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Hoag v. Saul

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

September 27, 2019

CIAIRRA HOAG, Plaintiff,
v.
ANDREW SAUL, Commissioner of Social Security, Defendant.

          JAMES S. GWIN, JUDGE

          REPORT AND RECOMMENDATION

          JONATHAN D. GREENBERG UNITED STATES MAGISTRATE JUDGE

         Plaintiff, Ciarra Hoag, (“Plaintiff” or “Hoag”), challenges the final decision of Defendant, Andrew Saul, [1] Commissioner of Social Security (“Commissioner”), denying her applications for Disability Insurance Benefits (“DIB”), and Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416(i), 423, 1381 et seq. (“Act”). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned United States Magistrate Judge pursuant to an automatic referral under Local Rule 72.2(b) for a Report and Recommendation. For the reasons set forth below, the Magistrate Judge recommends that the Commissioner's final decision be AFFIRMED.

         I. PROCEDURAL HISTORY

         On May 24, 2016, Hoag filed an application for DIB and SSI, alleging a disability onset date of May 1, 2014, and claiming she was disabled due to lower back problems and diabetes. (Transcript (“Tr.”) 142, 146, 174.) The applications were denied initially and upon reconsideration, and Hoag requested a hearing before an administrative law judge (“ALJ”). (Tr. 85, 88.)

         On January 23, 2018, an ALJ held a hearing, during which Hoag, represented by counsel, and an impartial vocational expert (“VE”) testified. (Tr. 24-42.) On May 2, 2018, the ALJ issued a written decision finding Hoag was not disabled. (Tr. 12-19.) The ALJ's decision became final on October 11, 2018, when the Appeals Council declined further review. (Tr. 1.)

         On December 11, 2018, Hoag filed her Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 13, 14, 16.) Hoag asserts the following assignments of error:

1. The ALJ's evaluation of Hoag's pain failed to meet the requirements of SSR 16-3p.
a. The ALJ failed to consider the impact of Hoag's obesity at Steps IV and V of the sequential evaluation process.
b. The ALJ's finding that the intensity, persistence and limiting effects of Hoag's pain was not consistent with the medical evidence and was not supported by substantial evidence because he failed to consider the record as a whole in reaching that conclusion. The ALJ also ignored relevant evidence and did not provide a rationale why that evidence was discounted.
2. The ALJ's determination of residual functional capacity (“RFC”) does not accurately portray Hoag, and is not supported by substantial evidence.

(Doc. No. 13.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Hoag was born in November 1987 and was 26 years-old at the time of her administrative hearing, making her a “younger” person under Social Security regulations. (Tr. 18.) See 20 C.F.R. §§ 404.1563. She did not complete high school but received a GED and is able to communicate in English. (Tr. 27.) She has past relevant work as a store clerk and fast food restaurant worker. (Tr. 175.)

         B. Relevant Medical Evidence[2]

         Hoag's diagnosed impairments are degenerative disc disease, obesity, diabetes and asthma. (Tr. 15.) Her degenerative disc disease includes spondylosis and spondylolisthesis at the L5 vertebrae, and foraminal stenosis, as well as degenerative changes. (Tr. 278.)

         Hoag claims her disability began on May 1, 2014, when difficulties with her first pregnancy made it “harder and harder” to stand and walk, causing her to resign from her job as a McDonald's crew member. (Tr. 27.) She suffered from back pain and gestational diabetes during that pregnancy. (Tr. 645.)

         After delivering her son, Hoag continued to have “significant low back pain.” (Tr. 740.) During her pregnancy, Dr. Kovach, her obstetrician-gynecologist, had prescribed pain medication, and post-pregnancy she continued to seek help with her pain. (Id.)

         After her pregnancy, she saw Dr. Martin Dufour as her primary care provider, and received pain management services through the Cleveland Clinic. (Tr. 735.) She explained that she had experienced back pain for 11 years, but pregnancy and delivery had made her pain worse. (Tr. 819.) Dr. Dufour prescribed Tramadol and Norco for her pain, and also ordered x-rays and an MRI to investigate its underlying cause. (Tr. 809, 815, 820.)

