United States District Court, M.D. Pennsylvania
BENNY J. WATSON, Plaintiff
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant
William J. Nealon United States District Judge.
August 14, 2015, Plaintiff, Benny J. Watson, filed this
instant appeal under 42 U.S.C. § 405(g) for review
of the decision of the Commissioner of the Social Security
Administration (“SSA”) denying his application
for disability insurance benefits (“DIB”) under
Title II of the Social Security Act, 42 U.S.C. § 1461,
et seq. (Doc. 1). The parties have fully briefed the
appeal. For the reasons set forth below, the decision of the
Commissioner denying Plaintiff's application for DIB will
protectively filed his application for DIB on December 7,
2012, alleging disability beginning on December 3, 2012, due
to a combination of degenerative disc disease, spinal
stenosis, and diabetes. (Tr. 22, 204, 207). The claim was
initially denied by the Bureau of Disability Determination
(“BDD”) on February 1, 2013. (Tr. 22). On February
21, 2013, Plaintiff filed a written request for a hearing
before an administrative law judge. (Tr. 22). A hearing was
held on April 8, 2014, before administrative law judge Reana
K. Sweeney, (“ALJ”), at which Plaintiff and an
impartial vocational expert Nancy Harter, (“VE”),
testified. (Tr. 22). On April 25, 2014, the ALJ issued a an
unfavorable decision denying Plaintiff's application for
DIB. (Tr. 22). On June 2, 2014, Plaintiff filed a request for
review with the Appeals Council. (Tr. 17). On June 18, 2015,
the Appeals Council concluded that there was no basis upon
which to grant Plaintiff's request for review. (Tr. 3-5).
Thus, the ALJ's decision stood as the final decision of
filed the instant complaint on August 14, 2015. (Doc. 1). On
December 1, 2015, Defendant filed an answer and transcript
from the SSA proceedings. (Docs. 11 and 12). Plaintiff filed
a brief in support of his complaint on February 16, 2016.
(Doc. 16). Defendant filed a brief in opposition on April 20,
2016. (Doc. 18). Plaintiff filed a reply brief on May 4,
2016. (Doc. 20).
was born in the United States on September 18, 1971, and at
all times relevant to this matter was considered an
“younger individual.” (Tr. 204). Plaintiff did not
graduate from high school or obtain his GED, but can
communicate in English. (Tr. 206, 208). His employment
records indicate that he previously worked as a diesel
mechanic and truck driver. (Tr. 209).
document entitled “Function Report - Adult” filed
with the SSA on December 21, 2012, Plaintiff indicated that
he lived in a house with family. (Tr. 215). When asked how
his injuries, illnesses, or conditions limited his ability to
work, Plaintiff stated, “I have a constant pain due to
my medical issues that makes it that the more I move the
worse it hurts. I can't sit, stand, stoop, walk, lift,
etc for any length of time. If I try to my legs go to sleep
and the pain  gets unbearable. I drive trucks for my job
and I am not allowed to by law do (sic) to being on
insulin.” (Tr. 215). From the time he woke up until he
went to bed, Plaintiff took “the kids to the bus
stop.” (Tr. 216). Plaintiff helped his children with
their homework, made them food, and helped them get ready for
school. (Tr. 216). Plaintiff reported no difficulty with
personal care, was able to prepare meals daily for one (1)
hour when his “back pain allow[ed], ” do yard
work until “the pain makes [him] stop, ” and was
able to drive a car and go out alone. (Tr. 216-218). He went
outside often, and shopped for groceries biweekly for three
(3) hours at a time with his wife. (Tr. 218). His hobbies
included watching television and fishing depending on his
pain level. (Tr. 218-219). He spent time with his family
doing things like watching movies and playing games when he
had the time. (Tr. 219). He could walk for a block before
needing to rest for about ten (10) to fifteen (15) minutes.
(Tr. 220). When asked to check what activities his illnesses,
injuries, or conditions affected, Plaintiff did not
check talking, hearing, seeing, memory, completing tasks,
concentration, understanding, following instructions, or
getting along with others. (Tr. 220).
his concentration and memory, Plaintiff did not need special
reminders to take care of his personal needs, take his
medicine, or go places. (Tr. 216). He could count change, pay
bills, handle a savings account, and use a checkbook. (Tr.
218). He could pay attention for about five (5) minutes, was
able to finish what he started, and handled stress and
changes in routine “normally” and
“good.” (Tr. 220-221).
also completed a Supplemental Function Questionnaire for
pain. (Tr. 223). He stated that his pain began in about 2004
due to disc degenerative disease, spinal stenosis, and five
(5) bulging discs. (Tr. 223). He described his pain as
constant pressure and pain that worsened over time, was
located in his lower back and neck and spread down the back
of both of his legs, was bad most days, and was not relieved
by pain medication that caused side effects. (Tr. 223-224).
oral hearing on April 8, 2014, Plaintiff initially testified
that he had spinal decompression surgery on May 3, 2013. (Tr.
54). Plaintiff stated that, since the surgery, he still
experienced numbness in his right leg and “a lot of
pain in his lower back, ” but that the pain in his legs
subsided considerably. (Tr. 58). He testified that he had not
been exercising due to pain. (Tr. 54). Regarding medications
for his pain, Plaintiff testified that he had taken morphine,
tizanidine, and gabapentin. (Tr. 55-56). He stated he had not
attended physical therapy as it was not recommended by his
doctor. (Tr. 56).
a typical day, Plaintiff testified that he did the following:
woke up at seven thirty in the morning, ate breakfast, took
his medicine, and checked his blood sugar; prepared his
children's breakfast and lunch boxes and walked them a
quarter of a block to the bus stop at eight thirty in the
morning; sat down on the couch because he would feel sleepy
and usually sleep until eleven in the morning or noon; eat
lunch and sit with his wife either talking or watching
television; pick the boys up from the bus around four in the
afternoon; take his medicine, check his blood sugar, and have
dinner around five at night; and fall asleep after dinner
until seven or eight at night. (Tr. 62-66). He testified that
he lived in a two-story house, but that he did not go
upstairs. (Tr. 72). He stated he did not do any chores around
the house, but rather his wife did. (Tr. 72-73).
asked by the ALJ why he was unable to work, Plaintiff
responded that it was due to back pain that occurred if he
was doing anything out of the ordinary other than relaxing.
(Tr. 68). He testified that Dr. Moore told him that he should
not lift, push, or pull anything over ten (10) pounds, and
that he should do only what felt comfortable. (Tr. 70).
December 11, 2012, Plaintiff had an appointment with Renu
Joshi, M.D. at Pinnacle Health for diabetes management. (Tr.
292). Plaintiff's self-reported symptoms included
increasing fatigue, nocturia, and weight loss. (Tr. 292).
Plaintiff was compliant with his medication and follow-up
appointments. (Tr. 292). His physical examination was normal.
(Tr. 293-294). He was assessed as having uncontrolled
diabetes, and was placed on medications, including Metformin,
Simvastatin, Humalog, Tramadol, and Lisniopril. (Tr. 294).
January 9, 2013, Plaintiff had an appointment with Paul
Baughman, D.O. to become established as a new patient. (Tr.
299). It was noted that Plaintiff had lost over twenty (20)
pounds in the prior four (4) to six (6) weeks and had
improving energy levels. (Tr. 299). Plaintiff also discussed
his chronic back pain, including a history of degenerative
disc disease and spinal stenosis, and reported that his back
pain was constant, located over the entire lower back and
legs, was a 10/10, worsened as the day went on, caused
significant difficulty with movement, and was not relieved by
medication. (Tr. 299). His physical examination revealed he
was obese, had a normal gait, had mild midline tenderness of
his lumbar spine without pain on palpation and with limited
range of motion, and had grossly intact sensation to light
touch. (Tr. 300). Plaintiff was assessed as having Lumbago,
Intervertebral Disc Degeneration of his lumbar spine,
Radiculitis Thoracic or Lumbosacral Unspecified, Diabetes
Mellitus, and Hyperlipidemia. (Tr. 300).
January 23, 2013, Plaintiff underwent a consultative
examination performed by Thomas McLaughlin, M.D. (Tr. 304).
Plaintiff reported that he had constant pain in his lower
back varying in intensity of a 5/10 to a 10/10 that radiated
into his lower legs after activities and standing and walking
more than one (1) block. (Tr. 304). He also stated that his
pain worsened with bending, walking, standing, or sitting for
greater than ten (10) to fifteen (15) minutes, and decreased
with rest and a hot tub. (Tr. 305). His MRI showed disc
disease with spinal stenosis and bulging at ¶ 4/L5 and
L5/S1 and disc disease at ¶ 3/L4 and L4/L5. (Tr. 305).
Plaintiff's examination revealed he had: normal
ambulation and gait; the ability to stand unassisted, rise
from a seated position, and step up and down from the
examination table without difficulty; the ability to
understand “normal spoken speech and follow
instructions;” a positive straight leg raise test on
the right to sixty (60) degrees; no tenderness over the
cervical spine and no evidence of paravertebral muscle spasm;
nontender shoulders, elbows, wrists, hands, knees, and hips;
normal curvature of the dorsolumbar spine; the ability to
walk on his heels, toes, and heel-to-toe and to squat without
difficulty; an intact sensory exam to light touch, pinprick,
and vibration as well as proprioception; 5/5 motor strength
in the upper and lower extremities bilaterally; normal
cerebellar function; diminished deep tendon reflexes in the
patellar and Achinlles; and � deep tendon reflexes in his
biceps, triceps, and brachioradialis. (Tr. 308-309). Dr.
McLaughlin assessed Plaintiff as having lumbosacral disc
disease with spinal stenosis at the L4-S1 levels, diabetes
mellitus type II, hypertension, hyperlipidema, and obesity.
(Tr. 309). Dr. McLaughlin opined in a Medical Source
Statement form of Plaintiff's Ability to Perform
Work-Related Activities that he: (1) could frequently lift
and/ or carry up to three (3) pounds and occasionally lift
and/ or carry up to ten (10) pounds; (2) could stand and walk
for up to two (2) hour in an eight (8) hour workday; (3)
could sit for up to eight (8) hours in an eight (8) hour
workday; (4) could engage in limited pushing and pulling in
the lower extremities; (5) could occasionally bend, kneel,
stoop, crouch, and balance, but never climb; (6) was limited
in “feeling;” and (7) should avoid heights and
moving machinery. (Tr. 311-312).
January 23, 2013, Plaintiff underwent an x-ray of his lumbar
spine. (Tr. 315). This revealed the following: (1)
disproportionate moderately advanced degenerative disc
disease at the lumbosacral junction; (2) mild levoscoliosis;
and (3) mild degenerative sclerosis of both SI joints. (Tr.
January 28, 2013, Plaintiff had an appointment with Lucinda
Sobkowiski, CRNP, for management of his diabetes. (Tr. 327).
He reported that he had been experiencing blurred vision and
increased fatigue. (Tr. 327). It was noted that he was
excellently compliant with his medication. (Tr. 327). His
physical examination revealed a normal range of motion,
muscle strength, and stability in all extremities with no
pain on inspection and a normal remainder of the exam. (Tr.
February 1, 2013, Laura Rumley, SDM, opined that, based on a
review of the record up to that point, Plaintiff could: (1)
occasionally lift and/ or carry twenty (20) pounds; (2)
frequently lift and/ or carry ten (10) pounds; (3) sit,
stand, and/ or walk for six (6) hours in an eight (8) hour
workday; and (4) engage in unlimited pushing and pulling
within the aforementioned weight restrictions. (Tr. 102-103).
She opined that Plaintiff had no further restrictions. (Tr.
February 5, 2013, Plaintiff had an appointment with Dr.
Baughman for lower back pain. (Tr. 351). At this visit,
Plaintiff's blood pressure was elevated, but he declined
an increase in his blood pressure medication. (Tr. 351). Dr.
Baughman prescribed Norco for Plaintiff's back pain. (Tr.
February 19, 2013, Plaintiff had an appointment with Dr.
Baughman for follow-up of his back pain, diabetes, and
bilateral leg pain. (Tr. 349). Plaintiff reported that his
pain was a 4/10 after taking Norco, that the Norco worked
well for pain and helped him function, and that he took this
medication every eight (8) hours. (Tr. 349). His blood
pressured remained uncontrolled so Dr. Baughman increased the
dosage of Lisinopril. (Tr. 349). His physical examination
revealed he had mild midline tenderness of his lumbar spine;
moderately limited range of motion with pain; bilateral
positive straight leg raise tests; and grossly intact
sensation to light touch. (Tr. 350).
February 27, 2013, Plaintiff underwent an MRI of his lumbar
spine. (Tr. 320). It revealed that Plaintiff had
“degenerative changes of the lumbar spin resulting in
canal and neural foraminal narrowings ranging from moderate
to severe. (Tr. 320-321).
March 14, 2013, Plaintiff had an appointment with Dr.
Baughman for lower back pain. (Tr. 346). He rated his back
pain at ¶ 10/10 without medication and a 5/10 with Norco
and noted that it had been worsening. (Tr. 346). His physical
examination was normal. (Tr. 347).
March 25, 2013, Plaintiff had an appointment with Lucinda
Sobkowski, CRNP, for diabetes management. (Tr. 323). It was
noted that Plaintiff was excellently compliant with
medication and fairly compliant with his diet. (Tr. 323).
Plaintiff reported that he was experiencing back pain and had
planned to follow-up with an orthopaedic physician. (Tr.
324). His physical examination revealed normal range of
motion, muscle strength, and stability in all extremities
with no pain on inspection; loss of protective sensation in
his heels; and an abnormal monolifament exam. (Tr. 325).
Plaintiff was instructed to continue his medications, and was
scheduled for a follow-up visit in three (3) months. (Tr.
March 28, 2013, Plaintiff underwent a sleep study. (Tr. 362).
The impression was that Plaintiff had severe Obstructive
Sleep Apnea. (Tr. 364).
April 15, 2013, Plaintiff had an appointment with Dr.
Baughman for diabetes management and back pain. (Tr. 342).
Plaintiff noted his back pain was “pretty good”
with Norco as long as he did not do anything active. (Tr.
342). He rated his back pain at ¶ 5/10, and noted it was
worse with activity and that he could ...