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Rodriguez v. Saul

United States District Court, E.D. Pennsylvania

September 25, 2019

ANDREW SAUL, Commissioner of Social Security[1]


          ELIZABETH T. HEY, U.S.M.J.

         Maritza Rodriguez (“Plaintiff”) seeks review, pursuant to 42 U.S.C. § 405(g), of the Commissioner’s decision denying her claim for disability insurance benefits (“DIB”). For the reasons that follow, I conclude that the decision of the Administrative Law Judge (“ALJ”) denying benefits is not supported by substantial evidence and will remand the case for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g).


         Plaintiff protectively filed her DIB application on October 2, 2014, see tr. at 139-42, claiming that she became disabled on July 9, 2014, due to type II diabetes with kidney pain, degenerative macular edema, neuropathy in the hands, arms and legs, and hypertension. Tr. at 183.[2] The application was denied initially, id. at 83-87, and Plaintiff requested an administrative hearing before an ALJ. Id. at 88-89. An administrative hearing took place on May 3, 2017. Id. at 35-71. On May 3, 2017, the ALJ found that Plaintiff was not disabled. Id. at 12-29. The Appeals Council denied Plaintiff’s request for review on October 26, 2017, id. at 1-6, making the ALJ’s May 3, 2017 decision the final decision of the Commissioner. 20 C.F.R. § 404.981.

         Plaintiff commenced this action in federal court on May 7, 2018. Docs. 1 & 2. The matter is now fully briefed and ripe for review. Docs. 9 & 10.[3]


         The court’s role on judicial review is to determine whether the Commissioner’s decision is supported by substantial evidence. 42 U.S.C. § 405(g); Schaudeck v. Comm’r of Soc. Sec., 181 F.3d 429, 431 (3d Cir. 1999). Therefore, the issue in this case is whether there is substantial evidence to support the Commissioner’s conclusions that Plaintiff is not disabled and can perform jobs that exist in significant numbers in the national economy. Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion, ” and must be “more than a mere scintilla.” Zirnsak v. Colvin, 777 F.2d 607, 610 (3d Cir. 2014) (quoting Rutherford v. Barnhart, 399 F.3d 546, 552 (3d Cir. 2005)). The court has plenary review of legal issues. Schaudeck, 181 F.3d at 431.

         To prove disability, a claimant must demonstrate an “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment . . . which has lasted or can be expected to last for . . . not less than twelve months.” 42 U.S.C. § 423(d)(1). The Commissioner employs a five-step process, evaluating:

1. Whether the claimant is currently engaged in substantially gainful activity;
2. If not, whether the claimant has a “severe impairment” that significantly limits her physical or mental ability to perform basic work activities;
3. If so, whether based on the medical evidence, the impairment meets or equals the criteria of an impairment listed in the listing of impairments (“Listings”), 20 C.F.R. pt. 404, subpt. P, app. 1, which results in a presumption of disability;
4. If the impairment does not meet or equal the criteria for a listed impairment, whether, despite the severe impairment, the claimant has the residual functional capacity (“RFC”) to perform her past work; and
5. 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.

See Zirnsak, 777 F.3d at 610; see also 20 C.F.R. § 404.1520(a)(4). Plaintiff bears the burden of proof at steps one through four, while the burden shifts to the Commissioner at the fifth step to establish that the claimant is capable of performing other jobs in the local and national economies, in light of her age, education, work experience, and RFC. See Poulos v. Comm’r of Soc. Sec., 474 F.3d 88, 92 (3d Cir. 2007).


         Plaintiff was born on November 10, 1962, and thus was fifty-one years of age at the time of her alleged disability onset date (July 9, 2014), and fifty-four at the time of the ALJ’s decision (May 3, 2017). Tr. at 139, 180. The Disability Report and initial disability determination indicate a height of five feet, five inches, and a weight of 174 pounds, but these numbers appear to be overestimates. Id. at 72, 183.[4] At the time of her administrative hearing, Plaintiff lived with her husband. Id. at 46. She has three adult children who live on their own, plus grandchildren. Id. Plaintiff completed two years of college and has specialized training as a medical technician. Id. at 184. She has past relevant work as a nurse aide and store laborer. Id. at 63, 184, 210.

         A. ALJ’s Findings and Plaintiff’s Claims

         The ALJ found that Plaintiff suffered from two severe impairments at the second step of the sequential evaluation; diabetes mellitus and disorders of the spine. Tr. at 17. The ALJ next found that Plaintiff did not have an impairment or combination of impairments that met the Listings, id. at 18, and that she retained the RFC to perform light work except she can lift twenty pounds occasionally and ten pounds frequently, and can sit, stand, and walk six hours each in an eight-hour day. Id. at 19. She could occasionally use the lower extremities for pushing and pulling or foot controls and occasionally perform postural maneuvers, must avoid climbing ladders, ropes, scaffolds, and unprotected heights, and could occasionally use ramps and stairs. Id. At the fourth step of the evaluation, the ALJ found that Plaintiff could return to her past relevant work as a store laborer. Id. at 27. Alternatively, the ALJ found, based on the testimony of a vocational expert (“VE”), that Plaintiff could perform work that exists in significant numbers in the national economy including jobs such as small product assembler, inspector, and garment folder. Id. at 27-28. Therefore, the ALJ concluded that Plaintiff was not under a disability from the application date though the date of the decision. Id. at 28.

