United States District Court, D. Nebraska
MICHAEL S. ALEXANDER Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security; Defendant.
MEMORANDUM AND ORDER
LAURIE SMITH CAMP, District Judge.
This matter is before the Court on the denial, initially and on reconsideration, of Plaintiff's application for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act (the "Act"), 42 U.S.C. §§ 1381-1385. For the reasons below, the ALJ's decision will be reversed and remanded.
Plaintiff Michael S. Alexander ("Plaintiff") protectively filed his application for SSI benefits on September 30, 2011, alleging that he became disabled on July 1, 2005, due to right knee and back impairments, depression, migraines, and diabetes. (Tr. at 93, 168-71, 223.) He subsequently amended his alleged disability onset date to his protective filing date. (Tr. at 32.) Plaintiff's application was denied initially and on reconsideration. (Tr. at 93, 95, 97-100, 109-12.) Plaintiff appealed the denial to the Administrative Law Judge ("ALJ"), who held an administrative hearing on March 20, 2013. (Tr. at 29-54.)
On April 26, 2013, the ALJ issued a decision finding that Plaintiff was not disabled. (Tr. at 13-23.) The ALJ found that Plaintiff had the following severe impairments: disorders of the back, obesity, diabetes, mild-to-moderate neuropathy, depression, and anxiety. (Tr. at 15.) The ALJ found that the Plaintiff did not have an impairment or combination of impairments that met or equaled any of the impairments listed in 20 C.F. R. Part 404, Subpart P, Appendix 1. (Tr. at 16.)
The ALJ determined that Plaintiff retained the residual functional capacity ("RFC") to: (1) lift and carry 20 pounds occasionally and 10 pounds frequently; (2) stand and walk for 2 hours in an 8-hour workday; (3) sit for 6 hours in an 8-hour workday; (4) occasionally climb stairs, but never climb ladders, ropes, or scaffolds; and (5) frequently balance and occasionally stoop, crouch, kneel, or crawl. (Tr. at 17.) In addition, Plaintiff needed to avoid unprotected heights and hazardous moving machinery. (Tr. at 17.) The ALJ determined that Plaintiff could perform tasks of simple to intermediate complexity, but he was limited to jobs not demanding attention to details or complicated job tasks or instructions. (Tr. at 17.) He could work in proximity of others, but he was limited to jobs not requiring close cooperation and interaction with coworkers and would work best in relative isolation. (Tr. at 17.) Thus, he also was limited to jobs requiring only occasional interaction and cooperation with the general public. (Tr. at 17). The ALJ further determined that Plaintiff retained the ability to maintain attention and concentration for a minimum of two hours at a time and could adapt to changes in the workplace on a basic level and accept supervision on a basic level. (Tr. at 17.)
The ALJ concluded that Plaintiff could not perform any past relevant work, but could perform other jobs existing in significant numbers in the national economy. (Tr. at 21-23.) Accordingly, the ALJ found that Plaintiff was not disabled from September 30, 2011, through the date of the decision. (Tr. at 23).
The Appeals Council denied Plaintiff's request for review of the ALJ's decision on July 25, 2014 (Tr. at 1-5), making the ALJ's April 26, 2013, decision the Commissioner's final decision subject to judicial review under the Act.
On August 31, 2011, Plaintiff sought treatment from Timothy Zimmerman, M.D.,  ("Dr. Zimmerman") for low back pain that had developed gradually over the previous seven years following a work injury. (Tr. at 330.) Plaintiff rated his back pain as "6/10" in severity and said it had an aching, pressure-like, burning, and throbbing quality that radiated into his legs. (Tr. at 330.) He reported that his back pain was aggravated by bending, sleeping, and walking long distances, and his pain was alleviated by lying supine. (Tr. at 330.) Dr. Zimmerman noted that a lumbar spine magnetic resonance imaging scan ("MRI") revealed degenerative disc disease and that Plaintiff's back pain had been treated previously with physical therapy, epidural steroid injections, medication, and bed rest. (Tr. at 330.) He noted that physical therapy had been ineffective, but the epidural steroid injections had been effective in alleviating Plaintiff's pain. (Tr. at 330.) Dr. Zimmerman diagnosed Plaintiff with lumbar disc degeneration and low back pain. (Tr. at 330.) He prescribed Percocet for Plaintiff's back pain (Tr. at 330-31) and completed forms indicating that, because of degenerative disc disease and chronic low back pain, Plaintiff could not lift more than 10 pounds; could not sit, walk, or stand for more than 15 minutes at a time, and needed to shift positions or lie down every 10 to 15 minutes. (Tr. at 331, 332-33.) In a September 23, 2011, letter, Dr. Zimmerman repeated these limitations and further noted that Plaintiff was "really unable to do much of anything"; had to constantly shift positions; was most comfortable lying down; and could not do much twisting, bending, or stooping. (Tr. at 338.)
