Lori v. Commissioner of Social Security Administration

CourtDistrict Court, N.D. Ohio
DecidedMarch 16, 2023
Docket5:22-cv-01036
StatusUnknown

This text of Lori v. Commissioner of Social Security Administration (Lori v. Commissioner of Social Security Administration) is published on Counsel Stack Legal Research, covering District Court, N.D. Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Lori v. Commissioner of Social Security Administration, (N.D. Ohio 2023).

Opinion

IN THE UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF OHIO EASTERN DIVISION

GARY WILLIAMS LORI, ) Case No. 5:22-cv-1036 ) Plaintiff, ) ) MAGISTRATE JUDGE v. ) THOMAS M. PARKER ) COMMISSIONER OF ) SOCIAL SECURITY, ) MEMORANDUM OPINION AND ) ORDER Defendant. )

Plaintiff, Gary Williams Lori, seeks judicial review of the final decision of the Commissioner of Social Security, denying his application for disability insurance benefits (“DIB”) under Title II of the Social Security Act. Lori challenges the Administrative Law Judge’s (“ALJ”) non-disability finding, claiming that the ALJ erred by not further developing the record with a consultative examination and not adequately explaining the basis for her RFC findings. Because the ALJ failed to apply proper legal standards by failing to adequately articulate on what basis she made her RFC findings or why further record development was unnecessary, the Commissioner’s final decision denying Lori’s application for DIB must be vacated and Lori’s case must be remanded for further consideration. I. Procedural History On June 8, 2020, Lori applied for DIB. (Tr. 194).1 Lori alleged that he became disabled on April 1, 2016 due to: (i) herniated cervical discs; (ii) thoracic pain and numbness; (iii) lumbar pain; (iv) restricted movement; and (v) arthritis. (Tr. 194, 228). The Social Security

Administration denied Lori’s applications initially and upon reconsideration. (Tr. 56–59, 61– 64). Lori requested an administrative hearing. (Tr. 81–82). ALJ Mary Lohr heard Lori’s case telephonically on March 4, 2021 and denied Lori’s application in an April 12, 2021 decision. (Tr. 15–21, 26–54). In so ruling, the ALJ determined that Lori had the RFC to perform work at the medium exertional level, except that: [Lori] can lift 50 pounds occasionally and 25 pounds frequently; carry[] 50 pounds occasionally and 25 pounds frequently; sit[] for 6 hours, stand[] for 6 hours, [and] walk[] for 6 hours, and push/pull as much as [he] can lift/carry. He can frequently reach overhead to the left and frequently reach overhead to the right. [Lori] can never climb ladders, ropes, or scaffolds[ or crawl. He can] stoop frequently, kneel frequently, [and] crouch frequently[.]

(Tr. 18–19). On April 12, 2022, the Appeals Council declined further review, rendering the ALJ’s decision the final decision of the Commissioner. (Tr. 1–3). On June 15, 2022, Lori filed a complaint to obtain judicial review. ECF Doc. 1. II. Evidence A. Personal, Educational, and Vocational Evidence Lori was born on June 25, 1958. (Tr. 194). He was 57 years old on the alleged onset date and 58 years old on the date last insured (March 31, 2017). (Tr. 17). Lori completed two years of college and had no specialized or vocational training. (Tr. 229). Lori had past work as a boiler room helper, driver at a sales route, grinder setup operator, landscaper, and taxi driver,

1 The administrative transcript appears in ECF Doc. 6. which, with the exception of grinder setup operator, the ALJ determined Lori could perform. (Tr. 20–21, 32–39, 47–49, 229). B. Relevant Medical Evidence Lori’s medical history around the time of the alleged onset date included: (i) an anterior

cervical discectomy and fusion in 2005 (Tr. 295); (ii) a lumbar discectomy in 2000 (Tr. 295); and (iii) emergency room treatment for kidney stone pain and chronic obstructive pulmonary disease (“COPD”) in 2014 and January 2016 (Tr. 284–87, 389–99, 403–11). Lori did not seek or receive medical treatment during the period under adjudication. See (Tr. 40–41, 43–44, 377). On November 20, 2017, Lori visited Gerardo Cisneros, MD, to establish care. (Tr. 334). Lori reported back pain, ear discomfort, muscle aches and cramps, neck pain, and stiffness. (Tr. 334, 337). His physical examination results were remarkable for impacted ear canals, tender lumbar paraspinal muscles, and decreased range of motion. (Tr. 338). Dr. Cisneros diagnosed Lori with cerumen impaction and chronic back/neck pain and ordered x-ray testing. (Tr. 339). On December 5, 2017, Lori underwent x-ray testing. (Tr. 384, 386). Lori’s lumbar x-ray

