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Farley v. Commissioner of Social Security Administration

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

July 22, 2019

GREGORY A. FARLEY, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

          MEMORANDUM OPINION & ORDER

          Kathleen B. Burke United States Magistrate Judge.

         Plaintiff Gregory Farley (“Farley”) seeks judicial review of the final decision of Defendant Commissioner of Social Security (“Commissioner”) denying his application for Disability Insurance Benefits (“DIB”). Doc. 1. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned Magistrate Judge pursuant to the consent of the parties. Doc. 13.

         As set forth below, the ALJ's decision with respect to Farley's daily activities is not supported by the evidence, and, with respect to Farley's treatment history, the ALJ's decision is not sufficiently explained, which prevents the Court from conducting a meaningful review. Accordingly, the Commissioner's decision is REVERSED and REMANDED for proceedings consistent with this opinion.

         I. Procedural History

         Farley filed an application for DIB in March 2012, alleging a disability onset date of January 1, 2011. Tr. 223, 232. He alleged disability based on the following: arthritis, herniated discs, disc displacement, spondylosis, and degenerative disc disease. Tr. 252. After denials by the state agency initially (Tr. 159) and on reconsideration (Tr. 176), Farley requested an administrative hearing (Tr. 104). A hearing was held before an Administrative Law Judge (“ALJ”) in August 2013 and the ALJ issued a decision determining that Farley was not disabled. Tr. 63, 48-58. The Appeals Council denied Farley's request for review and Farley appealed to the federal district court, which remanded the case for further consideration of VE testimony and the treating physician opinion. Tr. 674-696.

         Upon remand, the ALJ held a second hearing, on May 17, 2017. Tr. 610-634. In her July 25, 2017, decision (Tr. 588-603), the ALJ determined that there are jobs that exist in significant numbers in the national economy that Farley can perform, i.e. he is not disabled. Tr. 602-603. Farley requested review of the ALJ's decision by the Appeals Council (Tr. 722) and, on May 31, 2018, the Appeals Council denied review, making the ALJ's July 25, 2017, decision the final decision of the Commissioner. Tr. 577-581.

         II. Evidence

         A. Personal and Vocational Evidence

         Farley was born in 1961 and was 53 years old on his date last insured, March 31, 2014. Tr. 601. He has a high school education as well as vocational training as a tool and die maker; he is a certified journeyman. Tr. 68. He last worked in 2009 as a tool and die maker. Tr. 68.

         B. Relevant Medical Evidence[1]

         In March 2011, Farley had an MRI of his lumbar spine due to his complaints of low back pain and leg weakness. Tr. 341. The MRI showed “minimal” to “very minimal” disc bulging at several levels causing no significant compression other than “slight anterior thecal sac flattening” at one level. Tr. 341.

         On October 27, Farley saw orthopedic surgeon Jerold Gurley, M.D., for complaints of pain in his neck, shoulders, and back. Tr. 354. He had had fusion surgery at the T6-7 level nine years prior. Tr. 354. Dr. Gurley reviewed Farley's follow-up x-rays and remarked that the spinal instrumentation remained in good position and that the fusion was consolidating nicely, with “only very mild early spondolytic features in the adjacent C5-6 segment.” Tr. 354. Dr. Gurley diagnosed Farley with lumbar spondylosis L5-S1, chronic intermittent lumbago/lumbar radiculopathy, mild adjacent segment spondylosis at ¶ 6-7, chronic residual cervicalgia, and post laminectomy syndrome, cervical. Tr. 354. Dr. Gurley ordered an MRI of Farley's cervical spine prior to referring him to pain management. Tr. 355.

         On November 30, 2011, Farley returned to Dr. Gurley, who went over his neck MRI. Tr. 352. The MRI showed changes resulting in early bilateral foraminal stenosis. Tr. 352. He also had a small, contained, non-compressive central herniation at ¶ 3-4. Tr. 352. Dr. Gurley was prepared to refer him to pain management, but Farley told him, for the first time, that he had been stabbed in his thoracic spine with a screwdriver when he was 14 years old and had been unable to walk for days at that time. Tr. 352. Accordingly, Dr. Gurley ordered a thoracic MRI. Tr. 352.

         Farley returned to Dr. Gurley on December 28 to discuss his MRI results. Tr. 351. Dr. Gurley concluded that the MRI showed disc degeneration and loss of disc height but no evidence of any significant stenotic or neurocompressive pathology. Tr. 351. He recommended observation, symptomatic treatment, and maximizing nonoperative treatment before considering further surgery. Tr. 351. He referred Farley to a pain specialist and a rheumatologist to rule out an inflammatory disorder. Tr. 351.