         Hoag had x-rays on February 19, 2015, and an MRI on June 4, 2015, revealing a grade I spondylolithesis with bilateral pars defects, resulting in bilateral foraminal stenosis at L5-S1, with minimal degenerative spurring. (Tr. 323-5.) Based on these assessments, in August of 2015, Dr. Dufour referred her to Dr. Domingo Gonzalez, a neurologist. (Tr. 369.) He confirmed the MRI findings and noted that she had completed three months of physical therapy at the Cleveland Clinic with no improvement. (Id.) Since both physical therapy and pain management had failed, Dr. Gonzalez recommended that Hoag consider surgery. (Id.)

         Dr. Gale Hazen, a neurologic surgeon, evaluated Hoag on September 3, 2015. (Tr. 325.) His records indicate that Hoag reported significant pain, such that “She cannot even take care of her baby. She cannot work. She cannot sit. She cannot stand. She cannot do very much because of the low back pain.” (Id.) Yet, at the same appointment, Dr. Hazen observed, “She is able to get up and walk fairly well. She has good strength for the major muscle groups in the lower extremities.” (Id.) He explained that Hoag was a candidate for surgery, but that “weight loss would be very important” in determining the appropriate surgical intervention, and asked Hoag to attempt to reduce her weight from 270 pound to 240 pounds. (Id.)

         On December 3, 2015, Hoag returned to Dr. Hazen for her scheduled follow-up visit. (Tr. 330.) Her surgery was delayed because “she needed to lose twenty to twenty-five pounds and her hemoglobin would need to be more normal which may take several months.” (Id.) At this point, Hazen's records reflect that Hoag had “tried physical therapy, pain management, ” and “had nerve blocks, ” but “nothing helps.” (Id.)

         Hoag returned to Dr. Hazen a third time on April 14, 2016. (Tr. 335-336.) Her back pain was essentially unchanged, and she was about three months pregnant. (Tr. 336.) Surgery was no longer a treatment option until after the delivery of her baby. (Id.)

         On November 17, 2016, Hoag returned to Dr. Hazen for a fourth time, still in pain but twenty pounds lighter, at 251 pounds, and no longer pregnant, having delivered her second son. (Tr. 736.) Dr. Hazen determined that Hoag “meets all the criteria for surgery as she has instability, congenital spondylosis with spondylolisthesis and significant back pain that has not improved with therapy and pain management including injections.” (Id.) He noted that “she is able to get up. She can walk on toe walk and heel walk. She does have pain with any range of motion.” (Tr. 741.)

         Dr. Sanjay Kumar evaluated Hoag on December 21, 2016, at Dr. Hazen's request. (Tr. 742.) By this time, she had regained 8 pounds, and weighed 259 pounds. (Tr. 744.) Dr. Kumar noted that Hoag had experienced back pain “for about seven years, ” was obese and experienced sleep disturbance. (Tr. 742.) He also observed that her strength was “functional for ambulation, balance functional, coordination normal, ” although she had an “antalgic gait.” (Tr. 745.) He continued Hoag's prescription for Ultram because it was allowing her to “function, clean house, do chores, etc.” (Tr. 745.)

         On January 1, 2017, Hoag saw Caryn Delisio, NP, seeking help with her back pain. (Tr. 748.) Nurse Delisio noted her decreased range of movement and tenderness to palpitation, and renewed her Tramadol prescription. (Tr. 750.)

         On February 1, 2017, Dr. Hazen and Dr. Andrasko performed the recommended surgery: a left retroperineal anterior L5-S1 diskectomy, interbody fusion. (Tr. 734.) The medical records note that Hoag was, at the time, “non-morbidly obese, ” which made the surgery more difficult. (Tr. 734.)

         On February 15, 2017, Hoag saw Dr. Kumar for a post-surgical followup. (Tr. 759.) He viewed the surgery as successful, but observed she was walking with the aid of a walker, and still experiencing “some numbness in the left thigh, a lot of back pain, ” for which she was taking 10 mg of Percocet every 4 hours as well as some Tramadol. (Id.) He also observed she exhibited “decreased range of motion, pain and spasm” in her back. (Tr. 761.)

