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Walz v. Colvin

United States District Court, M.D. Pennsylvania

February 7, 2017

TINA MARIE WALZ, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM

          RICHARD P. CONABOY United States District Judge

         Pending before the Court is Plaintiff's appeal from the Commissioner's denial of supplemental security income (“SSI”) under Title XVI of the Social Security Act (“Act”). (Doc. 1.) She alleged disability beginning on April 7, 2011. (R. 17.) The Administrative Law Judge (“ALJ”) who evaluated the claim, Gerard Langan, concluded in his October 30, 2014, decision that Plaintiff had the severe impairments of degenerative disc disease of the cervical spine, status post lumbar fusion at ¶ 4-S1, bilateral carpal tunnel syndrome, and obesity which ALJ Langan concluded did not meet or equal a listing when considered alone or in combination. (R. 20.) He also found that Plaintiff had the residual functional capacity (“RFC”) to perform light work with certain nonexertional limitations and that she was capable of performing jobs that existed in significant numbers in the national economy. (R. 21-28.) ALJ Langan therefore found Plaintiff was not disabled from March 19, 2013, the date the application was filed, through the date of the decision. (R. 29.)

         Plaintiff alleges the ALJ made the following errors: 1) he improperly analyzed the medical opinion evidence; 2) he did not rely on any medical opinion when assessing residual functional capacity; and 3) he failed to order a consultative examination and/or failed to appoint a medical expert. (Doc. 10 at 9.) After careful review of the record and the parties' filings, the Court concludes this appeal is properly granted.

         I. Background

         A. Procedural Background

         Plaintiff protectively filed for SSI on March 19, 2013. (R. 17.) The claim was initially denied on May 15, 2013, and Plaintiff filed a request for a hearing before an ALJ on May 22, 2013. (Id.)

         ALJ Langan held a hearing on August 13, 2014, in Wilkes-Barre, Pennsylvania. (Id.) Plaintiff, who was represented by an attorney, appeared at the hearing as did Vocational Expert (“VE”) Nadine Henzes. (Id.) As noted above, the ALJ issued his unfavorable decision on October 30, 2014, finding that Plaintiff was not disabled under the Social Security Act during the relevant time period. (R. 29.)

         Plaintiff's request for review of the ALJ's decision was dated December 8, 2014. (R. 7-12.) The Appeals Council denied Plaintiff's request for review of the ALJ's decision on June 7, 2016. (R. 1-6.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)

         On August 3, 2016, Plaintiff filed her action in this Court appealing the Acting Commissioner's decision. (Doc. 1.) Defendant filed her answer and the Social Security Administration transcript on October 13, 2016. (Docs. 8, 9.) Plaintiff filed her supporting brief on November 7, 2016. (Doc. 10.) Defendant filed her brief on December 9, 2016. (Doc. 11.) With the filing of Plaintiff's reply brief (Doc. 12) on December 21, 2016, this matter was fully briefed and ripe for disposition.

         B. Factual Background

         Plaintiff was born on May 13, 1965, and was forty-seven years old on the date the application was filed. (R. 28.) She has a high school education and past relevant work as an inserting machine operator and plastic bag assembler. (R. 27.)

         1. Impairment Evidence[1]

         Plaintiff alleged disability due to back injury, neck problems, herniated disc, pinched nerves in the back of her left leg and shoulders, and unsuccessful fusion surgery. (R. 232.) The referenced surgery was a 2003 lumbar fusion from L4-S1. (See R. 27.)

         On March 7, 2012, Plaintiff was seen for follow-up at Summit Pain Medicine. (R. 300.) Plaintiff reported that the caudal epidural she received in June 2011 had significantly helped her low back pain. (Id.) She also reported that she was having muscle spasms, the pain in her back (which ranged from 4-10/10) radiated into her lower extremities bilaterally, she had tingling and bilateral arm numbness as well as weakness (especially in her right arm), and she had fairly frequent severe headaches. (Id.) Plaintiff said her pain was worst when she had to stand or sit for any prolonged period of time and it was better when she could lie down as long as she could reposition frequently. (Id.) Physical examination showed the following: Plaintiff had tenderness to palpation in the lumbar spine in the midline and over the paravertebral's bilaterally; she did not have any neurosensory deficits in her lower extremities; straight leg raising was negative bilaterally; her gait was nonantalgic; she had tenderness over cervical facets on the right at ¶ 5, C6 and C7; she had minimal tenderness over the cervical facets on the left at the same levels; she had full range of motion of the neck; she had some decreased sensation in her right upper extremity from her elbow to her two smallest fingers on her right hand; and her grip strength was equal bilaterally. (R. 300-01.) CRNP Marcia Helfrick assessed chronic low back pain, failed lumbar laminectomy syndrome, lower extremity radicular pain, more recent neck pain, and right upper extremity neurosensory deficits and radicular pain. (R. 301.) In addition to prescriptions for Lidoderm patch, Voltaren gel and Tramadol, the plan was to schedule another caudal epidural steroid injection, have an MRI of the spine “due to her new neurosensory deficits, ” and follow up after her injection. (Id.)

