United States District Court, N.D. Indiana, Hammond Division
OPINION AND ORDER
JOHN E. MARTIN, District Judge.
This matter is before the Court on a Complaint [DE 1], filed by Plaintiff Andy Borrero Padilla on May 21, 2012, and Plaintiff's Memorandum in Support of His Motion for Summary Judgement [DE 17], filed by Plaintiff on October 3, 2012. Plaintiff requests that the February 9, 2011, decision denying his application for Disability Insurance Benefits be remanded. For the reasons set forth below, the Court grants Plaintiff's request for remand.
On September 30, 2009, Plaintiff filed an application for Disability Insurance Benefits ("DIB"), alleging disability as of September 10, 2009, due to diabetes, high blood pressure, high cholesterol, neuropathy, and back problems. After his claim was denied on February 3, 2010, and again on reconsideration on April 5, 2010, Plaintiff requested a hearing. On January 28, 2011, a hearing was held in front of Administrative Law Judge ("ALJ") Edward Studzinski at which Plaintiff testified through an interpreter. A vocational expert ("VE") also testified. On February 9, 2011, the ALJ issued a decision finding Plaintiff not disabled and denying benefits. On March 21, 2012, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. See 20 C.F.R. § 404.981. On May 21, 2012, Plaintiff filed suit in this Court for review of the Commissioner's decision.
The parties filed forms of consent to have this case assigned to a United States Magistrate Judge to conduct all further proceedings and to order the entry of a final judgment in this case. Therefore, this Court has jurisdiction to decide this case pursuant to 28 U.S.C. § 636(c) and 42 U.S.C. § 405(g).
Plaintiff was 38 years old at the time of his alleged onset date. He is a native Spanish speaker and is unable to communicate in English. He has a limited education and has past relevant work as a meat blender and a janitor.
B. Medical Evidence
In April 2008, Plaintiff saw Dr. Ralph W. Richter regarding complaints of fingers in both hands locking, a condition he claimed to have had for several years. Plaintiff was diagnosed with trigger finger and, after conservative treatment failed, underwent surgery on November 13, 2009. Dr. Richter indicated that Plaintiff would be able to return to work approximately four weeks after surgery.
In March and April 2008, Plaintiff saw Dr. Jaime Ruiz-Montero, complaining of swelling in his legs. Dr. Ruiz-Montero prescribed Lasix and advised Plaintiff to decrease his salt intake and take his medications every day. On August 17, 2009, Plaintiff again saw Jaime Ruiz-Montero, complaining of swelling to his legs, which he reported was worse after work. Dr. Ruiz-Montero noted that Plaintiff was non-compliant with diet and medication. Dr. Ruiz-Montero diagnosed leg edema, morbid obesity, hypertension, and uncontrolled diabetes and advised Plaintiff to take his medications on a daily basis, to lose weight, and to increase his physical activity.
On September 11, 2009, Plaintiff saw Dr. Ruiz-Montero again, complaining of weakness in the left side of his face. Dr. Ruiz-Montero prescribed medications and advised Plaintiff to undergo a physical therapy evaluation. On September 15, 2009, Plaintiff saw Dr. Pradeep V. Kalokhe, who diagnosed Bell's Palsy, secondary to diabetes, and neuropathy, secondary to diabetes. On September 23, 2009, Plaintiff underwent a physical therapy evaluation. The attending physical therapist administered various treatments to Plaintiff, diagnosed Plaintiff with facial weakness on account of Bell's Palsy, and found Plaintiff to have a good prognosis. Plaintiff was instructed to undergo physical therapy three times per week for four weeks.
On October 20, 2009, Plaintiff saw Dr. Ruiz-Montero, complaining of pain in his lower back that radiated to his legs and of weakness in his legs. Dr. Ruiz-Montero ordered X-rays. On October 22, 2009, Plaintiff underwent a lumbar spine X-ray. It showed degenerative changes in Plaintiff's lumbar spine, but an MRI was suggested for further evaluation. On November 10, 2009, Plaintiff underwent a lumbar MRI. The results showed clumping of the nerve roots within the thecal sac which "may be secondary to arachnoiditis"; narrowing of the L5-S1 intervertebral disc space; a broad based posteriorly bulging disc with a superimposed left paracentral disc herniation; disc material extending somewhat caudally and abutting the left S1 nerve root; neuroforamina which are narrowed bilaterally at the L5-S1 level; and facet joint hypertrophy, most pronounced at the L5-S1 level. A post gadolinium MRI of the lumbar spine was suggested for further evaluation, but no record of further MRI testing exists in the record.
Dr. Ruiz-Montero referred Plaintiff to orthopedic surgeon Dr. Joseph P. Spott for his back problems, and on November 11, 2009, Plaintiff saw Dr. Spott. Plaintiff complained of radicular back pain into his bilateral legs, for which he reported no known cause but indicated that he had these symptoms for the past eight months. Dr. Spott diagnosed lumbar degenerative disc disease at L5/S1. He recommended nonoperative management first to be followed by surgical management if necessary.
