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Dennis v. Berryhill

United States District Court, E.D. Pennsylvania

June 6, 2018

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



         April Dawn Dennis, (“Plaintiff”) filed this action to review the final decision of the Commissioner of the Social Security Administration (“Commissioner” or “Defendant”), denying her application for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-434, 1381-1385 (“the Act”). This matter is before me for disposition, upon consent of the parties.[2] For the reasons that follow, Plaintiff's request for review will be GRANTED, and the matter remanded for proceedings consistent with this Memorandum and Opinion.


         Plaintiff protectively filed for DIB on December 21, 2012, and SSI on January 14, 2013. (R. 92-93, 623-28). She alleged disability as of April 15, 2012, due in relevant part to degenerative disc disease, leg weakness, and bi-polar disorder. (R. 21, 51, 62, 78, 92, 111, 623, 634). The Social Security Administration denied her claim for benefits at the initial level of review. (R. 78-86, 629-33). Following the denial, Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”), which occurred on October 10, 2014. (R. 639-76). Plaintiff, represented by an attorney, appeared and testified. (R. 646-61). Plaintiff's granddaughter and an impartial vocational expert (“VE”) also testified at hearing. (R. 661-73). On April 21, 2015, the ALJ issued a decision denying benefits under the Act. (R. 21-32). The Appeals Council denied Plaintiff's request for review, (R. 10-16), making the ALJ's decision the final decision of the Commissioner. Plaintiff commenced this action on December 21, 2016, and subsequently filed a Brief and Statement of Issues in Support of Request for Review. (ECF Nos. 1 and 13). Defendant filed a response. (ECF No. 18).


         To be eligible for Social Security benefits under the Act, a claimant must demonstrate that she cannot engage in substantial gainful activity because of a medically determinable physical or mental impairment which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of at least twelve months. 42 U.S.C. § 1382c (a)(3)(A). A five-step sequential analysis is used to evaluate a disability claim:

First, the Commissioner considers whether the claimant is currently engaged in substantial gainful activity. If [s]he is not, then the Commissioner considers in the second step whether the claimant has a “severe impairment” that significantly limits [her] physical or mental ability to perform basic work activities. If the claimant suffers a severe impairment, the third inquiry is whether, based on the medical evidence, the impairment meets the criteria of the impairment listed in the “listing of impairments, ” . . . which result in a presumption of disability, or whether the claimant retains the capacity to work. If the impairment does not meet the criteria for a listed impairment, then the Commissioner assesses in the fourth step whether, despite the severe impairment, the claimant has the residual functional capacity to perform [her] past work. If the claimant cannot perform [her] past work, then the final step is to determine whether there is other work in the national economy that the claimant can perform.

Sykes v. Apfel, 228 F.3d 259, 262-63 (3d Cir. 2000); see also 20 C.F.R. §§ 404.1520, 416.920. The disability claimant bears the burden of establishing steps one through four. If the claimant is determined to be unable to resume previous employment, the burden shifts to the Commissioner at step five to establish that, given the claimant's age, education, work experience, and mental and physical limitations, she is able to perform substantial gainful activities in jobs existing in the national economy. Poulos v. Comm'r. of Soc. Sec., 474 F.3d 88, 92 (3d Cir. 2007).

         Judicial review of a final decision of the Commissioner is limited. A district court is bound by the factual findings of the Commissioner if they are supported by substantial evidence and decided according to correct legal standards. Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999). Substantial evidence is “more than a mere scintilla, ” and “such relevant evidence as a reasonable mind might accept as adequate.” Burnett v. Comm'r of Soc. Sec., 220 F.3d 112, 118 (3d Cir. 2000) (citations omitted). Even if the record could support a contrary conclusion, the decision of the ALJ will not be overruled as long as there is substantial evidence to support it. Simmonds v. Heckler, 807 F.2d 54, 58 (3d Cir. 1986). The court has plenary review of legal issues. Schaudeck v. Comm'r of Soc. Sec., 181 F.3d 429, 431 (3d Cir. 1999).


         The Court has reviewed the administrative record in its entirety, and summarizes here the evidence relevant to the instant request for review.

         Plaintiff was fifty-two years old on her alleged disability onset date. (R. 51). Plaintiff completed ninth grade.[4] (R. 649). She previously worked as a cashier, an envelope stuffer, and a laundry sorter. (R. 112, 118-21). At the time of the administrative hearing, Plaintiff lived with her fifteen year old granddaughter and five year old grandson. (R. 647-48).

