United States District Court, M.D. Pennsylvania
William J. Nealon United States District Judge
August 10, 2015, Plaintiff, Ronald Farner, filed this instant
appealunder 42 U.S.C. § 405(g) for review of
the decision of the Commissioner of the Social Security
Administration ("SSA") 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. § 1461, ei
sea and U.S.C. § 1381 et. seq. respectively.
(Doc. 1). The parties have fully briefed the appeal. For the
reasons set forth below, the decision of the Commissioner
denying Plaintiffs applications for DIB and SSI will be
protectively filed his applications for DIB and SSI on
September 29, 2011, alleging disability beginning on December
30, 2010, due to a combination of heart problems, prior
kidney cancer, diabetes, high blood pressure, neuropathy, and
high cholesterol. (Tr. 257, 261). The claim was initially
denied by the Bureau of Disability Determination
("BDD") on August 9, 2011. (Tr. 111). On September
27, 2011, Plaintiff filed a written request for a hearing
before an administrative law judge. (Tr. 121). An initial
hearing was held on September 20, 2012, before administrative
law judge Randy Riley, ("ALJ"), at which Plaintiff,
his wife, and an impartial vocational expert Michael Gimlin
testified. (Tr. 49-84). Initially, the ALJ issued a an
unfavorable decision denying Plaintiffs applications for DIB
and SSI, and the Appeals Council remanded the matter back to
the ALJ for a second hearing. (Tr. 31-47). On April 15, 2014,
a remand hearing was held before the ALJ, and Plaintiff,
vocational expert Brian Bieriy, ("VE"), and medical
expert David Owens, ("ME"), testified. (Tr. 30-48).
On April 24, 2014, the ALJ issued an unfavorable decision
denying Plaintiffs applications for SSI and DIB. (Tr. 12-30).
On June 5, 2014, Plaintiff filed a request for review with
the Appeals Council. (Tr. 9). On June 10, 2015, the Appeals
Council concluded that there was no basis upon which to grant
Plaintiffs request for review. (Tr. 1-3). Thus, the ALJ's
decision stood as the final decision of the Commissioner.
filed the instant complaint on August 10, 2015. (Doc. 1). On
December 1, 2015, Defendant filed an answer and transcript
from the SSA proceedings. (Docs. 12 and 13). Plaintiff filed
a brief in support of his complaint on January 11, 2016.
(Doc. 16). Defendant filed a brief in opposition on February
11, 2016. (Doc. 17). Plaintiff did not file a reply brief.
was born in the United States on December 12, 1959, and at
all times relevant to this matter was considered an
"individual closely approaching advanced
age." (Tr. 257). Plaintiff did not graduate from
high school or obtain his GED, but can communicate in
English. (Tr. 260, 262). His employment records indicate that
he previously worked as a maintenance mechanic for a tire
manufacturer and a mechanic for several auto shops. (Tr.
document entitled "Function Report - Adult" filed
with the SSA on July 25, 2011, Plaintiff indicated that he
lived in a house with family. (Tr. 280). When asked how his
injuries, illness or conditions limited his ability to work,
Plaintiff stated, "fatigue, feet hurt bad, can't
stand for long periods. My chest and body hurts (sic) a lot
when I do things too long. I feel grumpy a lot and have
trouble concentrating. Also my legs swell - hurt a lot."
(Tr. 280). From the time he woke up until he went to bed,
Plaintiff did the laundry and dishes and made dinner, and
mostly in the seated position down and only for "short
periods" of time. (Tr. 281). Plaintiff reported no
difficulty with personal care, was able to prepare meals
three (3) to four (4) times a week for about one (1) hour at
a time, did the laundry and dishes, was able to mow the lawn
on a riding lawn mower, and was able to engage in "small
repair tasks." (Tr. 282). He was able to drive a car
alone. (Tr. 283). He went shopping one (1) to two (2) times a
week for "as little as possible [because he could not]
stand [for] too long." (Tr. 283). His hobbies included
watching television, fishing, hunting, camping, wood working,
and repairing. (Tr. 283). He went on family outings on a
regular basis. (Tr. 284). He could walk for five hundred
(500) feet before needing to rest for about five (5) to ten
(10) minutes. (Tr. 285). When asked to check what activities
his illnesses, injuries, or conditions affected, Plaintiff
did not check reaching, sitting, talking, understanding,
following instructions, using hands, or getting along with
others. (Tr. 285).
