United States District Court, D. South Carolina, Florence Division
MONROE J. TILLER, Plaintiff,
CAROLYN W. COLVIN, Commissioner of Social Security; Defendant.
REPORT AND RECOMMENDATION
E. ROGERS, III UNITED STATES MAGISTRATE JUDGE
an action brought pursuant to Section 205(g) of the Social
Security Act, as amended, 42 U.S.C. Section 405(g), to obtain
judicial review of a “final decision” of the
Commissioner of Social Security, denying Plaintiff's
claim for disability and disability insurance benefits (DIB).
The only issues before the Court are whether the findings of
fact are supported by substantial evidence and whether proper
legal standards have been applied.
filed an application for DIB on May 8, 2012, alleging
inability to work since May 11, 2012. (Tr. 81-82). His claims
were denied initially and upon reconsideration. Thereafter,
Plaintiff filed a request for a hearing. A hearing was held
on July 1, 2014, at which time Plaintiff and a vocational
expert (VE) testified. (Tr. 30). The Administrative Law Judge
(ALJ) issued an unfavorable decision on September 23, 2014,
finding that Plaintiff was not disabled within the meaning of
the Act. (Tr. 9-22). Plaintiff filed a request for review of
the ALJ's decision, which the Appeals Council denied on
October 14, 2015, making the ALJ's decision the
Commissioner's final decision. (Tr. 1-4). Plaintiff filed
this action on December 10, 2015.
Plaintiff's Background and Medical History
was born January 8, 1961, and was fifty-one years old at the
time of the alleged onset. (Tr. 148). Plaintiff completed his
education through twelfth grade and has past relevant work
experience as a textile supervisor, plumber's helper, and
truck driver. (Tr. 180). Plaintiff alleges disability due to
kidney carcinoma, diabetes type 1, thyroid, high blood
pressure, stress, anxiety, high cholesterol, spinal stenosis,
heart stints, vision problems, and back pain. (Tr. 81, 179).
Medical Records and Opinions
2, 2011, Plaintiff had a heart attack and had stints placed.
(Tr. 264-282, 286-87). In July 2011, Plaintiff was seen by
James R. Story, M.D. of Cardiology Consultants, P.A.. Dr.
Story noted that Plaintiff was stable on medication, his EKG
was normal, and he was scheduled for a follow-up in a year.
April 13, 2012, Plaintiff was seen by Carol A. Kooistra, M.D.
for lower back pain. Dr. Kooistra's diagnosis was lumbar
spondylosis and polyneuropathy. (Tr. 380-81). On May 2, 2012,
Dr. Kooistra noted a lumbar MRI showed moderate to severe
spinal stenosis at ¶ 34 and a mass on kidney. Dr.
Kooistra noted uncertainty as to whether the back pain was
caused by the kidney cancer or the spine issues. (Tr. 382).
August 2012, Plaintiff had surgery to remove his left kidney.
(Tr. 305-79). On August 27, 2012, Plaintiff was seen by
Robert G. Britanisky, M.D. for a post-kidney operation office
visit. Dr. Britanisky noted that Plaintiff was doing well and
denied any significant pain or discomfort. Dr. Britanisky
stated: “He can go back to work at the 6-week
mark.” (Tr. 401).
October 9, 2012, Plaintiff had a consultative examination by
Jeremy Burns, O.D. regarding Plaintiff's eyes. The
examination noted: 20/20 vision with correction in right eye,
20/200 vision with correction in left eye, cataract,
dermatocholosis, poor vision in left eye, no diabetic
retinopathy, and no working conditions to be avoided. (Tr.
October 31, 2012, Plaintiff was seen by Kameron Klosterman,
M.D. of Pacolet Family Medicine. Dr. Klosterman noted no
chest pains, no medication side effects, no symptoms of
hypothyroidism, and compliance with hypothyroid medications.
Dr. Klosterman noted that Plaintiff poorly controlled his
diabetes and needed to keep a diet, exercise, and sugar log.
November 25, 2012, Plaintiff had a mental consultative
examination with Caleb Loring, IV, Psy. D.. The examination
noted: situational stress, no thought process problems, no
significant social problems, and no concentration or memory
problems. Plaintiff stated the medications helped and he had
never been hospitalized for psychiatric reasons. Loring
stated that Plaintiff walked abnormally and seemed to be in a
moderate degree of pain. Loring concluded that Plaintiff
would be capable of working at a job with public contact.
show history of cataract surgery on January 19, 2013. (Tr.
492). On January 21, 2013, a lumbar spine MRI performed due
to low back pain revealed L3-4 severe spinal stenosis and
L4-5 moderate spinal stenosis. (Tr. 462-65). Plaintiff was
still experiencing back pain in February 2013. (Tr. 472). On
February 13, 2013, Dr. Kooistra referred Plaintiff to a
surgeon due to spinal stenosis. (Tr. 479-80).
February 19, 2013, Dr. Britanisky noted Plaintiff's
complaints of chronic back pain, numbness, and tingling. (Tr.
February 23, 2013, Plaintiff was seen by Robert Westrol,
M.D., Pain Management Associates. Plaintiff complained of
moderate to severe lower back pain for eight months and the
pain was exacerbated by stairs, walking, and lifting. Dr.
Westrol noted moderate edema of lower legs and low back
restricted in flexion, extension, and side bending. (Tr.
February 26, 2013, Dr. Westrol performed venous duplex
bilateral screening exam and Plaintiff was positive for deep
venous insufficiency. (Tr. 507-08). On March 19, 2013, Dr.
Westrol noted Plaintiff had pain in lower back that worsened
by stairs, walking, and lifting. (Tr. 509).
March 29, 2013, Plaintiff had facet steroid injections into
his spine by Jeffrey P. Smith, M.D. (Tr. 502).
April 15, 2013, Plaintiff was seen by Timothy R. Monroe, M.D.
with symptoms of low back pain, leg pain, and swelling. Dr.
Monroe planned decompression and instrumented fusion surgery.
(Tr. 498-99). On May 30, 2013, Plaintiff had decompression
and fusion surgery. (Tr. 513-17).
November 4, 2013, a scan of Plaintiff's right kidney
revealed a soft tissue nodule that was stable but had first
appeared on August scan. (Tr. 522, 526). On November 14,
2013, Dr. Kooistra noted that Plaintiff's back pain was
“way better than prior to surgery, ” but that he
still had issues on his right side and was still using
prescription pain medication. (Tr. 530-31).
December 2, 2013, Plaintiff was seen by Dr. Monroe for
six-month post-operation follow-up. Dr. Monroe noted that
Plaintiff had shown improvement in activity level and
symptoms and his musculoskeletal assessment was normal in
motor and strength. (Tr. 537-38).
March 5, 2014, Dr. Smith noted Plaintiff had pain for years
in back, legs, and hips that was aggravated by daily
activities. Dr. Smith stated surgery helped but Plaintiff was
unable to return to his previous job. Dr. Smith noted:
“Pain well controlled on current medication regimen.
allow patient to stay active.” (Tr. 582-83).
March 13, 2014, Plaintiff was seen by Dr. Kooistra “for
his chronic pain attributed to polyneuropathy and lumbar
spine disease.” Plaintiff was prescribed Norco through
his pain management doctor, and Dr. Kooistra noted Plaintiff