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Russell v. Berryhill

United States District Court, D. Connecticut

March 27, 2019



          Hon. Vanessa L. Bryant United States District Judge

         Claimant Jaron R. Russell (“Mr. Russell” or “Claimant”) challenges the Commissioner of Social Security's final decision to deny his application for disability benefits pursuant to 42 U.S.C. § 405(g). Mr. Russell moves to reverse or remand the decision, arguing that Administrative Law Judge I. K. Harrington's (the “ALJ” or “ALJ Harrington”) findings are not supported by substantial evidence in the Record and/or were not rendered in accordance with law. Commissioner Nancy A. Berryhill, Acting Commissioner of Social Security (the “Commissioner”), moves to affirm the Commissioner's final decision. For the reasons stated below, the Court GRANTS the Commissioner's motion to affirm and DENIES Claimant's motion to reverse.


         As a child, Claimant was diagnosed with epilepsy. Claimant stopped having seizures around age eight but started experiencing them again in March 2011. On April 7, 2014, Claimant filed for disability benefits and supplemental security income. Claimant is not insured under his own earnings record but filed as the adult child of an insured wage earner. [R. 21]. His application was denied initially on April 23, 2014 and reconsideration was denied on September 5, 2014. Claimant thereafter requested a hearing, which ALJ Harrington held on April 13, 2016. At the time of the ALJ's decision, Claimant was twenty-two years old. He had completed high school and was taking college classes part-time. [Dkt. 24-2 (Stipulation of Facts) at ¶ 1]. On July 5, 2016, ALJ Harrington issued her decision finding Claimant is not disabled under the Social Security Act (“SSA”) and denying his application for benefits. Claimant initiated this action on March 16, 2018 and moved to reverse the Commissioner's decision on July 31, 2018. The Commissioner subsequently moved to affirm the decision of the Commissioner.

         In accordance with the standing order on social security appeals, the parties filed a stipulation of facts, [Dkt. 42-2], which the Court hereby incorporates in full.

         I. Medical History

         Claimant had a history of epilepsy as a child. [R. 505]. After no seizures for a number of years, on March 13, 2011, at age seventeen, Claimant presented to the emergency room complaining of headache, dizziness, and vomiting following a suspected seizure. [R. 505, 825-46]. A CT scan of Claimant's head was normal. [R. 514, 830]. Dr. Ionita started Claimant on an anticonvulsant, Trileptal. [R. 467]. On April 14, 2011, Claimant saw a neurologist, Dr. David Shiling, for evaluation. [R. 467, 806, 819]. Dr. Shiling agreed with the Trileptal prescription and instructed Claimant he should continue to avoid driving and other dangerous activities. [R. 474]. At a follow-up visit six weeks later, Dr. Shiling reported that the MRI and EEG of Claimant's brain were normal. [R. 471].

         Claimant presented to the emergency room on July 9, 2011 following another seizure. [R. 501]. Claimant reported the breakthrough seizure to Dr. Shiling at an appointment on July 13, 2011. [R. 475]. Dr. Shiling increased Claimant's dosage of Trileptal and referred him to Yale Epilepsy Center. [R. 478].

         Claimant returned to Dr. Shiling on November 15, 2011 and reported a nocturnal seizure the night before. [R. 479]. Claimant reported that there were no precipitating factors, as with his previous seizures. [R. 479]. Dr. Shiling prescribed Keppra and recommended another appointment with the Yale Epilepsy Center. [R. 482]. An EEG taken that day showed “excessive slowing bilaterally with recurrent bilateral rhythmic frontal delta occasionally associated with possible very low amplitude or phantom spikes consistent with an underlying primary seizure disorder and perhaps some sort of encephalopathy.” [R. 484].

         On March 13, 2012, Claimant reported to Dr. Detyniecki, a Yale physician, that he had a seizure on February 20, 2012. [R. 570]. On February 20, 2012 and March 5, 2012, Claimant's urine toxicology screen was positive for cannabis. [R. 486, 519, 705]. Claimant was seen emergently by Dr. Detyniecki on March 28, 2012 following a seizure while Claimant was at school. [R. 569]. On June 19, 2012, Claimant told Dr. Detyniecki that he continued to have breakthrough seizures despite escalating doses of Keppra and Trileptal. [R. 565, 598]. Claimant admitted to forgetting some doses of his medication. Claimant's mother had begun monitoring his medication compliance. [R. 565]. As at each of the previous visits, on examination, Claimant was cooperative, alert, and fully oriented and he was neurologically intact with full strength throughout and had intact sensation, normal eye examination, and a normal gait. [R. 566, 599, 904].

         Claimant saw Dr. Detyniecki again on January 27, 2013, reporting episodes of nausea, then feeling hot and sweaty, but not losing consciousness. [R. 561]. Dr. Detyniecki prescribed Lamictal, another anticonvulsant, for these auras. [R. 561]. Claimant also reported having a seizure in December after being seizure free for six months. [R. 561]. A February 7, 2012 MRI of Claimant's brain was normal. [R. 598].

