United States District Court, N.D. Indiana, Hammond Division
OPINION AND ORDER
PAUL R. CHERRY, Magistrate Judge.
This matter is before the Court on a Complaint [DE 1], filed by Plaintiff Dewanda D. Coppage on November 13, 2013, and Plaintiff's Brief in Support of Her Motion to Reverse the Decision of the Commissioner of Social Security [DE 12], filed on March 28, 2014. Plaintiff requests that the February 14, 2014, decision of the Administrative Law Judge denying her claims for supplemental security income be reversed for an award of benefits or remanded for further proceedings. On July 7, 2014, the Commissioner filed a response, and Plaintiff filed a reply on July 21, 2014. For the following reasons, the Court grants Plaintiff's request for remand.
Plaintiff filed an application for supplemental security insurance benefits on December 6, 2010, alleging an onset date of June 1, 2010. Her initial claim was denied on June 9, 2011, and her request for reconsideration was denied on July 25, 2011. Plaintiff timely requested a hearing, which was held on August 30, 2012. Following the hearing, Administrative Law Judge ("ALJ") Edward P. Studzinski issued a written decision denying benefits and making the following findings:
1. The claimant has not engaged in substantial gainful activity since December 6, 2010, the application date.
2. The claimant has the following severe impairment: status-post bypass surgery; status-post right ventricular fistula; diabetes mellitus with peripheral neuropathy; and mood disorder.
3. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1.
4. After careful consideration of the entire record, I find that the claimant has the residual functional capacity to perform sedentary work as defined in 20 CFR 416.967(a), as the claimant can lift and/or carry 10 pounds occasionally and lighter weights more frequently; stand and/or walk for 2 hours; and sit for 6 hours in an 8-hour work day. The claimant can stand or walk for no more [than] 15 minutes at any time before needing to sit briefly; and she can sit for no more than an hour at a time before having to stand and/or walk for 5 minutes without abandoning her work tasks. The claimant cannot climb ladders, ropes, or scaffolds but can occasionally climb ramps and stairs; and occasionally balance, stoop, kneel, crouch, and crawl. The claimant can never reach overhead with her left non-dominant upper extremity; and can frequently perform fine and gross manipulation with her left non-dominant upper extremity. The claimant is unlimited in her ability to use her dominant right upper extremity. The claimant can never be around unprotected heights, large bodies of water, unexposed flames; and must avoid concentrated exposure to unguarded hazardous machinery. The claimant cannot drive or operate moving machinery. The claimant is limited to simple, routine, and repetitive tasks that require simple decision-making and the exercise of simple judgment. The claimant can handle occasional and minor changes in the workplace. The claimant can have brief and superficial interaction with coworkers and supervisors; and no direct public service jobs but can handle brief and superficial interactions with the public.
5. The claimant has no past relevant work.
6. The claimant was born [in 1963] and was 47 years old, which is defined as a younger individual age 45-49, on the date the application was filed.
7. The claimant has a limited education and is able to communicate in English.
8. Transferability of job skills is not an issue because the claimant does not have past relevant work.
9. Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform.
10. The claimant has not been under a disability, as defined in the Social Security Act, since December 6, 2010, the date the application was filed. (AR 13-23).
The Appeals Council denied Plaintiff's request for review, leaving the ALJ's decision the final decision of the Commissioner. See 20 C.F.R. § 416.1481. Plaintiff filed this civil action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) for review of the Agency'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).
A. Medical Background
In October 2010, an electromyogram ("EMG") was performed due to Plaintiff's history of severe pain in both lower extremities and her lower back. The EMG impression was an abnormal study showing evidence of peripheral neuropathy.
On November 10, 2010, Plaintiff was admitted to the hospital with abdominal pain, and it was discovered that she had markedly high blood sugar levels. She was discharged on November 14, 2010, with diagnoses of neuropathic pain, diabetes mellitus, depression, and high cholesterol.
Plaintiff was admitted to the hospital November 22, 2010. On December 1, 2010, she underwent a triple coronary artery bypass grafting and mitral valve repair. She was additionally diagnosed with congestive heart failure. After more than two weeks in the hospital, she was released on December 8, 2010. However, subsequent infection at the incision site and eventually in the sternum led to several additional surgeries and ongoing pain.
On December 15, 2010, Plaintiff complained of chest pain and was admitted to the hospital for eight days. She was diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) sternal wound infection. Plaintiff was released on December 22, 2010. On December 24, 2010, Plaintiff had complaints of chest pain and anxiety; she was admitted to the hospital for another six days. She was again treated for MRSA and discharged from the hospital on December 29, 2010.
Plaintiff visited Charles Okoro, D.O., on February 14, 2011, with complaints of chest pain. Dr. Okoro indicated that Plaintiff's "functional history" was that she did not suffer from any physical disability and that her daily living activities were normal. Dr. Okoro noted that Plaintiff lost over fifty pounds in two months from a failure to thrive. Dr. Okoro stated that, due to Plaintiff's poor pre-op ejection fraction, she was too weak for her routine echo test.
On February 24, 2011, Plaintiff was admitted to the hospital for approximately two weeks. She had drainage at the wound site from the December 2010 bypass surgery. On February 25, 2011, doctors debrided the sternal wound, removed the sternal wires, and performed a sternal wound biopsy. Two days later, doctors performed a cardiopulmonary bypass, patch repair of the right ventricular fistula, total sternotomy with sternal wound debridement, and bilateral pectoral flaps.
On March 2, 2011, the pathology report of the sternotomy specimen showed severe acute chronic osteomyelitis and marked fibrosis of the bone marrow. Plaintiff was discharged from this hospital stay on March 9, 2011.
J. Smejkal, M.D., performed a consultative exam at the state agency's request on March 21, 2011. Dr. Smejkal noted that Plaintiff walked with a straight posture and appeared comfortable in the seated and supine position. Dr. Smejkal also noted that Plaintiff was very sore from recent surgery and moved very slowly, holding the lower part of her chest. Shortness of breath on exertion was noted; however, there was no chest pain. He indicated that Plaintiff had a surgical scar and staples in her upper abdomen and lower chest due to recent surgery. No range of motion issues were noted in the spine, upper extremities, or lower extremities. Dr. Smejkal did note generalized weakness to the upper extremities due to recent surgery. Plaintiff had a normal gait, could stoop and squat with difficulty, could get on and off the examination table with difficulty but did not require assistance, and was able to stand from a sitting position with difficulty.
Plaintiff visited Charles Okoro, D.O., on April 1, 2011. A surgical/traumatic scar was seen on the sternum, and the site of the recent surgical wound was clean. Plaintiff stated that she was doing much better at this time. Dr. Okoro's assessment included: coronary artery disease, cardiomyopathy, congestive heart failure, costochondritis following the recent sternal surgery, and "disruption of internal operation wound of the sternum." (AR 729).
On April 27, 2011, Plaintiff visited Nathaniel Ross, M.D. At this visit, Plaintiff stated that her quality of life was currently good. Her symptoms included chest pain at rest and related to the sternal wound.
CT imaging of Plaintiff's chest was taken on May 12, 2011. It was noted that most of the sternum had been removed during the February surgery. There was a finding of an extensive area of deep soft tissue emphysema as well as a rounded soft tissue density which was located just ...