Pitts v. Saul

CourtDistrict Court, N.D. Texas
DecidedNovember 9, 2020
Docket3:19-cv-01539
StatusUnknown

This text of Pitts v. Saul (Pitts v. Saul) is published on Counsel Stack Legal Research, covering District Court, N.D. Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Pitts v. Saul, (N.D. Tex. 2020).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF TEXAS DALLAS DIVISION ERIC TYROME PITTS, § Plaintiff, § § § Civil Action No. 3:19-CV-1539-BH § ANDREW SAUL, § COMMISSIONER OF SOCIAL § SECURITY ADMINISTRATION, § Defendant. § Consent Case1 MEMORANDUM OPINION AND ORDER Eric Tyrome Pitts (Plaintiff) seeks judicial review of a final decision by the Commissioner of Social Security (Commissioner) denying his claim for disability insurance benefits (DIB) under Titles II of the Social Security Act. (See docs. 1, 20.) Based on the relevant filings, evidence, and applicable law, the Commissioner’s decision is AFFIRMED. I. BACKGROUND On January 5, 2017, Plaintiff filed his application for DIB, alleging disability beginning on April 4, 2016. (doc. 12-1 at 163.)2 His claim was denied initially on December 16, 2016, and upon reconsideration on March 15, 2017. (Id. at 75, 153). On May 2, 2017, Plaintiff requested a hearing before an Administrative Law Judge (ALJ). (Id. at 97.) He appeared and testified at a hearing on April 12, 2018. (Id. at 43-65.) On October 11, 2018, the ALJ issued a decision finding him not disabled. (Id. at 22-31.) Plaintiff timely appealed the ALJ’s decision to the Appeals Council on October 16, 2018. (Id. at 22-30, 216.) The Appeals Council denied his request for review on April 27, 2019, 1By consent of the parties and the order of transfer dated October 18, 2019 (doc. 17), this case has been transferred for the conduct of all further proceedings and the entry of judgment. 2Citations to the record refer to the CM/ECF system page number at the top of each page rather than the page numbers at the bottom of each filing. making the ALJ’s decision the final decision of the Commissioner. (Id. at 5-7.) He timely appealed the Commissioner’s decision under 42 U.S.C. § 405(g). (See doc. 1.) A. Age, Education, and Work Experience Plaintiff was born on November 9, 1971, and was 46 years old at the time of the hearing. (doc. 12-1 at 50-51.) He graduated high school and had past relevant work experience as a

cleaner. (See id. at 51-52.) B. Medical Evidence On April 4, 2016, Plaintiff went to the emergency room at Hunt Regional Medical Center moderate pain in the lower lumbar spine with no radiation after injuring his back at work by trying to pull apart three 150 lb rods that were stuck in a machine. (Id. at 341-45.) Physical exam revealed normal range of motion in his extremities, normal reflexes, and moderate vertebral point tenderness over the upper lumbar spine. (Id. at 342.) X-rays showed minimal osteophyte formation and facet arthritis, and no evidence of acute fracture or dislocation. (Id. at 342, 344.) Plaintiff was prescribed Robaxin and Tylenol with Codeine and discharged with

instructions to follow up with a doctor for his workman’s compensation claim. (Id. at 343.) From May 2016 through July 2016, Plaintiff saw Anthony Berg, M.D., at the Spine Team of Texas. (Id. at 357-395.) He reported severe back pain that was burning, sharp, achy, and constant and exacerbated by bending, twisting, walking, and lifting. (Id. at 389.) His MRI revealed a 2 millimeter L5 retrolisthesis on S1, an annular fissure that mildly narrowed with the left subarticular recess, and mild to moderate degenerative disc disease at L5-S1. (Id. at 392.) After physical therapy did not yield any improvement, Dr. Berg recommended that Plaintiff receive an epidural steroid injection to allow him to continue physical therapy, and advised that there were no “more aggressive treatments such as surgery for his problem[.]” (Id. at 371, 374.) 2 On July 28, 2016, Plaintiff saw Richard Channing, D.C., for a designated doctor impairment evaluation. (Id. at 316-320.) He complained of severe pain, tightness and discomfort in his lower back with a deep, sharp, stabbing, and aching sensation. (Id. at 316.) He also had some weakness, soreness, and stiffness in his lower back. (Id.) Examination revealed limited range of motion in his lumbar spine, positive straight leg raises on the left, positive Braggard’s

