United States District Court, S.D. Indiana, Indianapolis Division
TERRY D. LEDBETTER, Plaintiff,
CAROLYN COLVIN, Acting Commissioner of the Social Security Administration, Defendant.
ORDER ON MAGISTRATE JUDGE'S REPORT AND RECOMMENDATIONS
SARAH EVANS BARKER, District Judge.
This is an action for judicial review of the final decision of Defendant Carolyn Colvin, the Commissioner of the Social Security Administration ("Commissioner"), finding Plaintiff Terry D. Ledbetter not entitled to Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Title II and Title XVI of the Social Security Act. See 42 U.S.C. §§ 416(i), 423(d), 1381a, & 1382(a). This case was referred for consideration to Magistrate Judge Baker, who on June 13, 2014 issued a Report and Recommendation that the Commissioner's decision be upheld because an error made by the ALJ was harmless and the decision was otherwise supported by substantial evidence and in accordance with law. This cause is now before the Court on Plaintiff's objections to the Magistrate Judge's Report and Recommendation. For the reasons set forth below, we SUSTAIN Plaintiff's objections to the Report and Recommendation, and we REVERSE the decision of the Commissioner and REMAND the matter for further proceedings.
Factual and Procedural Background
Plaintiff Terry D. Ledbetter is a 53-year-old resident of Anderson, Indiana. A high-school graduate, Ledbetter has in the past worked as an electrician. He claims a disability onset date of November 1, 2008. R. 129-143.
Ledbetter has a history of back problems, with pain radiating from the back to his left hip and leg. He has presented records of treatment with pain specialist Dr. Charles Howe starting in 2009. Dr. Howe performed lumbar epidural injections to control pain in June 2009, August 2009, and September 2009, and a "mutifidus myofascial trigger-point" steroid injection on October 13, 2009. See R. 217, 220-221, 226-230, 245. Ledbetter underwent an MRI on July 8, 2009 that showed "lumbar degenerative disc disease" in his L4-L5 vertebrae with "mild central stenosis" and "mild facet degeneration." R. 225. Dr. Howe noted that Ledbetter reported his pain as ranging from 5/10 on a 10 point scale at best, to 10/10 at worst; he further noted in July 2009 that Ledbetter complained of "aching throbbing, stabbing [pain] shooting down his left leg in a global manner. Walking, sitting, and standing can be very difficult. Only lying supine offers him relief." R. 222. As Dr. Howe noted in his records, Ledbetter had been recommended for back surgery by a previous physician, Dr. Tekula, but he declined the surgery because it was not covered under his health insurance. R. 273. Dr. Howe prescribed Norco and Motrin to combat the pain. Id. Ledbetter also underwent physical therapy at the Erskine Rehabilitation Center in 2009, but his discharge notes indicated that, as of October 2009, most of the therapeutic goals were not met and he continued to have difficulty sleeping, "extremity/trunk weakness, " and difficulties with joint mobility and range of motion. R. 241.
Ledbetter's primary care physician is Dr. Charles Purdy, who stated in July 2011 that he had treated Ledbetter for back pain on nine occasions starting in June 2009, and that Ledbetter's back complaints dated back to 2007. R. 328. Dr. Purdy completed a "medical source statement" ("MSS") in December 2010, in which he provided opinions related to Ledbetter's ability to perform work functions. R. 286. Dr. Purdy certified that the following "objective signs" of Ledbetter's back impairment were present: reduced range of motion in the lumbar spine, tenderness, and muscle spasms. Id. He stated that Ledbetter was "severely" limited in his ability to "deal with work stress, " and that his pain would "constantly" interfere with his attention and concentration levels. R. 287. As for Ledbetter's capacity to perform physical functions, Dr. Purdy stated that he could sit for a maximum of less than 15 minutes before alternating positions and walking about for an hour period, and that he could sit a maximum of one hour cumulatively during an eight-hour workday and stand or walk for a cumulative four hours in an eight-hour workday. R. 288. Finally, he stated that Ledbetter would need at least one hour of "resting/lying down or reclining in a supine position" in an eight-hour workday. R. 289.