         Claimant was taken off of Keppra in April 2013. [R. 549]. Claimant saw Dr. Pue Farooque at Yale New Haven Hospital for evaluation of his seizures on April 19, 2013. [R. 545, 677]. Dr. Farooque noted that Claimant's physical examination, MRI, and EEG were normal. [R. 545-46, 677]. In June, Dr. Detyniecki switched Claimant to Oxtellar and increased his dosage; Claimant continued with Lamictal. [R. 676]. Claimant reported that he continued to have seizures. [R. 676].

         On September 10, 2013, Claimant presented to the emergency room following two seizures in the morning. [R. 487, 868-85]. Claimant had four additional seizures after an initial emergency room visit. [R. 487, 868-85]. The attending physician increased Claimant's Lamictal and instructed him to continue with his other antiseizure medications. [R. 499]. Claimant's urine analysis from the visit was positive for cannabis. [R. 537, 669, 671].

         Claimant saw Dr. Detyniecki on September 23, 2013 following the cluster of seizures earlier in the month. [R. 526]. Dr. Detyniecki suspected that medication noncompliance was an important factor in causing the additional seizures. [R. 528]. Claimant saw Dr. Detyniecki again on January 7, 2014 and reported a seizure in November and one a week prior to the visit. [R. 534]. Claimant admitted to smoking marijuana. [R. 524]. Dr. Detyniecki increased Claimant's Lamictal dosage but his assessment noted that Claimant's seizures “appear to be less often and milder (no sec GTC [general tonic-clonic, or grand mal, seizures]).” [R. 525]. Claimant had another appointment with Dr. Detyniecki on April 8, 2014. [R. 655]. Claimant reported having two seizures on March 28 and complained of some headaches and spitting. [R. 655]. Dr. Detyniecki noted that Claimant was compliant with his medication regimen. [R. 655]. EEG monitoring of Claimant in June 2014 showed two seizures. [R. 620, 638-54, 921].

         In connection with Claimant's disability benefits application, Dr. Maria Lorenzo reviewed the record evidence and her report dated April 23, 2014 opines that Claimant has no exertional, postural, manipulative, visual, or communicative limitations. [R. 245]. She indicated that a residual functional capacity should reflect seizure precautions. [R. 246]. Dr. Carl Bancoff reviewed the record evidence in September 2014 and opined that Claimant had no exertional limitations, but Claimant should avoid exposure to ladders and ropes. [R. 270, 272].

         On October 21, 2014, Claimant saw Dr. Detyniecki and complained of intermittent blurry vision since starting on a low dose of Depakote. [R. 924]. On February 19, 2015, Dr. Detyniecki increased Claimant's Depakote dosage upon Claimant's report of a seizure the previous month. [R. 789, 927]. In August 2015, Claimant reported having “walking seizures” twice a month and intermittent blurry vision. [R. 930]. Claimant's physical examination was normal. [R. 931].

         At an appointment with Dr. Detyniecki on January 27, 2016, Claimant reported only one cluster of seizures since his August visit. [R. 933]. Claimant used Ativan after the second seizure. [R. 933]. Dr. Detyniecki's assessment reported medically refractory localization-related epilepsy (LRE) and noted that Claimant was “[d]oing better with the increased dose of Clobazam.” [R. 935].

         Dr. Detyniecki completed a Medical Source Statement of Mental Health on March 14, 2016. [R. 937-42]. Dr. Detyniecki indicated moderate and extreme limitations with the ability to understand, remember, and carry out instructions as well as moderate limitations to the ability to interact appropriately with supervisors, co-workers, and the public and to respond to changes in the routine working setting. [R. 938-39]. Dr. Detyniecki stated that Claimant's epilepsy limited his educational opportunities, social interactions, and ability to be independent. [R. 941]. He further explained that Claimant “has undergone numerous tests to try and pinpoint his seizure focus in the hopes that an optimal plan can be made to manage his seizure disorder. Despite being on multi-modal drug therapy, [Claimant] still has seizures which are unpredictable and totally disabling.” [R. 941]. II. ALJ Decision ALJ Harrington rendered her decision on July 5, 2016, denying Claimant's request for disability insurance benefits and supplemental security income. [R. 11-26]. ALJ Harrington's conclusions are as follows.

         ALJ Harrington first found that Claimant had not engaged in substantial gainful employment since November 30, 2011, the alleged onset date. [R. 21]. She next found that Claimant has one severe impairment-epilepsy-and intermittent diplopia (double vision), which is non-severe. [R. 21].

         ALJ Harrington concluded that Claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. [R. 22]. Specifically, she found that “[n]o treating or examining physician has recorded findings equivalent in severity to the criteria of any listed impairment, nor does ...

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