United States District Court, N.D. Indiana, Fort Wayne Division
OPINION AND ORDER
RUDY LOZANO, JUDGE UNITED STATES DISTRICT COURT
This matter is before the Court for review of the Commissioner of Social Security’s decision denying Disability Insurance Benefits to the Plaintiff, Howard Crutchfield. For the reasons set forth below, the decision of the Commissioner is REVERSED and this case is REMANDED to the Social Security Administration for further proceedings consistent with this opinion pursuant to sentence four of 42 U.S.C. section 405(g).
On December 31, 2010, the Plaintiff Howard Crutchfield (“Crutchfield”) filed an application for Disability Insurance Benefits (“DIB”). Crutchfield alleged his disability began on April 6, 2010, due to: symptoms associated with diabetes; a heart condition only operating at 45%; blindness in his right eye; a kidney condition only operating at 24.6%; a hernia on the right side; poor short-term memory; high blood pressure; and being prone to sinus and eye infections. (Tr. 134.) The Social Security Administration denied Crutchfield’s initial application on May 20, 2011, and on reconsideration on August 1, 2011. (Tr. 44.) Crutchfield filed a written request for a hearing on August 25, 2011. (Id.) On June 22, 2012, a hearing was held before Administrative Law Judge Steven J. Neary (“ALJ”) in Fort Wayne, Indiana. (Tr. 15-38, 44-51.) Crutchfield appeared with counsel, Kenneth E. McVey, III. (Tr. 44.) Crutchfield and Marie N. Kieffer, an impartial Vocational Expert (“VE”), provided testimony at the hearing. (Tr. 17-37.) On August 31, 2012, the ALJ denied Crutchfield’s DIB claim, finding that Crutchfield was not disabled because, after consideration of the record, Crutchfield has the Residual Functional Capacity (“RFC”) to perform the full range of light work and is capable of performing past relevant work despite his limitations. (Tr. 47-51.)
On October 15, 2012, Crutchfield requested that the Appeals Council review the ALJ’s decision; his request was denied on October 9, 2013. (Tr. 6, 14.) Accordingly, the ALJ’s decision became the Commissioner’s final decision. See 20 C.F.R. § 404.981. Crutchfield has initiated the instant action for judicial review of the Commissioner’s final decision pursuant to 42 U.S.C. § 405(g).
Crutchfield was born on March 28, 1953, and was 57 years old on the alleged disability date of April 6, 2010. (Tr. 120.) In the past fifteen years, Crutchfield’s past relevant work involves work as a machinist making wooden musical instruments at Fox Products. (Tr. 18-19, 135.)
The medical evidence can be summarized as follows: Crutchfield was hospitalized on April 6, 2010, after experiencing chest pain. (Tr. 204-05.) Dr. Joseph Greenlee III, M.D., diagnosed Crutchfield with multivessel coronary artery disease, noting that he manifested inferior and lateral changes on his electrocardiogram with a bundle-branch pattern, and had suffered a significant size infarction based on troponins and wall motion abnormalities. (Tr. 205.) Dr. Greenlee recommended a surgical revascularization. (Id.) On the same date, Crutchfield went through cardiac catheterization, coronary angiography and left ventriculography. (Tr. 246-47.) The final impression of these tests were severe multivessel coronary artery disease involving the left anterior descending, circumflex, obtuse marginal one, distal right coronary artery, and posterior descending artery, mild ischemic cardiomyopathy with inferior wall motion abnormality, ejection fraction of 45%, elevated left ventricular filling pressures and an end-diastolic pressure of 22. (Tr. 247.) On April 7, 2010, Crutchfield underwent an echocardiogram (“EKG”), the final impressions of which were a mild segmental wall motion abnormalities of the septum and inferolateral wall of the left ventricle consistent with ischemic heart disease, mild left ventricular dysfunction reduced ejection fraction to 45%, left ventricular hypertrophy, and appearance of slightly dilated left atrium. (Tr. 269-70.) On April 7, 2010, Crutchfield was diagnosed with diabetes mellitus, type 2, and was noted to have no palpable pulses in his feet and diffusely hypoactive reflexes generally. (Tr. 207-08.)
On April 9, 2010, Crutchfield underwent coronary artery bypass grafting. (Tr. 219.) On April 11, 2010, Crutchfield had X-rays taken which showed the cardiomediastinal silhouette and pulmonary vessels were stable, the lungs showed stable perihilar infiltrates, and a left pleural effusion was seen, which suggested a resolving congestive heart failure with possible associated pneumonia. (Tr. 244-45.) Crutchfield was discharged on April 13, 2010, with the final diagnosis of (1) acute anterolateral/inferior lateral myocardial infarction likely occurring on April 5, 2010, (2) severe multilevel coronary artery disease, (3) mild left ventricular dysfunction secondary to ischemic cardiomyopathy, (4) hypertension with hypertensive vascular disease, and (5) diabetes mellitus. (Tr. 219.)
