Stokes v. Berryhill
Stokes v. Berryhill
Opinion of the Court
This matter is before the court on the parties' cross motions for judgment on the pleadings. (DE 17, 21). Pursuant to
*462BACKGROUND
On May 7, 2013, plaintiff protectively filed applications for a period of disability, disability insurance benefits, and supplemental security income, alleging disability beginning August 15, 2009. The claims were denied initially and upon reconsideration. Plaintiff requested hearing before an administrative law judge ("ALJ"), who, after hearing held May 21, 2015, denied plaintiff's claims by decision entered June 25, 2015. Following the ALJ's denial of her applications, plaintiff timely filed a request for review before the Appeals Council. The Appeals Council denied plaintiff's request, leaving the ALJ's decision as defendant's final decision. Plaintiff then filed this action seeking judicial review.
DISCUSSION
A. Standard of Review
The court has jurisdiction under
"A necessary predicate to engaging in substantial evidence review is a record of the basis for the ALJ's ruling," including "a discussion of which evidence the ALJ found credible and why, and specific application of the pertinent legal requirements to the record evidence." Radford v. Colvin,
To assist in its review of defendant's denial of benefits, the court may "designate a magistrate judge to conduct hearings ... and to submit ... proposed findings of fact and recommendations for the disposition [of the motions for judgment on the pleadings]." See
The ALJ's determination of eligibility for Social Security benefits involves a five-step sequential evaluation process, which asks whether:
(1) the claimant is engaged in substantial gainful activity; (2) the claimant has a medical impairment (or combination of impairments) that are severe; (3) the claimant's medical impairment meets or exceeds the severity of one of the impairments listed in [the regulations]; (4) the claimant can perform [his or her] past relevant work; and (5) the claimant can perform other specified types of work.
Johnson v. Barnhart,
In the instant matter, the ALJ performed the sequential evaluation. At step one, the ALJ found that plaintiff had not engaged in substantial gainful activity since August 15, 2009. At step two, the ALJ found that plaintiff had the following severe impairments: lumbar degenerative disc disease, status post fusion, and left foot drop. At step three, the ALJ determined that these impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listings in the regulations.
Before proceeding to step four, the ALJ determined that plaintiff had the residual functional capacity ("RFC") to perform sedentary work with the following restrictions: sit/stand option at one hour intervals; use of a cane; never climb ladders; occasional climb stairs, balance, stoop, crouch, or crawl; no concentrated exposure to hazards such as moving machinery or unprotected heights; and further limited to unskilled work.
At step four, the ALJ concluded plaintiff was unable to perform any past relevant work. At step five, the ALJ determined that jobs exist in the national economy that plaintiff can perform. Thus, the ALJ concluded that plaintiff was not disabled under the terms of the Social Security Act.
B. Analysis
Plaintiff argues the ALJ failed to consider evidence that may be probative of compromise of a nerve root and/or nerve root compression in determining that plaintiff's conditions do not meet or medically equal Listing 1.04A. See 20 C.F.R. Part 404, Subpart P, App'x 1, 1.04A ("Listing 1.04A"). Upon de novo review of plaintiff's objections, the court agrees that remand is required for this reason.
The regulations provide a "Listing of Impairments," organized by major body systems, that are deemed sufficiently severe to prevent a person from engaging in any gainful activity, regardless of age, education, or work experience. See
Listing 1.04A applies to disorders of the spine.
*46420 C.F.R. Part 404, Subpart P, App'x 1, § 1.04A. The listing specifically notes conditions such as "spinal stenosis" and "degenerative disc disease."
evidence of nerve root compression characterized by neuro-anatomic distribution of pain, limitation of motion of the spine, motor loss (atrophy with associated muscle weakness or muscle weakness) accompanied by sensory or reflex loss and, if there is involvement of the lower back, positive straight-leg raising test (sitting and supine);
Radford,
In Radford, the Fourth Circuit found insufficient an ALJ's explanation as to why the claimant did not meet Listing 1.04A.