his concentration and memory, Plaintiff did not need special
reminders to take care of his personal needs, but did need
reminders to take medicine and go places. (Tr. 282, 284). He
could count change, pay bills, handle a savings account, and
use a checkbook. (Tr. 283). He could pay attention for about
five (5) minutes, was not always able to finish what he
started, did not follow written and spoken instructions well,
and did not handle stress or changes in routine well. (Tr.
initial hearing on September 20, 2012, Plaintiff testified
that he was able to take care of his personal needs, shop
every other week for "a little bit, " cook with
breaks, do the dishes, vacuum and sweep once in a while,
maintain his yard with help from his children, drive a
vehicle once in a while, and could walk about five hundred
(500) yards and stand in one (1) position for no more than
fifteen (15) minutes before needing to sit due to pain in his
legs and feet. (Tr. 53-56, 62-63). He testified he did not do
laundry, was unable to bend over to put on his socks or pick
something up, had trouble climbing steps, and did not take
out the trash because his "trash can is pretty far away
and [he did not] like walking over to it." (Tr. 55-56,
64). He stated he took pain medications that he
"guessed" were helping, but that he experienced
side effects such as shakiness, sleepiness, and dizziness.
(Tr. 56-57). He also would sit down and elevate his feet, but
testified that doing so did not take his pain away
completely. (Tr. 65).
regards to his diabetes, Plaintiff testified that he had
taken his blood sugar readings since he was diagnosed, that
his highest blood sugar reading was around five hundred
(500), and that his lowest blood sugar reading was around
ninety-two (92). (Tr. 57). He stated that he was able to tell
when his blood sugar was high before even taking a reading
because he would feel light-headed and his legs and feet
would burn. (Tr. 58). He noted that eating helped to bring
his sugar back down, but that he would still have symptoms.
(Tr. 58). He testified that he was unable to tell when his
sugar was low other than feeling tired and confused. (Tr.
59-60). He stated that he had high blood sugar readings
"pretty much every day." (Tr. 60).
remand hearing on April 15, 2014, Plaintiff testified that,
since the initial hearing in 2012, due to increased leg
numbness resulting from peripheral neuropathy, he underwent
surgery to repair the nerves in his legs, which helped for
about three (3) months before his symptoms returned in an
increased state. (Tr. 33). He stated that the leg pain was
"like hitting your thumb with a hammer." (Tr. 34).
Plaintiff stated that his leg pain and numbness were
constant, that he had "extra pain" about twice a
week for four (4) hours at a time, and that he took Vicodin
and Methadone for pain relief. (Tr. 35). However, he reported
that these medications took only "some of the pain
away." (Tr. 35). When his "extra pain"
occurred, he had to sit down immediately, and stated that he
would not be able to read a newspaper with this type of pain
because it was excruciating. (Tr. 36-37). He stated he was
able to wash "two whole dishes, " sweep the floors
once a week, and "do a little walking around the
house." (Tr. 36).
12, 2011, Plaintiff presented to Mark Pinker, DPM with
complaints of burning feet, including sharp, shooting pains
that had been occurring "over the past 4-6 months and
[were] getting significantly worse." (Tr. 372). The pain
was always present, including during weightbearing and
non-weightbearing activities, and caused sleep difficulties.
