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Jones v. Commissioner of Social Security

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

June 19, 2018

MARK JONES, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          MEMORANDUM OF OPINION AND ORDER

          THOMAS M. PARKER MAGISTRATE JUDGE

         I. Introduction

         Plaintiff, Mark Jones, seeks judicial review of the final decision of the Commissioner of Social Security denying his application for Disability Insurance benefits (“DIB”) and Supplemental Security Income (“SSI”) benefits under Titles II and XVI of the Social Security Act (“Act”). The parties consented to my jurisdiction. ECF Doc. 16.

         Because the ALJ did not correctly apply the applicable legal standards and failed to build an accurate and logical bridge between her decision and the evidence, the final decision of the Commissioner must be VACATED and REMANDED for further proceedings.

         II. Procedural History

         Jones applied for DIB and SSI on December 23, 2014, alleging a disability onset date of July 4, 2013.[1] (Tr. 197-209) After his applications were denied initially on February 3, 2015 (Tr. 90-111) and after reconsideration on April 9, 2015 (Tr. 114-135), Jones requested an administrative hearing. (Tr. 160) Administrative Law Judge (“ALJ”) Penny Loucas heard the case on April 13, 2016 (Tr. 38-76) and denied Jones' claims in a June 1, 2016 decision. (Tr. 16-33) On May 26, 2017, the Appeals Council denied further review, rendering the ALJ's conclusion the final decision of the Commissioner. (Tr. 1-4) Jones filed this action on July 17, 2017 challenging the Commissioner's final decision. ECF Doc. 1.

         III. Evidence

         A. Personal, Educational and Vocational Evidence

          Jones was born in 1952 and was fifty-three years old at the time of the administrative hearing. (Tr. 197) He has a high school education (Tr. 197) and previous work experience as a chef and sous chef. (Tr. 52-53)

         B. Relevant Medical Evidence

         In July 2012, Jones burned his left hand at work with cooking oil. (Tr. 298) Examination showed a partial thickness burn at the base of the fourth and fifth fingers of the left hand. (Tr. 298) His burn was healed by August 7, 2012 when he returned for a follow-up appointment. (Tr. 297)

         On March 11, 2015, Jones presented to Care Alliance complaining of back pain, burning and numbness radiating down his left leg. Dr. James Brown examined Jones. Jones reported fatigue, joint pain, hand pain, chronic back pain, numbness and tingling in the feet, crying spells, depressed mood and insomnia. (Tr. 416) Dr. Brown noted limping gait, weakness of dorsiflexion in the left great toe, spinal tenderness in the lumbar region and positive straight leg raising on the left at 15 degrees. (Tr. 417) An x-ray of the lumbar spine showed degenerative changes with disc space narrowing and marginal osteophytic changes. (Tr. 418) Dr. Brown diagnosed elevated blood pressure, chronic low back pain, chronic depression, and Hepatitis C. Dr. Brown prescribed medications and referred Jones to physical therapy. (Tr. 339, 418)

         On April 13, 2015, Jones returned to Dr. Brown. Jones had not started physical therapy. (Tr. 414) Dr. Brown did not document any findings regarding Jones's back. (Tr. 414) Dr. Brown referred Jones to gastroenterology for Hepatitis C and to cardiology after an electrocardiogram showed tachycardia. (Tr. 414-415)

         Jones started physical therapy on April 21, 2015. He reported limitations with dressing, grooming, heavy exertion, squatting, and lifting more than five pounds. He said that he injured his back when he fell eight months earlier. (Tr. 339) Examination showed reduced range of motion in the lumbar spine and 4/5 strength in the lower extremities. (Tr. 340-341) The plan formed at physical therapy defined Jones's impairment as a “backache” and noted that the evaluation was limited due to Jones's fear of movement to avoid pain. (Tr. 342) Goals were set to decrease Jones's pain so that he could participate in his activities of daily living and reduce the pain so that he could stand and walk for 60 minutes each; could sleep through the night without pain; and could sit at least 2 hours without pain. (Tr. 342)

         At his second physical therapy visit on April 24, 2015, Jones's movements were slow and guarded. (Tr. 345-350) The therapist noted, “[p]atient exhibiting pain with every movement.” (Tr. 346) On May 1, 2015, Jones reported continued back pain. (Tr. 348) Jones completed three of eight visits. (Tr. 351-353)

