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Young v. Berryhill

United States District Court, D. Rhode Island

February 13, 2017

RUDY A. YOUNG, Plaintiff,


          JOHN J. MCCONNELL, JR., United States District Judge.

         Pursuant to 42 U.S.C. § 405(g), Rudy Young seeks judicial review of the final administrative decision of the Commissioner of Social Security denying his claim for Disability Insurance Benefits and Supplemental Security Income. (ECF No. 9). Mr. Young contends that the Commissioner erred as a matter of law because his decision was not based on substantial evidence. (ECF No. 9 at 1). Specifically, Mr. Young claims that the Administrative Law Judge ("ALJ") erred in finding that Mr. Young's cluster headaches did not meet the durational requirement (based on improper weighing the examining physician's testimony) and failing to follow the proper standards for evaluating Mr. Young's credibility. (ECF No. 9 at 7-9).

         The Appeals Council upheld the ALJ's decision. Mr. Young challenged these rulings by the Commissioner by filing this lawsuit.


         Mr. Young was forty-three years old when his alleged disability of cluster headaches began and forty-five at the time of the ALJ's decision. Tr. 11; Tr. 143. He earned a General Equivalency Degree and last worked as a kitchen helper and laborer. Tr. 178; 32-33. Mr. Young lives in a shelter and has two children. Tr. 31. He claims that he became disabled in November of 2012 due to cluster headaches. Tr. 143. Mr. Young testified that, because of his headaches that appear out of nowhere and last about 45 minutes to an hour, he would not be able to return to his past work. Tr. 35-38. He also testified that he has two to three headaches per day and never goes a twenty-four-hour period without a headache. Tr. 40. The headaches are not predictable and can happen at any time during the day or night, and he must stop what he is doing while he is having the headaches because he is bothered by noise and bright lights. Tr. 38; Tr. 43-44.

         In terms of daily activities, Mr. Young stated, "I get out and about but I basically keep it low key because the headaches will come on at any time." Tr. 41. When he gets onto a bus, he will sometimes develop a headache because of the people, the air conditioner, or the heater. Id., He has had to get off the bus when he has developed a headache. Tr. 44. Mr. Young testified that he enjoys walking, playing a little basketball, and reading. Tr. 40.

         Mr. Young first presented to the Miriam Hospital in May of 2012 with a right ear abscess. Tr. 252. Thereafter, in August of 2012, Mr. Young presented to the emergency room of Rhode Island Hospital, where the doctor indicated the Mr. Young likely suffered cluster headaches. Tr. 263.

         From May of 2013 to January of 2014, Mr, Young received treatment from the Providence Community Health Center. Tr. 271-97; Tr. 347-63. In May of 2013, Dr. Simon Melnick assessed Mr. Young with episodic cluster headaches and prescribed Prednisone. Tr. 291. During follow-up visit in June of 2013, Mr. Young met with Dr. Daniel Guevara-Pineda, who also assessed Mr. Young with cluster headaches. Tr. 285.

         In July of 2013, Dr. Guevara-Pineda conducted a physical examination report of Mr. Young. Tr. 265. The report indicated that Mr. Young can walk less than two hours, stand less than two hours, sit for four out of eight hours, reach occasionally, and bend occasionally. Tr. 267. Additionally, Mr. Young can lift/carry up to ten pounds occasionally, bend/stoop occasionally, and can push/pull occasionally. Id. As for Mr. Young's mental activities, the report indicates that he is moderately limited in remembering and carrying out simple instructions, moderately limited in maintaining attention and concentration in order to carry out tasks, moderately limited in making work-related decisions, slightly limited in his ability to interact with coworkers, moderately limited in his ability to work at a consistent pace without extraordinary supervisions, and markedly limited in his ability to respond to change in his work routine or environment. Id.

         Dr. Guevara-Pineda ordered an MRI of Mr. Young's head in August of 2013, which revealed a right maxillary sinus mucus retention cyst but an otherwise normal MRI. Tr. 299. In a follow-up concerning the MRI results, Dr. Guevara-Pineda continued to assess Mr. Young with cluster headaches and prescribe medication for the condition. Tr. 313.

         In September of 2013, upon referral to a neurology clinic, Mr. Young met with Dr. Robert Gross, who assessed Mr. Young with cluster headaches and prescribed treatment following a normal neurological exam. Tr. 329. Mr. Young presented again to the Rhode Island Hospital upon complaints of headaches, and Dr. Otis Warren examined a CT scan of Mr. Young's head. Tr. 337. Following a negative result, which ruled out a mass, Dr. Warren assessed Mr. Young with cluster headaches and prescribed treatment. Id.

         An October of 2013 follow-up visit with Dr. Guevara-Pineda indicated that Mr. Young had some success with the medication decreasing the pain. Tr. 313. Mr. Young continued to report headaches occurring two to three times per a day on the left side of his head. Tr. 347-48; Tr. 352-53. During follow-ups in December of 2013 and January of 2014, Dr. Guevara-Pineda continued treatment of Mr. Young for cluster headaches. Id.

         Upon referral from Dr. Guevara-Pineda, Mr. Young began treatment with Dr. Michele Mellion of the Neurology Foundation in June of 2014. Tr. 369. Following a general examination and a neurological examination, Dr. Mellion diagnosed Mr. Young with episodic cluster headaches and drug-induced headaches. Tr. 370. She also prescribed new medication to treat Mr. Young's headaches. Id. During a September of 2014 follow-up, Dr. Mellion noted that Mr. Young's headaches are at bay but still debilitating. Tr. 366.

         His physicians discussed Botox treatment.[1] Tr. 37. Other treatments, such as oxygen therapy were discussed as well. Tr. 38. Mr. Young had been treated with medications, including Lithium, Fioricet, Amitriptyline, and Verapamil. Tr. 38-40. The Vocational Expert ("VE") testified that the limitations described by Mr. Young would rule ...

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