Consultative examiner Mohammed Saquib examined Ledbetter on January 22, 2011. Dr. Saquib found that Ledbetter was "able to grasp, lift, carry, [and] manipulate objects in both hands and perform repeated movements with both feet, " but was "not able to bend over and... can squat [halfway]. [Ledbetter] is able to sit [and] stand normally and he walks with antalgic gait." R. 299. Dr. Saquib also noted during the examination that Ledbetter was able to walk without assistive devices, and was able to get on and off the examination table "with difficulties." R. 298. His examination revealed significantly reduced ranges of motion in Ledbetter's cervical and lumbar spine regions and his hips, and some limitations on range of motion in his shoulders and wrists. R. 300. X-rays conducted in February 2011 revealed cervical spondylosis with decreased disc height in the C3-C7 vertebrae, and "severe degenerative disc disease" in Ledbetter's lumbar spine. R. 300-303.
Later in February 2011, state agency reviewing physician Fernando Montoya filled out a residual functional capacity (RFC) report based on a review of Ledbetter's records; Dr. Montoya did not examine Ledbetter. Dr. Montoya found only "slight" limitations of Ledbetter's spine in the lower and upper extremity; he opined that Ledbetter could perform light work with occasional postural restrictions. R. 304-311. In contrast to Dr. Purdy, Dr. Montoya found that that Ledbetter could "stand and/or walk (with normal breaks)" for about six hours in a workday, and could sit (with normal breaks) for six hours in a workday as well. Dr. Montoya summarized his findings by stating that, while Ledbetter had back pain symptoms, "the intensity of the symptoms and their impact on functioning are not consistent with the totality of the evidence. Specifically the [claimant] is fully functional and [without] limitations." R. 309.
At the time of his testimony before the Administrative Law Judge (ALJ) in 2012, Ledbetter reported that his symptoms and pain were largely unchanged from the previous year. R. 36. He testified that he had moved in with his mother so that she could help him with tasks like cooking, laundry and transportation, and he related that he spends six to eight waking hours, on average, lying on his back because that posture provides the greatest pain relief. R, 40. He reported that he could drive a car, though he does so rarely; he also stated that, on occasion, he could walk roughly a city block. R. 43. Finally, he stated that he could sit only with frequent breaks, and that he avoided any lifting because it produced "immediate pain." R. 43-44. His most recent jobs were as an electrician with West Electric (2006) and Wyatt Electric (2007-2008). Ledbetter recounted that he had missed an average of five days a month because of his back pain at his most recent job, and had been laid off as a result of this chronic absenteeism. R. 33. He has not worked since 2008.
Plaintiff filed a Title II application for Disability Insurance Benefits (DIB) on November 8, 2010, and a Title XVI application for Supplemental Security Income (SSI) on November 19, 2010. His claims were denied initially on February 23, 2011, and upon reconsideration on April 18, 2011. Plaintiff requested a hearing, which ALJ Rebecca LaRiccia held on January 12, 2012. R. 13.
In a decision issued on February 3, 2012, the ALJ found that Plaintiff was not entitled to DIB or SSI benefits. Applying the five-step analysis employed in determining eligibility for Social Security benefits, the ALJ determined initially that Plaintiff had not engaged in substantial gainful activity since his alleged onset date of November 1, 2008 (Step One), and that he suffered from "severe" impairments: discogenic and degenerative disorders of the lumbar and cervical spine (Step Two). R. 15-16. At Step Three, however, the ALJ found that these impairments did not meet the criteria for Listing 1.04 (disorders of the spine) or any other listing. R. 16. After ruling out disability according to any listing, the ALJ then determined Plaintiff's residual functional capacity (RFC): "the claimant has the residual functional capacity to perform light work... except that he cannot climb ladders, ropes or scaffolds, but can occasionally climb ramps and stairs; he can occasionally stoop, kneel, crouch, and crawl. He must avoid exposure to hazards such as unprotected heights and dangerous moving machinery." R. 16 (citations omitted). At Steps Four and Five, the ALJ found that Plaintiff could not perform his past relevant work-but relied on the opinion of a vocational expert to conclude that jobs were available in the national economy which Plaintiff could perform, consistent with his RFC. R. 19-20.
The Appeals Council denied review of the ALJ's decision on April 17, 2013, thus ratifying it as the Commissioner's final decision. Plaintiff filed a timely civil action,  and Magistrate Judge Baker issued his ...