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Bansa v. Berryhill

United States District Court, M.D. Pennsylvania

July 19, 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. (Doc. 1.) Plaintiff filed an application for benefits on May 16, 2013, alleging a disability onset date of December 29, 2012. (R. 15.) After Plaintiff appealed the initial denial of the claim, a hearing was held on September 26, 2014, and Administrative Law Judge (“ALJ”) Jarrod Tranguch issued his Decision on April 24, 2015, concluding that Plaintiff had not been under a disability during the relevant time period. (R. 28.) Plaintiff requested review of the ALJ's decision which the Appeals Council denied on September 19, 2016. (R. 1-6.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)

         Plaintiff filed this action on November 14, 2016. (Doc. 1.) She asserts in her supporting brief that the Acting Commissioner's determination should be reversed or remanded for the following reasons: 1) the ALJ erred in failing to assign controlling weight to Plaintiff's treating physician; and 2) the ALJ's residual functional capacity (“RFC”) is not reviewable or not supported by substantial evidence. (Doc. 11 at 7.) After careful review of the record and the parties' filings, the Court concludes this appeal is properly granted.

         I. Background

         Plaintiff was born on December 23, 1967, and was forty-five years old on the disability onset date. (R. 32.) She has a high school education and past relevant work as a letter carrier and carrier supervisor. (R. 32; Doc. 11 at 2.)

         A. Medical Evidence

         Plaintiff reported a history of diabetes since 1994. (R. 210.) In February 2013, Plaintiff saw Christoper Yusko, D.O., of Geisinger Pocono's Family Practice Dpeartment for a diabetes mellitus evaluation with the chief complaint of burning pain in her feet. (R. 455.) He noted that Plaintiff had “a LONG history of poor compliance with her [Diabetes Mellitus] control, multiple cancelled and no showed apts.” (Id.) Dr. Yusko found decreased sensation in her feet and discussed with Plaintiff how her poor compliance had lead to her neuropathy and foot pain. (R. 450.) He stressed the need for daily exercise, weight loss/management, and medication compliance, and he prescribed Lyrica for the foot pain. (Id.)

         Howard Katz, M.D., of PMC Physician Associates noted in March 2013 that Plaintiff complained of persistent ankle pain, noting she had sprained her ankle and was using an aircast. (R. 555.) In April, Dr. Katz found a limited range of motion of the left ankle with dorsiflexion, pain over the deltoid ligament and peroneal tendon distribution. (R. 553.) He noted that the sprained ankle/foot was causally related to work accident in December 2012 where she dislocated her elbow. (Id.)

         At a follow up visit with Dr. Yusko on May 20, 2013, Plaintiff again complained of foot pain which she described as a sensation of both feet being on fire. (R. 488.) Dr. Yusko recorded that Plaintiff was frustrated with her diabetes mellitus and she was not following her MTM (medication therapy management) as suggested. (Id.) He again stressed the need for better compliance with suggested management and control strategies, stating that Plaintiff needed “to be more serious” about these things. (R. 489.) Dr. Yusko added Gabapentin to her medication regimen to address the foot pain. (Id.)

         On May 21, 2013, Dr. Katz noted that Plaintiff's ankle range of motion was improving steadily and the ankle felt better. (R. 551.) He noted that the sprain and strain without tendon injury was resolving and Plaintiff was able to work light duty only. (R. 551.)

         On June 4, 2013, Plaintiff had her initial visit at Mountain Valley Orthopedics with the chief complaint of left elbow pain. (R. 501.) Records signed by Gregory Mineo, M.D., indicate that Plaintiff reported the December 29, 2012, elbow dislocation which was reduced and she had done well postoperatively. (Id.) She said she had started with numbness and tingling in her left little finger which was worse if she rested her elbow on a hard surface. (Id.) Plaintiff also reported joint pain and stiffness and trouble walking using hip/knee joints. (R. 502.) Physical examination showed that Plaintiff ambulated “in a heel-to-toe fashion without noticeable limp.” (Id.) Dr. Mineo noted full range of motion of the elbow without instability, normal motor exam and muscle development, and minimal tenderness over the cubital tunnel. (Id.) He planned to review her EMG and see her in two weeks to discuss the results. (Id.) Dr. Mineo also noted that Plaintiff could work with limited use of her upper extremity. (Id.)

         At her June 7, 2013, visit with Dr. Yusko, he recorded that Plaintiff presented “for disability” for bilateral carpal tunnel and she was following with podiatry for foot pain. (R. 504.) He noted that Plaintiff was a mail carrier who did a lot of walking, and she was awaiting the results of the EMG. (Id.) Although physical examination did not reveal any problems, Dr. Yusko recorded that he would give six weeks disability related to carpal tunnel and neuropathy problems. (R. 505.)

         In June and July of 2013, EMG testing showed peripheral neuropathy of Plaintiff's upper and lower extremities. (R. 525-26, 528, 534-35.)

