United States District Court, W.D. Pennsylvania
KENNETH A. WAGNER, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
MEMORANDUM AND ORDER
CATHY BISSOON, District Judge.
For the reasons that follow, Plaintiff's Motion for Summary Judgment (Doc. 9) will be granted, Defendant's Motion for Summary Judgment (Doc. 12) will be denied, and this case will be remanded for further administrative proceedings.
Kenneth A. Wagner ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g) seeking review of the final determination of the Commissioner of Social Security ("Defendant" or "Commissioner") denying his applications for Disability Insurance Benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. § 401, et seq. and § 1381 et seq. ("Act"). Plaintiff filed for benefits, claiming a complete inability to work as of March 1, 2010, due to a back impairment and depression. (R. at 129-140, 162). An Administrative Law Judge ("ALJ") denied benefits to Plaintiff on February 23, 2013, following an administrative hearing. (R. at 19-28). A request for review by the Appeals Council was denied.
The ALJ determined that Plaintiff had medically determinable severe impairments, namely, degenerative disc disease, fibromyalgia, and depression. (R. at 21). However, he had the residual functional capacity ("RFC") to perform light work, except he could only lift 20 pounds occasionally and 10 pounds frequently, sit for four hours, and stand/walk for four hours with a sit/stand option, changing positions with a maximum frequency of 30 minutes. (R. at 23). Plaintiff was limited to simple, routine, and repetitive work that was not fast-paced, and required only occasional interaction with others. (R. at 23). Consistent with the testimony of the vocational expert, the ALJ found that Plaintiff thereby qualified for a significant number of jobs in existence in the national economy, and thus was not disabled within the meaning of the Act. (R. at 27-28).
Plaintiff's primary care physician was Bradley Fell, M.D. (R. 292-332). Plaintiff sought treatment for a sore throat in January 2010, and Dr. Fell reported Plaintiff had no psychiatric complaints, his physical examination was normal, and his gait was normal. (R. at 324). When seen in March, Plaintiff reported arthralgias but denied myalgia,  and his gait was normal. (R. at 317). In April, Plaintiff complained of arthralgias and myalgia and Dr. Fell reported his gait was normal. (R. at 314).
When seen in July 2010, Plaintiff complained of back pain stemming from an injury in 1995. (R. at 309). Dr. Fell diagnosed Plaintiff with lumbago, prescribed Flexeril, and referred him for an MRI. (R. at 311). In October, Plaintiff complained of heel pain and increased back pain aggravated with sudden movement. (R. at 305). He stated that he did not want to undergo injection therapy, but that chiropractic treatment helped his pain. (R. at 305). Plaintiff reported that he was "unable to hold his head up the next day" after taking Flexeril, and requested a different medication. (R. at 305). Plaintiff reported depression, but denied anxiety. (R. at 306). Dr. Fell noted that he walked with a "slow gait." (R. at 307). Dr. Fell ordered an MRI, the results of which showed multilevel disc bulges with a small annular tear at the L3-4 level and disc narrowing at the L4-5 level. (R. at 330).
Plaintiff had no musculoskeletal or psychiatric complaints when seen in October 2010, but complained of fatigue, arthralgias, myalgia, dizziness, lightheadedness, and depression at his office visit in November. (R. at 299, 302). Plaintiff's physical examination was normal, and he walked with a normal gait. (R. at 300). Plaintiff complained of back pain, bilateral hip pain, and bilateral foot pain in December 2010. (R. at 295). He denied experiencing dizziness, headaches, lightheadedness, or anxiety, but mentioned he felt depressed. (R. at 295, 297). His physical examination was unremarkable, and he walked with a normal gait. (R. at 296-297). Plaintiff was assessed with chronic pain syndrome. (R. at 297).
In March 2011, Plaintiff complained of bilateral groin pain and it was noted that he walked with a slow gait. (R. at 410). In April, he reported fatigue, arthritis, back pain, bilateral wrist pain, bilateral ankle and foot pain, dizziness, headache, lightheadedness, anxiety and depression. (R. at 292). Dr. Fell noted that his symptomatology was "strongly suggestive of fibromyalgia" and that he had "many tender areas scattered around his body." (R. at 292). He also found Plaintiff was "clearly depressed" and appeared chronically ill and worried. (R. at 292-293). His remaining physical examination was unremarkable, and he walked with a normal gait. (R. at 293-294).
In October 2011, Plaintiff reported that Celexa caused headaches. (R. at 394). He complained of anxiety, depression, arthralgias and myalgia. (R. at 394). Dr. Fell noted that he appeared chronically ill and anxious. (R. at 395). His physical examination was unremarkable, and he walked with a normal gait. (R. at 395). A thoracic spine x-ray in October 2011 showed mild age-indeterminate compression fractures at T8 and T9. (R at 381). A thoracic spine MRI revealed multilevel disc and endplate degenerative changes, small disc protrusions at T2-T3 and T5-T6, a small disc herniation at T7-T8, and mild scoliosis. (R. at 392). In November 2011, Dr. Fell found Plaintiff's entire spine was "a little stiff and sore" on physical examination, although Plaintiff reported feeling better on his medications. (R. at 388, 390).
Plaintiff was also evaluated by Matt El-Kadi, M.D., a neurosurgeon, in October 2010. (R. at 265-266). Plaintiff's physical examination was unremarkable and his EMG study was normal. (R. at 265, 270-272). Dr. El-Kadi concluded that Plaintiff was not a surgical candidate, and recommended treatment at a pain management clinic. (R. at 265, 413).
Plaintiff sought treatment from several pain management specialists (R. at 288-290, 419), the most recent being Richard Plowey, M.D. (R. at 421-424). On December 8, 2011, Plaintiff had multiple pain complaints, and reported that he took Vicodin, ibuprofen and Neurontin with minimal side effects. (R. at 422). Plaintiff walked with a slow gait and was unable to heel walk, but could toe walk and squat with some difficulty. (R. at 422). Plaintiff exhibited tenderness in the lumbar, thoracic and cervical spines, had full muscle strength in the upper and lower extremities, no edema or evidence of effusion, and negative straight leg raise testing bilaterally. (R. at 422). He was diagnosed with lumbar spine pain secondary to discogenic syndrome versus facet arthropathy, lower extremity radicular syndrome, cervical spine pain secondary to discogenic syndrome versus facet arthropathy, thoracic spine pain secondary to discogenic syndrome versus myofascial pain syndrome, and multiple arthralgias and myalgias secondary to degenerative joint disease. (R. at 423). Dr. Plowey recommended a combination of physical therapy, psychotherapy, non-narcotic medications, percutaneous procedures, and, if necessary, narcotic pain medication. (R. at 423). Plaintiff expressed reluctance at undergoing lumbar injections. (R. at 423). Dr. Plowey advised ...