BRISTOW MARCHANT, Magistrate Judge.
The Plaintiff filed the complaint in this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner wherein he was denied disability benefits. This case was referred to the undersigned for a report and recommendation pursuant to Local Civil Rule 73.02(B)(2)(a)(D.S.C.).
Plaintiff applied for Supplemental Security Income (SSI) on August 10, 2011 (protective filing date), alleging disability beginning March 24, 2011, due to a broken right leg. (R.pp. 18, 126, 166). Plaintiff's claim was denied both initially and upon reconsideration. Plaintiff then requested a hearing before an Administrative Law Judge (ALJ), which was held on April 30, 2013 (R.pp. 59-87). The ALJ thereafter denied Plaintiff's claim in a decision issued November 1, 2013. (R.pp. 18-37). The Appeals Council denied Plaintiff's request for a review of the ALJ's decision, thereby making the determination of the ALJ the final decision of the Commissioner. (R.pp. 1-5).
Plaintiff then filed this action in United States District Court. Plaintiff asserts that there is not substantial evidence to support the ALJ's decision, and that the decision should be reversed and remanded for further consideration. The Commissioner contends that the decision to deny benefits is supported by substantial evidence, and that Plaintiff was properly found not to be disabled.
Under 42 U.S.C. § 405(g), the Court's scope of review is limited to (1) whether the Commissioner's decision is supported by substantial evidence, and (2) whether the ultimate conclusions reached by the Commissioner are legally correct under controlling law.
The Court lacks the authority to substitute its own judgment for that of the Commissioner.
The record reflects that Plaintiff was hospitalized from March 24 (his alleged disability onset date) to 28, 2011 for a closed, comminuted, displaced supracondylar/intercondylar/spiral fracture of his right distal femur. After undergoing surgery (performed by orthopedic surgeon Dr. Walter Grady), Plaintiff was instructed to be absolutely non-weight bearing for approximately ten weeks. (R.pp. 210-232). Plaintiff had a follow-up appointment with Dr. Grady a little over a week later, on April 7, 2011, where Dr. Grady noted that Plaintiff's wound was clean and appeared to be healing well, and that x-rays showed good overall position and alignment. Dr. Grady diagnosed Plaintiff with status post ORIF (open reduction internal fixation) of an extremely complex fracture, distal femur right lower extremity and status post fasciotomy, right upper leg, and compartment syndrome. He advised Plaintiff to use a continuous passive motion machine, a locked hinge range of motion knee brace, and to remain non-weight bearing for at least ten more weeks. (R.pp. 249-251).
Dr. Grady reevaluated Plaintiff on April 21, 2011, at which time he suggested Plaintiff use a bone growth stimulator and a brace. A little more fragmentation and an element of rotation of his leg were noted, but x-rays showed excellent overall position and alignment. Even so, Dr. Grady opined, based on current radiographs, that the time for Plaintiff to begin weight-bearing was going to be a lot longer than the originally estimated ten weeks. (R.pp. 252-253).
On May 3, 2011, a medical equipment representative was present at Dr. Grady's office for placement of a bone growth stimulator. Dr. Grady cautioned Plaintiff against opening his brace and indicated he would try to get Plaintiff into physical therapy. (R.pp. 254-255). On May 10, 2012, Plaintiff reported that he had fallen the prior week, and had right lower extremity pain with a bruise on his right foot and ankle area. Dr. Grady noted that Plaintiff had zero to 126 degrees of clinical range of motion of his right lower extremity. He adjusted Plaintiff's leg brace, continued the use of the bone stimulator, and instructed Plaintiff to be non-weight bearing for an additional four weeks. (R.pp. 256-257). Plaintiff thereafter attended physical therapy from May 18 to June 16, 2011, stopping at that time due to his non-weight-bearing status and the fact that he was a self-pay. (R.pp. 233-237).