         On January 17, 2012, Farley saw pain management specialist Abdallah Kabbara, M.D., for back pain for the last 20 years. Tr. 349. Upon exam, Farley had an antalgic gait and some limited range of motion in his cervical spine. Tr. 349-350. Otherwise, Farley had a normal range of motion in his low back, his back was not tender, he had normal sensation and reflexes, normal power in his arms and legs, a negative Hoffman sign, and he was able to stand on toes and heels without difficulty. Tr. 349-350. Dr. Kabbara commented that the extent of Farley's disease made intervention challenging due to the multi-level nature of his condition. Tr. 350. He prescribed Methadone and Gabapentin and recommended a trial thoracic epidural steroid injection. Tr. 350. Eight days later, he administered a steroid injection in Farley's mid-back. Tr. 348.

         On February 10, 2012, Farley reported to Dr. Kabbara that he had no significant improvement from the injection but had relief with medication. Tr. 346. Upon exam, he had an antalgic gait but otherwise normal findings, including power “at baseline” in his arms and legs. Tr. 346. Dr. Kabbara increased the dose of both medications and stated that he would not administer further injections. Tr. 346-347.

         On March 9, 2012, Farley returned to Dr. Kabbara and described some improvement with medications and no side effects. Tr. 345. His physical exam findings were unchanged from his prior visit. Tr. 345. Dr. Kabbara continued his methadone and increased his gabapentin. Tr. 345. Dr. Kabbara remarked, “I do not believe that the patient is a candidate to continue working for long hours.” Tr. 345.

         On April 5, 2012, Farley saw Dr. Kabbara and described his condition as stable on medication and rated his pain 5/10, which represented an improvement. Tr. 370. He expressed interest in seeking disability benefits and “confirmed that he is unable to perform his duty at work.” Tr. 370. Upon exam, he had an antalgic gait and otherwise normal findings. Tr. 370. Dr. Kabbara made no medication changes, refilled his prescriptions for four months, and stated that he believed that Farley had “significant extensive disease which supports him to be placed on disability.” Tr. 370.

         On September 4, 2012, Farley returned to Dr. Kabbara for a medication refill, denying medication side effects and reporting that, on medication, his pain was tolerable. Tr. 472. Upon exam, Dr. Kabbara noted no abnormalities and observed him to be “[a]mbulating at baseline without any neurological deficit apparent.” Doc. 472. Dr. Kabbara continued his current medications for three months and concluded that Farley was currently maintained on medication with reasonable results. Tr. 472.

         On December 11, 2012, Farley returned to Dr. Kabbara and reported exacerbations of pain recently that had been treated with steroids, which were beneficial. Tr. 909. Farley requested Dr. Kabbara adjust his Gabapentin and Dr. Kabbara started Lyrica instead and continued his Methadone. Tr. 909.

         In January 2013, Farley saw Dr. Kabbara and reported that, for the majority of the time, his new medication regime kept his pain well under control, but he had an exacerbation of his pain when he was cleaning his garage and lifted a few items that he was not supposed to lift. Tr. 911. His exam findings were normal. Tr. 911. Dr. Kabbara recommended thoracic/upper lumbar injections, which Farley had three times in January and February. Tr. 911, 913, 915, 916.

         On April 16, 2013, Farley saw neurosurgeon R. Goel, M.D., for a second opinion for back surgery. Tr. 529. He reported dragging his right foot for several months, lower back pain that radiates to his right leg, and having to sit in a flexed position due to feeling a sharp pain in the upper part of his lumbar spine. Tr. 529. His three injections helped with back pain for a few weeks but did not help his leg pain. Tr. 529. Upon exam, he had normal findings and Dr. Goel ordered a lumbar MRI. Tr. 529.

         On April 25, 2013, Farley told Dr. Kabbara that he believed his condition was getting worse; the methadone was “not holding him up as good as it used to be in the past.” Tr. 918. His back pain was 10/10 and some of it radiated down his right leg. Tr. 918. Upon exam, he looked to be in some distress. Tr. 918. He had minimal weakness in his right leg and he ambulated without assistance. Tr. 918. Dr. Kabbara increased his methadone, continued his Lyrica, and advised he follow up with Dr. Goel to discuss the need for surgical intervention. Tr. 918.

         On May 7, Farley followed up with Dr. Goel. Tr. 530. His MRI showed epidural lipomatosis[2] in his lower back causing lumbar stenosis at ¶ 4 and L5 and compression on the thecal sac. Tr. 530. Dr. Goel described two options: surgery or weight loss. Tr. 530. Because Farley had gained weight due to having been on steroids to treat his sarcoidosis (and was still on steroids), Dr. Goel opined that weight loss seemed unlikely and the only course of treatment was surgery to decompress the thecal sac and remove the epidural fat. Tr. 530.

