United States District Court, S.D. Indiana, New Albany Division
REPORT AND RECOMMENDATION
TIM A. BAKER, Magistrate Judge.
The parties appeared by counsel December 10, 2014, for an oral argument on Plaintiff's appeal of her denial of disability benefits. Set forth below is the Magistrate Judge's recommended decision issued from the bench following that argument. This ruling recommends that the ALJ's determination be reversed and that this case be remanded pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings. Any objections to the Magistrate Judge's Report and Recommendation shall be filed with the Clerk in accordance with 28 U.S.C. § 636(b)(1). Failure to file timely objections within fourteen days after service shall constitute waiver of subsequent review absent a showing of good cause for such failure.
THE COURT: All right. We're back on the record. Everybody still with us?
MS. MARCUS: Yes, Your Honor.
MR. WOLTERING: Yes, Your Honor.
MR. KIEPER: Yes, Your Honor.
THE COURT: I appreciate your patience. I will now give you my recommended decision.
By way of background, plaintiff filed applications for disability benefits on May 26, 2010, alleging disability as of August 24, 2009, due to degenerative arthritis, high blood pressure, and nerve damage in her right lower extremity, as well as depression. The applications were initially denied.
On October 12, 2011, plaintiff appeared before an ALJ via video conference. On July 27th, 2012, the ALJ denied plaintiff's disability claim. Record at 16. The appeals counsel then denied plaintiff's request for review on September 17, 2013.
I will now recite the facts of the case briefly, but I would note that the Commissioner conceded in her brief at Docket No. 22, page 3, that the ALJ's decision accurately summarizes the relevant medical evidence. Therefore, I do not need to rehash all of the evidence. However, I'd like to emphasize a few important points.
Going back to 2007, the plaintiff underwent evaluation for complaint of bilateral tingling and numbness in her hands, in addition to back and neck pain that radiated into her right leg.
Imaging studies revealed spondylosis at C3-L4, marked disk changes at C4 through C5, and C5 through L6, with compressed cord and white matter change. Spinal surgery was recommended, and on September 26th, 2007, plaintiff underwent an anterior cervical disk excision and interbody fusion at C4 through 5, and C5 through 6 for diagnoses of central and left herniated disks with myelopathy. That's in the record at pages 262 through 263.
Plaintiff's pain subsided, but returned shortly thereafter, and she again sought treatment for her symptoms in May of 2008. By that time, plaintiff was taking several medications, including Hydrocodone, Baclofen, Gabapentin, and oral steroids in an effort to control her pain.
After examining her and reviewing a recent MRI, Dr. Andrew Robertson diagnosed plaintiff with multilevel degenerative facet changes at L3 through 4, L4 through L5, and L5 through S1, as well as a disk bulge at L5 through S1. Record, pages 280 through 283.
Plaintiff then began a regimen of physical therapy, medication, and nerve blocks at L3 and L5. Even with these measures, plaintiff continued to complain of pain. Plaintiff was unable to pay for her medical care at times and had to rely on hospital emergency rooms for treatment.
Beginning in August of 2008, plaintiff was repeatedly seen at Columbus Regional Hospital for back pain. Record, pages 349 through 64, and 372 through 378.
On July 27, 2009, plaintiff underwent evaluation by Dr. Stephen Kirk Douglas, MSN. I think I referred to Douglas as a doctor, let me clarify that. Stephen Kirk Douglas, MSN, also ACNP, for increasing back pain. Patient was observed to be limping and had a positive straight leg raise test on the right side. Record, at page 288.
She also complained of fatigue and low back pain that was increasing in frequency. Douglas referred plaintiff for additional imaging studies that subsequently confirmed disk protrusion and bilateral neural foraminal narrowing at L4 through 5, along with disk desiccation and protrusion with neural foraminal airway at L5 through S1. Record, pages 289 through 309.
On August 16, 2010, consultative examiner, Dr. Theodora Saddoris, examined plaintiff as part of her Social Security disability process and observed the plaintiff complained of a significant weight gain and muscle, joint and lower back pain. She walked with a limp, and was unable ...