On May 31, 2011, Plaintiff reported that he had been using the bone stimulator for 27 days. He had pain situated over the proximal medial incision region with some occasional pain in the proximal gastroc region, but the swelling in the anterior lateral aspect of his right knee had gone down significantly. Dr. Grady reviewed x-rays and indicated that Plaintiff's bone stimulator use was working. He directed Plaintiff to continue using the stimulator, and instructed him to remain nonweight-bearing for another four weeks. (R.pp. 258-260). Plaintiff thereafter participated in vocational rehabilitation (including some physical therapy) from that day, May 31, 2011, continuing until March 28, 2012. (R.pp. 195-205).
On June 28, 2011, x-rays showed greater definitive healing, Plaintiff's range of motion was zero to 90 with effort, extension strength was 3 out of 5, flexion strength was 4 to 4+ out of 5, he had tenderness along the medial aspect of his knee primarily, and his knee was warm to touch without signs of infection. Dr. Grady ordered a CT scan and indicated that if the results were positive, Plaintiff would be advanced to "partial" weight bearing of 25%. (R.pp. 261-262). However, on July 11, 2011, Dr. Grady noted that Plaintiff had not obtained a CT scan because he had been unable to afford one. Plaintiff's right lower extremity range of motion at that time was from zero to 90 within the confines of his brace, and he had tenderness in the lateral joint line region, likely due to scar tissue. Dr. Grady continued Plaintiff's use of a bone stimulator, and stated that he wanted Plaintiff to be about 65% healed before attempting significant weight bearing. (R.pp. 263-264).
Plaintiff did eventually obtain a CT scan of his right knee on July 20, 2011, which showed status post intraoperative fixation of a slightly displaced comminute fracture of his distal femur via metallic fixating hardware in satisfactory alignment and position, no endosteal or periosteal callus formation which was consistent with 0% healing, tri-compartmental osteoarthritis with advanced changes in the medial tibiofemoral joint compartment, and a very small retropatellar joint effusion. (R.p. 265). On August 1, 2011, Plaintiff reported that the feeling in the back of his knee had come back, but complained of pain and popping. Dr. Grady indicated that this and fluid collection in the lateral aspect of the knee were not unusual with the degree of injury Plaintiff had suffered. He agreed to Plaintiff's therapists working more aggressively, ordered a repeat CT scan in six weeks, and continued Plaintiff's use of the bone stimulator. (R.pp. 267-286). X-rays on August 29, 2011 indicated greater consolidation of Plaintiff's fracture site with definitive healing. Dr. Grady allowed Plaintiff to progress to 50% weight-bearing, and indicated that the plan was to get plaintiff a brace to stabilize his knee, which tended to flare into valgus. (R.pp. 269-270).
On September 8, 2011, Plaintiff's physical therapists indicated that Plaintiff had made gains in the prior four-week period, that Plaintiff should wean from crutch use, and thought Plaintiff required a different leg brace. (R.p. 202). Plaintiff thereafter complained about swelling on September 28, 2011, but Dr. Grady did note that Plaintiff had made nice gains with physical therapy, had a new brace, and that x-rays showed excellent overall position. (R.p. 247-248). On September 30, 2011, Plaintiff's physical therapists noted that Plaintiff had made remarkable gains over the previous three weeks and had improved his functional ambulation. (R.p. 201).
On October 14, 2011, Dr. Ted Roper, a state agency physician, reviewed Plaintiff's medical records and opined that Plaintiff had the physical RFC to perform medium work.
On October 18, 2011, Dr. Grady wrote a treatment summary in which he indicated that he first saw Plaintiff in March 2011,
On October 27, 2011, Dr. Grady wrote that Plaintiff was getting good grades from physical therapy, was starting to bend his knee, continued to have reduced range of motion, continued to have some swelling which was decreasing, and had intact strength. Dr. Grady continued Plaintiff on physical therapy and 75% weight-bearing. (R.pp. 243-245). X-rays on December 1, 2011 showed evidence of healing, and Dr. Grady recommended a six-month follow-up. (R.pp. 241-242). On January 10, 2012, Plaintiff's physical therapist noted that, up until recently, Plaintiff had essentially had a "nonfunctional right leg", but indicated improvement in Plaintiff's symptoms, noted that Plaintiff was walking at that time with just one crutch and a knee brace, and recommended a shoe lift and lateral wedge for his right foot to correct a discrepancy in leg length. (R.p. 194).
