Alley v. Astrue

862 F. Supp. 2d 352, 2012 U.S. Dist. LEXIS 71889, 2012 WL 1889784
CourtDistrict Court, D. Delaware
DecidedMay 23, 2012
DocketCiv. No. 10-777-SLR
StatusPublished
Cited by6 cases

This text of 862 F. Supp. 2d 352 (Alley v. Astrue) is published on Counsel Stack Legal Research, covering District Court, D. Delaware primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Alley v. Astrue, 862 F. Supp. 2d 352, 2012 U.S. Dist. LEXIS 71889, 2012 WL 1889784 (D. Del. 2012).

Opinion

MEMORANDUM OPINION

SUE L. ROBINSON, District Judge.

I. INTRODUCTION

James Alley (“plaintiff’) appeals from a decision of Michael J. Astrue, the Commissioner of Social Security (“defendant”), denying his application for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under Title II and Title XVI of the Social Security Act (“the Act”), 42 U.S.C. §§ 401-438, 1381-1383Í. [354]*354The court has jurisdiction over this matter pursuant to 42 U.S.C. § 405(g).1

Currently before the court are the parties’ cross motions for summary judgment. (D.I. 13, 15) Plaintiff seeks an award of benefits in his favor or, alternatively, a reversal and remand for further review. For the reasons set forth below, plaintiffs motion will be granted and defendant’s denied. The decision of the Commissioner dated September 11, 2009 will be reversed, and this matter will be remanded for further findings and/or proceedings consistent with this opinion.

II. BACKGROUND

A. Procedural History

Plaintiff filed his claim for DIB and SSI on November 16, 2006, alleging disability since the amended onset date of September 8, 2006 2 due to lower back and left leg pain. (D.I. 11 at 117, 123) Plaintiffs applications were denied initially and on reconsideration. (Id. at 71; 213-14) On April 29, 2009, a hearing on plaintiffs claims was held before an ALJ. (Id. at 21-47) At the hearing, the ALJ heard testimony from plaintiff and a vocational expert (“VE”). (Id. at 23, 40)

On September 11, 2009, the ALJ issued an unfavorable decision, finding plaintiff not disabled and denying plaintiffs claim for DIB and SSL (Id. at 10-20) The ALJ found that, while plaintiff could not perform his past work, he could perform a limited range of light work available in the national economy. Plaintiff appealed the ALJ’s decision to the Appeals Counsel, which declined to review the decision, making it a final decision reviewable by this court. (Id. at 1^4) Plaintiff filed the present action on September 13, 2010. (D.I. 1)

B. Factual Background

1. Plaintiffs medical history, treatment and condition

Plaintiff3 was born in 1965 and attended high school up to and including 11th grade.4 (D.I. 11 at 24, 242) Plaintiff was 41 years old at the time that he stopped working and is a younger individual under 20 C.F.R. §§ 404.1563(c), 416.963. (Id. at 114, 117) He was previously employed as a maintenance worker, for approximately 16 years at the same job at a farmers’ market in Delaware. (Id. at 195-196) Plaintiff had polio as a child. (Id. at 256, 364, 380)

The record medical evidence reflects that plaintiff commenced treatment for back problems in 1998. Specifically, in [355]*355July 1998, Michael G. Sugarman, M.D., a neurosurgeon, performed a lumbar L5-S1 diskectomy. (Id. at 263) Dr. Sugarman’s notes reveal that plaintiff “did very well following his surgery up until” about sometime in 2005, when his back pain recurred. (Id.) Plaintiff described this pain as radiating from his back down into his left leg and into the middle of his foot. He also experienced intermittent numbness and tingling.

On September 15, 2006, Mohammed Kamali, M.D., an orthopedic specialist, examined 5 plaintiff and evaluated his complaints of left hip pain. (Id. at 260) Dr. Kamali observed “no visible abnormality” in the left hip and the “range of hip motion [was] almost full and only minimally painful.” (Id.) Dr. Kamali noted that plaintiff walked very well with “no discernible limp.” After comparing x-rays, Dr. Kamali found changes in plaintiffs hip due to Perthes disease.6 He averred that if degenerative arthritis progressed, plaintiff might require hip replacement. Conservative treatment, including anti-inflammatory medication and exercise, was ordered. Dr. Kamali observed that plaintiff had an ongoing back problem and was under the care of Dr. Sugarman. A four month follow-up appointment, including x-rays, was recommended.

Plaintiff returned to Dr. Sugarman7 for an evaluation on November 3, 2006. (Id. at 263) Dr. Sugarman observed that plaintiff experienced “pain in his back going down into [his] left leg” extending to the inside of his foot. (Id.) Plaintiff complained of intermittent numbness and tingling, as well as stiffness and discomfort in his back. Although plaintiff took pain medication prescribed by Dr. Papa, the pain continued to interrupt his night time sleep. Dr. Sugarman’s notes also reflect that plaintiff experienced pain, numbness and tingling in his left hand. Plaintiff indicated that an EMG of this hand showed carpal tunnel syndrome.

After examining plaintiff and reviewing an MRI scan of the lumbosacral spine, Dr. Sugarman opined that

it shows degenerative disc disease at L5-S1 where there is a narrowing of the disc space and decreased signal on the T2 weighted images. There is mild decreased signal at L-5 as well. There does appear to be a slight residual/recurrent disc protrusion present more prominent to the left at L5-S1.

(Id.) Dr. Sugarman recommended surgical intervention, a fusion at L5-S1. (Id. at 264) He advised plaintiff to stop smoking cigarettes to increase the chances of a successful surgery. Dr. Sugarman recommended a two month follow-up visit to assess plaintiffs pain and progress with not smoking. In the meantime, Dr. Sugarman concluded that, considering plaintiffs pain level, doing anything other than a light duty position would be very difficult. (Id. at 264).

On March 6, 2007, Dr. Sugarman examined plaintiff during a preoperative visit. (Id. at 302) After reviewing plaintiffs MRI “again,” Dr. Sugarman questioned whether [356]*356he had a “clinically significant left sided disc herniation at L4-5” that required the planned surgery (decompression and fusion of L5-SI). To investigate further, Dr. Sugarman scheduled a selective nerve root block at L4 (on the left side).

On March 9, 2007, Dr. Sugarman reviewed the results of the nerve root block injection with plaintiff. (Id. at 300) Plaintiff reported that his level of pain was greatly improved, “dropping him from a pain level of a 6 or 7 to a pain level of 2.” (Id.) As a result, Dr. Sugarman told plaintiff that a fusion operation was unnecessary. Plaintiff agreed to continue the injections and scheduled a follow-up appointment to assess pain threshold in a month.

During a follow-up appointment with Dr. Sugarman on April 18, 2007, plaintiff stated that the injections were providing insufficient long term relief8 and requested that surgery be scheduled. (Id. at 299) After discussing the risks of surgery, Dr. Sugarman scheduled a left L-4-5 microdiscectomy.

On May 10, 2007, Dr.

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Cite This Page — Counsel Stack

Bluebook (online)
862 F. Supp. 2d 352, 2012 U.S. Dist. LEXIS 71889, 2012 WL 1889784, Counsel Stack Legal Research, https://law.counselstack.com/opinion/alley-v-astrue-ded-2012.