         On May 22, Farley saw Dr. Kabbara and reported the increased methadone was helping his pain, but he did not believe that the methadone dose he took in the morning would hold his pain until the next dose 12 hours later and requested additional medication. Tr. 920. Upon exam, his lower extremity power and range of motion was baseline. Tr. 920. Dr. Kabbara increased his methadone and stated that he would reevaluate him after his upcoming surgery with Dr. Goel on May 30. Tr. 920.

         On June 8, 2013, shortly after his surgery, Farley went to the emergency room complaining of back pain, nausea, and fever. Tr. 893. His exam findings were normal except for decreased strength in his legs, which the doctor stated was “most likely due to poor effort.” Tr. 895. He was treated for pain and released with a diagnosis of post-operative lumbar pain. Tr. 897. On June 11, Farley followed up with Dr. Goel and stated that he was “very pleased with the results” of the surgery. Tr. 538. He had 80% relief from leg pain, although his back pain persisted, and his pain level was 2-3/10. Tr. 538. His incision cite was healthy. Tr. 538. He reported some neck pain and hand numbness and Dr. Goel ordered x-rays and referred him to one of his colleagues for “guidance in physical therapy for the neck.” Tr. 538, 868. The cervical spine x-ray showed degenerative and postsurgical changes. Tr. 539.

         On June 21, 2013, Farley saw Dr. Kabbara and reported that his pain was under reasonable control and he was able to reduce the methadone. Tr. 922. Upon exam, he ambulated with an antalgic gait. Tr. 922.

         On September 23, 2013, Farley reported to Dr. Kabbara that his current medication regimen seemed to have his pain well under control: his neck pain was 2-3/10, his back pain was 5/10, and he noticed some tingling in his right arm to his fingers. Tr. 924. Upon exam, he had normal findings and ambulated without difficulty at baseline. Tr. 924. Dr. Kabbara continued his medications and recommended an EMG/nerve conduction study of his right arm. Tr. 924-925.

         On October 29, 2013, Farley saw Dr. Goel stating that his leg pain had returned. Tr. 868. Dr. Goel recommended back and abdominal strengthening and stretching exercises, a walking program, wearing a back brace for 10 hours a day, use of ice and heat, and using a lumbar support cushion when sitting or driving. Tr. 868.

         On January 24, 2014, Farley saw Dr. Kabbara and reported that his pain was 2-3/10 with the medication and 7-8/10 without, explaining that he believed the methadone worked for 5-6 hours only. Tr. 926. He still had tingling in his right arm but had been unable to schedule an EMG. Tr. 926. Dr. Kabbara stated that an MRI taken on January 10 showed status-post laminectomy at ¶ 4-L5, L5-S1 without residual measurable canal stenosis, no abnormal enhancement, no evidence of bulging or herniated disc, and bilateral hypertrophy. Tr. 926. His physical exam findings were normal and he ambulated at baseline. Tr. 926. Dr. Kabbara increased Farley's methadone and explained, “even though [Farley] did undergo the laminectomy in the lumbar spine area, he still has multilevel disk bulges in the cervical and the lumbar spine area that could explain the persistent pain in his lower extremities and could also explain the pain and tingling going down his right upper extremity.” Tr. 927. He recommended titration of medication and a trial of spinal cord stimulation if he was not a candidate for additional surgery. Tr. 927.

         On February 28, 2014, Farley reported continued benefit from his medication and denied any side effects. Tr. 928. His physical exam findings remained unchanged and Dr. Kabbara continued his medications. Tr. 928.

         Evidence after date last insured, March 31, 2014:

         On April 5, 2014, Farley went to the emergency room for gastrointestinal symptoms, which he attributed to his withdrawal from Lyrica, which he had stopped taking. Tr. 898. Upon exam, he had a full range of motion in his extremities, intact sensation, a normal gait, and intact motor function. Tr. 900.

         On June 4, 2014, Farley followed up with Dr. Kabbara, reporting medication effectiveness and no new complaints. Tr. 930. On September 3, 2014, Farley reported that his medication was effective; the majority of the time his pain was well under control. Tr. 932. His exam findings were baseline at each of these visits. Tr. 930, 932.

         On December 1, 2014, Farley saw Dr. Kabbara and complained that his methadone was not working as it had before. Tr. 934. He reported severe pain, 8/10, in his lower lumbar spine radiating down to his leg. Tr. 934. Upon exam, he had “minimal weakness” in his right leg compared to his left, but he “continue[d] to ambulate without assistance.” Tr. 934. Dr. Kabbara scheduled a lumbar steroid injection, which he performed on December 16. Tr. 934, 936.

         On March 20, 2015, Farley went to the emergency room for chest pain. Tr. 903. He reported chronic back pain and denied pain in his extremities and neck. Tr. 904. Upon exam, he had a full range of motion in his extremities, ...


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