United States District Court, N.D. Indiana, South Bend Division
OPINION AND ORDER
CHRISTOPHER A. NUECHTERLEIN, Magistrate Judge.
In January 2011, Plaintiff, Brian Manser ("Manser") filed his complaint in this Court seeking reversal of the Commissioner's final decision denying his application for Disability Insurance Benefits. Alternatively, Manser seeks remand for further consideration of his application for Disability Insurance Benefits. On June 6, 2014, Manser filed Plaintiff's Social Security Opening Brief in Support of Judgment or Remand to the Commissioner. [Doc. No. 18]. On September 11, 2014, Defendant Commissioner of Social Security ("Commissioner") filed a response, asking the Court to affirm the decision denying benefits. [Doc. No. 23]. Manser filed a reply brief on September 26, 2014. [Doc. No. 24]. This Court may enter a ruling in this matter based on the parties consent, 28 U.S.C. § 636(c), and 42 U.S.C. § 405(g).
I. RELEVANT BACKGROUND
A. Previous Disability Application and Adjudication
In January 2011, Manser filed an application for Title II Disability Insurance Benefits ("DIB") and Title XVI Supplemental Security Income ("SSI") with the Social Security Administration ("SSA") alleging disability beginning December 23, 2010. This was Manser's second application for DIB and SSI. The first application, filed in 2010, alleged an onset date of December 14, 2007, the last day Manser worked. On December 22, 2010, Manser's first application was denied. The ALJ's unfavorable decision became final when the Appeals Council denied review. Manser did not seek judicial review of this decision. Instead, Manser filed the application at issue in this case, which was denied by the SSA on March 2, 2011, and upon reconsideration on April 4, 2011. An administrative law judge ("ALJ") held a hearing regarding Manser's second application on April 24, 2012, and issued an opinion denying both claims on June 7, 2012. The Appeals Council denied Manser's request for a review on October 17, 2013, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review.
B. Personal Facts
Manser was born on April 10, 1976, making him thirty-one years old at the time of the initially alleged date of disability onset and thirty-four years old at the time of his second DIB/SSI application. He lives with his wife and two children along with his aunt who provides financial support for the family. Manser has a GED and, prior to his original 2007 alleged onset date, worked as a machine operator, engine part inspector, and muffler repair technician. The jobs required extensive time on his feet. His work as a machine operator and inspector required constant lifting of items weighing between twenty and seventy-five pounds.
C. Relevant Medical Evidence
As part of the proceedings related to his second DIB/SSI application, Manser provided the ALJ with medical evidence from his December 2010 application date until the hearing date in August 2012. He also referred the ALJ to the medical evidence included in the record of his first DIB/SSI application. As relevant in this action, the records documented Manser's doctor visits and treatment for back pain, ankle, and carpel tunnel pain.
Prior to the current adjudication onset date, Manser was diagnosed in 2008 by neurosurgeon Dr. Langheinrich with spinal stenosis after an MRI revealed disc degeneration, even though Manser's neurological exam had shown no major deficits. Dr. Langheinrich recommended that Manser should consider spinal fusion surgery if epidural steroid injections did not provide relief. After Medicaid refused to conduct another MRI to ascertain Manser's surgical options, Dr. Langheinrich referred Manser to Dr. Phuong, a neurosurgeon with Indiana University Medical Center.
In July 2009, Dr. Phuong ordered a new MRI, which showed moderate spinal stenosis at L4-S1 and more severe stenosis at T11-T12. While surgery was among the treatment recommendations, Manser was concerned about the associated risks of invasive back surgery. Dr. Phuong opined that Manser's condition could progressively degenerate over time. He also concluded that Manser would have difficulty sitting for more than twenty minutes at a time without changing positions and that standing for more than an hour a day would likely be challenging. Dr. Phoung also believed Manser would need to lie down periodically during the day to ease his back pain.
Dr. Phuong's findings were consistent with the conclusions drawn by two Social Security consultative physicians engaged in response to Manser's first DIB/SSI application. In March 2009, Dr. Rudolph examined Manser and noted that he complained of back pain and reported his spinal stenosis diagnosis. Dr. Rudolphs exam revealed muscular skeletal abnormalities including a wide based gait. Another Social Security consultant, Dr. Montoya, then reviewed Manser's medical file on April 29, 2009, and opined that Manser would be able to stand for at least two hours in an eight-hour day.
In addition to back pain, Manser also had been experiencing foot and ankle pain in 2011. In February, Manser met with Dr. Sheedy to address his symptoms. A MRI of his ankles showed moderate to severe degeneration, edema, and tearing of the prevoneus brevis tendon. In that same month, Manser visited Dr. Coulter, a Social Security consultative examiner. Dr. Coulter conducted a disability physical and found skeletal abnormalities associated with arthritic degenerative disc disease, which was causing Manser's joint pain and stiffness. Dr. Coulter also noted that Manser displayed a slightly unsteady gait and was unable to raise them when lying down. Dr. Coulter concluded that Manser could maintain his balance and carry ten pounds occasionally, but Manser would be unable to stand or walk more than two hours in an eight-hour day.
On March 2, 2011, Dr. Dobson, a Social Security medical expert, provided a second opinion regarding Manser's ability to work after reviewing Manser's medical file. Dr. Dobson opined that Manser could frequently lift ten pounds, stand or walk for at least two hours in an eight-hour day, sit for six hours in an eight-hour day, and occasionally climb, stoop, kneel, crouch, but never crawl or balance. Dr. Dobson based his assessment on Dr. Coulter's findings and Manser's 2009 lumbar and thoracic MRI. In 2011, Dr. Sands, another Social Security expert, reconsidered Manser's medical file and reaffirmed that Manser only retained the capacity to perform sedentary work.
In June 2011, Manser met with Dr. Ronback, a treating physician, regarding increased ankle and foot pain. Based on the X-rays that showed further degenerative changes, the doctor prescribed physical therapy and a foot brace. Dr. Ronback also recommended that Manser visit his neurosurgeon to reevaluate his spinal stenosis because she believed his neurological condition seemed to be deteriorating. In August, Manser met with Dr. Ronback again to discuss hand pain related to carpal tunnel at which time she referred him to Dr. Rahn, a neurosurgeon, regarding his back pain. On August 25, 2011, Manser met with Dr. Rahn who ordered an MRI. At an appointment in September, Dr. Rahn explained that the MRI imaging result showed "disc herniation centrally causing moderate stenosis at L 4-5 and 5-S1, [with the] lateral recess [being] fairly severe." Doc. No. 14 at 560. Dr. Rahn prescribed Tramadol, a pain reliever, and recommended epidural injections.
D. ALJ's Opinion
After the hearing, the ALJ issued a written decision with the following findings based on the five-step disability evaluation prescribed in the SSA's regulations. At Step One, the ALJ found that Manser had not engaged in substantial gainful activity since December 23, 2010, the day after the previously issued, administratively final, unfavorable decision. At Step Two, the ALJ found Manser suffers from severe impairments consisting of multilevel degenerative disc disease, bilateral degenerative joint disease of the ankles, and obesity. The ALJ also found two "non-severe" medical impairments: bilateral "trigger" finger and mild right carpal tunnel syndrome ("CTS"). At Step Three, the ALJ found that Manser's impairments did not meet or ...