(Tr. 372). It was noted that his sugar was high in the
"300 hundred range." (Tr. 372). An orthopedic
examination revealed no gross deformities in either foot,
normal range of motion of the bilateral ankles, ST joint, MT
joint and without pain bilaterally except for "ST joint
eversion which does elicit discomfort across the balls of
both feet near the 5th metatarsal area, " and
discomfort upon palpation of both balls of the feet. (Tr.
373). It was noted that Plaintiffs stance and gait were
unremarkable although he had some trepidation about
"dorsiflexing across the balls of both feet when he
walks forward." (Tr. 373). His deep tendon reflexes were
intact and symmetrical, and his epicritic sensations were
within normal limits to light touch and vibratory sensations.
(Tr. 373). Plaintiff was assessed as having uncontrolled
Diabetes Mellitus, diabetic peripheral neuropathy, and pain
and metatarsalgia in his feet bilaterally. (Tr. 373). It was
suggested to Plaintiff that he be evaluated by an
Endocrinologist to get his blood sugars under control, to
cease smoking and chewing tobacco, and to take Neurontin for
the neuropathy in his feet. (Tr. 373). On June 2, 2011,
Plaintiff did not show for his follow-up appointment. (Tr.
13, 2011, Plaintiff had an appointment with Louie Myers, D.O.
due to complaints of chest pain, foot pain, and poorly
controlled diabetes. (Tr. 382). It was noted that Plaintiff
smoked cigarettes. (Tr. 383). Dr. Myers ordered a nuclear
stress test due to symptoms "concerning for stable
angina." (Tr. 383).
22, 2011, Plaintiff underwent a chest x-ray. (Tr. 394). This
test showed no pleural effusion. (Tr. 394). Plaintiff also
had an appointment with Rena C. DeArment, M.D. for Diabetes
Mellitus. (Tr. 421). It was noted that Plaintiff's blood
sugar levels were uncontrolled and that he had peripheral
neuropathy with considerable lower extremity numbness,
tingling, and pain. (Tr. 421). His physical examination
revealed that he had no edema or calf tenderness in his
bilateral lower extremities. (Tr. 422). Plaintiff was
assessed as having Diabetes Mellitus- Type 2, and was placed
on insulin. (Tr. 422).
20, 2011, Plaintiff had a follow-up appointment with Dr.
DeArment for his diabetes. (Tr. 419). His blood sugar level
on the insulin remained "in the 200's" with no
lows. (Tr. 419). Plaintiff denied experiencing the following:
fatigue, tingling, numbness, and cold and heat intolerance.
(Tr. 419). His physical examination was normal. (Tr. 420).
Plaintiff was instructed to increase his insulin and to begin
mealtime insulin. (Tr. 420).
August 15, 2011, Plaintiff had a follow-up appointment with
Dr. DeArment for diabetes. (Tr. 417). It was reported that
Plaintiffs blood sugar levels remained in the two hundred
(200) range with no hypoglycemic episodes and that he
continued to have neuropathy in his feet. (Tr. 417).
Plaintiff denied experiencing fatigue and cold or heat
intolerance. (Tr. 417). Plaintiff was instructed to continue
insulin. (Tr. 418).
August 31, 2011, Plaintiff underwent a nuclear stress test
for the following indications: "exertional CP, CAD, s/p
RCA stenting (07), tobacco abuse, diabetes mellitus and
hypertension." (Tr. 384). The conclusion of the test was
as follows: "Borderline positive pharmacologic stress
test for ischemia by EKG criteria. No cardiovascular
symptoms. Mildly abnormal myocardial perfusion study. There
is a moderate sized area of mild to moderate scarring/
infarction involving the basal/ mid inferior wall." (Tr.
September 19, 2011, Plaintiff presented to the Carlisle
Regional Medical Center due to generalized abdominal pain.
(Tr. 399). An examination revealed Plaintiff was positive for
back pain and obesity, had a normal joint range of motion
with no swelling, deformities, cyanosis, clubbing, or edema,
and had no sensory or motor deficits. (Tr. 399-400).
