CATHERINE D. PERRY, District Judge.
This is an action for judicial review of the Commissioner's decision denying Ronald Prater's application for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq. Section 205(g) of the Act, 42 U.S.C. § 405(g), provides for judicial review of the Commissioner's final determination. Prater alleges that he is disabled due to bilateral carpal tunnel syndrome. Because I find that the decision denying benefits was not supported by substantial evidence, I will reverse the decision of the Commissioner.
Prater protectively filed his application for benefits on March 21, 2008. The claim was initially denied on May 21, 2008. On September 18, 2008, following a hearing, an Administrative Law Judge denied Prater's claim. On January 27, 2011, the Appeals Council of the Social Security Administration denied Prater's request for review. Thus, the decision of the ALJ stands as the final decision of the Commissioner.
In his application for benefits, Prater stated that he was born in 1954 and became disabled beginning on February 26, 2008. In the disability report filed in connection with his claim, Prater alleged that he was unable to work because of "worn out hands, anxiety, and problems with left elbow." Prater worked in Coca-Cola's warehouse for 35 years. He stated that "my hands do not work any more and I cannot do my duties like I should be able to. They hurt. They are numb. ..." He also complained of a pinched nerve in his neck.
Prater first complained of numbness and tingling in both hands in 2003. He was referred to Mark Keohane, M.D., an orthopedic surgeon, who performed right carpal tunnel release surgery in May of 2003.
In July and August of 2005, Prater was seen by Richard E. Coin, M.D., to assess his bilateral hand complaints. Dr. Coin's examination revealed some discomfort over the carpal tunnels and equivocal Tinel's sign. Dr. Coin indicated that his examination was consistent with left carpal tunnel syndrome and right recurrent carpal tunnel syndrome. Dr. Coin attributed Prater's diagnosis to his "30+ years of hand-manipulative duties at Coca-Cola Enterprises." Dr. Coin opined that Prater was a candidate for a left carpal tunnel release and a recurrent right carpal tunnel release, but determined that he was "fit to proceed with regular duties without restriction."
Prater was next seen by Robert P. Poetz, D.O., a doctor of osteopathic medicine, on April 4, 2007 for work-related injuries. Prater complained that his hands were cold and numb and that he lacked control and grip strength. He also said that his hands kept him awake at night. During his physical examination of Prater, Dr. Poetz noted decreased pin prick sensation along the median nerve distributed bilaterally, positive Phalen's test
Prater saw his primary care physician, Shobha Dixit, M.D., for healthcare services unrelated to his disability claim
On March 3, 2008, Prater saw Dr. Keohane for bilateral wrist pain. Prater reported ongoing, intermittent pain since his last carpal tunnel surgery and that this pain had gotten "much worse in the last couple of months." Prater told Dr. Keohane that he believed the problem was a recurrence of his carpal tunnel syndrome. Dr. Keohane noted a positive Tinel and paresthesias in the thumb, index, and long finger of both wrists, but he observed that Prater's wrist scars had healed well. Dr. Keohane's impression was probable recurrent carpal tunnel. He told Prater to get a nerve conduction study and have an evaluation with Dr. Simowitz. Dr. Koehane believed that repeat operative care would be necessary, and he stated that "it is reasonable [for Prater] to stay off work until his symptoms are appropriately managed."
Dr. Frederic Simowitz performed an electromyography (EMG) study on March 6, 2008 and found that the results for both arms and hands were normal, including "muscles served by anterior interosseus branch of median nerve bilaterally." Dr. Simowitz also noted an isolated finding of marginally prolonged distal ulnar sensory latency at left Guyon's canal.
Prater was evaluated about a week later by Min Pan, M.D., for bilateral hand and arm pain. Prater reported to Dr. Pan that he had noticed improvement in his symptoms by wearing a wrist splint. Dr. Pan's examination revealed normal motor strength in all extremities and no gait difficulty. Prater's reaction to pinprick, temperature, and vibration sensation in all extremities was normal. Dr. Pan recommended increasing Prater's Lyrica prescription to 100 mg three times a day and referred Prater for a magnetic resonance imaging (MRI) of the cervical spine.