and Bechterew’s tests on the left, absent reflexes in the right Achilles and Patellar tendons, and lumbar guarding. (Id. at 317-18.) Plaintiff was diagnosed with a lumbar strain. (Id. at 319.) Dr. Channing found that Plaintiff could not return to work because he would be a hazard on the job, and the job would further damage his condition. (See id. at 319.) From August 2016 through September 2016, Plaintiff saw Dr. Berg for a bilateral L5 transforaminal epidural steroid injection and follow up visit. (Id. at 364, 479.) He had a stabbing and constant lower back that radiated down his legs, which he rated at a 9 on a scale of 10. (Id. at 364.) Dr. Berg recommended that Plaintiff see a surgeon for a possible lumbar fusion of L5-S1, second epidural steroid injection, or discogram. (Id. at 367.)

On March 15, 2017, State Agency Medical Consultant (SAMC) Jim Takach, M.D., completed a physical residual functional capacity (RFC) assessment based upon the medical evidence in the record. (Id. at 82-85.) He found that Plaintiff had the following exertional limitations: occasionally lift/carry 10 pounds; frequently lift/carry less than 10 pounds; stand and/or walk for a total of 2 hours; sit for about 6 hours in an 8-hour workday; push and pull unlimited weight (other than shown for lift and carry) with no restrictions on hand or foot controls; frequently climb ramps and stairs; occasionally climb ladders, ropes, and scaffolds; occasionally stoop; frequently balance, kneel, crouch, and crawl, with no manipulative limitations; and no visual, communicative, or environmental limitations. (Id. at 83-84.) Based on 3 his physical RFC, Plaintiff had the maximum sustained work capability for sedentary work. (See id. at 85.) The SAMC found that Plaintiff’s alleged symptoms were partially consistent with the objective medical and other evidence in the record. (Id.) On April 4, 2017, Plaintiff saw Dr. Channing for a designated doctor impairment evaluation. (Id. at 809.) He reported lower back pain of 9 on a scale of 10, with pain extending to

his right and left legs in a nonspecific pattern. (Id. at 810.) His pain was aggravated by lifting, walking, standing, sitting, and squatting. (Id.) He had positive toe walk and straight leg raises bilaterally, and his strength in his lower extremities was reduced to a 4 out of 5. (Id. at 811-12.) There was “no palpatory evidence of joint fixation, articular and segmental dysfunction in the lumbo-sacral pelvic regions.” (Id. at 812.) Dr. Channing diagnosed Plaintiff with a lumbar strain and found that he was able to return to work with restrictions. (Id.) On April 11, 2017, Robert Holliday, M.D., completed a peer review of Plaintiff’s medical records. (Id. at 859-872.) He found that Plaintiff’s subjective extreme pain levels and reported decrease in function could not be explained objectively by the reported diagnostic

findings and were related to psychosocial factors. (Id. at 868.) On June 26, 2017, Plaintiff saw Dee McCrary, M.D., at Greenville Health Care Associates for evaluation. (See id at 744.) He reported being in constant pain since his accident at work. (Id.) Physical examination revealed positive tenderness in his left paraspinals, decreased range of motion to all planes, no signs of instability, no postural motor deficits, slowed gait, and positive straight leg raises bilaterally. (Id.) Dr. McCrary assessed Plaintiff with lower back pain, and recommended a “NS consult” and discogram to determine if that was the source of his persistent pain. (Id.)

4 From July 2017 through December 2017, Plaintiff followed up with Dr. McCrary monthly. (Id. at 688-95.) He reported lower back pain that was exacerbated by walking, coughing, driving, lifting, twisting, and physical activities. (Id.

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Pitts v. Saul, Counsel Stack Legal Research, https://law.counselstack.com/opinion/pitts-v-saul-txnd-2020.