         Dr. Brown also referred Jones for a behavioral health assessment on April 24, 2015. (Tr. 407) Jones reported symptoms of depression since losing his job in 2013. He had attempted suicide in 1997. (Tr. 407) Jones also reported depression, anger, anxiety, difficulty concentrating, self-destructive behavior, mood swings and thoughts of suicide. (Tr. 408) Examination showed some anxiousness/restlessness, depressed/blunted affect and depressed mood. (Tr. 410) Social Worker Cathy Alexander diagnosed major depressive disorder, severe, without psychotic features; hypertension; chronic back pain. He was assigned a 40 Global Assessment of Functioning (“GAF”) score. (Tr. 411) In a follow up visit on May 27, 2015, Ms. Alexander noted that Jones was spending most of his time watching TV at home. (Tr. 406)

         On June 15, 2015, Jones followed-up with Dr. Brown. (Tr. 403-405) Jones reported that he went to physical therapy four times but stopped because it made his pain worse. He was having pain and numbness traveling down his left leg. Examination showed tenderness in the lumbar spine, positive straight leg raise test on the left at 30 degrees, normal gait, normal and symmetric reflexes, and grossly normal sensation. (Tr. 403) Dr. Brown diagnosed major depressive disorder, recurrent, severe; benign essential hypertension; insomnia; and chronic pain. He added methylprednisolone for back pain and referred Jones to physical therapy again. (Tr. 404)

         Jones returned to see Ms. Alexander on July 2, 2015. His mood was depressed and his affect was flat; he was having suicidal ideation. (Tr. 401) At his following visit on July 9, 2015, Jones was still experiencing anhedonia, anxiety, decreased appetite, depressed mood, difficulty concentrating, excessive alcohol consumption, fatigue and feelings of worthlessness/guilt. (Tr. 399) Ms. Alexander referred Jones to the Crisis Stabilization Unit to be admitted the same day. (Tr. 400) At Frontline Services an initial crisis plan was formed to stabilize Jones's medications, help him sleep for eight straight hours, to teach him coping skills and to provide support/encouragement. (Tr. 429) On July 19, 2015, Jones was discharged from Frontline after 10 days with the diagnosis of major depressive disorder with psychosis. He was referred for further mental health treatment. (Tr. 446-447)

         On July 28, 2015, Jones met with Dr. Brown reporting low back pain. (Tr. 396-400) Dr. Brown told Jones he needed to complete physical therapy before he could be referred to pain management. Dr. Brown did not note any examination findings for Jones's back. (Tr. Tr. 397)

         On August 19, 2015, Jones returned to physical therapy. Jones reported no change in his condition since his last visit. (Tr. 354) The therapist noted improved gait quality and ability to perform transfers. (Tr. 355) Jones's diagnosis was left-sided low back pain without sciatica. (Tr. 356) At his next visit on August 24, 2015, Jones reported that he fell when taking out the trash on August 21, 2015. He also stated that his pain was decreasing and intermittent with medications. He reported decreased pain and symptoms following physical therapy. (Tr. 358) On September 1, 2015, Jones continued to complain of pain and spasm in his lumbar spine. He had significant limitations in all ranges of motion of the lumbar spine. (Tr. 360) However, Jones reported more equal step length and improved postural awareness. (Tr. 361) Jones did not attend his final three physical therapy appointments. (Tr. 360)

         Jones saw psychiatrist, Dr. Vrabel, on September 15, 2015. He was still depressed and was afraid to go out. Dr. Vrabel diagnosed major depressive disorder with psychosis and noted that Jones continued to have significant mood and psychotic problems. He increased Seroquel to 100 mg. (Tr. 448)