For the nonoperative management options, Dr. Spott referred Plaintiff to Dr. Rajive K. Adlaka. On November 24, 2009, Dr. Adlaka wrote that he thought Plaintiff was a good candidate for tranforaminal epidural injection and noted that Plaintiff "was agreeable to proceed." AR 368. Dr. Adlaka also noted that he had discussed medication management options with Plaintiff but that "[a]t this point in time [Plaintiff] is not interested in anything." AR 368. In a January 25, 2010, note, Dr. Adlaka indicated that Plaintiff had been unable to pursue the recommended epidural injections because of elevated blood sugar levels but that Plaintiff continued to be "agreeable to proceed" once his blood sugar was under control. AR 366.
On February 1, 2010, state agency reviewing psychologist, Donna Unversaw, Ph.D., prepared a Mental Residual Functional Capacity Assessment, checking boxes indicating some moderate limitations in areas of concentration, persistence, and pace. She opined that Plaintiff "show[ed] adequate ability to learn, remember, and follow instructions consistent with his physical abilities and when instructed in his language, " that despite "some interruption in [attention/concentration] and overall pace due to mood/pain factors, [Plaintiff] retains sufficient abilities to attend/complete tasks consistent with the above, " and that "[h]e may have some interruption in stress tolerance, though this would not preclude him from performing routine tasks." AR 379.
On February 16, 2010, Plaintiff returned to Dr. Kalokhe for reasons not specified in Dr. Kalokhe's notes. Dr. Kalokhe recommended Plaintiff undergo EMG studies of both upper extremities and an MRI of his cervical spine. On February 24, 2010, Plaintiff underwent EMG studies of his upper and lower extremities. The results showed normal upper extremities, but the lower extremities study was consistent with sensorimotor polyneuropathy without evidence of denervation. On March 31, 2010, Plaintiff returned to see Dr. Kalokhe. Dr. Kalokhe note again provides few details of the visit, but it includes diagnoses of diabetes, peripheral neuropathy, and "lumbar spondylitis disc disease?, " and also mentioned arachnoiditis. Dr. Kalokhe referred Plaintiff for a neurosurgery/spine surgery evaluation and noted that "[b]ecause of the above problems he could be considered disabled from physical jobs." On May 4, 2010, Plaintiff saw Dr. Kalokhe for a follow up. Dr. Kalokhe note again provides few details but lists as diagnoses severe peripheral neuropathy secondary to diabetes, lumbar spondylitis, arachnoiditis, and stenosis. Dr. Kalokhe also noted that "[t]his patient should be considered disabled for any job due to his multiple problems listed above." AR 405.
C. Plaintiff's Testimony
Plaintiff testified at the hearing with the aid of an interpreter. He testified that he suffers from back pain that lasts all day, increasing with activity and decreasing when he is seated. He also stated that he wakes to fingers on both hands being "stuck" every morning, a condition that can last for some time. Plaintiff stated he uses a cane on a daily basis, both while standing and walking, because at times he experiences an electrical sensation in his legs that causes his knees to give out. He also stated that he purchased a recliner to keep his legs elevated because they swell up on a daily basis. He said he would not be able to walk more than a half-block due to his back pain. Plaintiff also testified that he had sought treatment from a psychiatrist but had stopped seeing her due to her inability to speak Spanish and his inability to communicate in English.
D. ALJ's decision
On February 9, 2011, the ALJ issued a decision finding Plaintiff not disabled. He found that Plaintiff suffered from the following severe impairments: degenerative disc disease of the lumbar spine (DDD); insulin dependent diabetes mellitus (IDDM); major depressive disorder with psychosis (MDD); and obesity. He further found that Plaintiff does not have an impairment or combination of impairments that meets or medically equals one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1. He determined that Plaintiff had a residual functional capacity ("RFC") to perform light work "except that claimant can never climb ladders, ropes, or scaffolds; the claimant is limited to work comprised of simple, routine, repetitive tasks; and, the claimant is limited to only occasional interaction with the general public." AR 21. He further limited Plaintiff's RFC to require an "option to alternate between sitting and standing once an hour." AR 21. In determining Plaintiff's RFC, the ALJ found Plaintiff's statements regarding "the intensity, persistence and limiting effects of [his] symptoms... not credible to the extent they are inconsistent with the above residual functional capacity" and assigned "little weight" to Dr. Kalokhe's opinion that Plaintiff should be considered disabled. AR 21, 25.
Based on Plaintiff's RFC and the testimony of the VE, the ALJ determined he was unable to perform any past relevant work. However, the ALJ found that there are jobs that exist in significant numbers in the national economy that Plaintiff can perform given his age, education, work experience, and residual functional capacity. Accordingly, the ALJ found Plaintiff not disabled from September 10, 2009, through the date of the decision.
STANDARD OF REVIEW
The Social Security Act authorizes judicial review of the final decision of the agency and indicates that the Commissioner's factual findings must be accepted as conclusive if supported by substantial evidence. 42 U.S.C. § 405(g). Thus, a court reviewing the findings of an ALJ will reverse only if the findings are not supported by substantial evidence or if the ALJ has applied an erroneous legal standard. See Briscoe v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005). Substantial evidence consists of "such relevant evidence as a reasonable mind might accept as adequate to ...