MARCIA S. KRIEGER, Senior District Judge.
The Court has jurisdiction over an appeal from a final decision of the Commissioner under 42 U.S.C. § 405(g).
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.
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.
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.
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."
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.
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.
In January 2015, Mr. Cheasebro had another MRI on his back that revealed "normal" results.
In July 2016, Mr. Cheasebro fell in the shower and sought emergent treatment for a shoulder injury at the Prowers Medical Center.
In March 2017, Mr. Cheasebro underwent another MRI of his spine which showed "subtle disc bulging from L3-4 through L5-S1." However, there was "no substantial canal or foraminal stenosis" and "[n]o evidence of fracture or malalignment."
In October 2014, James J. Wanstrath, Ph.D., an agency psychological consultant, provided a mental assessment of Mr. Cheasebro.
Also in October 2014, Aimee Henley, Ph.D., performed a consultative mental examination of Mr. Cheasebro.
In November 2014, Joseph Sever, M.D., performed a consultative physical examination of Mr. Cheasebro.
In November 2014, Pamela McKenzie, M.D., evaluated the record and opined that Mr. Cheasebro was not disabled under the agency's definition for child disability.
In June 2017, the ALJ issued a Decision unfavorable to Mr. Cheasebro. At step one, the ALJ found he had not engaged in substantial gainful activity since July 29, 2014, the application date.
The ALJ then assessed Mr. Cheasebro's Residual Functional Capacity ("RFC") as of the date of his 18th birthday and determined that:
Then, because Mr. Cheasebro did not turn 18 years old until six weeks after he filed his SSI application, the ALJ evaluated his "functional equivalence for children" as set forth in 20 C.F.R. § 416.926a. In order to establish that a child "functionally" equals a listing, the claimant must establish that he has an impairment that results in "marked limitations in two domains of functioning or an extreme limitation in one domain." 20 C.F.R. § 416.926a(a) (internal quotation marks omitted). The Agency considers how a child functions in the actions in the following six domains (broad areas of functioning intended to capture all of what a child can or cannot do): (1) Acquiring and using information; (2) Attending and completing tasks; (3) Interacting and relating with others; (4) Moving about and manipulating objects; (5) Caring for yourself; and (6) Health and physical well-being. 20 C.F.R. § 416.926a(b)(1). As to Mr. Cheasebro, the ALJ found "less than a marked limitation" in all six domains, thus, Mr. Cheasebro did not functionally equal any listed impairment and was not disabled prior to reaching the age of 18 years old.
The ALJ then found, at step four, that Mr. Cheasebro had no past relevant work.
The ALJ therefore found that Mr. Cheasebro was not disabled after turning 18 years of age as defined by the Social Security Act.
Though the Court's review is de novo, the Court must uphold the Commissioner's decision if it is free from legal error and the Commissioner's factual findings are supported by substantial evidence. See Fischer-Ross v. Barnhart, 431 F.3d 729, 731 (10th Cir. 2005). Substantial evidence is evidence a reasonable person would accept to support a conclusion, requiring "more than a scintilla, but less than a preponderance." Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007). The Court may not reweigh the evidence, it looks to the entire record to determine if substantial evidence exists to support the Commissioner's decision. Wall v. Astrue, 561 F.3d 1048, 1052 (10th Cir. 2009).
Mr. Cheasebro initiated and prosecuted this appeal without the assistance of an attorney. Accordingly, the Court reads his pleadings liberally. Haines v. Kerner, 404 U.S. 519, 520-521 (1972). Such liberal construction is intended merely to overlook technical formatting errors and other defects in Mr. Cheasebro's filings. Hall v. Bellmon, 935 F.2d 1106, 1110 (10th Cir. 1991). Indeed, although he is not represented by counsel, Mr. Cheasebro must still comply with procedural rules and satisfy substantive law to be entitled to relief. See Murray v. City of Tahlequah, 312 F.3d 1196, 1199 n.3 (10th Cir. 2008).
Mr. Cheasebro filed a "Case Brief" asserting the following issues in his appeal:
Mr. Cheasebro first argues that the Appeals Council erred in denying his request for review and in doing so, finding his additional medical records, dated December 13, 2017 and April 10, 2018, did not relate to the period at issue.
"[T]he Appeals Council must consider additional evidence offered on administrative review—after which it becomes a part of our record on judicial review—if it is (1) new, (2) material, and (3) related to the period on or before the date of the ALJ's decision." Krauser v. Astrue, 638 F.3d 1324, 1328 (10th Cir. 2011) (citing Chambers v. Barnhart, 389 F.3d 1139, 1142 (10th Cir. 2004)). However, "the Appeals Council is not required to expressly analyze new evidence when it denies review;" it must only consider the new evidence, and a "conclusory statement that it has done so is sufficient." Vallejo v. Commissioner, SSA, 762 F. App'x 532, 533 (10th Cir. 2019). Accordingly, here, the Appeals Council did all it was required to do under the regulations.