         Jones went to the emergency department at the Cleveland Clinic on January 15, 2016. He had fallen down his steps and injured his lower back and head. He reported moderate back pain and loss of consciousness. Bruising was noted on his forehead. (Tr. 365) Physical examination showed normal range of motion, normal strength, and no tenderness in his neck and back. (Tr. 369-370) A CT scan of his cervical spine showed severe acquired C5-6 and C6-7 narrowing with endplate remodeling cystic changes, including gas-containing cysts, endplate spurring and paravertebral ossifications. There was also distal cervical uncovertebral arthrosis with osteophytes and limited apophyseal joint arthrosis. (Tr. 377) An x-ray of Jones's lumbar spine showed degenerative disc space narrowing at the L3-4 and L4-5 levels with anterior and posterior vertebral body spurring. (Tr. 378) Jones was diagnosed with a head injury, acute back pain and osteoarthritis of the spine with radiculopathy, cervical region. At discharge, the doctor noted no numbness; Jones was able to dress himself and sit, stand, and walk without any difficulty or assistance. Jones was instructed to follow-up with orthopedics. (Tr. 371)

         Jones followed up with Dr. Brown on January 19, 2016. Jones reported weakness and soreness since his fall. (Tr. 394) Dr. Brown found weakness in Jones's upper extremities and limited range of motion in the cervical spine. (Tr. 395) Dr. Brown added ibuprofen and Flexeril to Jones's medications. (Tr. 395)

         C. Opinion Evidence

         1.Consultative Exam - Hasan Assaf, M.D. - January 2015

         Hasan Assaf, M.D., evaluated Jones on January 26, 2015. (Tr. 324-333) Jones reported a history of two car accidents in 1985 and 2008 that caused back problems and headaches. He also reported a knife cut to his upper left arm in 2001 that caused pain and numbness in his left hand, which was worse with lifting and reaching. Jones also reported pain in both wrists extending to his thumbs, which began five to six years earlier. Jones had not seen a doctor since 2008. He took Aleve and/or Tylenol for pain. (Tr. 324-325)

         Jones told Dr. Brown he lived with his mother and cooked and cleaned twice a week. He did laundry and shopped once a week. He took daily showers or baths and dressed himself. (Tr. 325)

         Examination showed that Jones was able to walk on his toes but declined walking on his heels due to pain. (Tr. 326) Dr. Assaf observed a positive straight leg test on the left at 30 degrees and on the right at 50 degrees. Jones had tenderness over both wrists and thumbs, left shoulder and left upper arm. (Tr. 327) Muscle testing revealed weakness in Jones's upper extremities and in his left lower extremity. Dr. Assaf also noted a weak left hand grasp. (Tr. 329) Jones had decreased range of motion in his cervical spine, left shoulder, right and left wrists and dorsal lumbar spine. (Tr. 330-331) Jones had no muscle atrophy or spasms. (Tr. 330) An x-ray revealed degenerative changes in the lumbar spine with disc space narrowing and marginal osteophytic changes. (Tr. 333) Dr. Assaf diagnosed low back pain, probably lumbar disc disease; left upper arm pain, status post remote soft tissue injury; and bilateral wrist and thumb pain, probably DeQuervain tenosynovitis. (Tr. 327) Dr. Assaf opined that Jones would have marked limitation in activities requiring prolonged standing, walking, bending and lifting; and moderate limitations in activities requiring holding with his hands. (Tr. 328)

         2.State Agency Reviewing Physicians

         Michael Delphia, M.D., reviewed Dr. Assaf's report on February 3, 2015. Dr. Delphia opined that Jones was capable of lifting 20 pounds occasionally and 10 pounds frequently; that he could sit, stand and/or walk for 6 hours in an 8 hour work day; could never climb ladders, ropes or scaffolds; could occasionally crouch and crawl; could frequently climb ramps and stairs, stoop, handle and finger. (Tr. 96) Dr. Delphia opined that Jones must avoid all exposure to hazards. (Tr. 97) Dr. Delphia felt that Dr. Assaf's opinion was an overestimate of the severity of Jones's restrictions and/or limitations. (Tr. 98) Dr. Delphia opined the maximum sustained work Jones could do would be at the light exertional level. (Tr. 99)

         On April 9, 2015, Diane Manos, M.D., reviewed Jones's records and affirmed Dr. Delphia's findings. (Tr. 119-121) Dr. Manos noted that Jones's activities of daily living including his ability to cook and clean implied that he would not have marked limitations in standing, walking and/or using his arms and hands. (Tr. 119) Dr. Manos, like Dr. ...


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