Anthony Reeves v. Comm'r of Social Security

618 F. App'x 267
CourtCourt of Appeals for the Sixth Circuit
DecidedJuly 13, 2015
Docket14-4140
StatusUnpublished
Cited by303 cases

This text of 618 F. App'x 267 (Anthony Reeves v. Comm'r of Social Security) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Anthony Reeves v. Comm'r of Social Security, 618 F. App'x 267 (6th Cir. 2015).

Opinion

OPINION

AVERN COHN, District Judge.

This is a social security case. Plaintiff-Appellant Anthony Mark Reeves (“Reeves”) challenges the decision of an Administrative Law Judge (“ALJ”) of the Social Security Administration (“SSA”) denying his application for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”), which became the final decision of Defendant — Appellee Commissioner of Social Security (“Commissioner”). Reeves appealed to the district court, which granted the Commissioner’s motion for summary judgment. Reeves appeals, arguing that the ALJ made errors of law and fact that resulted in an incorrect decision to deny benefits. For the reasons that follow, we AFFIRM the district court’s judgment.

I. BACKGROUND

A. Employment History

Reeves was born in 1967 and was forty-four years old at the time of the ALJ’s decision. He has an eleventh-grade education. Prior to applying for Social Security benefits, Reeves was employed in a steel mill for six years and worked as a dump truck and fork lift operator for ten years. In addition, he worked part time at a supermarket for approximately ten years until it closed in November of 2007. Reeves has not worked since that time and unsuccessfully sought employment for two years before filing for Social Security benefits.

B. Relevant Medical History 1

1. Treatment Records for Physical Impairments

In August 2007, Reeves sought treatment for left neck and scapulothoracic pain and ear ringing with Nicholas Finley, M.D. Dr. Finley noted that Reeves had some signs of cervical disc disease, as well as tenderness along his left rotator cuff and trapezius muscle. Dr. Finley prescribed a muscle relaxant, recommended heat and massage treatment, and suggested a steroid injection, which Reeves refused.

Two years later, Reeves saw Paula Sprow, MSN, CRNP, for high blood pressure and neck pain, as well as numbness in his left arm when his neck pain flared. Ms. Sprow found no abnormalities in Reeves’s neck and noted that he had a full range of motion. Ms. Sprow recommended a pain reliever for his neck pain, along with stretching exercises and alternating heat/ice treatments. She increased Reeves’s blood pressure medication and advised him to follow up in three months. (R. 13 at 337, ID 383)

On May 24, 2010, Reeves went to an emergency room complaining of neck pain that radiated down his left arm and numbness that affected his grip. He also reported a restricted range of motion in his left arm. The report noted that Reeves underwent neck surgery in 1990 for a fracture he sustained in a car accident. A CT scan of his cervical spine showed degenerative spondylosis with marginal spurs at *270 multiple levels and disc degeneration with postsurgical changes at the site of the earlier fracture. However, the CT scan revealed no recent evidence of acute fracture, dislocation, disc herniation, or spinal stenosis. Reeves was diagnosed with cervical radiculopathy, prescribed a pain reliever and a soft cervical collar, and advised to follow up with his family doctor and to undergo physical therapy. (R. 13 at 338-45, ID 384-91)

A year later, Reeves saw M. Stalter, M.D., complaining of weakness in his upper left arm and some pain and numbness in the lower extremity. Dr. Stalter observed that Reeves had tenderness along his cervical spine and slightly reduced strength (four out of five) in his left arm. Dr. Stalter noted that this was consistent with cervical radiculopathy and referred Reeves to an orthopedic surgeon, Ashok Biyani, M.D., for consultation and treatment of his neck pain. (R. 13 at 420, ID 466)

At Reeves’s appointment with Dr. Biya-ni, he reviewed Reeves’s medical file, including the May 24, 2010, CT scan. Dr. Biyani noted that Reeves displayed tenderness with range of motion deficits in cervical extension, flexion, and rotation. Dr. Biyani determined that Reeves had degenerative disc disease in his cervical spine and left arm radiculopathy, and recommended that Reeves start physical therapy. (R. 13 at 409-10, ID 455-56) Reeves did not return to see Dr. Biyani, nor has he sought physical therapy per Dr. Biya-ni’s recommendation.

2. Consultative Records for Physical Impairments

Reeves met with consultative examiner Lamberto Diaz, M.D., for a disability examination. Dr. Diaz stated that Reeves presented with the “rather interesting syndrome” of numbness on the left side of the body, which extended periodically to the right hand. Dr. Diaz further noted that while Reeves claimed to have weakness in'his left arm and loss of fine manipulation, his musculature was well preserved. Dr. Diaz concluded that based on Reeves’s history, he would not be suitable for sedentary work. However, Dr. Diaz also suggested that Reeves undergo neurological/neurosurgical and psychiatric evaluations to make a final determination as to whether his symptoms were attributable to malingering, neurological changes, or neuropathy cause by his alcoholism. (R. 13 at 405-07, ID 451-53)

Reeves additionally underwent consultation by two state agency physicians. In August 2010, Willa Caldwell, M.D., opined that Reeves retained the ability to perform a reduced range of light work. Dr. Caldwell found that, despite Reeves’s impairments, he could lift twenty pounds occasionally, ten pounds frequently, and stand, sit, and/or walk six hours in an eight hour day. She also found that Reeves was limited to occasional pushing, pulling, overhead reaching with his left arm, and climbing ladders, ropes, and scaffolding. However, Dr. Caldwell stated that Reeves was unlimited in his ability to balance, stoop, kneel, crawl, crouch, climb ramps and stairs, and did not have any manipulative, visual, communication, or environmental limitations. (R. 13 at 85-87, ID 131-33)

In March 2011, state agency physician Lynne Torello, M.D., reached similar conclusions to those of Dr. Caldwell, with a few additional limitations. Dr. Torello opined that Reeves could not climb ladders, ropes, or scaffolds and could only occasionally balance and crawl. Dr. Torel-lo additionally stated that Reeves was limited in his ability to perform fine and gross manipulation with his left hand, and that he should avoid heights, moderate expo *271 sure to dangerous machinery, and concentrated exposure to vibrations. (R. 13 at 114-16, ID 160-62)

S. Treatment Records for Mental Impairments

Between December 2010 and November 2011, Reeves sought mental health treatment at Maumee Valley Guidance Center under the care of psychiatrist Enedina Berrones, M.D., and counselor David Brown, P.C.C. Reeves initially sought counseling to help with anger management and binge drinking. During this period, his mental health treatment consisted of counseling and a medication regimen. In January 2011, Mr. Brown diagnosed Reeves with adjustment disorder with mixed anxiety and depressed mood and alcohol abuse, and assessed his Global Assessment Functioning score (“GAF”) at 51, indicating “moderate symptoms.” Dr.

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