On April 30, 2010, treating cardiologist Dr. Michael J. Mirro, M.D., noted that Crutchfield was unable to attend formal cardiac rehabilitation due to cost issues. (Tr. 295-97.) Crutchfield was provided with instructions for a home walking program and guidelines to assess his heart rate and exercise currently at a heart rate of “no higher than 20 beats from his resting heart rate.” (Tr. 295.) Dr. Mirro summarized the diagnosis as multivessel atherosclerotic coronary artery disease with an un-bypassed hazy 25-50% stenosis in the mid-left main and non-obstructive proximal circumflex, with complete occlusion of the circumflex after the takeoff of the first obtuse marginal, with 75% proximal stenosis in the first obtuse marginal. (Tr. 296.) Dr. Mirro further noted that Crutchfield had previously had 50-75% narrowing of the left anterior descending, but this had been grafted, as well as two serial 75% narrowing of the distal right coronary artery, which had also been grafted. (Id.) Dr. Mirro also noted that Crutchfield had mild ischemic cardiomyopathy with an ejection fraction of 45%. (Id.)
From April 16, 2010, to November 16, 2010, Crutchfield went to multiple treatment visits with Dr. C. Bryan Wait, M.D., and reported to be feeling “pretty good” with no dyspnea or chest pain. (Tr. 298-305, 310-32.) However, Crutchfield’s diabetes was reported as not controlled several times. (Id.)
On February 21, 2011, Dr. Randell Coulter, D.O., examined Crutchfield at the Commissioner’s request. (Tr. 266-67.) Crutchfield’s blood pressure was high at 164/99, and his active medications were Coreg, Plavix, Zocor, ASA, Lisinopril, Novolog, and Lantus. (Tr. 266.) Crutchfield reported numbness and tingling in his feet, and informed Dr. Coulter of his history of coronary artery bypass surgery. (Id.) Upon examination, Dr. Coulter noted Crutchfield’s right inguinal hernia, “grossly normal” gait, and decreased sensation in the feet. (Tr. 267.) Dr. Coulter opined that Crutchfield’s diabetes and resulting neuropathy in his feet may cause difficulty with prolonged standing and walking, and that Crutchfield is able to maintain balance during ambulation while carrying objects less than ten lbs. (Id.) Dr. Coulter further stated that Crutchfield could lift or carry less than ten pounds or over ten pounds occasionally, and is able to stand/walk two hours in an eight hour day. (Id.)
On February 26, 2011, psychologist, Dr. Amanda L. Mayle, Psy.D., evaluated Crutchfield at the Commissioner’s request. (Tr. 256-64.) Dr. Mayle noted that Crutchfield mentioned his memory problems began after his April 2010 heart attack. (Tr. 256.) Crutchfield reported examples of his memory problems, such as: causing a flood in the bathroom because he forgot to turn off water; needing to stay with food he is cooking or he fears he will cause a fire; and forgetting what his wife tells him, despite repeating herself multiple times. (Tr. 259.) Crutchfield also stated he could no longer hold a job because of the rapid decline in his memory and not being able to remember instructions or what he was doing. (Id.) Crutchfield also needed his wife’s assistance to manage his funds. (Tr. 258.) Based on Dr. Mayle’s clinical evaluation, she opined that Crutchfield had poor immediate memory and marginal recent and remote memory. (Tr. 257, 259.) Based on testing with the WMS-IV to assess Crutchfield’s memory function, Dr. Mayle determined that Crutchfield had low average memory level overall, with borderline function of visual working memory, low average function in auditory and immediate memory and average function in visual and delayed memory. (Tr. 259-60.) Dr. Mayle found “No Diagnosis” of clinical or personality disorders and a Global Assessment of Functioning (“GAF”) score of 50, and noted “[h]ealth issues, unemployment, [and] memory difficulty” in summarizing Crutchfield’s diagnosis. (Tr. 258.)
On March 3, 2011, a non-examining State agency psychologist, Dr. William A. Shipley, Ph.D., found that Crutchfield had no medically determinable impairment. (Tr. 342.) He noted Crutchfield’s “[p]oor short term memory, ” as well as Dr. Mayle’s findings of “memory issues. Intermediate memory was poor; recent & remote memory were marginal. . . . Auditory memory was low average; visual memory was average; and visual working memory was borderline.” (Tr. 354.) He also noted that Dr. Mayle had not given Crutchfield a diagnosis. (Id.) A second non-examining psychologist, Dr. Joelle J. Larsen, Ph.D., reviewed and affirmed this opinion without comment. (Tr. 374.)
On April 25, 2011, Crutchfield underwent an EKG at the Commissioner’s request. (Tr. 357-58.) The assessment revealed a very mild septal hypokinesis, but with preservation of left ventricular systolic function, and an ejection fraction of 56%. (Tr. 358.)
On May 17, 2011, Crutchfield underwent an ophthalmology evaluation at the Commissioner’s request. (Tr. 361-65.) Crutchfield’s uncorrected visual acuity was 20/70 right and 20/50 left, but corrected with glasses was 20/40 right and 20/25 left. (Tr. 362.) The examining ophthalmologist noted, ...