United States District Court, M.D. Pennsylvania
REPORT AND RECOMMENDATION
JOSEPH F. SAPORITO, Jr., Magistrate Judge.
This is an action brought under 42 U.S.C. §1383(c)(3), seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying Hakeem Jefferson's claim for supplemental security income under Title XVI of the Social Security Act. Jurisdiction is conferred upon this Court pursuant to 42 U.S.C. §§ 1383(c)(3) (incorporating 42 U.S.C. §405(g) by reference), and this matter has been referred to the undersigned Magistrate Judge for the preparation of a report and recommended disposition pursuant to the provisions of 28 U.S.C. §636(b) and Rule 72(b) of the Federal Rules of Civil Procedure.
For the reasons stated herein, we recommend that the decision of the Commissioner denying Jefferson's application for benefits be VACATED and the case be REMANDED to conduct a new administrative hearing.
I. BACKGROUND & PROCEDURAL HISTORY
Jefferson alleges that he was involved in a motor vehicle accident in February 2008. The record in this case, however, does not contain any evidence of Jefferson's involvement in a motor vehicle accident in 2008. Instead, emergency room records reflect that Jefferson presented with complaints of back pain on February 9, 2010, due to a motor vehicle accident that occurred the previous day. (Admin Tr. 424). Jefferson reported no injuries at the time of the accident, but presented to the emergency room the next day with complaints of cervical and low back pain. X-rays of Jefferson's cervical and lumbar spine taken on February 9, 2010, were negative for any fracture. (Admin Tr. 311-12). After the accident, he was referred for outpatient physical therapy for treatment of lumbar strain. (Admin Tr. 275). During his initial evaluation, Jefferson denied radicular symptoms and described lower back pain (right greater than left) aggravated by heavy lifting, and cervical pain. Id. The physical therapist also noted that Jefferson's pain was resolving, but it is unclear whether this comment referred to Jefferson's cervical pain or to both his lumbar and cervical pain. Id. It was recommended that Jefferson participate in physical therapy sessions two to three times per week for an estimated two to three weeks. (Admin Tr. 276). Jefferson attended five sessions between February 17, 2010, and March 24, 2010.
On April 6, 2010, Jefferson attended one physical therapy session to address right knee pain. (Admin Tr. 286). Jefferson reported that his knee pain originated in September 2009 after hitting his knee on a coffee table. On examination Jefferson had no reproducible pain or locking, and his greatest impairment appeared to be weakness. Id. An MRI of Jefferson's right knee taken in December 2009 was unremarkable. (Admin Tr. 347). As of April 2010, Jefferson reported that he was very active and continued to play basketball. (Admin Tr. 285).
An October 2010 MRI of Jefferson's lumbar spine revealed the impression of a lesion in the region of the iliac vein. It was unclear whether the lesion was related to the iliac vein or to some other abnormality. (Admin Tr. 310). A follow-up CT scan of Jefferson's pelvis, however, was compatible with the impression of a large left iliac vein. (Admin Tr. 309). No other pelvis abnormality was noted. Id. Further, the MRI of Jefferson's lumbar spine did not show any herniated disc or spinal stenosis. (Admin Tr. 316).
On January 6, 2011, Jefferson protectively filed an application for supplemental security income under Title XVI of the Social Security Act due to back problems and right knee problems in which he alleged a disability onset of January 20, 2009. (Admin Tr. 231). In pre-hearing memorandum dated March 2, 2012, Jefferson amended his alleged onset date to January 6, 2011, and updated his claim to include degenerative disc disease, chronic pain, depression, and anxiety. (Admin Tr. 104).
On March 10, 2011, nonexamining state agency medical consultant James Caramanna, M.D., opined that the evidence established a medically determinable disorder of the spine. (Admin Tr. 130-31). Dr. Caramanna noted that the record reflected that Jefferson's treatment had been routine and conservative in nature, and that he did not require an assistive device to ambulate. Id. He opined that Jefferson could: occasionally lift or carry twenty pounds and frequently lift or carry ten pounds; stand or walk up to six hours per eight-hour workday; and sit up to six hours per eight-hour workday. Id.
In February 2011, Jefferson completed a function report in which he described his exertional and nonexertional limitations. (Admin Tr. 237-46). Jefferson stated that his lower back feels like someone took a hammer to it, and that this pain radiates down both of his legs. Id. In this report, Jefferson indicated that his impairments limited his abilities to lift, squat, bend, stand, reach, kneel, climb stairs, complete tasks, and concentrate. Id. He also stated that he is able to walk up to twenty feet at one time and is able to tend to his own hygiene with some postural modifications. Id. Jefferson admitted that, despite his limitations, he prepares his own meals, goes outside four times per day, is able to drive a car, is able to go out alone, goes to church and visits friends and family on a regular basis, and shops for light-weight household items in stores once per month, but does not do housework. Id.
On March 11, 2011, the date that this claim was initially denied, nonexamining state agency psychologist Arlene Rattan, Ph.D., found that Jefferson had no medically determinable mental impairment. (Admin Tr. 129-30). She explained that her assessment was based on the fact that there was no diagnosis of any mental impairment, or indication of a medically determinable mental impairment, in the medical evidence of record as it existed at the time she rendered her opinion. Id. It appears that, Jefferson was subsequently diagnosed with a myriad of mental impairments in early 2012.
On July 13, 2011, an MRI of Jefferson's lumbar spine revealed some mild disc space narrowing at L4-L5 with minimal bulging of the disc. (Admin Tr. 339). Jefferson continued to report lower back pain. On August 23, 2011, Jefferson told a certified registered nurse practitioner (CRNP) that his back is very painful when he lifts his disabled adult sister. (Admin Tr. 355).
In January 2012, at the insistence of his family, Jefferson entered inpatient treatment for opioid dependence. Jefferson participated in inpatient treatment for five days, and then signed himself out against medical advice. On January 24, 2012, he was seen by Psychiatrist Syyeda Syed for outpatient care, but was discharged from treatment after he failed to schedule a second appointment. (Admin Tr. 585).
On February 27, 2012, Jefferson completed a daily activities questionnaire. (Admin Tr. 264-267). Unlike in the February 2011 function report, in this questionnaire, he reported that he is able to sweep, mop, and do some laundry with the assistance of another person. Id. Otherwise, the statements made in the February ...