Consultative physician Ryan Clauson, M.D. ("Dr. Clauson"), examined Plaintiff on November 21, 2011. (Tr. at 347-55.) Dr. Clauson noted that Plaintiff was able to sit comfortably through the 10-minute history portion of the examination, had normal gait and ambulation, and rose from sitting to standing and got on and off of the examination table without any assistance. (Tr. at 350.) He noted that Plaintiff had pain with lumbosacral spine range of motion; had normal range of motion in his cervical spine, but reduced range of motion in his lumbar spine; was palpably tender in his lower back; had negative straight leg raising; and had no muscle spasms or erythema. (Tr. at 350-51.) He further noted that Plaintiff could not squat, had normal gait, and could walk on his heels and toes although that was painful for him. (Tr. at 351.) Neurological examination findings were normal. (Tr. at 351.) Dr. Clauson concluded that Plaintiff's back pain limited his activities, he could not sit and stand for more than 10 to 15 minutes or do much lying down, and he would not be able to perform a job where he had to sit for long periods of time. (Tr. at 352.) He further concluded that Plaintiff's other impairments would not further limit his ability to work. (Tr. at 352.)
On December 6, 2011, state agency physician Jerry Reed, M.D. ("Dr. Reed"), reviewed Plaintiff's records (Tr. at 393-403) and opined that Plaintiff could lift and carry 20 pounds occasionally and 10 pounds frequently; stand and walk at least 2 hours in an 8-hour workday; sit about 6 hours in an 8-hour workday; push and pull without further limitation; frequently balance; and occasionally climb, stoop, kneel, crouch, and crawl. (Tr. at 394-395.) Dr. Reed noted the limitations assessed by Dr. Zimmerman and Dr. Clauson, but he concluded that they were reflective of Plaintiff's allegations and unsupported by their examination findings. (Tr. at 402-403.) State agency physician Glen Knosp, M.D. ("Dr. Knosp"), reviewed Plaintiff's records a month later, on January 23, 2012, and noted that Plaintiff's description of his symptoms and pain were not consistent with the evidence, concluded Plaintiff was capable of working, and affirmed Dr. Reed's assessment of Plaintiff's functional capabilities. (Tr. at 427-28.)
On March 20, 2013, Plaintiff appeared at an administrative hearing before the ALJ. (Tr. at 29-54.) The March 2013 hearing was Plaintiff's third hearing in a series of hearings for prior applications. (Tr. at 32.) The first two applications were unsuccessful. (Tr. at 32.) Plaintiff claimed that his depressive symptoms had "become worse" after his second disability report (Tr. at 267), and he asserted that he did not go anywhere and lay in bed most of the day every day. (Tr. at 256.)
At the March 2013 hearing, Plaintiff testified that he was unable to work because of his back, which he originally hurt in 2002. (Tr. at 36, 45.) He said that sitting and standing irritated his back pain, and he said his back pain prevented him from being able to bend, twist, turn, or lift. (Tr. at 36.) He said that his neuropathy caused severe tingling in his legs that felt like being electrocuted. (Tr. at 36.) Plaintiff testified that he had trouble going up and down stairs because of his back and knees, could not lift anything heavier than a two-liter bottle of soda, and could not crouch or squat. (Tr. at 39-40.) He said that he could not perform a sit-down job because constantly had to move around to due to his back pain and he could not sit for more than 15 minutes before having to stand. (Tr. at ...