         Plaintiff claims that the ALJ’s decision is not supported by substantial evidence because the ALJ (1) failed to properly consider the medical opinion evidence, (2) failed to properly consider Plaintiff’s subjective complaints, and (3) violated her duty to develop the record. Doc. 9 at 12-23. Defendant responds that the ALJ properly considered the medical opinions and Plaintiff’s subjective complaints and was under no duty to further develop the record, and that her decision is supported by substantial evidence. Doc. 10 at 6-15.


         Summary of Medical Evidence

         On June 4, 2014, Plaintiff was seen at Stauffer Family Practice by Giles Baker, CRNP, with active problems including dyslipidemia, esophageal reflux (“GERD”), hypertension, peripheral neuropathy, and Type II diabetes mellitus with ophthalmic manifestations, uncontrolled. Tr. at 251.[5] Plaintiff complained of an increased burning sensation in her feet, ongoing numbness and tingling, weight loss, headaches, and insomnia. Tr. at 250-51. Id. Plaintiff exhibited abnormal reflexes, with “0” recorded on the right and left patella, diminished vibratory sensation and position sense in the toes, and diminished tactile sensation and monofilament testing throughout both feet. Id. at 253. Mr. Baker added a trial of nortiptyline, id. at 250, to Plaintiff’s existing medications, which included glipizide, lisinopril, NovoLog, omeprazole, insulin pens, and simvastatin. Id. at 252.[6]

         On September 22, 2014, Plaintiff sought treatment at St. Luke’s Hospital emergency room for a burning sensation and pain in her bilateral feet and legs which had been progressively worsening for three days. Tr. at 314. Plaintiff indicated that she was unable to afford her diabetic medications and had not taken them for a month. Id. She ambulated on her heels due to foot pain, her bilateral feet and calves were tender to touch, and proprioception of the big toes was absent, [7] and her neurological exam was otherwise normal with intact cranial nerves, reflexes, gait, strength, and sensation. Id. at 316. The attending physician opined that Plaintiff’s pain was secondary to diabetic neuropathy, and discharged her with a prescription for a glucose meter and strips so that she could monitor her glucose at home. Id.

         On October 31, 2014, Plaintiff returned to the St. Luke’s emergency department with complaints of worsening lower back pain that radiated into her right leg. Tr. at 325. Plaintiff indicated that she was unable to receive medications and follow-up care due to a lack of insurance. Id. at 332. Plaintiff could not ambulate normally due to radiating pain, and a straight-leg test was positive. Id. at 326, 327.[8] She had normal pedal pulses and good lower extremity strength. Id. at 326. Plaintiff was discharged with diagnoses of chronic back pain and sciatica. Id. at 330-31.

         On November 20, 2014, Plaintiff returned to St. Luke’s for an outpatient clinic follow-up. Tr. at 304-08. Plaintiff reported that her sciatica was progressively getting worse, she had a left foot wound attributed to diabetic neuropathy, and she was not taking her diabetic medication due to financial constraints. Id. at 304. She exhibited decreased bilateral reflexes and sensation in her feet. Id. at 307. The physician discontinued glipizide, metformin, and NovoLog, and started Plaintiff on Novolin R for diabetes, gabapentin for peripheral neuropathy, and tramadol for sciatica. Id. at 304.[9] Four days later, Plaintiff sought emergency treatment for blisters on the toes of her left foot, with complaints of chronic neuropathy and ongoing sciatica which caused her to favor her left side when ambulating. Id. at 335-37.

         On January 12, 2015, Plaintiff returned to the emergency department again for worsening leg pain. Tr. at 770-73, 1036-52. She stated that she had been unable to see her primary care provider because she lost her insurance. Id. During a visit to Bethlehem Family Practice three days later, Plaintiff complained of back pain radiating into her pelvis and right leg. Id. at 1670. At a follow-up on January 23, 2015, she was prescribed Lidoderm patch, Norco5, and gabapentin. Id. at 1658.[10]

         On February 5, 2015, Irene Cherfas, M.D., performed an ophthalmologic consultative examination. Tr. at 354-55. Dr. Cherfas diagnosed diabetic retinopathy in both eyes, and noted that Plaintiff had cataracts in both eyes which required no intervention. Id. at 354. In a further notation dated February 10, 2015, Dr. Cherfas opined that Plaintiff’s visual acuity did not render her legally blind or prohibit her from driving, and that she was employable from a visual perspective. Id.[11]

         On February 12, 2015, Plaintiff received treatment from Gregory Bentzinger, D.P.M., a podiatrist, for complaints of difficulty walking due to diabetic foot complications. Tr. at 427-28. He removed a callus, and on examination found weakened pulses and decreased sensation to pressure, touch, and vibration. Id. at 427. During follow-up appointments with Dr. Bentzinger in February and March 2015, Plaintiff continued to report pain on ambulation. Id. at 425, 426. The doctor provided Plaintiff diabetic insoles on February ...

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