         In January 2014, Dr. Yusko noted that Plaintiff had a history of poor diabetes control and she was following at the time with a diabetes educator and endocrinology for her diabetes mellitus. (R. 609.) He recorded that her diabetes control was “horrible, ” her compliance was “terrible, ” and this would likely lead to worsening problems. (Id.)

         On May 8, 2014, Plaintiff saw Gary Hrobuchak, D.P.M., for the chief complaint of painful feet with numbness. (R. 550.) She also complained of a sore ankle for two months and pain when walking and reported high blood sugars. (Id.) Physical examination findings included non-palpable PT pulses and pain on range of motion of left ankle. (Id.) Dr. Hrobuchak noted that he explained poor circulation, neuropathy, and the importance of maintaining good blood sugar to Plaintiff. (Id.) At her next visit, Dr. Hrobuchak administered a steroid injection. (R. 549.) Two weeks later, Plaintiff reported that she felt much better after the injection but still felt pain. (R. 548.) Dr. Hrobuchak gave Plaintiff another injection and instructed her to take motrin. (Id.) At her next two-week follow up appointment on June 26, 2014, Plaintiff reported that she was no better since the last injection and she could not walk due to pain. (R. 547.) Dr. Hrobuchak prescribed Tramadol and noted that he awaited MRI results. (Id.) The MRI showed osteochondral lesion of the medial talar dome and mild edema in Kaker's fat pad, nonspecific but consistent with mild Achilles peritendinitis. (R. 603.)

         On Dr. Yusko's referral, Plaintiff was seen by Douglas C. Nathanson, M.D., of Geisinger Pocono's Neurology Department on July 31, 2014, for a chief complaint of neuropathy. (R. 600.) Plaintiff stated that her symptoms were getting progressively worse, she had burning pain in both feet which increased with ambulation and standing, she had more recent onset of pain in the lower lumbar area with radiation into her buttocks and posterior aspect of both legs into her feet, and she had pain/numbness/tingling in both hands, especially upon wakening. (R. 600-01.) Plaintiff told Dr. Nathanson that she had difficulty driving and occasionally dropped things. (R. 601.) Physical examination showed 5/5 strength in upper and lower extremities, decreased sensation to pinprick in bilateral feet with radiation to ankles, vibratory sense decreased at bilateral toes, positive Tinel's bilaterally, decreased sensation to pinprick in fingertips of bilateral hands, deep tendon reflexes and symmetrical in bilateral upper extremities, at the knees and absent at the ankles, and a normal gait and stance. (R. 598.) Dr. Nathanson diagnosed neuropathy, lower back pain, and carpal tunnel syndrome. (R. 598.) He noted that the Neurontin dosage was recently increased, he encouraged tight blood glucose control in regard to modifying symptomatology, and he prescribed wrist splints for bilateral carpal tunnel. (Id.)

         On September 5, 2014, Plaintiff presented as a new patient to Elmo Baldassari, D.P.M., at his Pocono facility. (R. 575.) Plaintiff exhibited pain on range of motion and palpation, medial aspect of the anterior aspect of her left ankle. (Id.) On September 12, 2014, Dr. Baldassari saw Plaintiff for follow up of her left ankle pain, noting that he reviewed earlier x-rays and her MRI. (R. 574.) He also noted that Plaintiff fractured her ankle in December 2013, she was not treated properly for it, and she was “somewhat noncompliant, ” having showed up at the emergency room and never followed up with orthopedics. (Id.) He further noted that Plaintiff had a lot of ankle instability and she had not played volleyball since the injury because her ankle kept giving out on her and she had pain. (Id.) Dr. Baldassari recommended “ankle arthroscopy with ankle arthrotomy with lateral ankle stabilization with a Mitek anchor if needed.” (Id.) He added that surgery would be scheduled for October. (Id.)

         B. Opinion Evidence

         On June 11, 2013, Carol Latzanich, D.P.M., wrote on Pocono Podiatry Associates, P.C., prescription pad paper that Plaintiff “may not do prolonged standing or walking, may not drive mail truck. She has severe neuropathy--this is for indefinite time.” (R. 520.)

         On June 17, 2013, Dr. Katz completed a Physical Residual Functional Capacity Questionnaire. (R. 576-79.) He stated that Plaintiff needed a “sedentary job that she can change positions from at will.” (R. 579.) He also opined that every other day Plaintiff would need to take unscheduled breaks of five minutes, she would need to elevate her legs knee high thirty percent of the day, she would be limited in her abilities to reach, handle and finger with her right side seventy percent of the day and with her left side five percent of the day, and she would miss work about four days per month as a result of her impairments. (R. 578-79.)

         State agency consultant Alex Siegel, Ph.D., reviewed Plaintiff's records on July 2, 2013, and concluded that Plaintiff had no medically determinable mental health impairments. (R. 97-98.)

         On August 1, 2013, state agency consultant Louis B. Bonita, M.D., reviewed the records and concluded that Plaintiff's diabetes mellitus and peripheral neuropathy were severe impairments. (R. 97.) His assessments included findings that Plaintiff could lift and carry up to twenty pounds, and could sit and stand/walk for six hours in an eight-hour workday. (R. 99.)

         C. Function Report and ...

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