An MRI of Prater's cervical spine was taken on March 20, 2008 and revealed a small central disc protrusion at C4/5 superimposed on diffuse disc bulging and uncovertebral osteoarthritis, both of which caused diffuse narrowing of the vertebral canal, though no overt stenosis, with the small disc protrusion causing a mild but definite impression on the thecal sac. At C5/6, the MRI showed "severe disc degeneration, with disc bulging and uncovertebral osteoarthritis causing diffuse narrowing of the vertebral canal, though without overt stenosis. In addition, there is a subtle, mostly left-sided broad-based disc protrusion or pseudobulging is supported by minimal forward subluxation of C6 under C5, probably by no more than 2 mm." At C6/7, the MRI revealed a "broad left paracentral disc protrusion, with mild but definitive impression on the thecal sac, extending into the origin of the left intervertebral neural foramen which is mildly narrowed as a result."
Prater saw Dr. Pan for a follow-up visit on April 16, 2008. Dr. Pan noted that Prater's EMG and nerve conduction study did not show evidence of bilateral upper extremity entrapment neuropathy and that his MRI revealed degenerative joint disease with no spinal stenosis or large herniated disc. Prater reported to Dr. Pan that he was not working and had applied for disability. During his examination, Dr. Pan found that Prater had normal motor strength, tandem walk and sensory reflexes, but a mild tremor in his upper extremities. Because the MRI could not explain Prater's symptoms of bilateral hand and arm pain, Dr. Pan referred Prater to the Washington University Neuromuscular Clinic for a second opinion.
Although neither party discusses it, the record also contains a physical residual functional capacity assessment from Nancy Dunlap, a medical consultant, on May 21, 2008. Ms. Dunlap lists Prater's primary diagnosis as degenerative disc disease and his secondary diagnosis as carpal tunnel syndrome. She found that Prater could occasionally lift 20 pounds, frequently lift 10 pounds, stand and/or walk about six hours in an eight hour work day, but that he was limited in his pushing and pulling activities in his upper extremities and that he had to alternate between sitting and standing to alleviate pain. She stated that Prater should never climb a ladder, rope, or scaffolds, and that he had limited ability to handle and feel objects. Ms. Dunlap noted that Prater had a history of carpal tunnel surgery with continuing pain, positive Tinel's sign, with parasthesias in thumb, index finger, and both wrists as found by Dr. Koehane. She also noted the MRI findings of degenerative disc disease without severe spinal stenosis or large herniated disc, and that he has not seen much improvement with his increased medication.
A hearing before an ALJ was held on Prater's disability claim on September 2, 2008. Prater testified and was represented by counsel. Prater told the ALJ that he graduated from high school, had no vocational or technical training, no experience in retail or sales, and had never served in the military or been self-employed. Prater worked in the warehouse for Coca-Cola, where his job involved opening and filling CO2 tanks that weighed between 20 and 55 pounds. He testified that he opened and closed the CO2 valves about 130 times per day. When the ALJ asked him when he was planning on attending vocational rehabilitation, Prater responded, "After this date." During the examination of Prater, the ALJ held the following exchange with counsel on the record:
During questioning about his daily activities, Prater testified that he typically gets up at about 5:00 a.m., drinks coffee, cooks breakfast, cleans the house, bathes, and then watches television. Sometimes he cooks dinner for his wife, performs basic household maintenance chores, naps, or mows the lawn. However, he later stated that he has difficulty performing these tasks, and that he has problems grasping silverware and other objects in his hands. Prater does his own laundry and goes shopping with his wife. He visits with friends or family if they come to see him, and occasionally he goes fishing. Prater changes the oil in his truck. Prater testified that he could stand "as long as I need to," could walk "as far as I need to," and could sit all day. Prater said that his hands limit his ability to lift things, and that he can lift 20-25 pounds. In an attempt to relieve the pain in his hands, Prater wears splints on his wrists, soaks his hands in warm water, limits the use of his hands, and massages or rubs Bengay on them. He also takes Lyrica for pain but testified that he has had difficulty affording the medication since he no longer has insurance coverage through Coca-Cola. Prater has difficulty sleeping and wakes up throughout the night.
