Halloran v. Berryhill

290 F. Supp. 3d 307
CourtDistrict Court, M.D. Pennsylvania
DecidedNovember 21, 2017
DocketCIVIL ACTION NO. 3:17–CV–11
StatusPublished
Cited by7 cases

This text of 290 F. Supp. 3d 307 (Halloran v. Berryhill) is published on Counsel Stack Legal Research, covering District Court, M.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Halloran v. Berryhill, 290 F. Supp. 3d 307 (M.D. Pa. 2017).

Opinion

RICHARD P. CONABOY, United States District Judge

Pending before the Court is Plaintiff's appeal from the Commissioner's denial of Disability Insurance Benefits ("DIB") under Title II of the Social Security Act. (Doc. 1.) Plaintiff filed an application for benefits on November 9, 2013, alleging a disability onset date of August 1, 2012. (R. 18.) After he appealed the initial denial of the claim, a hearing was held on August 4, 2015, and Administrative Law Judge ("ALJ") Michelle Wolfe issued her Decision on October 6, 2015, concluding that Plaintiff had not been under a disability from the alleged onset date of August 1, 2012, through the date of the decision. (R. 40, 50.) Plaintiff requested review of the ALJ's decision which the Appeals Council denied on February 6, 2017. (R. 1-6.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)

Plaintiff filed this action on January 3, 2017. (Doc. 1.) He asserts in his supporting brief that the ALJ erred at step three in his determination that Plaintiff did not meet the requirements of Impairment Listings 1.02, 1.03, or 1.04 and when he afforded great weight to the state agency reviewer's decision in assessing Plaintiff's residual functional capacity ("RFC"). (Doc. 18 at 21-22.) After careful review of the record and the parties' filings, the Court concludes this appeal is properly granted.

I. Background

Plaintiff was born on August 16, 1963, and was forty-eight years old on the date last insured. (R. 26.) He has a college degree, served in the United States Air Force for four years, and worked for the United States Postal Service for more than twenty-four years as a mail clerk, letter carrier, and postmaster. (R. 61; Doc. 18 at 3.) He alleged disability as of August 1, 2012, due to his progressive spinal condition, hip joint dysfunction, and depression. (Doc. 18 at 3.) Plaintiff died on August 8, 2017. (Doc. 24 at 1.)

*310A. Medical Evidence2

Plaintiff had a partial laminectomy at the L4-5 level in 1985 while serving in the Air Force. (R. 472.) He had a second spinal fusion surgery at the same level in 1992 due to ongoing complaints. (Id. ) Plaintiff ultimately had a third spinal surgery in 1993 to remove damaged hardware. (Id. ) Citing evidence of a progressive spinal impairment leading up to the disability onset date (see Doc. 18 at 4-12 (internal citations omitted) ), the first record evidence cited during the relevant time period is a December 20, 2012, visit with Dr. Metgud at the VA Medical Center in Wilkes-Barre, Pennsylvania (Doc. 18 at 12 (citing R. 421) ). On December 20th, Plaintiff complained of chronic bilateral leg pain rated at 5/10 which he described as throbbing and aggravated by cold weather, walking, and activity. (R. 421.) He also complained of back pain. (R. 415.) Dr. Metgud noted that Plaintiff had spinal stenosis as per MRI done in September 2008, he had right hip replacement in 2006 and left hip replacement in 2011. (Id. ) On examination, Dr. Metgud did not find edema, cyanosis, or clubbing of the extremities, and he found no local tenderness of the back but observed a scar in the lumbosacral region. (R. 415-16.) Plaintiff was directed to follow up with an outside surgeon for his chronic back pain and continue with vicodin. (R. 416.) Dr. Metgud's examination and recommendation were the same in August 2013. (R. 831.)

September 2013 evaluation by the Department of Veterans' Affairs indicate a diagnosis of bilateral hip degenerative joint disease, bilateral total hip replacements, degenerative disc disease, lumbosacral spine, lumbar spinal stenosis status post lumbar laminectomy and fusion, and lumbar radiculopathy. (R. 812, 820.) Both the hip/thigh and spinal conditions resulted in daily pain flares. (R. 813, 821.)

Plaintiff had a decreased range of motion in both hips with objective evidence of painful motion throughout. (R. 813-14.) Functional loss and/or functional impairment of the hip and thigh were assessed bilaterally and, after repetitive use, the following contributing factors of disability were identified: less movement than normal; weakened movement; pain on movement; disturbance of locomotion; and interference with sitting, standing, and/or weight bearing. (R. 816.) Localized tenderness to palpation was noted for the joints/soft tissue of the right hip. (Id. ) Findings also indicated degenerative or traumatic arthritis of both hips documented by imaging studies. (R. 819.) The Disability Benefits Questionnaire further indicated that Plaintiff's hip and/or thigh condition functionally impacted his ability to work due to pain, decreased mobility, and difficulty with prolonged standing, walking, or sitting. (R. 819.)

Plaintiff had restricted lumbar flexion and extension as well as limited bilateral lateral flexion and rotation. (R. 822.) Functional loss and/or functional impairment of the thoracolumbar spine was assessed and the contributing factors of disability after repetitive use were identified to be the following: less movement than normal; weakened movement, excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and/or weight bearing. (R. 823-24.) The questionnaire indicated that Plaintiff had localized tenderness or pain to palpation of the lumbar spine, paraspinal and SI joint tenderness with palpation and movement.

*311(R. 824.) It also indicated that Plaintiff had guarding or muscle spasm of the thoracolumbar spine severe enough to result in an abnormal gait. (Id. ) Sensory exam showed decreased sensation to light touch of the upper anterior right thigh, the right thigh/knee, the right lower leg/ankle, and the right foot/toes. (R. 825.) Straight leg raising test was positive on the right and negative on the left. (Id. ) Radiculopathy evaluation indicated that Plaintiff had radicular pain which could be excruciating at times: he had moderate constant pain in the right lower extremity and mild intermittent pain in the left lower extremity; he had severe paresthesias and/or dysesthesias in the right lower extremity and mild paresthesias and/or dysesthesias in the left lower extremity; and he had severe numbness in the right lower extremity. (R. 826.) Nerve root involvement was identified at right L4/L5/S1/S2/S3. (Id. ) The severity of the radiculopathy and side effects was assessed to be moderate. (Id. ) Plaintiff's back condition was found to impact Plaintiff's ability to work due to pain, decreased mobility, difficulty with lifting, bending, twisting, and prolonged standing, walking or sitting. (R. 828.)

On January 18, 2014, Matthew Kozicki, M.D., saw Plaintiff for a disability evaluation. (R. 214.) At the time, Plaintiff rated his lower back pain as 8/10 in severity, intermittent in nature, and worsened by any type of bending, crouching, or activity. (Id. ) Plaintiff also described radiation down his right leg and associated numbness and tingling. (Id. ) Plaintiff listed his medications to be Naproxen, Flexeril, Vicodin, and hydrochlorothiazide. (R. 216.) Physical examination showed normal ambulation, no difficulty getting out of a chair but difficulty lying flat on the exam table, and no difficulty getting off the exam table. (R.

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Bluebook (online)
290 F. Supp. 3d 307, Counsel Stack Legal Research, https://law.counselstack.com/opinion/halloran-v-berryhill-pamd-2017.