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Hubert Knowles v. Michael J. Astrue

October 25, 2011

HUBERT KNOWLES,
PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Vecchiarelli Magistrate Judge

MEMORANDUM OPINION AND ORDER

Plaintiff, Huber Knowles ("Plaintiff"), challenges the final decision of Defendant, Michael J. Astrue, Commissioner of Social Security ("the Commissioner"), denying Plaintiff's applications for a Period of Disability ("POD") and Disability Insurance Benefits ("DIB"), and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416(i), 423, 1381 et seq. ("the Act"). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned United States Magistrate Judge pursuant to the consent of the parties entered under the authority of 28 U.S.C. § 636(c)(2). For the reasons set forth below, the Commissioner's final decision is REVERSED and REMANDED for further proceedings consistent with this Memorandum Opinion and Order.

I. PROCEDURAL HISTORY

On September 28, 2000, Plaintiff applied for SSI and alleged a disability onset date of September 26, 2000. (Tr. 211.) The claim was denied initially and upon reconsideration, so Plaintiff requested a hearing before an administrative law judge ("ALJ"). (Tr. 73-76.) On June 11, 2003, ALJ Michael Cianci held Plaintiff's hearing and continued it so that Plaintiff could obtain medical records and an attorney. (Tr. 211.)

On June 22, 2004, ALJ Alfred V. Lucas resumed Plaintiff's hearing. (Tr. 211.) On September 23, 2004, ALJ Lucas found that Plaintiff could perform a range of sedentary work and was not disabled. (Tr. 216, 218-19.) The Appeals Council vacated and remanded ALJ Lucas's decision for further proceedings for the following reasons: Although Plaintiff filed an application only for SSI, the evidence showed that Plaintiff could be eligible for DIB as well and ALJ Lucas did not consider whether Plaintiff was entitled to DIB; Plaintiff was not informed of his rights after ALJ Lucas proposed to introduce additional evidence into the record, including a right to a supplemental hearing; ALJ Lucas did not address certain medical evidence; and ALJ Lucas did not reconcile all of the opinions of Dr. Dariush Saghafi, upon which ALJ Lucas's residual functional capacity ("RFC") determination was based. (Tr. 221-23.)

On September 1, 2006, ALJ Lucas held Plaintiff's hearing upon the Appeals Council's remand. (Tr. 267-74.) On September 29, 2006, ALJ Lucas determined that Plaintiff could perform a range of light work and was not disabled. (Tr. 274.) On March 27, 2008, the Appeals Council again vacated and remanded ALJ Lucas's decision for further proceedings for the following reasons: ALJ Lucas failed to address whether Plaintiff was entitled to DIB; ALJ Lucas did not determine to what extent Plaintiff's ability to perform a range of light work would be eroded by a need to alternate between sitting and standing; and ALJ Lucas did not elicit whether the vocational expert's ("VE") testimony was consistent with the Dictionary of Occupational Titles ("DOT") and its companion publication, the Selected Characteristics of Occupation ("SCO"). (Tr. 277-78.) The Appeals Counsel instructed that a different ALJ reassess whether Plaintiff was disabled pursuant to its instructions. (Tr. 278.)

On September 17, 2008, ALJ Thomas A. Ciccolini ("the ALJ") held Plaintiff's hearing upon the Appeals Council's second remand. (Tr. 19.) Plaintiff appeared, was represented by an attorney, and testified. (Tr. 19.) A medical expert ("ME") and VE also appeared and testified. (Tr. 19.) On November 26, 2008, the ALJ found Plaintiff not disabled. (Tr. 26.) On August 27, 2010, the Appeals Council declined to review the ALJ's decision, so the ALJ's decision became the Commissioner's final decision. (Tr. 9.)

On October 28, 2010, Plaintiff timely filed his complaint to challenge the Commissioner's final decision. (Doc. No. 1.) On February 24, 2011, Plaintiff filed his Brief on the Merits. (Doc. No. 12.) On April 27, 2011, the Commissioner filed his Brief on the Merits. (Doc. No. 16.) Plaintiff did not file a Reply Brief.

Plaintiff asserts two assignments of error: (1) the ALJ improperly assessed the credibility of Plaintiff's subjective complaints of pain; and (2) the ALJ's RFC determination is not supported by substantial evidence because it is inconsistent with consultative examiner Dr. Mehdi Saghafi's opinion.

II. EVIDENCE

A. Personal and Vocational Evidence

Plaintiff was 36 years old on his alleged disability onset date (Tr. 24) and 44 years old at the time of his last hearing before ALJ Ciccolini (Tr. 417). He has a limited education and is able to communicate in English. (Tr. 24.) He has past relevant work as a "machine operator." (Tr. 24.)

B. Medical Evidence

Plaintiff has alleged both mental and physical impairments, but takes issue with the ALJ's analysis of only his physical impairments. Therefore, the following review of the medical evidence will be limited to Plaintiff's physical impairments-namely, Plaintiff's back problems and related physical limitations and pain.

On September 19, 2000, Plaintiff presented to the emergency room with complaints of pain in his low back and numbness in his legs. (Tr. 133.) The nurse who attended to Plaintiff indicated that Plaintiff reported he did not suffer a particular injury that caused his pain. (Tr. 133.) An MRI of Plaintiff's lumbosacral spine taken the next day revealed early disc space narrowing at L4-L5 and L5 - S1. (Tr. 136.)

On April 2, 2001, Plaintiff presented to Dr. Shu Que Huang, M.D., for an examination upon referral from the Bureau of Disability Determination. (Tr. 151-52.)

