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Franklin v. Berryhill

United States District Court, M.D. Pennsylvania

May 15, 2017

NANCY A. BERRYHILL, [1] Acting Commissioner of Social Security, Defendant.


          RICHARD P. CONABOY United States District Judge

         Pending before the Court is Plaintiff's appeal from the Commissioner's denial of Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act and Supplemental Security Income (“SSI”) under Title XVI. (Doc. 1.) Plaintiff filed applications for benefits on June 17, 2015, alleging a disability onset date of September 1, 2014. (R. 11.) After Plaintiff appealed the initial denial of the claims, a hearing was held on May 23, 2016, and Administrative Law Judge (“ALJ”) Patrick S. Cutter issued his Decision on May 7, 2015, concluding that Plaintiff had not been under a disability during the relevant time period.[2] (R. 23.) Plaintiff requested review of the ALJ's decision which the Appeals Council denied on July 12, 2016. (R. 1-6, 7.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)

         Plaintiff filed this action on November 15, 2016. (Doc. 1.) He asserts in his supporting brief that the Acting Commissioner's determination should be reversed or remanded for the following reasons: 1) the ALJ committed legal error when he failed to provide an explanation as to why he applied the light grid rule; and 2) the ALJ's finding is an RFC for sedentary work and Plaintiff must be found disabled under the Medical-Vocation rules if he is limited to sedentary work. (Doc. 12 at 3.) After careful review of the record and the parties' filings, the Court concludes this appeal is properly granted.

         I. Background

         Plaintiff was born on March 9, 1962, and was fifty-two years old, which is defined as an individual closely approaching advanced age, on the alleged disability onset date. (R. 17.) He has a high school education and past relevant work as a supervisor, materials handler supervisor, and warehouse supervisor. (Id.)

         A. Medical Evidence

         Plaintiff presents sparse medical evidence, simply listing medical conditions and briefly reviewing the findings of a consultative examiner, Spencer Long, M.D. (See Doc. 12 at 2-3.) Conditions identified are Diabetes Mellitus, diabetic peripheral neuropathy, diabetic retinopathy with right-eye blindness, and amputation of his great right toe due to diabetes complications. (Id. at 2.) Defendant summarizes medical evidence of record, particularly that relied upon by ALJ Cutter. (See Doc. 13 at 2-7.) In his reply brief, Plaintiff did not object to Defendant's factual recitation. (See Doc. 14.) Therefore, the Court will set out the medical evidence summarized by Defendant.[3]

Throughout this decision (e.g. Tr. 14, 16), the ALJ referenced findings of Meghan L. Edwards, PA-C, Plaintiff's primary care provider, who conducted several examinations during the relevant period:
• On October 28, 2014, PA Edwards noted that Plaintiff's past medical history included (among other things) hypertension, gastroesophageal reflux disease (GERD), and diabetic retinopathy (Tr. 239). On examination, PA Edwards found pale and swollen nasal turbinates and thick post-nasal drip related to a probable upper respiratory infection (Tr. 239). PA Edward's objective physical examination findings were otherwise completely unremarkable (Tr. 239);
• On March 13, 2015, Plaintiff complained of sinus pressure and congestion, and PA Edwards found red and swollen nasal turbinates, with a remarkable appearing throat (Tr. 237). But, PA Edward's objective physical examination findings were otherwise completely unremarkable (Tr. 237);
• On June 10, 2015, Plaintiff complained of an ongoing cough for several weeks, though PA Edwards objective physical examination findings (including as to Plaintiff's pulmonary function) were completely unremarkable (Tr. 235);
• On July 24, 2015, PA Edward's objective physical examination findings were completely unremarkable (Tr. 295); and
• On September 11, 2015, PA Edwards noted that Plaintiff was doing well, and his blood pressure and blood sugars were well controlled (Tr. 283). Once again, her objective physical examination findings were completely unremarkable (Tr. 284).
Consultative examiner Spencer Long, M.D., also examined Plaintiff in September 2015 and noted his slow and antalgic gait; and Plaintiff reported pain bilaterally on a straight-leg raise test at 45 degrees; but Plaintiff was in no acute distress; his stance was normal; he could get on and off the examination table and rise from a chair without difficulty; he exhibited no evident joint deformity; he had no scoliosis, kyphosis or abnormality in his thoracic spine; he had no trigger points, sensory deficit, or muscle atrophy; his hand and finger dexterity was intact; his strength was 5/5 in his arms and legs; and his grip strength also was 5/5 (Tr. 255-56).
In view of this evidence, throughout his decision, the ALJ analyzed Plaintiff's impairments. With respect to peripheral neuropathy, the ALJ noted in particular that Dr. Long had identified Plaintiff's normal stance, as well as his capacity to get on and off the examination table or rise from a chair (Tr. 14, referencing Tr. 255). Similarly, with respect to GERD and hypertension, the ALJ aptly noted an absence of ongoing evidence functional limitations (Tr. 14). Dr. Long had noted that Plaintiff was negative for heart disease, and PA Edwards discussed in September 2015 that Plaintiff was doing well in controlling his blood pressure (Tr. 14, referencing Tr. 254, 283).
With respect to diabetes, the ALJ noted Dr. Long's finding an absence of sensory of motor deficits, and indeed, full strength (Tr. 15, referencing Tr. 256). He also pointed out PA Edward's finding that Plaintiff's blood sugars were well controlled (Tr. 15, referencing Tr. 283).
With respect to the condition of Plaintiff's right eye, the ALJ noted that Plaintiff described total right-eye blindness, and that he did not drive as the result of it (Tr. 16, referencing Tr. 31). The ALJ also explained that Dr. Long had assessed total right-eye blindness (Tr. 16, referencing Tr. 254). As Dr. Long detailed, Plaintiff had undergone laser surgery, but it had not repaired the vision in his right eye (Tr. 16, referencing Tr. 254).
However, with respect to the condition of Plaintiff's left eye, the ALJ pointed to PA Edward's statement in June 2015 and his diabetic retinopathy was controlled (Tr. 16, referencing Tr. 235). Although at the time Plaintiff's diabetes was itself not controlled (Tr. 235), withing several months his blood sugars also were under good control (Tr. 283). Dr. Long had noted, as the ALJ explained, that Plaintiff had undergone successful left-eye laser surgery (Tr. 16, referencing Tr. 254). The ALJ also found that Plaintiff retained a capacity to shop, do laundry, and attend to his personal care (Tr. 16, referencing Tr. 195-97).
With respect to Plaintiff's right-shoulder and right-arm complaints, the ALJ noted that Dr. Long had assessed no sensory or motor deficits (Tr. 16, referencing Tr. 255-56). He also exhibited 5/5 arm strength (Tr. 16, referencing Tr. 256). But, the ALJ acknowledged and credited Plaintiff's testimony that he had obtained a recent injection for right shoulder pain (Tr. 16, referencing Tr. 32).