A court's role on review is to determine whether the Commissioner's findings are supported by substantial evidence on the record as a whole.
To determine whether the decision is supported by substantial evidence, the Court is required to review the administrative record as a whole and to consider:
Disability is defined in social security regulations as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months. 42 U.S.C. § 416(i)(1); 42 U.S.C. § 1382c(a)(3)(A); 20 C.F.R. § 404.1505(a); 20 C.F.R. § 416.905(a). In determining whether a claimant is disabled, the Commissioner must evaluate the claim using a five step procedure.
First, the Commissioner must decide if the claimant is engaging in substantial gainful activity. If the claimant is engaging in substantial gainful activity, he is not disabled.
Next, the Commissioner determines if the claimant has a severe impairment which significantly limits the claimant's physical or mental ability to do basic work activities. If the claimant's impairment is not severe, he is not disabled.
If the claimant has a severe impairment, the Commissioner evaluates whether the impairment meets or exceeds a listed impairment found in 20 C.F.R. Part 404, Subpart P, Appendix 1. If the impairment satisfies a listing in Appendix 1, the Commissioner will find the claimant disabled.
If the Commissioner cannot make a decision based on the claimant's current work activity or on medical facts alone, and the claimant has a severe impairment, the Commissioner reviews whether the claimant can perform his past relevant work. If the claimant can perform his past relevant work, he is not disabled.
If the claimant cannot perform his past relevant work, the Commissioner must evaluate whether the claimant can perform other work in the national economy. If not, the Commissioner declares the claimant disabled. 20 C.F.R. § 404.1520; 20 C.F.R. § 416.920.
When evaluating evidence of pain or other subjective complaints, the ALJ is never free to ignore the subjective testimony of the plaintiff, even if it is uncorroborated by objective medical evidence.
The ALJ denied Prater's claim for benefits about two weeks after the hearing in a written decision dated September 18, 2008. Although she found that Prater had the medically determinable impairments of residuals from carpal tunnel surgeries on both wrists and degenerative disc disease of the cervical spine, the ALJ terminated the analysis at step two because she concluded that Prater did not have a severe impairment or combination of impairments. In deciding that Prater did not suffer from any severe impairments, the ALJ stated that she considered "all symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence. ..." The ALJ found that Prater's medically determinable impairments "could have been reasonably expected to produce some symptoms; however, the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not credible to the extent they are inconsistent with finding that the claimant has no severe impairment or combination of impairments. ..." To conclude that Prater had no impairment causing functional limitations lasting twelve consecutive months, the ALJ relied on Dr. Coin's 2005 report that Prater could return to work at Coca-Cola without restrictions. However, she discounted Dr. Poetz' 2007 report because "this evaluation is over one year old" and Prater had gone back to work during the pendency of his worker's compensation claim. The ALJ also found that "there are no complaints in the records from the claimant's current primary care provider, Shobha Dixit, M.D., until February 28, 2008." The ALJ discounted Prater's complaints of pain because "there were no complaints of pain that precluded the claimant from working aside from medical consultations for carpal tunnel syndrome for the claimant's ongoing Workers Compensation litigation." Although acknowledging Prater's strong work record, the ALJ nevertheless concluded that Prater's testimony "indicates a strong motivation for secondary gain" because he testified "he was waiting for the resolution of his disability claim before he tried to get vocational training" and performed most household chores.
The AlJ gave controlling weight to the assessment of Prater's treating physician, David Brown, M.D., who performed Prater's second surgery in 2005 and released him to return to work,
The ALJ concluded as follows:
Prater argues that the ALJ erred by not finding his complaints of the residuals of carpal tunnel surgery in both wrists and degenerative disc disease as severe impairments at step two of her analysis. At step two of the sequential evaluation process, an ALJ determines the medical severity of a claimant's impairments.
Here, the ALJ erred in terminating the analysis at step two by finding that Prater did not suffer from a severe impairment because he was released to return to work three years before the onset date of his alleged disability. The ALJ discounted Dr. Poetz' findings that Prater had recurrent carpal tunnel syndrome in 2007 and may need additional surgery because the evaluation was "over a year old," yet she relied instead on the much older report of Dr. Coin, who cleared Prater to return to work in 2005 after his second surgery. In doing so, the ALJ clearly erred. "`It is the ALJ's function to resolve conflicts among the various treating and examining physicians.'"
