The opinion of the court was delivered by: Yohn, J.
Plaintiff, Marvin L. Dyson, seeks reversal or remand of a decision by the Commissioner of the Social Security Administration denying Dyson's application for Supplemental Security Income ("SSI") benefits. Pursuant to 28 U.S.C. § 636(b)(1)(B), the court referred this case to United States Magistrate Judge David R. Strawbridge for a Report and Recommendation. The Magistrate Judge recommended that the court reverse the decision and remand the case for further consideration. The Commissioner objects, arguing that the findings of the Administrative Law Judge ("ALJ") are properly supported by substantial evidence, including the finding that Dyson is capable of a full range of medium work such as his previous work as a cleaner/janitor. After conducting a de novo review of the Report and Recommendation, the court will overrule the objections, adopt the report, and approve the recommendation. It is impossible to determine from the ALJ's findings whether she properly considered the medical opinion of Dyson's treating physician when she decided to give the opinion "little weight," and therefore it is impossible to determine whether the decision is supported by substantial evidence. Accordingly, the court will reverse the decision and remand the case for further consideration.
I. Factual and Procedural Background
Dyson protectively filed his application for SSI benefits on May 17, 2007, alleging that he was disabled beginning on that date. (R. 109, 115.) He was fifty-five years old at the time. (R. 23.) In the past, he had worked as a custodian and for a cleaning company in "general maintenance." (R. 25, 116, 129.) He asserted that he was disabled due to a back impairment, hepatitis C, high blood pressure, anxiety, and drug abuse. (R. 115.)
In January 2003, Dyson began a course of treatment with Dr. Scott Sulman at Delaware Valley Medical Specialists for hepatitis C, lower back pain, and anxiety. (R. 199, 201-02, 433.) This continued until January 2005, when he began seeing Dr. Cheryl Branon, a specialist in internal medicine at the same practice. (R. 197, 205.) Although Dr. Branon saw Dyson as many as eleven times between January 20, 2005, and July 3, 2007, and prescribed Percocet to him on approximately fifteen occasions, the record only reflects that Dyson complained of back pain on May 17, 2006, and on July 3, 2007, his last recorded visit. (R. 119, 205-215.)
On that last visit, Dr. Branon completed a form "Medical Source Statement of Ability to do Work-Related Activities (Physical)." (R. 194-197.)*fn1 In this medical source statement, Dr. Branon stated that Dyson could lift only twenty-five pounds occasionally and ten pounds frequently. (R. 194.) She also stated that he could "stand/walk" for only two hours in an eight- hour workday, was unable to crawl or stoop, and should avoid temperature extremes, vibration, and work-related hazards. (R. 194-97.) She stated that the "medical/clinical findings" that supported her conclusions included that "crawling and stooping causes severe pain in low back" and "vibration exacerbates back pain." (R. 195, 197.)
On July 25, 2007, while his SSI claim was being considered initially, Dyson was involved in a car accident and was taken to the emergency room of Mercy Hospital of Philadelphia. (R. 270.) Although he left the hospital against medical advice the night of the accident, he returned for further testing when he was called by hospital personnel the following day, July 26, 2007. (R. 269.)*fn2 On that day, he underwent an MRI and CT scan of his cervical spine. The MRI revealed that Dyson had "[m]ultilevel cervical spondylosis with areas of central and neural foraminal stenosis as detailed in the body of [the] report[,]" although there was "no evidence of abnormal signal within the spinal cord." (R. 249.) The MRI further revealed that Dyson had "left paracentral disc herniation osteophyte complex" at the C3-C4 level, "posterior disc bulge osteophyte complex" at C4-C5 and C5-C6, and "disc bulge osteophyte complex" at C6-C7. (Id.) The CT scan of his cervical spine noted "[e]xtensive degenerative changes throughout the cervical spine... and most prominent from the C4-C5 to the C6-C7 levels with spinal canal narrowing with effacement of ventral CSF space and bilateral neural foraminal narrowing." (R. 263.) The CT scan also noted degenerative disc disease from the C2-C3 through C6-C7 levels.
(Id.)*fn3 After undergoing these tests, Dyson again left the hospital against medical advice. (R. 242.) According to the record, he did not seek further medical treatment until April 28, 2008.
Dyson's SSI claim was denied on November 9, 2007. (R. 10.) On November 9, 2007, he filed a timely request for a hearing. (R. 71.)
On April 28, 2008, he began treatment with an orthopedist named Dr. Wren. (R. 10, 357.)*fn5 Dr. Wren prescribed Dyson with Endocet, a pain medication, on approximately eleven occasions between April 28, 2008, and April 28, 2009. (R. 36, 357-63.)
Dyson's hearing was held on November 18, 2008. (R. 20.) At the hearing, Dyson testified that his back impairment limited his ability to walk, although he was able to walk "like two blocks or a block and a half" to catch the bus. (R. 42.)*fn6 He also asserted that he could only lift "around 15 to 20 pound[s]" and had difficulty sitting for long periods of time. (R. 43.) He testified that he did not prepare his own meals, but that he did go to a methadone maintenance program every day and to church twice a week with his girlfriend. (R. 33-34, 43, 52-53.)
The ALJ issued an unfavorable ruling on March 23, 2009, in which she found that Dyson is capable of "performing past relevant work as a cleaner/janitor." (R. 16.) The ALJ's decision centered on whether Dyson had been disabled since May 17, 2007, the date of his protective filing. (R. 10.) The ALJ followed the standard five-step "sequential evaluation process":
The sequential evaluation process is a series of five "steps" that we follow in a set order. If we can find that you are disabled or not disabled at a step, we make our determination or decision and we do not go on to the next step. If we cannot find that you are disabled or not disabled at a step, we go on to the next step. Before we go from step three to step four, we assess your residual functional capacity ["RFC"]. (See paragraph (e) of this section.) We use ...