On January 13, 2012, State agency psychologist Dr. Larry Clanton reviewed Plaintiff's records and opined that Plaintiff's mental impairments were not severe. (R.pp. 101-102). That same date state agency physician Dr. Hugh Clarke completed a physical RFC assessment opining that Plaintiff was capable of performing medium work, to include an ability to stand and/or walk (with normal breaks) for a total of about six hours in an eight hour work day. When completing the section of the evaluation that asked how this opinion reconciled with source opinions, Dr. Clanton wrote "there is no indication that there is opinion evidence from any source". (R.pp. 102-103).
On February 15, 2012, Plaintiff complained to Dr. Grady about a catching sensation in the lateral aspect of his right lower extremity. Plaintiff was using a crutch to ambulate, was wearing a brace, and used a bone growth stimulator until he had to return it (it was on loan). Plaintiff complained of a 10/10 level of pain when walking. Plaintiff's weight was 294 pounds, with a BMI of 42.34. Dr. Grady noted that Plaintiff had crepitation over the lateral aspect of his distal femur which Dr. Grady thought was likely a combination of scar tissue and perhaps fascia. X-rays showed continued delayed union of Plaintiff's fracture with a little greater degree of lucency, and Plaintiff had reduced range of motion. Dr. Grady advised Plaintiff to use the bone growth stimulator again and indicated they would try to get Plaintiff a consultation with a traumatologist. Meloxicam (a nonsteroidal anti-inflammatory medication) was stopped, and Plaintiff was started on Vitamin D3, calcium, and magnesium. Plaintiff was instructed to continue using his brace and crutch and to avoid quick turns or torsional activities. (R.pp. 238-240).
Plaintiff was evaluated on March 12, 2012 by Dr. Scott Broderick, an orthopedic surgeon, at Dr. Grady's request. Plaintiff complained of continued pain with range of motion. Dr. Broderick noted that Plaintiff was approximately one year out from a right distal femur fracture, and that there was x-ray evidence that Plaintiff's screws were backing out and no longer properly aligned. New x-rays indicated that Plaintiff was in varus (abnormal inward turning of the bone). Plaintiff's weight was 291.6 with a BMI of 41.84. Dr. Broderick diagnosed nonunion of fracture, and recommended surgery including removal of hardware and bone grafting. (R.pp. 273-274). However, on April 9, 2012, Plaintiff reported being nervous about the process, with concern about not being able to help with activities due to incapacitation. Dr. Broderick noted that Plaintiff was using a crutch and had a basically unchanged gait. Range of motion was zero to 100. Dr. Broderick continued Plaintiff's medications, which included testosterone, meloxicam, vitamin D, and glucosamine. Surgery was scheduled for the following week. (R.pp. 271-272).
On August 30, 2012, Plaintiff reported that he had the same amount of pain, he was trying to maneuver on one crutch, his leg bothered him at rest and more when he was trying to ambulate, and he had continued swelling. Dr. Broderick indicated that, compared to prior films, xrays showed better alignment and more callus formation. Even so, now over one year after Plaintiff's accident, fracture was still evident. It was difficult to get Plaintiff on the exam table, he was very slow, and he was moved into a wheelchair to go to the x-ray room. Dr. Broderick prescribed oxycodone and ordered a CT scan. (R.pp. 293-294).
