United States District Court, Western District of Pennsylvania
DAVID STEWART CERCONE UNITED STATES DISTRICT JUDGE
Plaintiff, Keith Edwin Davis (“Plaintiff”) brings this action pursuant to 42 U.S.C. § 405(g) of the Social Security Act (the “Act”), seeking judicial review of the final decision 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”). The record has been developed at the administrative level. The matter is before the Court on cross-motions for summary judgment. (ECF Nos. 11, 14). For the reasons that follow, Plaintiff’s Motion for Summary Judgment will be granted and Defendant’s Motion for Summary Judgment will be denied. The Commissioner’s decision will be vacated, and the case will be remanded for further proceedings consistent with this Memorandum Opinion.
II. PROCEDURAL HISTORY
Plaintiff applied for DIB and SSI benefits on January 18, 2011, alleging that he had been disabled since January 1, 2007 due to asthma, chronic obstructive pulmonary disease (“COPD”), and back and neck pain. (R. at 143-155, 168). The applications were denied, and Plaintiff filed a written request for an administrative hearing. (R. at 78-87, 94). On September 4, 2012, a hearing was held before Administrative Law Judge (“ALJ”) Leslie Perry-Dowdell. (R. at 29-51). Plaintiff, who was represented by counsel, appeared and testified. (R. at 33-47). Additionally, an impartial vocational expert, David Zak, testified at the hearing. (R. at 46-51).
In a decision dated November 16, 2012, the ALJ determined that Plaintiff was not disabled within the meaning of the Act. (R. at 14-24). The Appeals Council denied Plaintiff’s request for review on January 25, 2013 (R. at 1-7), thereby rendering the ALJ’s decision the final decision of the Commissioner in this case. The instant action followed.
III. STATEMENT OF THE CASE
A. General background
Plaintiff was born on August 23, 1958, making him 50 years old on his alleged onset date, and 54 years old at the time of the hearing. (R. at 23). Plaintiff completed school through the tenth grade, and had prior work experience as a laborer. (R. at 169).
B. Medical evidence submitted to the ALJ
On April 28, 2010, Plaintiff was seen by Arif Rafi, M.D., for complaints of back, right arm and neck pain after falling off a truck at work. (R. at 232). Some tenderness of the lumbar paraspinal muscles was found on physical examination, but Plaintiff’s remaining examination was unremarkable. (R. at 233). He was assessed with a backache, unspecified, and degenerative joint disease (lumbar), and prescribed physical therapy and medication. (R. at 233). On June 23, 2010, Plaintiff reported that his fall had actually occurred fifteen years prior. (R. at 230). He continued to complain of intermittent sharp pain. (R. at 230). He was assessed with lumbar and cervical degenerative disc disease with radiculopathy, and right shoulder arthralgia. (R. at 231).
On January 12, 2011, Dr. Rafi noted that Plaintiff “[s]till [had] pain” and was waiting for insurance before undergoing an MRI. (R. at 227). On February 10, 2011, Plaintiff reported to Dr. Rafi that he felt sore in his low back and neck after shoveling snow. (R. at 225). On March 9, 2011, Plaintiff was seen by Dzenita Turcinhodzic, PA-C, and continued to complaint of low back soreness. (R. at 275). A CT scan of Plaintiff’s lumbar spine dated March 25, 2011 showed multilevel degenerative changes. (R. at 235-236).
On April 29, 2011, Plaintiff underwent a consultative physical examination performed by Henry Holets, Jr., M.D. (R. at 239-243). Plaintiff reported smoking a pack of cigarettes a day for thirty years. (R. at 239). Plaintiff claimed an inability to work due to asthma, COPD, arthritis, and back and neck pain. (R. at 239). Plaintiff stated that he had been “bothered” by asthma for ten years, but admitted that he had not been treated for this condition or undergone any pulmonary function testing. (R. at 239). Plaintiff’s lungs were clear, and his remaining physical examination was essentially unremarkable. (R. at 241). Dr. Holets diagnosed Plaintiff with obesity, tobacco usage, history of low back complaints, and history of drug detox. (R. at 242). He opined that Plaintiff could lift twenty to twenty-five pounds, had no limitations in his ability to stand, walk or sit, could engage in occasional postural activities, and had no environmental restrictions. (R. at 242).
When seen by Dr. Rafi on May 4, 2011, Plaintiff complained of soreness for the past three days after working on his truck. (R. at 271). On physical examination, tenderness and spasms in the lumbar spine were noted, but his remaining physical examination was unremarkable. (R. at 272). He was assessed with low back pain and continued on medication. (R. at 272).
On May 10, 2011, Dilip Kar, M.D., a state agency reviewing physician, reviewed the medical evidence of record and concluded that Plaintiff could perform light work. (R. at 57-60). Dr. Kar found that Plaintiff could lift or carry twenty pounds occasionally; lift or carry ten pounds frequently; stand, walk or sit about six hours in an eight-hour workday; and could occasionally perform postural activities. (R. at 58-59). He further found that Plaintiff needed to avoid exposure to extreme weather conditions, and avoid concentrated exposure to fumes, odors, dusts, gases and poor ventilation due to his tobacco usage. (R. at 59). Dr. Kar found that Plaintiff’s statements were only partially credible since his daily activities were not significantly limited in relation to his alleged symptoms. (R. at 59). Dr. Kar observed that Plaintiff had ...