         A. Medical Evidence

         1. Physical Impairments

         The record reflects a history of Plaintiff experiencing low back pain with radicular symptoms and weakness in her legs.[5] (R. 27). An August 28, 2009, MRI of Plaintiff's lumbar spine showed “degenerative disc disease and facet arthropathy superimposed on a moderately congenitally narrow spinal canal, resulting in severe central canal stenosis at ¶ 3-L4 and moderate central canal stenosis at ¶ 4-L5.” (R. 251-52). A subsequent MRI of her lumbar spine on May 26, 2012, showed “mild worsening of a diffuse disc bulge at ¶ 5-S1, ” “mild to moderate congenital spinal canal narrowing, ” and “moderate to severe and moderate central canal stenosis at levels L3-L4 and L4-L5, respectively.” (R. 156-57).

         Between 2009 and 2014, Plaintiff treated at Physical Therapy Physicians, P.C. with Dr. James F. Bonner, M.D., and physicians' assistant Joan Formiglia, PA-C.[6](R. 217-52, 466, 575-620). Plaintiff complained of pain in her lower back associated with spinal stenosis and degenerative changes in her lumbar spine. (R. 219-39). On physical examination, Plaintiff displayed an antalgic gait[7], difficulty with postural changes, positive straight leg raises[8], and palpable pain in her low back. (R. 219-30). Notes reflected that Plaintiff “ambulates with a straight cane.” (R. 220, 223-25, 229-31). She received monthly outpatient evaluations, and management of her pain medication. Although medication prescribed on a monthly basis made Plaintiff's pain “more tolerable, ” (R. 219), epidural injections were recommended to alleviate Plaintiff's pain. (R. 219, 220, 223, 224-30, 233, 234). On November 11, 2013, Dr. Bonner noted that Plaintiff's condition precludes “any type of employment due to her chronic pain syndrome.” (R. 219).

         On September 14, 2014, Dr. Bonner completed a Medical Source Statement related to Plaintiff's physical ability to perform work. (R. 193-94). Dr. Bonner opined that Plaintiff was able to: (1) sit for 2-4 hours and stand/walk for 1 hour in an 8-hour workday with the option to sit/stand every 15 minutes; (2) frequently lift/carry less than 10 pounds and occasionally lift/carry 10 pounds; (3) rarely push and/or pull with her lower extremity and occasionally push and/or pull with her upper extremity; (4) rarely climb ramps/ladder/robe/scaffold, and balance; (5) occasionally climb stairs, and bend/stoop; and (6) never kneel or crouch. (Id.). According to Dr. Bonner, Plaintiff required 10 minute walking breaks every 15 minutes, and 15 minute sitting breaks every 5 minutes in an 8-hour workday. (R. 194). Dr. Bonner also indicated that Plaintiff was medically required to use a cane for ambulation. (R. 193). Dr. Bonner based his opinion on, inter alia, his clinical observations of Plaintiff's antalgic gait, difficulty walking, positive straight leg raise testing, and guarding, as well as Plaintiff's need for daily pain medication. (R. 194). In a clinical note dated October 13, 2014, Dr. Bonner reiterated that Plaintiff is “unable to perform any gainful employment” due to “severe back pain requiring opioid medication.” (R. 575).

         Plaintiff also treated with internal medicine specialist, Dr. Christopher Hannum, between 2011 and 2014. (R. 201-10). Although difficult to read, Dr. Hannum's notes reflected treatment for a variety of ailments. (R. 201-04). On August 6, 2013, Dr. Hannum noted Plaintiff's lower back problems secondary to “disc disease.” (R. 202). On January 25, 2014, Dr. Hannum completed a form for the Department of Public Welfare by checking a box that indicated Plaintiff was “permanently disabled.” (R. 463).

         2. Mental Impairments

         On January 29, 2013, Plaintiff presented to Crozer Community Hospital for a psychiatric evaluation. (R. 167-76). She reported feeling depressed and stressed due to medical issues and issues with her grandchildren. (R. 167, 171). Upon mental status examination, Plaintiff appeared healthy, well-groomed and cooperative. (R. 175). She displayed slow and monotonous speech; depressed mood; constricted affect; organized and goal-directed thought processes; memory, concentration, and ...

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