On October 11, 2012, Plaintiff reported that his pain was not satisfactorily controlled, he was having trouble putting weight on his right leg, he was dealing with care for his mother, was caring for a grandchild, and was now ready to discuss surgery. Dr. Broderick noted that Plaintiff was using a single crutch; X-rays indicated that Plaintiff had a combination of malalignment, both rotationally and angularly in that plane; and a CT scan showed a nonunion. Plaintiff's right knee showed significant crepitance, and his gait was extremely antalgic with a little bit of a gluteus medius lurch. Medications (including oxycodone) were continued, and a temporary handicap parking sign was continued. Surgery was recommended, but Plaintiff said he was not ready to proceed with surgery at that time. (R.pp. 291-292). Medications were continued again on February 21, 2013 for Plaintiff's continued right leg pain, and a consultation with Dr. Thomas M. Schaller, an orthopedic surgeon, was recommended by Dr. Broderick. (R.pp. 289-290).
On March 8, 2013, Plaintiff was seen by Dr. Schaller, where he reported intermittent and sharp right knee pain. X-rays showed a varus malunion or nonunion, and examination revealed that Plaintiff's right knee had crepitance and prominence of the plate laterally. Dr. Schaller noted that Plaintiff ambulated with a single crutch with discomfort. Dr. Schaller indicated that Plaintiff had likely nonunion, or at best, a minimal union of his distal femur fracture, and discussed surgical correction. (R.pp. 286-288). Plaintiff was seen by Dr. Schaller again for a preoperative appointment on March 19, 2013, at which time Plaintiff reported intermittent, sharp, throbbing pain in his right leg. Medications, including oxycodone and meloxicam, were continued. (R.pp. 284-285). Plaintiff was thereafter hospitalized between March 21 and 24, 2013 for right femur nonunion open reduction with internal fixation with autologous bone grafting. (R.pp. 276-280).
On April 4, 2013, Plaintiff reported that he was taking no pain medication, was "very satisfied thus far," and felt much better than he did preoperatively. Dr. Schaller indicated that Plaintiff's wound was healthy and knee range of motion was 20 to 75. He indicated Plaintiff's need for a temporary handicap parking sign; stopped Plaintiff's oxycodone; and continued glucosamine, vitamin D, meloxicam, and testosterone. (R.pp. 282-283).
Following Plaintiff's hearing before the ALJ on April 30, 2013, x-rays taken on May 9, 2013 showed evidence of progression towards healing, Plaintiff had nearly full range of motion, and he had no swelling at his incision site. Dr. Schaller indicated that Plaintiff's quad tone was a little diminished compared to his left side, and ordered physical therapy. Plaintiff was to return in six weeks, at which time Dr. Schaller hoped to "progress his weight bearing . . . .". (R.pp. 296-297). This was now two (2) years after Plaintiff's accident.
Plaintiff was forty-five years old on his alleged disability onset date, and forty-seven years old at the time of the ALJ's decision. He has a high school equivalent education (GED) and past relevant work experience as a framing constructor, caregiver, and prep worker. (R.pp. 35, 68, 126, 166, 167). In order to be considered "disabled" within the meaning of the Social Security Act, Plaintiff must show that he has an impairment or combination of impairments which prevent him from engaging in all substantial gainful activity for which he is qualified by his age, education, experience and functional capacity, and which has lasted or could reasonably be expected to last for a continuous period of not less than twelve (12) months.
After a review of the evidence and testimony in the case, the ALJ determined in his decision of November 1, 2013 that, although Plaintiff does suffer from the "severe" impairments
On January 30, 2014, after the ALJ had issued his decision, Dr. Schaller completed a questionnaire in which he indicated that on the date he first evaluated Plaintiff, a solid union was not evident on radiographic imaging and that Plaintiff's fracture was not clinically solid. He opined that Plaintiff's fracture interfered very seriously with his ability to independently initiate, sustain, and complete activities due to pain, mal-alignment, a limp, and weakness. He thought it was advisable for Plaintiff at that time to use two hand-held devices in order to minimize pain and stability of gait, and further opined that it was "not likely that Plaintiff would be able to sustain a reasonable walking pace over a sufficient distance to be able to carry out activities of daily living." He also opined that Plaintiff had most probably been so limited since the date of his injury on March 24, 2011, and stated that Plaintiff had only gotten to the point that he could safely use a single handheld device as of his appointment on June 27, 2013 (well over two (2) years after his accident). (R.pp. 299-300).