Dr. Huang indicated that Plaintiff reported the following. Plaintiff suffered low back pain that radiated down his legs and caused tingling and numbness in his toes. (Tr. 151.) The pain also radiated to his face. (Tr. 151.) The pain was intermittent and was aggravated by walking for more than ten minutes at a time. (Tr. 151.) The pain rated at 10 on a scale of 1 to 10 in severity. (Tr. 151.) Dr. Huang concluded upon examination that Plaintiff was generally healthy but had signs and symptoms of lumbar radiculopathy with no significant neurological deficits. (Tr. 152.) Dr. Huang opined that Plaintiff required proper pain management, and that with proper pain management Plaintiff "would be able to function at a medium level of physical demands." (Tr. 152.)

On April 17, 2001, state agency reviewing physician Roy W. Starkey, M.D., assessed Plaintiff's physical RFC as follows. (Tr. 157-62.) Plaintiff could occasionally lift and carry 50 pounds and frequently lift and carry 25 pounds. (Tr. 158.) He could sit, stand, and walk for about 6 hours in an 8-hour workday with normal breaks. (Tr. 158.) He had an unlimited ability to push and pull except to the extent that he was limited in lifting and carrying. (Tr. 158.) He could frequently climb ramps and stairs, balance, stoop, kneel, crouch, and crawl. (Tr. 159.) He could occasionally climb ladders, ropes, and scaffolds. (Tr. 159.) He had no manipulative, visual, communicative, or environmental limitations. (Tr. 159-61.) On September 18, 2001, state agency reviewing physician W. Jerry McCloud, M.D., affirmed Dr. Starkey's findings. (Tr. 162-63.)

On January 4, 2002, Dr. Donald J. Rohl, D.O., authored a letter to Dr. Disa Smith, M.D., explaining that he had examined Plaintiff. (Tr. 178-79.) Dr. Rohl reported that Plaintiff presented to him with complaints of low back pain and bilateral leg pain. (Tr. 178.) Dr. Rohl was of the impression that Plaintiff suffered a herniated disc at L4-5, advanced degenerative disc disease at L4-5 and L5-S1, and bilateral lower extremity radiculopathy. (Tr. 179.) On January 16, 2002, Plaintiff presented to Dr. Rohl for a follow-up examination. (Tr. 181.) Dr. Rohl reported that he was of the impression that Plaintiff suffered a herniated disc at L4-5 with moderate to severe foraminal and central stenosis, and a herniated disc at L5-S1 with some foraminal and central stenosis. (Tr. 181.) Dr. Rohl further reported that Plaintiff desired to undergo decompression of his herniated discs. (Tr. 181.)

On January 25, 2002, Plaintiff returned to Dr. Rohl for a follow-up on his decompression surgery and laminectomy.*fn1 (Tr. 182.) Dr. Rohl indicated that Plaintiff reported the following. Plaintiff's leg pain and numbness were gone, but his back continued to hurt. (Tr. 182.) Plaintiff's back pain was different, manifesting itself in spasms. (Tr. 182.) Dr. Rohl indicated that Plaintiff's back spasms were "significant," so Dr. Rohl would have to "retain" Plaintiff's back. (Tr. 182.) Dr. Rohl further indicated that he gave Plaintiff medication, intended to place Plaintiff in physical therapy, and would see Plaintiff again in two weeks. (Tr. 182.)

Plaintiff continued to present to Dr. Rohl for follow-up evaluations of his back through 2003. (See Tr. 177-183.) On February 8, 2002, Dr. Rohl reported that Plaintiff no longer had back pain; that Plaintiff rated his leg pain at 1 out of 10 in severity; and that Plaintiff had stopped taking his medication and was doing well. (Tr. 183.) On June 7, 2002, Dr. Rohl reported that Plaintiff's leg pain had resolved, Plaintiff's back pain was minimal, and Plaintiff had returned to work and tolerated work well. (Tr. 187.) On December 11, 2002, Dr. Rohl reported that Plaintiff continued to do well, although Plaintiff suffered some back pain that Plaintiff related to the weather. (Tr. 189.)

On June 25, 2003, Ms. Linda A. Hautmann, Dr. Rohl's administrative assistant, authored a letter stating that Plaintiff was Dr. Rohl's patient and that Plaintiff was not currently able to work. (Tr. 177.) Ms. Hautmann did not explain why Plaintiff was not able to work, but indicated that Plaintiff underwent back surgery to address an injury he sustained from an automobile accident on December 6, 2001. (Tr. 177.)

On July 23, 2003, Dr. Rohl indicated that Plaintiff reported numbness in his left great toe; and that Plaintiff rated his back pain at 6 out of 10 in severity and leg pain at 3 out of 10 in severity. (Tr. 190.) Dr. Rohl further indicated that he would have Plaintiff undergo an MRI to determine whether Plaintiff's stenosis had become worse, and that he would "keep [Plaintiff] off work until further notice to make sure that there is nothing going on and he is not going to further damage his neurologic status." (Tr. 190.)

An MRI taken on August 6, 2003, evidenced degenerative disc disease with mild to moderate stenosis and enhancing tissues surrounding the spinal cord and abutting the S1 nerve root. (Tr. 167.) The same day, Ms. Hautmann authored another letter identical to the letter she authored on June 25, 2003. (Tr. 177.)

Between October 28, 2003, and December 12, 2005, Plaintiff presented to Dr. Carl Robson, M.D. with continuing complaints of low back pain that radiated into his buttocks and legs and ...


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