United States District Court, N.D. Ohio, Western Division
LISA A. URICH, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
G. CARR JUDGE.
REPORT AND RECOMMENDATION
R. Knepp II United States Magistrate Judge.
Lisa Urich (“Plaintiff”) filed a Complaint
against the Commissioner of Social Security
(“Commissioner”) seeking judicial review of the
Commissioner's decision to deny disability insurance
benefits (“DIB”). (Doc. 1). The district court
has jurisdiction under 42 U.S.C. §§ 1383(c) and
405(g). This matter has been referred to the undersigned for
preparation of a report and recommendation pursuant to Local
Rule 72.2. (Non-document entry dated April 20, 2018).
Following review, and for the reasons stated below, the
undersigned recommends the decision of the Commissioner be
reversed and remanded for further proceedings.
filed for DIB in May 2013, alleging a disability onset date
of October 10, 2012. (Tr. 317-19). Her claims were denied
initially and upon reconsideration. (Tr. 175-78, 180-82).
Plaintiff then requested a hearing before an administrative
law judge (“ALJ”). (Tr. 189-90). Plaintiff
(represented by counsel), and a vocational expert
(“VE”) testified at a hearing before the ALJ on
June 9, 2015. (Tr. 76-106). On August 19, 2015, the ALJ found
Plaintiff not disabled in a written decision. (Tr. 138-55).
On October 26, 2016, the Appeals Council remanded the
decision for further consideration of medical opinion
evidence, and the inclusion of new material evidence. (Tr.
(again represented by counsel), and a vocational expert
(“VE”) testified at a second hearing before the
ALJ on February 15, 2017. (Tr. 42-75). On May 10, 2017, the
ALJ found Plaintiff not disabled in a written decision. (Tr.
11-28). The Appeals Council denied Plaintiff's request
for review, making the hearing decision the final decision of
the Commissioner. (Tr. 2-4); see 20 C.F.R.
§§ 404.955, 404.981. Plaintiff timely filed the
instant action on April 20, 2018. (Doc. 1).
Background and Testimony
was born in 1966 making her 46 years old on her alleged onset
date. See Tr. 49. Plaintiff had past work in
inventory management for Walmart. (Tr. 53). There, she lifted
and pulled approximately 50 to 100 pounds at a time. (Tr. 53,
85). Plaintiff left Walmart due to pain in her back. (Tr.
53-54). She also had past work as a licensed practical nurse.
(Tr. 54, 84).
believed she could no longer work due to back pain. (Tr. 87).
She took prescription pain medications to control the pain
and received injections. Id. Plaintiff testified the
injections did “not really” help relieve her
pain, because they provided only short-term relief.
Id. Plaintiff described the lower back pain as
“constant” and it radiated down her sides to her
hips. (Tr. 88). Plaintiff had a lumbar fusion in 2012 which
she believed “actually made the symptoms worse than
better.” (Tr. 89). She also had pain in her shoulders
and neck (Tr. 88), and numbness and tingling in her hands
estimated she could walk one city block, stand in one place
for approximately fifteen minutes, and sit for approximately
20-25 minutes without changing positions. (Tr. 89). She had
trouble pushing and pulling due to shoulder pain.
Id. Plaintiff could not lift or carry more than ten
pounds. (Tr. 90).
typical day, Plaintiff “slept in”, watched
television, and watched her grandchildren play. Id.
Plaintiff did not babysit her grandchildren because she could
not lift them without “very bad” back pain. (Tr.
96-97). She could sometimes help with the dishes, but it took
her “a while”. (Tr. 90). Her daughter cleaned
Plaintiff's home and did her laundry. Id.
Plaintiff's husband did the grocery shopping and she went
with him approximately once per month but did not carry
anything. (Tr. 91). Her husband cooked their meals
id., and cared for their three dogs (Tr. 93).
believed she could no longer work due to back pain which
radiated to her legs, neck pain, carpal tunnel syndrome, and
numbness in her fingers. (Tr. 54-56). Plaintiff also had
bipolar disorder. (Tr. 57-58).
lived in a two-story home. (Tr. 49). She had two adult
children and two grandchildren (all living outside of the
home). (Tr. 49-50). She saw her grandchildren “every
other day” but did not babysit them. (Tr. 50, 58-59).
Plaintiff could not pick up her infant grandchild due to back
pain. (Tr. 58).
had a driver's license and drove a few times per week
“for short periods”. (Tr. 51). During an average
day, Plaintiff sat in her recliner and napped until her
daughter and grandchildren came over in the afternoon. (Tr.
59-60). Plaintiff estimated she could stand for approximately
ten to fifteen minutes at a time and sit for 20-25 minutes.
(Tr. 61-62). She could not lift more than ten pounds with
both hands. (Tr. 62). She had trouble buttoning and could not
open a bottle of water due to numbness in her fingers. (Tr.
63). Plaintiff could not wash her hair due to shoulder pain
and did not perform any household chores. (Tr. 63-64).
October 2012, Plaintiff underwent a decompressive laminectomy
with a posterior lumbar interbody fusion, posterior
non-segmental instrumentation, and an insertion of an
intervertebral device. (Tr. 472). At a post-operative visit
later in October with orthopedist J. Andrew Huddleston, D.O.,
Plaintiff reported general improvement, had 6/10 pain,
tolerated her pain medication well, and was “full
weight bearing” without any assistive devices. (Tr.