This additional evidence was submitted to the Appeals Council, which nevertheless upheld the ALJ's decision. (R.pp. 1-2). Plaintiff asserts, however, that the Appeals Council erred by failing to remand the case to the ALJ to consider this new evidence from his treating physician (Dr. Schaller), which Plaintiff argues might have affected the ALJ's decision, and after careful review and consideration of the evidence and arguments presented, the undersigned is constrained to agree with the Plaintiff that the Appeals Council failed to properly consider and evaluate the new evidence submitted to that body in compliance with the standards set forth in
Pursuant to 20 C.F.R. §404.970
20 C.F.R. § 404.970(b). In order to be "new" evidence, the evidence must not be "duplicative or cumulative"; and in order to be "material," there must be a "reasonable possibility that it would have changed the outcome."
However, although the Appeals Council considered this evidence, it found that it did "not provide a basis for changing the [ALJ's] decision," form language found in many Appeals Council decisions. (R.pp. 1-2). No further discussion or analysis was provided, nor was an explanation given for why this new evidence was rejected. Concededly, the Fourth Circuit held in
The Commissioner contends that Dr. Schaller's questionnaire does not warrant remand because this evidence was not "new", arguing that Plaintiff could have asked this physician to provide an opinion on his behalf and submit it to the ALJ prior to the ALJ's decision. The Commissioner further argues that remand is not warranted because this new evidence is not "material", as Plaintiff has not made a showing that the ALJ's decision "might reasonably have been different" had the new evidence been before him. In making these arguments, the Commissioner appears to be using the definitions of "new evidence" and "material" as they relate to sentence six remands. However, as this evidence was presented to the Appeals Council as part of Plaintiff's appeal of the ALJ's decision, this evidence is considered under sentence four of § 405(g), not sentence six.
Under a sentence four analysis, the letter from Dr. Schaller is new because it contains findings that were not before the ALJ at the time of the ALJ's decision and is therefore not duplicative or cumulative of the evidence before the ALJ.
With respect to whether this new evidence is "material" such that there is a reasonable possibility that this opinion
In sum, Dr. Schaller's opinion provides information as to whether Plaintiff could effectively ambulate prior to the second surgery and relating to his improvement thereafter. While the Commissioner argues the Appeals Council was justified in rejecting this new evidence because the ALJ already had Dr. Schaller's records and opinion before him when he made his decision, those records did not specifically address the findings made by Dr. Schaller in his opinion of January 2014, findings contrary to the findings of the ALJ. Hence, as was the case in
Such is the case here.
Therefore, under the facts of this particular case, remand is required in order to have a finding made as to the weight to be given to this new evidence and, if appropriate, the reason for the Commissioner's rejection of a treating physician's opinion.
Based on the foregoing, and pursuant to the power of this Court to enter a judgment affirming, modifying or reversing the decision of the Commissioner with remand in Social Security actions under Sentence Four of 42 U.S.C. § 405(g), it is recommended that the decision of the Commissioner be
The parties are referred to the notice page attached hereto.
The parties are advised that they may file specific written objections to this Report and Recommendation with the District Judge. Objections must specifically identify the portions of the Report and Recommendation to which objections are made and the basis for such objections. "[I]n the absence of a timely filed objection, a district court need not conduct a de novo review, but instead must `only satisfy itself that there is no clear error on the face of the record in order to accept the recommendation.'" Diamond v. Colonial Life & Acc. Ins. Co., 416 F.3d 310 (4th Cir. 2005) (quoting Fed. R. Civ. P. 72 advisory committee's note).
Specific written objections must be filed within fourteen (14) days of the date of service of this Report and Recommendation. 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b); see Fed. R. Civ. P. 6(a), (d). Filing by mail pursuant to Federal Rule of Civil Procedure 5 may be accomplished by mailing objections to: