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Watson v. Colvin

United States District Court, M.D. Pennsylvania

February 28, 2017

BENNY J. WATSON, Plaintiff
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant

          MEMORANDUM

          William J. Nealon United States District Judge.

         On August 14, 2015, Plaintiff, Benny J. Watson, filed this instant appeal[1] 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 be vacated.

         BACKGROUND

         Plaintiff protectively filed[2] 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).[3] The claim was initially denied by the Bureau of Disability Determination (“BDD”)[4] 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 the Commissioner.

         Plaintiff 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).

         Plaintiff was born in the United States on September 18, 1971, and at all times relevant to this matter was considered an “younger individual.”[5] (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).

         In a 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).

         Regarding 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).

         Plaintiff 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).

         At the 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).

         Regarding 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).

         When 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).

         MEDICAL RECORDS

         On 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).

         On 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).

         On 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).

         On 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. 315).

         On 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. 329).

         On 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. 103).

         On 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. 352).

         On 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).

         On 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).

         On 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).

         On 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. 325).

         On March 28, 2013, Plaintiff underwent a sleep study. (Tr. 362). The impression was that Plaintiff had severe Obstructive Sleep Apnea. (Tr. 364).

         On 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 ...


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