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McKenzie v. Commissioner of Social Security

United States District Court, S.D. Ohio, Eastern Division

May 25, 2017

WILLIE JAMES MCKENZIE, JR., Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          OPINION AND ORDER

          KIMBERLY A. JOLSON UNITED STATES MAGISTRATE JUDGE

         Plaintiff, William James McKenzie, Jr., filed this action under 42 U.S.C. § 405(g) seeking review of a decision of the Commissioner of Social Security (the “Commissioner”) denying his application for a period of disability and disability insurance benefits. For the reasons that follow, the Court REVERSES the Commissioner of Social Security's non-disability finding and REMANDS this case to the Commissioner and the Administrative Law Judge (“ALJ”) under Sentence Four of § 405(g).

         I. FACTUAL AND MEDICAL BACKGROUND

         Plaintiff filed this case on June 20, 2016 (Doc. 3), and the Commissioner filed the administrative record on August 22, 2016 (Docs. 12-13). Plaintiff filed a Statement of Specific Errors on October 24, 2016 (Doc. 14), and the Commissioner responded on November 21, 2016 (Doc. 16). Plaintiff filed a Reply Brief on December 6, 2016. (Doc. 18). Upon the parties' consent and pursuant to 28 U.S.C. § 636(c), this case was referred to the Undersigned to conduct all further proceedings.

         A. Personal Background

         Plaintiff was born on July 19, 1960, and was fifty-one years old on the alleged onset date of disability. (See Tr. 29, PAGEID #: 88). He has a high school education and work experience as an industrial sweeper/cleaner and steel laborer. (Id.). This case primarily concerns impairments in Plaintiff's lumbar and cervical spines and right hip. (See generally Tr. 24, PAGEID #: 83).

         B. Relevant Hearing Testimony

         Administrative Law Judge Terrence Hugar (the “ALJ”) held a hearing on October 29, 2014. (Tr. 22, PAGEID #: 81). During the hearing, Plaintiff testified that he had an accident while working at a steel mill in Weirton, West Virginia. (Tr. 445, PAGEID #: 506). Specifically, Plaintiff explained that he was cleaning the gratings when they gave way, causing him to fall to the floor below. (Id.). The accident caused injuries to his neck, back, and hip. (Id.).

         Plaintiff testified that, after the accident, he “wasn't able to function.” (Tr. 446, PAGEID #: 507). He elaborated about the resulting back impairment, lack of mobility in his hip, and pain down his right leg. (Id.). Plaintiff received a right hip replacement and has used a cane since that surgery. (Tr. 447, 450, PAGEID #: 508, 511). As of the hearing date, Plaintiff had pain in his back, hip, and knee, for which medication provided minimal relief. (Tr. 450-51, PAGEID #: 511-12). Plaintiff testified that his injuries do not, however, prohibit him from bending over to pick up an item on the floor. (Tr. 451, PAGEID #: 512; see also id. (Plaintiff explaining that he could lift “nothing really, ” with five or ten pounds being the maximum amount)).

         C. Relevant Medical Evidence

         John Columbus, M.D. of Trinity Workcare, in addition to other doctors, treated Plaintiff for his conditions and the resulting pain for years after the accident. Plaintiff's first appointment with Dr. Columbus was on January 25, 2012, during which Dr. Columbus found Plaintiff totally disabled from work. (Tr. 248-49, PAGEID #: 307-308). At a follow-up appointment on February 8, 2012, however, Dr. Columbus released Plaintiff to return to “light office work” with restrictions, including that Plaintiff could lift or carry no more than ten pounds, could bend, twist, and push/pull only occasionally, and could not reach below the knee, squat, or kneel. (Tr. 243, PAGEID #: 302). Dr. Columbus prescribed Plaintiff pain medication and physical therapy, and return appointments. (Tr. 246, PAGEID #: 305).

         Ravinder Chopra, M.D. examined Plaintiff on February 22, 2012. (Tr. 240-42, PAGEID #: 299-301). He prescribed Plaintiff medication for a “cervical, lumbar strain” and continued his work restrictions. (Id.). Hence, Dr. Chopra also concluded that Plaintiff could lift or carry no more than ten pounds, could bend, twist, and push/pull only occasionally, and could not reach below the knee, squat, or kneel. (Tr. 240, 242 PAGEID #: 299, 301). Dr. Chopra continued the same restrictions on March 9. 2012. (Tr. 237, PAGEID #: 296).

         Dr. Columbus continued Plaintiff's medication, physical therapy, and the same work restrictions upon examination on March 29, 2012. (Tr. 233-35, PAGEID #: 292-94 (noting “desk duty” and restricting lifting or carrying to no more than ten pounds; bending, twisting, and pushing/pulling only occasionally; and prohibiting reaching below the knee, squatting, or kneeling)). Dr. Columbus observed that Plaintiff had not had “enough clinical improvement at 12 weeks now.” (Tr. 235, PAGEID #: 294; see also id. (indicating that Plaintiff should have an MRI)). During the following month's visit, Dr. Columbus continued Plaintiff's medication and work restrictions. (See Tr. 229-31, PAGEID #: 288-90 (April 24, 2012 visit restricting lifting or carrying to no more than ten pounds; bending, twisting, and pushing/pulling only occasionally; and prohibiting reaching below the knee, squatting, or kneeling)).

         Dr. Columbus examined Plaintiff again on June 29, 2012. (Tr. 224, PAGEID #: 283). Plaintiff described his pain as “basically miserable” and impacting “his ability to ambulate.” (Id.). Plaintiff told Dr. Columbus that “he want[ed] to have something done” to address the pain. (Id.). Dr. Columbus recommended an MRI of the lumbrosacral spine and right hip and prescribed Plaintiff pain medication and physical therapy. (Id.). Dr. Columbus continued Plaintiff's work restrictions. (Tr. 222, PAGEID #: 281) (restricting lifting or carrying to no more than ten pounds; bending, allowing twisting, and pushing/pulling only occasionally; and prohibiting reaching below the knee, squatting, or kneeling)).

         At Plaintiff's next four monthly appointments, Dr. Columbus again continued pain medication and imposed work restrictions. (Tr. 218-20, PAGEID #: 277-79 (July 31, 2012 visit restricting lifting or carrying to no more than ten pounds; allowing bending, twisting, and pushing/pulling only occasionally; and prohibiting reaching below the knee, squatting, or kneeling); Tr. 217, PAGEID #: 276 (August 29, 2012 visit noting that Plaintiff “will press on forward with work restrictions”); (Tr. 210-13, PAGEID #: 269-72 (September 27, 2012 visit restricting lifting or carrying to no more than ten pounds; allowing bending and twisting only occasionally; and prohibiting and pushing/pulling, squatting, or kneeling); (Tr. 206-209, ...


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