test results showed diffuse lumbar spondylosis which was most severe at L5-S1: “[M]oderate to severe disc space narrowing at L5-S1 with endplate sclerosis, spurring and vacuum disc phenomenon. There is mild disc space narrowing throughout the remainder [of] the lumbar spine with minimal endplate spurring. … There are bilateral facet degenerative changes at L5- S1.” (Tr. 384). Lori’s cervical x-ray test results showed: (i) moderate to severe multilevel degenerative disc disease and degenerative facet arthropathy throughout the cervical spine; (ii) grade 1 degenerative listhesis at C3-C4 and C4-C5; (iii) congenital fusion of the C6 and C7 vertebral bodies; and (iv) severe multilevel bilateral foraminal stenosis secondary to a combination of hypertrophic degenerative facet arthropathy and uncovertebral spurring. (Tr. 386). On December 11, 2017, Lori returned to Dr. Cisneros to review his x-ray results, reporting back pain and neck pain with radiation to his extremities. (Tr. 328, 330). Lori’s

physical examination results were remarkable for tender paraspinal muscles and decreased range of motion. (Tr. 331). Dr. Cisneros diagnosed Lori with cervical spine stenosis and referred Lori to a specialist. (Tr. 332). On January 3, 2018, Lori visited neurosurgeon Georges Markarian, MD. (Tr. 295). Lori reported cervical neck pain with radiation to his upper extremities with numbness and weakness and back pain with radiation to his groin and anterior thigh. Id. Lori reported that his pain started in January 2016 but had worsened within the previous six months. Id. Lori’s physical examination results were remarkable for: (i) 4+/5 strength with elbow flexion and hand abduction; (ii) hyper-reflexive upper extremities with numbness in both arms; and (iii) 45° cervical spine extension, flexion, and rotation. (Tr. 297–98). Dr. Markarian diagnosed Lori with

cervical and lumbar radiculopathy and cervical myelopathy. (Tr. 298). Dr. Markarian ordered CT and MRI testing. Id. On January 18, 2018, Lori visited Dr. Cisneros for a follow-up, indicating that he did not “want to proceed” with Dr. Markarian’s recommended evaluations. (Tr. 323). He also reported back and neck pain. (Tr. 325). Dr. Cisneros recommended that Lori continue with Dr. Markarian’s recommendations. (Tr. 326). On April 4, 2018, Lori returned to Dr. Markarian, reporting neck pain with radiation into his upper extremities, numbness, tingling, and weakness. (Tr. 291). Lori reported loss of balance, dropping items from his hands, and fine motor difficulty. Id. And Lori reported midback pain. (Tr. 293). Lori’s physical examination results were remarkable for: (i) 15° cervical extension and rotation; (ii) 30° cervical flexion; and (iii) 3/4 reflex. (Tr. 292–93). According to Dr. Markarian, Lori’s MRI test results showed: “a previous C6-7 fusion anteriorly and his disc C5-6 looks reasonable. He has a C7-T1 disc bulge as well as C3-4 and C4-5 disc

bulge. … These areas of spondylosis at C3-4 and C4-5 result in moderate foraminal stenosis.”2 (Tr. 293). Dr. Markarian recommended that Lori undergo physical therapy. Id. On May 14, 2018, Lori visited Dr. Cisneros, requesting a referral for pain management and rehabilitation therapy. (Tr. 318). Lori also reported arthritis, back, and neck pain. (Tr. 320). His physical examination results were remarkable for tender lumbar paraspinal muscles and decreased range of motion. (Tr. 321). Dr. Cisneros issued a referral to a “Specialist.” (Tr. 321– 22). On December 9, 2019, Lori visited Nicole D’Amico, PA-C, for an orthopedic evaluation of his back pain. (Tr. 377). Lori reported that he started having back pain in April 2016 but could not afford to see a doctor. Id. Lori reported pain in the center of his low back, hips, and

calves rated at 6/10 in severity. Id.

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