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SSA Considered Entire Treatment Record

Deborah Elkins//September 25, 2014

SSA Considered Entire Treatment Record

Deborah Elkins//September 25, 2014

Although a claimant with ongoing treatment for spinal injuries since 2003 contends the Social Security Commissioner did not consider the entire record of his medical treatment or the combined impact of his severe impairments of degenerative disc disease, adjustment disorder and obesity, the 4th Circuit says the agency review met the statutory standards and affirms denial of disability benefits.

Claimant filed for social security disability benefits on Dec. 7, 2006, alleging he became unable to work on June 4, 2004, when he fell off a roof during work. His medical history showed that, prior to his fall, he visited Dr. George Khoury for chronic neck pain. He was diagnosed with cervical disc disease and in December 2003, Dr. Khoury performed a two-level anterior cervical discectomy and fusion.

Claimant suffered two spinal fractures when he fell off the roof. He continued to treat with Dr. Khoury for pain and the physician performed a posterior fusion in 2005. Claimant also began treating with Dr. Todd Joye and in 2006, he began seeing Dr. Kerri Kolehma for severe bilateral leg pain. Claimant underwent an iliac artery angioplasty in 2006, performed by Dr. Kevin Beach. In 2007, he visited with Dr. William Kee, a clinical psychologist, for help with anxiety and pain management. In September 2007, he began seeing Drs. Marc Dubick and Tony Azzolino, who noted claimant’s severe pain below the fusion site and weakness in the lower lumbar area. Finally, several times in 2008, claimant visited Summerville Behavioral Health, complaining of obsessive-compulsive disorder symptoms and panic attacks.

After a hearing, the administrative law judge found that claimant suffered from several medical impairments, but he did not find credible claimant’s statements about the intensity, persistence and effects of his pain and other symptoms in light of the objective evidence of his residual functionality and positive response to treatment. The ALJ found claimant could engage in sedentary work.

After a second hearing on remand from the Appeals Council, the ALJ again denied benefits. He found that claimant’s severe impairments included adjustment disorder and a history of obesity, in addition to degenerative disc disease, but concluded he did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments. After recounting claimant’s medical history in substantial detail, the ALJ found that claimant had the residual functional capacity to perform unskilled sedentary work and thus was not disabled. This time, the Appeals Council found claimant’s adjustment disorder was not severe and he could perform the full range of sedentary work. The district court affirmed the denial of benefits.

On appeal, claimant contends the denial of benefits was not based on the entire record and did not account for his medical history from 2004 to 2006. We conclude the commissioner’s decision satisfied the statutory requirements. The commissioner, through the ALJ and Appeals Council, stated the whole record was considered and, absent evidence to the contrary, we take her at her word.

The record shows the ALJ’s decision specifically referenced claimant’s history of thoracic and lumbar fusion, noting that treatment notes from the relevant period document that claimant was responding well to treatment with minimal complaints. Claimant has failed to point to iiianyiii specific piece of evidence not considered by the commissioner that might have changed the outcome of his disability claim. Claimant’s contention that the commissioner failed to consider his impairments in combination also is without merit.

Denial of benefits is affirmed.

Reid v. Commissioner of Social Security (Niemeyer) No. 13-1480, July 2, 2014, Amended Sept. 16, 2014; USDC at Greenville, S.C. (Cain) Beatrice E. Whitten for appellant; Sarah V. Berry, SSA, for appellee. VLW 014-2-161, 12 pp.

VLW 014-2-161

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