United States District Court, N.D. Indiana, Hammond Division At Lafayette.
FINDINGS, REPORT AND RECOMMENDATION OF UNITED STATES MAGISTRATE JUDGE PURSUANT TO 28 U.S.C. § 636(b)(1)(B) & (C)
JOHN E. MARTIN, Magistrate Judge.
This matter is before the Court on a Complaint [DE 1], filed by Plaintiff Edward Boyer on June 27, 2013, and a Memorandum of Plaintiff [DE 11], filed by Plaintiff on January 3, 2014. Plaintiff requests that the April 18, 2012, decision of the Social Security Administration denying him disability benefits be reversed and remanded with instructions to award benefits. On February 21, 2014, the Commissioner filed a response. Plaintiff did not file a reply, and the time to do so has passed.
On May 2, 2014, District Court Judge Theresa L. Springmann entered an Order [DE 13], referring this matter to the undersigned Magistrate Judge for a report and recommendation on the instant motion pursuant to 28 U.S.C. § 636(b)(1)(B). This Report constitutes the undersigned Magistrate Judge's combined proposed findings and recommendations pursuant to 28 U.S.C. § 636(b)(1)(C).
For the following reasons, the Court recommends that Judge Springmann GRANT the relief requested in the Brief in Support of Complaint and remand this case for further proceedings.
On January 27, 2010, Plaintiff filed an application for Social Security Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI), alleging he became disabled on April 21, 2009, due to chronic neck and back pain, nerve damage in his legs and arms, and anxiety. After his DIB application was denied initially and on reconsideration, Plaintiff requested a hearing in front of an Administrative Law Judge (ALJ). On May 2, 2011, a hearing was held in front of ALJ William M. Manico. On May 11, 2011, ALJ Manico issued a decision finding Plaintiff disabled as of December 2, 2009. However, on September 14, 2011, the Appeals Council notified Plaintiff that it had on its own motion reviewed the decision and was remanding it to the ALJ.
On March 2, 2012, a second hearing was held in front of ALJ Edward P. Studzinski. On April 18, 2012, ALJ Studzinski issued a decision in which he found Plaintiff not disabled. On April 26, 2013, 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 June 27, 2013, Plaintiff filed this civil action, pursuant to 42 U.S.C. § 405(g), for review of the Commissioner's decision.
A. Medical Evidence
1. Treatment Records
Plaintiff's records indicate that he began receiving physical therapy and injections to treat back and neck pain after suffering an injury to his neck some time in 2004. On February 23, 2009, Plaintiff began seeing Dr. Keith Whiteside. On March 24, 2009, Dr. Whiteside noted that an MRI from a few years earlier showed signs of disease in the C5-6 and C6-7 vertebrae. Dr. Whiteside ordered another MRI, which was performed on April 14, 2009. The MRI results noted the existence of a large left paracentral/lateral herniated nucleus pulposus with cord impingement at C5-C6 and an annular herniated nucleus pulposus with moderate to severe central canal stenosis at C6-C7.
Dr. Whiteside referred Plaintiff to neurosurgeon Randy Gehring, who first saw Plaintiff on April 21, 2009. Plaintiff reported to Dr. Gehring that the pain radiating from his neck down his left arm and, to a lesser extent, his right arm since his neck injury had gotten much worse in the prior two months. After reviewing X-rays of Plaintiff's spine, Dr. Gehring concluded that Plaintiff had "long-term neck pain with multilevel degenerative change, congenital stenosis, possible ossification of the posterior longitudinal ligament at C5-C6 and C6-C7, and now with a left-sided disk herniation." AR 391. Dr. Gehring recommended disk arthroplasty if Plaintiff's insurance would pay for it or, if not, a diskectomy. On April 27, 2009, Dr. Gehring performed a diskectomy.
At a follow-up with Dr. Gehring on May 21, 2009, Plaintiff reported that his pain had not changed. Dr. Gehring recommended physical therapy. On June 5, 2009, Plaintiff returned to Dr. Gehring and reported that his pain remained severe. Dr. Gehring recommended a second diskectomy and fusion at C5-C6 and C6-C7, which he performed on June 12, 2009.
On July 20, 2009, Plaintiff was evaluated by a physical therapist. He reported a "bone on bone sensation" in his neck, shoulder tightness, shooting pains down his left upper extremities, and dull, shooting pain and numbness in the fingers of his left hand. His physical therapy plan called for him to be seen two to three times a week for three to four weeks. Reports from the physical therapy sessions indicate that Plaintiff continued to experience pain or numbness in his neck and left arm and ...