In this case, the ALJ's explanation as to why plaintiff did not meet Listing 1.04A was insufficient. The ALJ acknowledged that plaintiff suffered from lumbar degenerative disc disease, (Tr. 29), but found that the evidence shows that plaintiff's spinal disorder does not involve compromise of a nerve root or the spinal cord. In support of this conclusion, the ALJ cites a June 7, 2011 assessment by Dr. Eric Laxer ("Laxer"), wherein Laxer notes a broken right S1 screw but no other problems visible on x-rays. (Tr. 368). The ALJ notes also that a January 2015 CT scan showed grade I anterolisthesis of L5 on S1, surgical changes with posterior hardware and fusion, and no significant protrusions or stenosis. (Tr. 29 (citing Tr. 544) ).
However, the administrative record includes also discussion by Dr. Kenneth Wolfson ("Wolfson") of an August 30, 2010 MRI. (Tr. 459-60). Wolfson concluded that the MRI showed "[t]here is significant flattening of the thecal sac at the L5-S1 level from spondylolisthesis and broad disc protrusion although a decompression laminectomy has been performed." (Tr. 460). On January 14, 2011, plaintiff complained of persistent low back pain and right foot weakness, and a physical examination showed limited flexion of the lumbar spine, positive straight leg raise, diminished patellar and Achilles jerks on the right compared to the left, notable dorsiflexion in the right foot, and right foot drop. (Tr. 333-34). Following another physical exam conducted March 8, 2011, Laxer concluded that plaintiff exhibited weakness in the left foot that shows chronic changes affecting *465the left L4-L5 and S1 nerve roots. (Tr. 370). In sum, although the record contains no specific diagnosis of "nerve root compression" expressed in those terms, the foregoing evidence is germane to existence of "flattening" of the thecal sac, neuro-anatomic distribution of pain, limitation of motion of the spine, motor loss, sensory reflex loss, and presence of a positive straight leg raise. See Listing 1.04A.
Nothing indicates whether the ALJ considered any of the foregoing evidence. On these facts, where there exists "a fair amount of evidence[,]" Radford,
Defendant argues that any conclusion regarding existence of nerve root compression grounded in Wolfson's August 30, 2010, evaluation is speculative where Wolfson's evaluation "fails to confirm" the presence of nerve root compression characterized by symptoms noted in Listing 1.04A. (Def.'s Br., DE 22 at 5). This argument fails, however, because remand is required by virtue of the ALJ's failure to consider this evidence and to explain the reasons for any conclusions that may follow therefrom. See Radford,
Defendant argues further that, notwithstanding any other errors in the ALJ's decision, plaintiff cannot prevail under Listing 1.04A because the administrative record contains no evidence that any straight leg raise test was performed in both the sitting and supine positions, as Listing 1.04A requires. However, as another judge in this district reasoned, where an examiner performs a straight-leg raise test, it must be performed in some position. Newkirk v. Berryhill, No. 7:15-cv-273-BO,
In sum, the case must be remanded because, in evaluating whether plaintiff was disabled pursuant to Listing 1.04A, the ALJ failed to consider pertinent evidence of plaintiff's spinal condition and failed to explain on the record any reasons why such evidence was discounted or ignored, in violation of standards set forth in Radford and Monroe.
CONCLUSION
Based on the foregoing, and upon de novo review of the administrative record, the court REJECTS the recommendation in the M & R, GRANTS plaintiff's motion for judgment on the pleadings, (DE 17), DENIES defendant's motion for judgment on the pleadings, (DE 21), and REMANDS this matter to defendant, pursuant to sentence four of
SO ORDERED this the 27th day of February, 2018.
Reference
- Full Case Name
- Tasha STOKES v. Nancy A. BERRYHILL, Acting Commissioner of Social Security
- Cited By
- 9 cases
- Status
- Published