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Ali v. Colvin

United States District Court, D. Nebraska

July 15, 2016

CAROLYN W. COLVIN, Acting Commissioner of Social Security Administration, Defendant.


          LYLE E. STROM, Senior Judge United States District Court

         This matter is before the Court for judicial review of a final decision of the Commissioner of the Social Security Administration (“the Commissioner”). Nasser Khalil Ali (“Ali”) appeals the Commissioner’s final decision denying Ali’s application for disability benefits. After reviewing the record, the briefs, and the applicable law, the Court finds that the Commissioner’s decision should be affirmed.

         Procedural Background

         On or about August 10, 2012, Ali filed an application for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) (Tr. 180-95). On October 4, 2012, the plaintiff’s applications were initially denied (Tr. 94-97). Ali requested a reconsideration of his denial, which was again denied (Tr. 102-11).

         On January 17, 2013, Ali requested a hearing before an administrative law judge (“ALJ”) (Tr. 114-15). Ali disagreed with the denial because he claimed he was unable to work due to depression, stress, dizziness, sadness, and anger issues (Id.).

         The ALJ, James Harty, held an administrative hearing on October 21, 2013, in Wichita, Kansas (Tr. 34-55). On January 23, 2014, the ALJ found that Ali was not under a disability within the meaning of the Social Security Act from June 30, 2009 to the date of the decision (Tr. 15-33). On March 29, 2015, the Appeals Council denied Ali’s request for review and affirmed the ALJ’s decision (Tr. 1-6). Ali timely filed this appeal on May 28, 2015 (Filing No. 1).

         Factual Background

         Ali alleges that he became disabled on June 30, 2009, because depression, stress, dizziness, sadness, and anger issues limited his ability to work (Tr. 180-95, 229). Ali was born on January 1, 1979, and was 34 at the time of the administrative hearing (Tr. 180). He has a sixth grade education, and has been unemployed since 2011 (Tr. 229-30). He speaks very little English and has to use an interpreter when visiting doctors (See Tr. 340-42). His previous job history includes dishwasher, meat cutter, temporary laborer, and line worker (Tr. 230). Ali has been diagnosed with major depressive disorder, post traumatic stress disorder (“PTSD”), and schizoaffective disorder (Tr. 318, 399).

         Ali sought treatment at the Community Mental Health Center (“CMHC”) as early as 2001 (Tr. 333). However, he has not received continuous treatment from the CMHC throughout the years. On May 9, 2012, Ali sought mental health treatment from the CMHC (Tr. 316-27). Ali reported frequent headaches and occasional dizziness (Tr. 324). He was diagnosed with major depressive order, recurrent, and PTSD (Tr. 318). Ali was referred to Tina Vest, MSN, APRN, a mental health nurse practitioner (Id.).

         On June 21, 2012, Ali visited Tina Vest (“Vest”) (Tr. 340-42). Ali informed Vest that he felt like he could not work due to marked agitation, anger, anxiety, and depression (Tr. 340). Vest found Ali to be guarded but cooperative (Tr. 341). Vest found no evidence of cognitive decline and Ali’s insight and judgment to be fair (Id.). Vest diagnosed Ali with major depressive disorder recurrent, mood disorder NOS, and PTSD (Id.). Vest prescribed Symbyax to address anger and hostility issues (Tr. 342). In addition, Ali was referred to psychotherapy (Id.).

         On August 6, 2012, Ali had a follow up appointment with Vest (Tr. 339). Vest noted some improvement (Id.). Ali reported doing much better, which included sleeping better, less anxiety, and hearing voices on a less frequent basis (Id.). On September 10, 2012, Ali visited Vest for another follow up (Tr. 338). Vest’s impression was that Ali was stabilized (Id.). Ali reported doing much better, and he was less anxious and depressed (Id.). At this time, Ali had not been to psychotherapy, even though he was referred (Id.). Vest recommended therapy (Id.). On November 26, 2012, Ali saw Vest again complaining of headaches (Tr. 446). Vest‘s impression was that Ali did not have a lot of improvements (Id.). Vest signed Ali up for case management services (Id.). On December 27, 2012, Ali had another follow up with Vest (Tr. 447). Vest found that Ali was improving (Id.). Vest initiated case management to help with socialization and access to services (Id.). Vest stated, “I value whether or not he has capacity or ability to work given his diagnosis.” (Id.). On January 24, 2013, Ali saw Vest and his case manager (Tr. 448). Vest noted that Ali had been out of his medications for four or five days (Id.). Vest found him to be stable, but needed to work on socialization (Id.).

         On February 26, 2013, and March 6, 2013, Ali underwent a two-day psychological evaluation with Kristen Laib, M.S. (“ Ms. Laib”), and Joseph Swoboda, Ph.D. (“ Dr. Swoboda”)(393-401). Ali was referred for a diagnostic evaluation by his community support worker, and because Ali’s brother expressed concerns about Ali’s ability to function independently and maintain employment (Tr. 393). The Brief Psychiatric Rating Scale (“BPRS”) was administered (Tr. 396). Ali received a score of 65, which falls within the “markedly ill” category indicating a significant presence of symptoms that are likely to affect Ali’s level of functioning (Id.). The Vineland-II was also administered to assess adaptive behavior (Tr. 397). Ali’s Adaptive Behavior Composite was classified as “low” which indicates that his adaptive functioning is below 99 percent of his peers (Id.).

         Ms. Laib and Dr. Swoboda diagnosed Ali with schizoaffective disorder and PTSD rule out: cognitive disorder, NOS (Tr. 399). They found that Ali “is likely to experience severe deficits in living independently and caring for his daily needs.” (Tr. 400). In addition, “occupational achievement is likely to be severely limited.” (Id.). Ms. Laib and Dr. Swoboda found that Ali may have suffered a head injury as a young child (Tr. 401). They recommended that Ali participate in a full neurological evaluation to identify possible brain abnormalities (Id.).

         On March 19, 2013, Vest met with Ali and noted no real change and recommended injectable medication therapy for compliance and adherence (Tr. 449). On May 3, 2013, Vest noted that Ali was much more improved (Tr. 450). Ali had been working with his case manager (Id.). Ali’s mood was more stable, and he was less paranoid and suspicious (Id.). He was more social, and joined a gym for exercise (Id.). On May 28, 2013, Vest noted that Ali had improved, and that his mental status was essentially normal (Tr. 451). On June 27, 2013, Ali had a follow up with Vest (Tr. 452). Vest found Ali was responding ...

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