There is no evidence in this record, let alone the required substantial evidence of record, to support the ALJ's conclusion that Prater's recurrence of carpal tunnel syndrome was not a severe impairment or would not be expected to last 12 consecutive months simply because he was able to return to work after his first set of surgeries ending in 2005. Instead, the objective medical evidence of record suggests that Prater was suffering from recurrent bilateral carpal tunnel syndrome, in pain, had difficulty using his hands, and that he may need additional surgery. In 2007, Dr. Poetz noted decreased pin prick sensation along the median nerve distributed bilaterally, positive Phalen's test and Tinel's signs bilaterally, and decreased grip strength at 3/5 bilaterally. Dr. Poetz diagnosed Prater with right carpal tunnel syndrome and status post right carpal tunnel release from May of 2003, as well as left carpal tunnel syndrome and status post left carpal tunnel release from October of 2003. Dr. Poetz characterized Prater's prognosis as "guarded" and recommended that he wear wrist splints, avoid heavy lifting and strenuous activity, avoid pushing and pulling, avoid excessive and repetitive use of upper extremities, avoid use of equipment that creates torque, vibration, or impact to the upper extremities, avoid any activities that exacerbate his symptoms, and undergo a comparative EMG nerve conduction study, "followed by additional surgery if indicated." In March of 2008, Dr. Koehane, the surgeon who performed Prater's 2003 surgery, also diagnosed Prater with "probable recurrent carpal tunnel" after noting a positive Tinel and paresthesias in the thumb, index, and long finger of both wrists. Dr. Koehane believed that repeat operative care would be necessary, and he stated that "it is reasonable [for Prater] to stay off work until his symptoms are appropriately managed."
At the hearing and in her decision, the ALJ made much of the fact that Prater's subsequent EMG and nerve conduction study did not show evidence of bilateral upper extremity entrapment neuropathy. Yet, there is no evidence in the record to suggest that positive EMG results are required for a diagnosis of carpal tunnel syndrome. Here, the objective and diagnostic testing of both Dr. Poetz and Dr. Koehane indicated recurrence of carpal tunnel syndrome. Dr. Pan, who treated Prater for arm and hand pain following the 2008 EMG and MRI, referred Prater to the Washington University Neuromuscular Clinic for a second opinion and believed a repeat EMG and nerve conduction study might be necessary. The ALJ points out in her decision that these follow-up tests and visits were not done, but there is no evidence in the record explaining why this had not taken place.
Here, the ALJ determined, without any supporting medical evidence, that Prater's impairments were not severe merely because he was able to return to work after his surgery in 2005. Yet there is nothing in the record to support her conclusion that Prater's treatment and prognosis for recurrent carpal tunnel syndrome would necessarily be the same as his treatment and prognosis for carpal tunnel syndrome, or that it would last the same duration. Here, two treating physicians and one consulting, examining physician all diagnosed Prater with probable recurrent carpal tunnel syndrome. Their diagnoses were supported by objective diagnostic testing, not merely Prater's statement of symptoms. The ALJ is not free to substitute her own medical opinion for that of a physician.
On remand the ALJ should consider all of the relevant evidence in making a determination of the severity of Prater's impairments, including an evaluation of any additional evidence, testing or consultative examinations that may be required. This includes a reevaluation of Prater's credibility under the standards set forth in
Here, the ALJ concluded that Prater's testimony "indicates a strong motivation for secondary gain" because he testified "he was waiting for the resolution of his disability claim before he tried to get vocational training" and performed most household chores. Credibility determinations, when adequately explained and supported, are for the ALJ to make.
Because substantial evidence in the record as a whole does not support the ALJ's decision, this matter is remanded to the Commissioner for a consideration of Prater's claim in light of all medical records on file and development of any additional facts as needed. The Commissioner should reevaluate Prater's impairments and complaints in accordance with
Therefore, I reverse and remand pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings consistent with this order.
Accordingly,
A separate Judgment in accord with this Memorandum and Order is entered this date.