However, because the new medical records dated December 13, 2017 and April 10, 2018 were accepted into the record, the Court must still consider whether the ALJ's Decision is supported by substantial evidence in the record as a whole, including these two new records. See Vallejo v. Berryhill, 849 F.3d 951, 956 (10th Cir. 2017) (holding that when evidence is submitted to the Appeals Council and it becomes a part of the record, the district court must "conduct a substantial evidence review by assessing the entire agency record," including the new "never-before assessed opinion."). The medical record dated December 13, 2017 is from an appointment with Mark Porter, M.D. Dr. Porter noted Mr. Cheasebro's right knee pain and "findings suggestive of potential meniscal pathology as well as patellofemoral pathology."
After considering this new evidence, the Court finds the ALJ's determination that Mr. Cheasebro was not under a disability for the period between July 29, 2014 and June 1, 2017 is supported by substantial evidence, even taking into account the new records from Dr. Porter and Dr. Michaud. First, these records are consistent with the wealth of other providers' treatment notes in the record. Second, Mr. Cheasebro's subjective complaints as to his back and knee pain are substantially the same as he has been making to his providers for years and are well documented in the record. Third, neither Dr. Porter nor Dr. Michaud could determine the etiology of Mr. Cheasebro's pain, and they continued to recommend the same course of treatment as previous providers (pain medication, physical therapy, etc.). The Court notes that Dr. Porter did recommend that Mr. Cheasebro undergo an MRI on his knee. However, it is unclear from the treatment notes whether this MRI ever occurred and if so, what were the results? Thus, even if these new medical records were determined to be time relevant, they are entirely consistent with the medical records the ALJ reviewed in this case. Even after considering this post-Decision evidence, the Court cannot say the ALJ's Decision was not supported by adequate evidence in the record.
Mr. Cheasebro next contends the ALJ erred when she refused to allow his mother to remain in the room during his January 2017 hearing. The Court has carefully reviewed the hearing transcript and all relevant documents and can find nothing that refers to Ms. Cheasebro's presence at the hearing. Neither the ALJ nor Mr. Cheasebro made any statements at the beginning of the hearing regarding whether Ms. Cheasebro was permitted to attend the hearing. Indeed, at the beginning of the hearing, the ALJ gave Mr. Cheasebro an advisement as to his right to be represented by an attorney or a qualified non-attorney representative, and Mr. Cheasebro confirmed that he wished to proceed without a representative.
Mr. Cheasebro argues that portions of the record are inaccurate, incomplete, confusing and/or untrue. However, based on the Court's review of the appeal history, Mr. Cheasebro had an opportunity to object to the accuracy of the administrative record once it was filed with the Court by the Commissioner on October 30, 2018.
Mr. Cheasebro takes issue with the Commissioner's statements that he has never been gainfully employed because he was a minor at the time he filed his SSI application. He also claims that contrary to the ALJ's RFC findings, he cannot "hop, jump, squat, run, climb onto scaffolding, climb stairs very often" due to his pain.
Credibility determinations are the province of the finder of fact and will not be upset on appeal when supported by substantial evidence. Newbold v. Colvin, 718 F.3d 1257, 1267 (10th Cir. 2013). In evaluating Mr. Cheasebro's allegations regarding disabling pain, the ALJ was required to consider the evidence as a whole along with numerous factors listed in the Commissioner's regulations. 20 C.F.R. § 404.1529(c). These factors include Mr. Cheasebro's prior work record, his statements regarding his symptoms, evidence submitted by medical sources, and observations by others. 20 C.F.R. § 404.1529(c)(3). Thus, it was not improper for the ALJ to find that Mr. Cheasebro had no past work history.
Further, as to Mr. Cheasebro's complaints that he cannot perform the activities set forth in the ALJ's RFC, he cites no specific evidence to bolster his own statements nor any evidence which the ALJ failed to consider. Here, the ALJ identified and discussed the medical evidence in detail including Mr. Cheasebro's own statements describing his pain. Among other evidence, the ALJ noted that the MRI and imaging tests revealed "normal" or "subtle" findings related to Mr. Cheasebro's back pain, that he reported similar symptoms for many years, and that his treating physician suggested the possibility of psychosomatic issues as a possible cause of Mr. Cheasebro's pain. The ALJ also discussed the medical opinions and the weight she gave them. Thus, the Court finds the ALJ's conclusions are supported by substantial evidence and sees no error in the ALJ's treatment of the evidence, including Mr. Cheasebro's allegations regarding his pain and its limiting effects. "[D]isability requires more than mere inability to work without pain." Gossett v. Bowen, 862 F.2d 802, 807 (10th Cir. 1988) (citing Brown v. Bowen, 801 F.2d 361, 362-63 (10th Cir. 1986)). There is substantial evidence supporting the ALJ's conclusion that Mr. Cheasebro was not totally disabled and could perform the light, unskilled work described in the RFC.
For the foregoing reasons, the Commissioner's decision is