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Keach v. Berryhill

United States District Court, D. Massachusetts

March 22, 2018

NANCY A. BERRYHILL, Commissioner of Social Security, Defendant.



         Plaintiff Jennifer S. Keach (“Ms. Keach” or “Claimant”) brings this action pursuant to section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), challenging the final decision of the Commissioner of the Social Security Administration (the “Commissioner”) denying her claim for Social Security Disability Insurance (“SSDI”) benefits. Currently pending are Claimant's motion to reverse the Commissioner's decision denying her disability benefits [ECF No. 21], and the Commissioner's cross-motion for an order affirming the decision. [ECF No. 27]. For the reasons described herein, the Court finds that the Administrative Law Judge's decision was supported by substantial evidence and therefore DENIES Claimant's motion to reverse and remand and ALLOWS the Commissioner's motion to affirm.

         I. BACKGROUND

         A. Statutory and Regulatory Framework: Five-Step Process to Evaluate Disability Claims

         “The Social Security Administration is the federal agency charged with administering both the Social Security disability benefits program, which provides disability insurance for covered workers, and the Supplemental Security Income program, which provides assistance for the indigent aged and disabled.” Seavey v. Barnhart, 276 F.3d 1, 5 (1st Cir. 2001) (citing 42 U.S.C. §§ 423, 1381a).

         The Social Security Act (the “Act”) provides that an individual shall be considered to be “disabled” if he or she is:

unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than twelve months.

42 U.S.C. § 1382c(a)(3)(A); see also 42 U.S.C. § 423(d)(1)(A). The disability must be severe, such that the claimant is unable to do his or her previous work or any other substantial gainful activity that exists in the national economy. See 42 U.S.C. § 1382c(a)(3)(B); 20 C.F.R. § 416.905.

         When evaluating a disability claim under the Act, the Commissioner uses a five-step process, which the First Circuit has explained as follows:

All five steps are not applied to every applicant, as the determination may be concluded at any step along the process. The steps are: 1) if the applicant is engaged in substantial gainful work activity, the application is denied; 2) if the applicant does not have, or has not had within the relevant time period, a severe impairment or combination of impairments, the application is denied; 3) if the impairment meets the conditions for one of the “listed” impairments in the Social Security regulations, then the application is granted; 4) if the applicant's “residual functional capacity” is such that he or she can still perform past relevant work, then the application is denied; 5) if the applicant, given his or her residual functional capacity, education, work experience, and age, is unable to do any other work, the application is granted.

Seavey, 276 F.3d at 5 (citing 20 C.F.R. § 416.920).

         B. Procedural Background

         Ms. Keach filed her application for SSDI benefits on September 26, 2013. [R. 28].[1] She alleged that she became disabled on September 26, 2013 due to narcolepsy.[2] [R. 30, 43-45]. Her date last insured was December 31, 2017. [R. 30].

         The Social Security Administration (the “SSA”) denied Ms. Keach's application for SSDI benefits on November 14, 2013 [R. 94-96], and again upon reconsideration on March 20, 2014. [R. 98-100]. Thereafter, Ms. Keach requested an administrative hearing [R. 104-05], which took place before Administrative Law Judge (“ALJ”) Paul S. Carter on March 31, 2015. [R. 249]. Ms. Keach, who was represented by counsel, appeared and testified at the hearing. Id. On June 10, 2015, the ALJ issued a decision finding that Ms. Keach was not disabled. [R. 25, 32]. The SSA Appeals Council denied Ms. Keach's Request for Review on January 11, 2017. [R. 1-3, ECF No. 1 at 2]. On January 26, 2017, Ms. Keach filed a timely complaint with this Court, seeking review of the Commissioner's decision pursuant to section 205(g) of the Act. [ECF No. 1].

         C. Factual Background

         Ms. Keach was born in September 1973 and resides at 42 Tremont Avenue in Taunton, Massachusetts with her boyfriend and two children. [R. 47-48]. She graduated from high school and studied criminal law at Massasoit Community College for two years, but did not obtain a degree. [R. 49]. She then completed schooling for massage therapy and obtained a certification, which expired approximately five years ago. [R. 50]. She testified that she receives support from her boyfriend and $500 in food stamps. [R. 52].

         D. Medical Evidence[3]

         On February 26, 2013, neurologist Syed T. Ali, M.D. examined Ms. Keach and diagnosed her with narcolepsy without cataplexy.[4] [R. 290]. Her physical, neurological, and mental examinations were all normal. Dr. Ali ordered a sleep study and an MRI of the brain. [R. 288-92]. On March 16, 2013, Hirschel D. McGinnis, M.D., conducted a brain MRI which showed normal appearance and no abnormal findings. [R. 291-92]. On March 19, 2013, Ms. Keach had a sleep consultation at Bristol Pulmonary and Sleep Medicine. [R. 314-15]. Certified physician's assistant (“PA-C”) Beth Mastria conducted the consult and documented Ms. Keach's complaints. Id. She recorded that Ms. Keach complained of postnasal drip, sinus congestion, chest pain/pressure, gastroesophageal reflux, nausea, dysuria, arthralgia, and vision change. [R. 314]. The physical examination was normal and PA-C Mastria recommended an additional sleep study, diet, exercise, and weight reduction. [R. 315].