Plaintiff underwent a CT scan of his abdomen and pelvis due
to complaints of right flank pain. (Tr. 395). The impression
was that there was no obstructive uropathy on the right, that
there was evidence of prior left nephrectomy, and that there
was epiploic appendigitis adjacent to the splenic fixture.
November 18, 2011, Plaintiff presented to the Carlisle
Regional Medical Center due to complaints of leg swelling and
pain that began earlier in the day. (Tr. 407). It was noted
that Plaintiff was unable to flex his knees, denied numbness
and tingling, rated his pain at a "2/2, " and had
warmth over the affected knee. (Tr. 407). Plaintiff was
diagnosed with "gout, knee effusion, " and was
prescribed pain medications. (Tr. 412).
November 29, 2011, Plaintiff had a follow-up appointment with
Dr. DeArment for diabetes management. (Tr. 415). Plaintiff
reported that his feet still hurt, but that he did not follow
up for this problem, and that his blood sugars were routinely
below two hundred (200) with no lows. (Tr. 415). He denied
heat and cold intolerance and fatigue. (Tr. 415). Plaintiff
was prescribed Cymbalta for his neuropathy and was instructed
to continue taking his insulin. (Tr. 415).
February 21, 2012, Dr. Phelan opined that Plaintiff was
permanently disabled based on physical examination and
clinical records due to coronary artery disease, diabetes,
peripheral neuropathy, gastrointestinal reflux disease,
hyperlipidemia, and hypertension. (Tr. 555).
3, 2012, Plaintiff had an appointment with Dr. DeArment for a
follow-up for diabetes. (Tr. 494). He reported he continued
to have foot pain, had been sweating from his knees down at
night, that his blood sugar levels were in the two hundred
(200) range, and that he did not have low blood sugar. (Tr.
494). His physical examination was normal. (Tr. 495). Dr.
DeArment increased Plaintiffs insulin dose, and referred him
to Dr. Kosenski for his "quite severe" neuropathy.
16, 2012, Plaintiff had an appointment with Marlene Ascione,
D.O. as a new patient. (Tr. 538). Plaintiff denied
experiencing muscular aches and weakness, and numbness and
tingling. (Tr. 539). His examination was normal. (Tr. 538).
He was assessed as having the following: controlled Diabetes
Mellitus; hypertension; gastroesophageal reflux disease;
hypercholesterolemia; coronary artery disease; chronic pain;
and cellulitis. (Tr. 538).
September 14, 2012, Dr. Phelan completed a "Medical
Source Statement of Ability to Do Work-Related Activities
(Physical)." (Tr. 502). He opined Plaintiff: (1) could
occasionally lift up to twenty (20) pounds maximum; (2) could
occasionally carry up to ten (10) pounds maximum; (3) could
sit for eight (8) hours, stand for four (4) hours, and walk
for three (3) hours at one time without interruption and in
an eight (8) hour workday; (3) could continuously for over
two thirds (2/3) of the day reach, handle, finger, and feel
with bilaterally with his hands; (4) could frequently for one
third (1/3) to two thirds (2/3) of the day reach overhead and
push and pull bilaterally with his hands; (5) could
occasionally up to one third (1/3) of the day operate foot
controls bilaterally; and (6) could never climb stairs,
ladders, ramps, or scaffolds, balance, stoop, kneel, crouch,
or crawl. (Tr. 502-507).
October 13, 2012, Plaintiff had an appointment with Mark
Stutzman, D.O. after falling and landing on his back days
earlier that resulted in low back pain. (Tr. 540). Plaintiff
reported that he had been seeing a pain management specialist
for his foot neuropathy, and that the Lyrica and Tramadol he
was taking to control this problem were helping. (Tr. 540).
February 22, 2013, Plaintiff had an appointment at Carlisle
Regional Medical Center. (Tr. 565). Plaintiff reported that
he continued to have leg pain, numbness, and tingling, and