537). At a November post-operative visit, Plaintiff reported
7/10 pain with a “fair” response to her pain
medication. (Tr. 539). She remained “full weight
bearing” with no assistive devices, but Dr. Huddleston
listed her work status as “no work/activity”.
had a third post-operative visit with Dr. Huddleston in
January 2013. (Tr. 541-43). She reported
“constant” 5/10 pain. Id. On
examination, Plaintiff had “acceptable” range of
motion, normal muscle strength, normal gait, and diffuse
tenderness over the lumbar spine. (Tr. 542). Dr. Huddleston
instructed her to avoid heavy lifting for three months. (Tr.
in January 2013, Plaintiff saw Diana Rodriguez, C.N.P., a
nurse practitioner at a neurology clinic, for lumbar back
pain. (Tr. 586). Plaintiff reported pain at ¶ 5/10.
Id. On examination, Plaintiff had a normal gait, and
normal sensation. (Tr. 588). Ms. Rodriguez prescribed pain
medication. (Tr. 589).
February 2013, Plaintiff saw John Hughes, M.D., for,
inter alia, back pain. (Tr. 602-04). On examination,
Plaintiff had normal range of motion in all joints. (Tr.
604). Later that month, Plaintiff had a normal MRI of the
upper spine (Tr. 1164), and an MRI of the lower spine which
showed intact hardware and post-operative erosion of the
inferior L5 vertebral body. (Tr. 527). A thoracic x-ray
revealed mild degenerative changes in the mid-dorsal spine.
April 2013, Plaintiff saw neurologist Brendan Bauer, M.D.,
for continued lumbar back pain that she rated as 8/10. (Tr.
558). She also reported left leg numbness and tingling.
Id. Dr. Bauer assessed lumbar radiculopathy due to
degenerative disc disease. (Tr. 561).
had a final post-operative visit later in April 2013. (Tr.
544). She reported 5/10 pain in her lower back which radiated
to her left buttock. Id. Her pain was aggravated by
bending, standing, walking, and riding in a car. Id.
Dr. Huddleston told Plaintiff to return as needed. (Tr. 546).
saw Dr. Bauer again in April 2013. (Tr. 699-700). She
reported a February 2013 lumbar injection provided immediate
relief, and she continued to have no pain on her right side
for approximately two weeks thereafter. (Tr. 700).
Plaintiff's left side had “minimal relief”
following the injection however. Id. She rated her
left-side pain at 8/10 immediately following the injection.
October 2013, Plaintiff saw Dr. Bauer for continued lumbar
pain, pain between her shoulders, and bilateral arm weakness.
(Tr. 695). On examination, Plaintiff had decreased sensation
in both legs and positive straight leg raises. (Tr. 696). A
lumbar spine x-ray the following day was unremarkable. (Tr.
710). Plaintiff also underwent an MRI that month, which
revealed minimal thoracolumbar spondylosis. (Tr. 1154).
Finally, Plaintiff underwent a nerve conduction study that
same month which revealed carpal tunnel syndrome and moderate
bilateral cervical motor radiculopathies. (Tr. 1151).
had a lumbar epidural injection in January, and cervical
epidural injections in March, and July of 2014. See
Tr. 1531, 1533, 1536.
January 2014, Plaintiff saw Dr. Hughes for a chest cold,
reporting only respiratory symptoms. (Tr. 732-33). In
February, Plaintiff treated at the emergency room for chest
pain which radiated to her back. (Tr. 875). Providers found
normal strength in all extremities and opined her chest pain
was musculoskeletal. (Tr. 877).
returned to Dr. Bauer in March 2014 because her most recent
cervical epidural injection did not relieve her pain. (Tr.
1509). On examination, Plaintiff had a normal gait and normal
strength in all extremities, but had positive straight leg
raises bilaterally. (Tr. 1511). Dr. Bauer observed absent
reflexes in her hands and legs. (Tr. 1511-12). He noted
Plaintiff's cervical disc disease was worsening and
epidural injections did not provide relief. (Tr. 1512).
April 2014, Plaintiff saw Dr. Hughes for a rash/allergic
reaction. (Tr. 1075). Plaintiff also had complaints of joint
and back pain. (Tr. 1076). She had a normal physical
examination. (Tr. 1075-77).
2014 x-ray of Plaintiff's right shoulder revealed
calcification adjacent to the humeral head, suggesting
calcific tendinosis. (Tr. 1062).
returned to Dr. Bauer's office in August 2014, seeing Ms.
Rodriguez. (Tr. 1500-03). Plaintiff reported 5/10 back pain.
(Tr. 1500). On examination, Plaintiff had normal strength in
her extremities and normal gait. (Tr. 1502). In September,
Plaintiff reported to Dr. Bauer that her lower back pain
increased significantly to 8/10, and she had difficulty with
ambulation. (Tr. 1526). Dr. Bauer performed a lumbar epidural
injection. (Tr. 1527-28). In October, Plaintiff reported the
injection did not work and she continued to have lower back
pain. (Tr. 1496). Further, she reported burning and aching in
her hips at night. Id. Ms. Rodriguez prescribed
additional pain medications. (Tr. 1498).
January 2015, Plaintiff saw Dr. Hughes for a leg rash but
otherwise reported feeling ...