         Ms. Keach had a follow-up appointment with Dr. Ali on March 26, 2013. [R. 293-97]. He conducted a physical examination, which was normal, and Ms. Keach denied having any pain, anxiety, or other symptoms. [R. 293-96]. He noted new problems with caffeine excess, narcolepsy without cataplexy, and recorded an improvement in her chronic tension type headache. Id.

         On May 27, 2013, George Chilazi, M.D. examined Ms. Keach and noted she was doing “tremendously well, without any complaint, ” and the physical exam conducted that day was “completely unremarkable.” [R. 487-89]. On May 29, 2013, Jennifer F. Miley, NP, examined Ms. Keach and documented her complaints of fatigue, chest pains, and frequent headaches, although the physical exam was normal. [R. 298-302]. NP Miley recorded problems associated with chronic tension type headache and narcolepsy without cataplexy. [R. 301]. She noted Ms. Keach's scheduled sleep consultation for July, and indicated she should not drive when feeling tired. Id.

         On June 7, 2013, PA-C Mastria examined Ms. Keach after she presented with daytime hypersomnolence.[5] [R. 316]. Ms. Keach reiterated complaints of postnasal drip, sinus congestion, cough, diarrhea, gastroesophageal reflux, dysuria, and dizziness, but the physical exam was overall normal. [R. 316-17]. On July 31, 2013, Ms. Keach underwent a sleep study evaluation which was recorded by PA-C Mastria. [R. 480]. PA-C Mastria wrote that “[t]his is a patient with significant snoring, but no obstructive sleep apnea. However, the frequency of her arousals do not completely explain her significant excessive daytime sleepiness.” [R. 481]. Treating physician Imad J. Bahhady, M.D. also conducted a sleep study on August 16, 2013 and stated that Ms. Keach had severe hypersomnia, “suggesting the possibility of narcolepsy, ” and recommended increased sleep time, improvement in sleep hygiene, and a follow-up appointment. [R. 482].

         On August 19, 2013, NP Miley examined Ms. Keach a second time. [R. 303-06]. Ms. Keach complained of fatigue and sleep disorder, although the physical examination was normal. [R. 304-05]. NP Miley wrote that Ms. Keach's chronic tension type headache had been well-controlled with B complex, although her fatigue due to narcolepsy continued. [R. 306]. On August 22, 2013, PA-C Mastria examined Ms. Keach and noted largely the same diagnosis and complaints as were present at the June visit. [R. 318-19]. PA-C Mastria recommended Nuvigil for Ms. Keach's narcolepsy, taking scheduled naps daily, keeping a regular sleep schedule, and avoiding driving long distances. [R. 319].

         On September 24, 2013, Ms. Keach visited Dr. Bahhady. [R. 322-23]. She presented with fatigue, but Dr. Bahhady wrote that she was doing better with Nuvigil. [R. 322, 464]. He also noted possible cataplexy “during sig emotions, ” but none recently. [R. 322]. The physical examination was normal, and he recommended continued use of the medication. [R. 323]. He also indicated that Ms. Keach could take one nap in the “pm” and instructed her to keep a regular schedule. Id.

         On November 11, 2013, state-agency physician Phyllis Sandell, M.D. reviewed Ms. Keach's medical records and completed a disability determination explanation. [R. 73-81]. Although Dr. Sandell indicated that Ms. Keach had narcolepsy, she opined that she did not have any exertional limitations, postural limitations, visual limitations, communicative limitations, or environmental limitations other than that she should avoid heights and hazardous equipment and drive with caution. [R. 77-78]. She concluded that Ms. Keach retained the residual functional capacity (“RFC”)[6] to perform her past relevant work as a collection clerk, massage therapist, rural carrier associate, and child caretaker, and was therefore not disabled. [R. 79-80].

         On March 5, 2014, state-agency physician Herbert Kushner, M.D., also reviewed Ms. Keach's medical records and completed a disability determination explanation. [R. 82-92]. He indicated that she suffered from narcolepsy which causes daytime sleepiness, but that her neurological exam was normal. [R. 87]. He detailed the credibility of her allegations and indicated that she described no discrete physical limitations except for the need to nap, which can be remedied by adjustments in medication. Id. Dr. Kushner completed a physical RFC assessment and opined that Ms. Keach had no exertional limitations, manipulative limitations, visual limitations, communicative limitations, or environmental limitations, except that she should avoid heights and hazardous equipment and should not drive. [R. 88-90]. He recorded her postural limitations caused by cataplexy as follows: she can never climb ladders, ropes, or scaffolds; she can frequently ...

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