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Mozelle v. Berryhill

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

April 10, 2019

NANCY A. BERRYHILL, Acting Commission of Social Security, Defendant.


          Andrew P. Rodovich United States Magistrate Judge

         This matter is before the court on petition for judicial review of the decision of the Commissioner filed by the plaintiff, Adriane W. Mozelle, on January 30, 2018. For the following reasons, the decision of the Commissioner is REMANDED.


         The plaintiff, Adriane W. Mozelle, filed an application for Disability Insurance Benefits on May 20, 2014, alleging a disability onset date of May 15, 2013. (Tr. 14). The Disability Determination Bureau denied Mozelle's application initially on August 19, 2014, and again upon reconsideration on November 23, 2014. (Tr. 14). Mozelle subsequently filed a timely request for a hearing on January 5, 2015. (Tr. 14). A hearing was held on November 9, 2016, before Administrative Law Judge (ALJ) Michelle Whetsel, and the ALJ issued an unfavorable decision on November 25, 2016. (Tr. 14-23). Vocational Expert (VE) Toni M. McFarland testified at the hearing. (Tr. 14). The Appeals Council denied review, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-3).

         Mozelle met the insured status requirements of the Social Security Act through December 31, 2016. (Tr. 16). At step one of the five-step sequential analysis for determining whether an individual is disabled, the ALJ found that Mozelle had not engaged in substantial gainful activity since May 15, 2013, the alleged onset date. (Tr. 16).

         At step two, the ALJ determined that Mozelle had the following severe impairments: Cauda Equina syndrome, spinal stenosis, and hypertension. (Tr. 16). The ALJ determined that Mozelle's severe impairments significantly limited her ability to perform basic work activities. (Tr. 16).

         At step three, the ALJ concluded that Mozelle did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 16). The ALJ considered Mozelle's impairments against the criteria set forth in listings 1.04 and 4.00 et seq. (Tr. 16). The ALJ indicated that no specific listing pertained to hypertension, so the ALJ considered the entirety of the listings 4.00 et seq., cardiovascular system. (Tr. 17). The ALJ determined that based on a review of the totality of the evidence, Mozelle did not meet or medically equal the listed impairments. (Tr. 17). However, she required accommodation in her residual functional capacity. (Tr. 17).

         After consideration of the entire record, the ALJ then assessed Mozelle's residual functional capacity (RFC) as follows:

[T]he claimant has the residual functional capacity (RFC) to lift and carry up to 10 pounds occasionally, 5 pounds frequently, stand and/or walk about 2 hours in an 8-hour workday, and sit about 6 hours in an 8-hour workday with normal breaks. The claimant must never climb ladders, ropes, or scaffolds, but can occasionally climb ramps and stairs, balance, stoop, kneel, crouch, or crawl. She must avoid concentrated exposure to wet, uneven terrain, and hazards such as machinery, and unprotected heights. She must also be allowed to alternate between sitting and standing, without being off task, sitting for 15 to 20 minutes then standing for similar durational periods.

(Tr. 17). The ALJ explained that in considering Mozelle's symptoms she followed a two-step process. (Tr. 17). First, she determined whether there was an underlying determinable physical or mental impairment that was shown by a medically acceptable clinical or laboratory diagnostic technique that reasonably could be expected to produce Mozelle's pain or other symptoms. (Tr. 17). Then, she evaluated the intensity, persistence, and limiting effects of the symptoms to determine the extent to which they limited Mozelle's functioning. (Tr. 17).

         Mozelle alleged disability due to Cauda Equina syndrome, spinal stenosis, and hypertension. (Tr. 18). At the hearing, she testified that she stopped working in 2013 because of pain in her lower back and buttocks, down into her right leg. (Tr. 18). She stated that as a certified nursing assistant (CNA) she was on her feet most of the workday and that standing and lifting equipment and patients was very difficult on her. (Tr. 18). She tried medication management, but she experienced fatigue and falling in public. (Tr. 18). She also testified that epidurals were effective for a week or two, but then the pain would intensify. (Tr. 18). Additionally, she underwent surgery in May of 2013 which relieved the radiation of pain into the buttock but not the back pain. (Tr. 18). She continued physical therapy, medications, and attempted returning to work but reported that the pain was so intense she could not fulfill the duties of the medium exertional work and needed to sit or alternate positions. (Tr. 18). The ALJ determined that Mozelle was incapable of performing her last job as a nurse, which required medium exertion. (Tr. 18).

         Mozelle testified to her activities of daily living. (Tr. 18). She indicated that she performed daily physical therapy exercises and drove to and from therapy. (Tr. 18). She also alleged that she could sit for 15-20 minutes and lift 10 pounds. (Tr. 18). Mozelle reported that she washed dishes 2 to 3 times a week and that she went up and down stairs at her home at least 1 to 2 times daily. (Tr. 18).

         The ALJ limited Mozelle to no more than sedentary exertional work, no more than lifting 10 pounds on an occasional basis, and provided an allowance to alternate positions. (Tr. 18). The ALJ found that Mozelle's medically determinable impairments reasonably could be expected to cause the alleged symptoms. (Tr. 18). However, her statements concerning the intensity, persistence, and limiting effects of these symptoms were not entirely consistent with the medical evidence and other evidence in the record. (Tr. 18).

         On May 9, 2014, Dr. Mekhail performed a right L5-S1 decompression laminectomy, foraminotomy, and partial facetectomy with micro discectomy on Mozelle. (Tr. 19). A few weeks post-surgery, Mozelle reported only some weakness in her right leg and some nausea. (Tr. 19). She denied worsening back pain, yet she indicated that she had some pain when she twisted her back. (Tr. 19).

         She met with consultative examiner, Sorai Arora, M.D., after the surgery and reported low back pain with radiation to the right leg and severe tingling and numbness in her right lower extremity. (Tr. 19). Mozelle also stated that she frequently fell. (Tr. 19). The ALJ noted that Mozelle's reports to Dr. Arora contradicted her reports to Dr. Mekhail, yet were not supportive of disabling limitations. (Tr. 19). Additionally, her physical ...

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