         At her May 4, 2012, visit, Plaintiff was seen by Timothy Sempowski, D.O., who recorded Plaintiff said her shot had helped initially (50% relief for one month) but it was starting to wear off. (R. 302.) Plaintiff also reported that she recently had an MRI for neck pain but the back pain was worse and she wanted to address that first. (Id.) Physical examination showed no new findings “that are changed from baseline.” (Id.) Office records indicate the MRI done on March 31, 2012, showed a small broad-based posterior central disc protrusion at ¶ 6-7 with superimposed degenerative disc disease and facet degeneration as well as moderate to marked degenerative disc disease at ¶ 4-5 and C5-6. (R. 303.)

         In June 2012, Plaintiff reported continuing pain, and repeat injections were planned. (R. 305.) Dr. Sempowski noted that if Plaintiff again experienced only temporary benefit, he would recommend evaluation by Dr. Eva Malinowksi to discuss possible dorsal column stimulator trial for treatment of her chronic radiculopathy secondary to postlaminectomy syndrome. (Id.)

         In July Plaintiff was seen at Summit Pain Medicine by Dr. Malinowski. (R. 307-08.) Plaintiff reported that her pain was constant and ranged fron 9-10/10 with daily living activites, and she had intermittent weakness and numbness. (R. 306.) Physical examination showed that she ambulated “sparing her left lower extremity, ” her range of motion of the left lumbosacral region was diminished, and she had no significant new changes from the previous examination. (R. 307.) The plan was to continue Plaintiff on her current treatment and add Percocet twice daily and a neurotransmitter, Neurontin, three times a day. (R. 307.)

         At her September 2012 visit to Summit Pain Medicine, Plaintiff was seen by Amanpreet Sandhu, M.D. (R. 308-10.) She reported worsening neck pain radiating down bilateral upper extremities as well as numbness and weakness of bilateral upper extremities with symptoms worse on the right hand. (R. 308.) Plaintiff also said her pain interfered with her sleep, activities of daily living, and social functioning. (Id.) Physical exam was basically normal except lumbar flexion and extension caused pain. (R. 309.) Dr. Sandhu recorded the following plan: possible cervical epidural steroid injection for neck pain and upper extremity numbness and weakness; referral to Wellspan neurosurgery for possible surgical treatment of moderate to severe cervical spinal stenosis; referral to orthopedic surgery for carpal tunnel release; adjust her medication regimen; and for lower back radiating pain repeat injections, medial branch blocks would be considered as well as consideration for radiofrequency ablation in the future. (R. 310.) Dr. Sandhu's October plan was similar. (R. 313.) He noted that Plaintiff's low back pain was mostly secondary to failed back surgery syndrome and lumbar spondylosis. (Id.) His diagnoses included spinal stenosis. (Id.)

         In November 2012, Dr. Sandhu noted that Plaintiff had left lumbosacral medial branch blocks from L3-L5 and had greater than 80% relief of her left-sided low back pain lasting about one day. (R. 314.) He added that the neurosurgery clinic had recommended surgery for cervical stenosis and bilateral upper extremity numbness and weakness. (Id.) Despite reports of continuing pain that interfered with her sleep, activities of daily living and social functioning, Dr. Sandhu recorded that Plaintiff “noted significant improvement in her quality of life as well as her ability to function socially and taking care of her young daughter.” (Id.) Her phsyical exam showed a normal gait, 2 deep tendon reflexes bilaterally in the upper and lower extremities, single leg raise test negative bilaterally, Faber negative bilaterally, no SI tenderness bilaterally, no midline or bilateral tenderness of the lumbosacral spine, lumbar flexion and extension caused pain, and facet loading was strongly positive bilaterally, left greater than right. (R. 315.) In his plan, Dr. Sandhu commented “[s]ince the patient has greater than 80% relief of her left-sided low back pain after her left lumbosacral medial branch blocks we will schedule the patient for left lumbosacral medial radiofrequency ablation for levels above the fusion.” (R. 316.)