         Hoag also began physical therapy post-surgery. Kevin Dusenbury, PT, initially observed she had “functional range of motion in the lower extremities, ” and judged her to be “progressing well.” (Tr. 766.) But at her second appointment, he noted that she reported feeling “worse since surgery.” (Tr. 768.)

         Hoag saw Dr. Hazen on March 2, 2017, and he reported that “the spondylolisthesis is about the same unchanged, ” but “her implant is in excellent position.” (Tr. 773.) She was “able to get up independently without the walker, ” and “support her weight on both heel walk and toe walk.” (Id.)

         Hoag reported to the Nurse Practitioner monitoring her recovery that her pain level with medication was “2/10” and “‘20/10' without medication” on March 15, 2017. (Tr. 776.) Her weight also kept climbing, reaching 270 pounds by mid-March. (Id.)

         On May 11, 2017, Hoag again returned to see Dr. Hazen “because she is not good. She has back spasms beginning in her lower back going all the way up to the neck. She has some numbness in her lower left extremity. . . . Bending and standing hurt.” (Tr. 782.)

         By June 15, 2017, Hoag was reporting pain levels of 8/10 with medication, and 10/10 without medication. (Tr. 785.) The nurse who examined her noted her “decreased [range of motion] with flexion and extension of lower back, ” as well as tenderness in the lumbar area and tight hamstrings. (Tr. 786.)

         On July 19, 2017, Hoag reported a lower pain level with medication of “4/10.” (Tr. 788.) Dr. Kumar, who examined her, noted in her records that “She has chronic pain and spasms. She is frustrated with the pain. Achy pain.” (Id.) He continued her medications, including Percocet, and discussed weaning her off them. (Id.) He suggested a nerve branch block to help alleviate the pain. (Id.)

         Hoag returned to the doctor for medication follow-ups in August and September 2017. (Tr. 793, 798.) Each time, she reported pain levels of “4-5/10” with medication, and “10/10 ” without medication, explaining “medication helps her function and improves her quality of life.” (Tr. 795, 800.) Each time, her providers noted, “[patient] feels her medication helps her function and improves her quality of life, ” and her medications were continued. (Id.) At the September appointment, she was prescribed gabapentin for leg spasms and the doctor recommended radio frequency ablation to treat her pain. (Tr. 801-802.)

         Hoag's obesity is detailed throughout the medical record. (Tr. 241, 322-336, 333-335, 368, 734, 736, 754, 759, 764-766, 766, 772-773, 774, 783, 793, 795-796, 796, 801, 806, 808, 831-832). The records make clear her obesity and back pain impacted each other. Her back pain led to inactivity that worsened her obesity. (Tr. 325.) Her obesity complicated treatment for her back pain, contributing to a delay in scheduling the recommended lumbar surgery. (Tr. 325, 330, 335-6, 740, 806.)

         C. State Agency Reports

         State Agency reviewer Leslie Green, M.D., reviewed the file as constituted on July 26, 2016. (Tr. 49.) She found that Hoag had medically determinable impairments including spine disorders, diabetes and obesity. (Tr. 55.) She also found that Hoag's statements regarding her symptoms were “fully consistent” with the evidence in her file, noting “objective evidence shows that she has difficulty sitting or standing [due to] back pain. However, she is able to walk fairly well.” (Tr. 56.) Her report contains internal contradictions, as, on the same page, she concluded that Hoag could stand or walk for about 6 hours in an 8-hour workday, and also that she was limited to standing 2 out of 8 hours. (Tr. 57.) She found Hoag capable of light work. (Id.)

         State Agency reviewer Teresita Cruz, M.D., reviewed the file as constituted on October 24, 2016, and concurred entirely with the findings of Dr. Green, including the contradictory findings. (Tr. 66-69.)

         D. Hearing Testimony

         During the January 8, 2018, administrative hearing, Hoag testified to the following:

• She is 30 years old. (Tr. 27.)
• She has received her GED. (Tr. 27.)
• She previously worked as a Dairy Mart clerk and a McDonald's crew member. (Tr. 27.)
• She is 5 feet 8 inches tall and weighs 270 pounds. (Tr. 29.)
• Her back problems became disabling during her first pregnancy. After the birth of her son, the pain continued, so ...

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