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Miller v. Colvin

United States District Court, N.D. Indiana, Hammond Division

April 24, 2015

NOAH M. MILLER, Plaintiff,
v.
CAROLYN W. COLVIN, COMMISSIONER OF SOCIAL SECURITY, Defendant.

OPINION AND ORDER

RUDY LOZANO, District Judge.

This matter is before the Court for review of the Commissioner of Social Security's decision denying Disability Insurance Benefits to Plaintiff Noah M. Miller. 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).

BACKGROUND

On June 9, 2010, Noah M. Miller ("Miller") filed an application for Social Security Disability Benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. section 401 et seq. Miller alleged that his disability began on February 13, 2009. The Social Security Administration ("SSA") denied his initial application and also denied his claim upon reconsideration.

Miller requested a hearing, and on December 22, 2011, Miller appeared with his attorney at an administration hearing before Administrative Law Judge ("ALJ") Henry Kramzyk. Testimony was provided by Miller and vocational expert ("VE") Leonard M. Fisher. On December 29, 2011, the ALJ issued a decision denying Miller's claim, finding him not disabled because he is capable of making a successful adjustment to other work that exists in significant numbers in the national economy. (Tr. 25.)

Miller requested that the Appeals Council review the ALJ's decision, but that request was denied. Accordingly, the ALJ's decision became the Commissioner's final decision. See 20 C.F.R. ยง 422.210(a). Miller has initiated the instant action for judicial review of the Commissioner's final decision pursuant to 42 U.S.C. section 405(g).

DISCUSSION[1]

Facts

Miller was born in September 1979, and was 29 years old on the alleged disability onset date of February 13, 2009. (Tr. 165.) He has a high school education. (Tr. 170.) Miller's past relevant work includes employment as an assembler, carpenter, and final finisher. ( See id.) Miller alleges the following impairments: degenerative disc disease; essential tremors disease; arthritis; and knee and hip problems. (Tr. 169.)

Medical Evidence

The medical evidence can be summarized as follows:

Prior to his alleged onset date, Miller suffered from low back pain and tremors in his hands. (Tr. 253.) In June 2007, Miller's orthopedic surgeon, Dr. Alan W. McGee, M.D., recommended physical therapy and pain medication for his back pain. (Tr. 249-50.)

On January 15, 2008, Miller underwent an L4-5, L5-S1 bilateral decompressive laminotomies, foraminotomies, and fusion. (Tr. 313.) In April 2008, Miller told Dr. McGee that he was "doing exceptionally well" after surgery, though he had some low back pain. (Tr. 301.) Miller was prescribed Vicodin for pain, and was allowed to return to work with no restrictions. (Id.) In December 2008, Miller met with his primary care physician, Dr. James F. Hanus, D.O., regarding pain in his knee, and numbness in his right arm and hand. (Tr. 259-61.)

From February 2009 to July 2010, Miller did not see a physician. (Tr. 19.) In July 2010, Miller received a physical consultative evaluation from Dr. Gina Moore Dudley, M.D. (Tr. 264-67.) Among other things, Dr. Moore Dudley recorded Miller's spinal fusion surgery and claims of tremors in his hands since age eight. (Tr. 264.) Miller told Dr. Moore Dudley that he could stand for three to four hours in an eight hour day, walk on level ground for a mile, sit for one hour, lift up to 25 pounds, and walk upstairs with difficulty. (Tr. 265.) Dr. Moore Dudley found that Miller's "ambulation was normal, " his "gait was okay with no assistive device required for ambulation." (Tr. 266.) Dr. Moore Dudley provided, in part, the following functional assessment of Miller: stand and walk for at least six hours; sit without restrictions; "have no restrictions in terms of an assistive device as he did not require one;" lift and carry occasionally 50 pounds and frequently 25 pounds, with some decrease in his range of motion; have infrequent postural limitations secondary to his decreased range of motion; infrequently have some difficulty with bending, stooping and kneeling; and no manipulative or environmental limitations. (Tr. 266-67.)

On August 18, 2010, State agency physician Dr. Fernando Montoya, M.D., completed a Physical Residual Functional Capacity Assessment of Miller. (Tr. 269-76.) Dr. Montoya's assessment of Miller's standing, walking and lifting limitations was the same as Dr. Moore Dudley's. (Tr. 270.) In addition, Dr. Montoya limited Miller to six hours of sitting in an eight hour day, and suggested the following postural limitations: never climbing scaffolding; and only occasionally balancing, stooping, kneeling, crouching, crawling, or climbing ramps or stairs. (Tr. 271.) Dr. Montoya also suggested that Miller avoid uneven slippery surfaces and unprotected heights. (Tr. 273.) State agency physician, Dr. J. Sands, M.D., affirmed Dr. Montoya's opinion on December 21, 2010. (Tr. 277.)

In December 2010, Miller reported that the pain in his back was worse than it had been in August 2010, and that he was taking over-the-counter pain medications, which "help[ed] a little bit." (Tr. 192.) Miller also noted that he could stand for one hour and sit for 30 minutes. (Id.)

On February 15, 2011, Dr. Hanus conducted a physical exam of Miller. (Tr. 291.) Dr. Hanus noted that Miller had severe pain in his lower back that caused him to limp, and right leg pain. (Id.) Miller rated his pain as 8 out of 10. (Id.) Miller also complained of numbness and tingling in his hands and forearms, and that he was dropping objects. (Id.) Neurological testing revealed decreased grip strength in both hands, as well as Phalen and Tinel in both arms, indicating probable bilateral carpal tunnel syndrome. (Id.) The results of a straight leg lifting test were negative. (Id.) Dr. Hanus recommended a magnetic resonance imaging ("MRI") of Miller's lumbosacral spine and an electromyography ("EMG") of both arms, but because Miller had "no insurance and no money coming in, " they would delay these tests until Miller could pay for them. (Id.)

On March 18, 2011, an MRI of Miller's lumbar spine was performed that displayed post operative changes of posterior fusion at L4-5 and L5-S1. (Tr. 289.) It did not show recurrent disc bulge or herniation, central canal stenosis, lateral recess or foraminal stenosis. (Id.)

On March 30, 2011, Dr. Bhupendra K. Shah, M.D., performed an electromyogram ("EMG") on Miller. (Tr. 284.) The EMG results suggested a mild degree ulnar nerve entrapment of the right wrist and borderline to very minimal ulnar nerve entrap at the left wrist. (Id.) Because the changes were "very minimal at best, " Dr. Shah recommended clinical correlation. (Id.)

On April 7, 2011, Miller underwent an MRI of his cervical spine, the results of which were "unremarkable" with minimal disc desiccation and disc bulge present in the mid-cervical spine with no encroachment. (Tr. 279-80.) In a letter to Dr. Hanus dated April 12, 2011, Dr. Shah noted that Miller walked with a limp, used a cane, and had mild tremors of his right hand. (Tr. 279.)

On May 11, 2011, Dr. Hanus completed a Medical Source Statement diagnosing Miller with severe and constant back pain and tremors. (Tr. 294-98.) Dr. Hanus determined that Miller was limited to sitting, standing and walking for less than one hour during an eight-hour work day, lifting ten pounds occasionally, and occasionally balancing, but never stooping. (Tr. 296-97.)

Dr. Hanus's treatment notes from June, July, and August 2011 document Miller's complaints of pain in his back and neck, and his right arm shakiness and muscle spasms. (Tr. 429-30.) Dr. Hanus prescribed Percocet for pain, as well as ...


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