         In February 2013, Dr. Sandhu noted that Plaintiff had had the radiofrequency ablation since her last visit and reported good relief but she also reported worsening pain and symptoms since then. (R. 317.) Dr. Sandhu again noted reports of continuing pain that interfered with sleep, activities of daily living and social functioning, and also recorded that Plaintiff “noted significant improvement in her quality of life as well as her ability to function socially and taking care of her young daughter.” (Id.) Physical examination showed the following: sensory soft touch decreased in the left lower extremity; antalgic gait; deep tendon reflexes 1 bilaterally upper and lower extremities; leg raise negative on the right and positive on the left; Faber strongly positive on the left and mildly positive on the right; left greater than right SI tenderness bilaterally; muscle tenderness of the lumbosacral spine; lumbar flexion and extension caused pain; and facet loading strongly positive on the right and mildly positive on the left. (R. 318.) In addition to a review of Plaintiff's medications, Dr. Sandhu provided the following summary of Plaintiff's status:

Currently the patient has significant pain originating in her left lower back and buttock and radiating down her left lower extremity all the way down to her left foot along with left leg weakness and numbness. This pain is likely secondary to combination of sacroiliitis as well as left lumbar radicuopathy secondary to degenerative disc disease and postlaminectomy syndrome. We will obtain an MRI of her lumbosacral spine with contrast in order to further elucidate the etiology of her left lower extremity pain as well as worsening numbness and weakness. The patient [may] also be candidate for left sacroiliac joint steroid injections as well as left transforaminal epidural injections at ¶ 3 through S1 versus interlaminar ESI. We will also refer the patient to neurosurgery at Wellspan for further evaluation of her symptoms. The patient was recommended surgery for her neck however her left lower extremity and back symptoms are worse at this time and she wants to hold off on cervical surgery for now.

(R. 319.)

         Plaintiff had an initial evaluation at The Reading Neck & Spine Center on June 17, 2013, conducted by Yong Park, M.D. (R. 402-03.) He recorded that Plaintiff was self-referred after previously treating at Summit Pain Management where she had several epidural injections using multiple approaches, a median branch block, and a radiofrequency ablation, and she denied relief from these procedures. (R. 402.) Plaintiff rated the intensity of her radiating back pain as 10/10 and intermittent; she rated her radiating neck pain as 5-9/10. (Id.) Examination showed the following: cervical range of motion 40 degrees rotation to the right and 30 to the left, full flexion, extension 10 degrees, pain provoked primarily with bilateral rotation and extension; lumbar spine flexion of 15 degrees and 0 degrees extension, single leg raise positive bilaterally, and Patrick's test negative bilaterally; sensory examination diminished on the right from C4 to S1; MMT shows trace weakness in the right upper extremity in all major muscle groups, left side intact; reflexes absent in both the upper and lower extremities and symmetric; and Hoffman's negative. (R. 403.) Dr. Park's impression was complex pain syndrome. (Id.) He noted that it was difficult to determine where the pain was coming from, the cervical MRI showed multilevel disc protrusions and a small central protrusion in the lumbar spine at ¶ 5-S1. (Id.) Dr. Park planned to repeat the upper extremity EMG and renew pain medication prescriptions. (Id.)

         The August 29, 2013, Electrodiagnostic Report showed mild chronic right median neuropathy at the wrist but no cervical radiculopathies. (R. 401.) Dr. Park renewed Plaintiff's pain medications, prescribed a wrist splint, and scheduled a cervical epidural injection at the C6-7 level.

         CRNP Robert Davis of the Neck & Spine Center saw Plaintiff on Novmeber 4, 2013. (R. 399-400.) Plaintiff reported 8/10 back pain and 9/10 left leg pain. (R. 399.) Examination showed the following: midline tenderness over L4; antalgic gait, wide and unsteady; seated SLR examination positive on left at 60 degrees and negative on right; motor examination 3/5 muscle strength over left hip flexors, left knee flexors and extensors and left ankle flexors and extensors; sensation decreased to light touch over the left lateral thigh, left anterior thigh and left lateral calf; and expressed hypersensitivity with palpation over left lateral calf. (Id.) The disagnosis was postlaminectomy syndrome with low back pain and lumbar radiculopathy. (Id.) The plan was to obtain MRI of the lumbar spine, after which Plaintiff would return to the office to discuss therapeutic options. (Id.)

         MRI of the cervical spine performed on July 18, 2014, showed:

1. There has been some development of reactive discogenic endplate signal changes and edema at ¶ 6-C7 compared with 3/30/2012. There is a small stable mild posterior central broad-based disc protrusion, superimposed moderate annular bulging and spondylosis changes again resulting in moderate to marked canal stenosis and progression of bilateral neuroforaminal narrowing at this level.
2. Stable moderate posterior disc protrusions and slightly progressed spondylosis changes at ¶ 4-C5 and C5-C6 resulting in progression of moderate canal stenosis at ¶ 4-C5 and moderate to marked canal stenosis C5-C6. There has been some progression of marked bilateral neuroforaminal narrowing at these levels as well.
3. Stable annular bulging with slightly increased spondylosis changes at ΒΆ 3-C4 resulting in slightly progressed mild canal and now bilateral neuroforaminal narrowing at this level. No other evidence for frank cervical disc herniation, other areas of ...

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