United States District Court, N.D. Ohio, Eastern Division
GREGORY A. FARLEY, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.
MEMORANDUM OPINION & ORDER
Kathleen B. Burke United States Magistrate Judge.
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. Â§
405(g). This case is before the undersigned Magistrate Judge
pursuant to the consent of the parties. Doc. 13.
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.
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.
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.
Personal and Vocational Evidence
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.
Relevant Medical Evidence
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.
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.
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.
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.
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.
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.
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.
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.”
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.
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.
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.
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.
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.
7, Farley followed up with Dr. Goel. Tr. 530. His MRI showed
epidural lipomatosis 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.
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.
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.
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.
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.
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.
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.
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.
after date last insured, March 31, 2014:
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.
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.
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.
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, ...