(Doc. 13 at 2-7.)

         B. Opinion Evidence

         Dr. Long opined that Plaintiff could lift up to 10 pounds occasionally, but never any higher weight, and he could never carry any weight. (R. 258.) He noted that these limitations were due to left shoulder pain and “DJD.”[4] (R. 258.) Dr. Long found that Plaintiff could stand and walk for five minutes without interruption and could perform either function for a total of fifteen minutes in an eight-hour day. (R. 259.) He found that Plaintiff could sit for thirty minutes without interruption and could sit of a total of eight hours in an eight-hour day. (Id.) Dr. Long noted that Plaintiff required the use of a cane to ambulate, he could ambulate for fifty feet without a cane, the use of a cane was medically necessary, and he could use his free hand to carry small objects. (Id.) He indicated that his assessments were supported by medical or clinical findings of bilateral foot pain and bilateral peripheral neuropathy. (Id.) Regarding use of his hands, Dr. Long opined that left shoulder pain and DJD limited Plaintiff to occasionally reaching overhead and pushing/pulling, and frequently reaching otherwise, handling, fingering, and feeling with his right hand; findings for the left hand differed in that he could never reach overhead and occasionally reach otherwise. (R. 260.) Dr. Long concluded that, due to foot pain and poor balance, Plaintiff could never climb ladders or scaffolds, balance, stoop, kneel, crouch, or crawl, and could occasionally climb stairs and ramps. (R. 261.) He also concluded that Plaintiff could never be exposed to unprotected heights, moving mechanical parts, operating a motor vehicle, extreme cold, extreme heat, and vibrations; he could occasionally be exposed to dust, odors, fumes and pulmonary irritants; and he could frequently be exposed to humidity and wetness. (R. 262.) These assessed limitations were due to peripheral neuropathy, diabetic retinopathy, and poor balance. (R. 262.) Dr. Long also concluded that Plaintiff's physical impairments would affect his ability to climb a few steps at a reasonable pace with the use of a single hand rail, prepare a simple meal and feed himself, care for his personal hygiene, and sort, handle and use paper files. (R. 263.) He indicated that the medical findings supporting the assessments were bilateral foot pain, diabetes, peripheral neuropathy, diabetic retinopathy, and poor balance. (Id.)

         C. Hearing Testimony

         At the May 23, 2016, hearing before ALJ Cutter, Plaintiff testified that his biggest problems were his balance and dizziness. (R. 30.) He explained that the balance issue was persistent throughout the day and the dizziness was sporadic. (R. 31.) Plaintiff said he could stand and/or walk for about ten minutes at a time, and he tries not to sit too much. (R. 32.) He also identified right shoulder problems. (R. 32-33.)

         When asked about his living situation and personal care, Plaintiff said he lives alone and he can handle personal care but his uncle comes to help him with things around the house like laundry, cooking, doing dishes, and cleaning. (R. 33.) He explained that the problem with performing these tasks was his balance and dizziness. (R. 35.)

         Regarding handling and fingering things, Plaintiff said that he is right-handed but uses his left hand most of the time because of the pain that shoots up his arm on the right side. (R. 34.) He also said that, if he drops something, it stays on the floor until his uncle comes over. (R. 34-35.)

         Plaintiff's attorney pointed out that Plaintiff had a long and steady work history for many years with significant earnings and he would be working if he could. (R. 39.)

         ALJ Cutter then questioned Vocational Expert Andrew Caporale and asked him to consider a hypothetical person with Plaintiff's

vocational profile and the residual functional capacity to perform a range of light work as defined in the regulations subject to the following limitations. The individual can continuously sit, only occasionally stand, walk, climb ramps or stairs, balance, stoop, kneel, crouch and crawl, cannot perform any overhead use of both . . . arms, can only frequently reach, handle, finger, feel, push or pull bilaterally, can never work at unprotected heights, operate motor vehicles, tolerate exposure to temperature extremes or vibration and the individual can perform work that does not ...

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