty-five.[5]

         On November 20, 2012, Chappelle visited Grzesiak and reported that he was “putting up with more pain so that he can be alert to interact with his children while they are off on the holidays.” (Tr. 625.) Chappelle also reported that he “successfully graduated” from an online associate's degree program. (SeeTr. 625; see alsoTr. 408, 574, 695, describing the online program.)

         On January 16, 2013, Chappelle scored in the moderately depressed range on the Beck Depression Inventory.[6]

         On March 20, 2013, Chappelle was taken to a hospital and given fluids and glucose, because he experienced an episode of hypoglycemia while hiking on a trail in Astoria, Oregon. (Tr. 658.) Chappelle reported that he had been “dieting and losing weight, ” which meant his blood sugars had “been decreasing” and he was using less insulin. (Tr. 658.) Dr. Moser provided Chappelle with a “Glucagon Pen to be used if he is hiking and requires a boost in glucose[.]” (Tr. 670.)

         On August 15, 2013, Dr. Moser noted that Chappelle reported feeling “pretty good, ” that he had a disability hearing scheduled because “[h]e apparently is permanently disabled due to his chronic back condition, ” that he felt nauseated after eating “chili at the rodeo in Cottage Grove, ” and that he continued to lose weight by managing his portions, eating less, and not eating when full. (Tr. 663.)

         On November 15, 2013, Chappelle visited Grzesiak and underwent a second Adult Mental Health Assessment. Grzesiak noted that Chappelle attended therapy every two to three weeks over the course of the past year, was eating better and had lost thirty-five pounds, had “made progress over the past year, ” and was able to reduce “his high frustration and irritability” with “effective” medication. (Tr. 571.) Grzesiak added that Chappelle continued to meet the criteria for a dysthymic disorder, but major depression was ruled out and the criteria for an anxiety disorder were not satisfied.

         In an addendum dated November 4, 2013, Grzesiak updated Chappelle's file to reflect that he also suffers from posttraumatic stress disorder stemming from emotional abuse by his father. (SeeTr. 566; see alsoTr. 568, 572, ...


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