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Heise v. Astrue

August 2, 2010

PAUL R. HEISE, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Simandle, District Judge

OPINION

This matter comes before the Court pursuant to Section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), to review the final decision of the Commissioner of the Social Security Administration denying Plaintiff Paul R. Heise's request for Disability Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401-434. The Court must determine whether the Administrative Law Judge ("ALJ"), who denied Plaintiff's request, improperly failed to assign significant weight to the opinions of Plaintiff's treating physicians. The Court must also determine whether the ALJ incorrectly concluded that Plaintiff was capable of performing other substantial gainful activity in the national economy, despite his impairments. For the reasons discussed herein, the Court will remand the case to the Commissioner of Social Security to reconsider Plaintiff's request for Disability Insurance Benefits.

I. BACKGROUND

A. Procedural Background

Plaintiff Paul R. Heise filed an application for Disability Insurance Benefits under Title II of the Social Security Act on June 27, 2006. (R. at 93-95.) The application was denied on September 29, 2006. (R. at 66-68.) Plaintiff then filed a timely request for reconsideration on October 14, 2006, (R. at 71), which was also denied in a notice dated April 11, 2007, (R. at 72-74).

Plaintiff subsequently requested a hearing before an ALJ on May 31, 2007. (R. at 71, 75.) The hearing was held on October 27, 2008, before ALJ Mark G. Barrett. (R. at 23-61.) On March 3, 2009, the ALJ issued a final decision, finding that Plaintiff was not disabled under the Social Security Act and was therefore not entitled to disability benefits. (R. 11-22.) The Appeals Council affirmed this decision on August 27, 2009, by denying Plaintiff's request for review. (R. at 1-5.) Plaintiff timely filed the instant complaint on October 26, 2009, asking the Court to reverse the final judgment of Commissioner of Social Security, or alternatively remand the case to reconsider Plaintiff's request. [Docket Item 1.] Briefing was completed on July 1, 2010, and the case is ripe for adjudication.

B. ALJ Opinion

After reviewing the applicable law, the ALJ first determined that Plaintiff last met the insured status requirements of the Social Security Act on December 31, 2003. (R. at 16.) The ALJ then proceeded through the regulatory five-step analysis for determining whether an individual is "disabled" or "not disabled," as defined by the Act and to be discussed in Part II.B, below.

In step one, the ALJ found that Plaintiff did not engage in substantial gainful activity during the time period from his amended alleged onset date of May 9, 2001, through his date last insured. (R. at 16.) In step two, the ALJ concluded that Plaintiff had two severe impairments, lumbar disc disease and osteoarthritis of the knees, both of which caused significant work-related limitations, but that neither met the 12-month durational requirement. (R. at 17.) In step three, the ALJ determined that Plaintiff did not have an impairment or combination of impairments that met or medically equaled one of the impairments listed in 20 C.F.R. §§ 404.1525-26. (R. at 17.)

In steps four and five, the ALJ found that through the date last insured, Plaintiff was unable to perform any past relevant work, but that he nonetheless "had the residual functional capacity to lift and/or carry 10 pounds and to stand and/or walk for 2 hours and sit for 6 hours in an 8-hour workday," alternating positions during regularly scheduled breaks and meals. (R. at 17.) The ALJ's step five determination was largely based on Plaintiff's testimony that he rode to Florida in a motor home on two occasions since the alleged onset date; was capable of performing basic household activities such as cleaning, laundry, cooking, and collecting rent; had no difficulty dressing, bathing, or otherwise completing self-care tasks; and was able to drive, shop, pay bills, and manage a savings account. (R. at 20.) The ALJ found this level of daily activity to be wholly consistent with an ability to perform a full range of sedentary work. (R. at 20.)

The ALJ also explained in his step five analysis that while the medical opinions of Dr. Simon and Dr. Dubowitch would normally be afforded significant weight, they were, in this case, only entitled to "little weight." (R. at 21.) He reasoned that the opinions were "not relevant to the time period at issue" because they were rendered approximately five years after the Plaintiff's date last insured. (R. at 21.) The ALJ also noted that the "weight of the evidence establishes at least some deterioration of claimant's condition." (R. at 20.)

Based on Plaintiff's determined RFC, age, education, and work experience, the ALJ found that jobs existed in significant numbers in the national economy that Plaintiff could have performed, (R. at 21), and ultimately concluded that Plaintiff was not under a disability, as defined by the Social Security Act, at any time before December 31, 2003. The ALJ therefore denied Plaintiff's application for Disability Insurance Benefits.

(R. at 22.)

C. Evidence in the Record

1. Medical Records and Opinion from Dr. Simon

Dr. Richard M. Simon is a general physician with Wolfe-Simon Medical Associates. He first treated Plaintiff in 1999 for severe pain in his right shoulder. (R. at 323.) Dr. Simon's fellow physician, Dr. Warren Wolfe, has been treating Plaintiff since 1966, when Plaintiff was approximately five years old. (R. at 323.)

Although portions of the medical records supplied by Wolfe-Simon Medical Associates are illegible, they do indicate that Plaintiff began complaining of shoulder and back pain in 2000.

(R. at 364, 366.) The following year, in his March, May, June, July, November, and December visits, Plaintiff again reported that he was experiencing back pain. (R. at 363-364.) In December of 2002, Plaintiff reported pain in his shoulders, but in February of 2003 noted that his joint pain was feeling better.

(R. at 361.)

By letter dated May 30, 2001, Dr. David H. Kramer of South Jersey Radiology Associates wrote to Dr. Wolfe concerning a CT Scan of Plaintiff's lumbar spine, performed on May 29, 2001. (R. at 368.) The letter informed Dr. Wolfe that Plaintiff had a concentric annular bulge at L3-4 and a shallow annular bulge at L4-5. (R. at 368.)

On January 15, 2002, Dr. Wolfe wrote a letter to Charles J. Block, Esq., briefly summarizing Plaintiff's history of shoulder and back pain. (R. at 323.) Dr. Wolfe treated Plaintiff in September, 2000 for worsening chronic lower back pain and suggested orthopedic consultation. (R. at 323). Plaintiff did well until May, 2001, at which time he complained that his back pain was severe and worse than ever. (R. at 323.) Dr. Wolfe ordered a CT Scan of the lumbar spine, discussed above. The results showed bulging at L3-4 and L4-5, which Dr. Wolfe believed to be the source of his pain. Due to the increasing severity of the pain, Dr. Wolfe asked Plaintiff to obtain an MRI. (R. at 323.)

Dr. Simon issued a clinical assessment of Plaintiff's pain on October 14, 2008. (R. at 357-358.) It addresses Plaintiff's condition "on and before December 31, 2003." The assessment is summarized as follows:

(1) Plaintiff's pain is present to such as extent as to be distracting to adequate performance of daily activities or work;

(2) Physical activity, such as walking, standing, bending, stooping, and moving of extremities, is likely to greatly increase Plaintiff's pain, and to such a degree as to cause distraction from a task or even total abandonment of a task;

(3) Medications prescribed to Plaintiff, or medications typically prescribed in cases like this one, can be expected to cause significant side effects, limiting the effectiveness of work duties or the performance of everyday tasks such as driving an automobile;

(4) Pain or drug side effects can be expected to be severe and to limit effectiveness due to distraction, inattentiveness and drowsiness;

(5) Although the level of pain may be less intense or less frequent in the future, it will still remain a significant element in Plaintiff's life; and

(6) Treatments of this kind have had no appreciable impact or have only briefly altered the level of pain that this patient experiences.

(R. at 357.)

2. Medical Records and Opinion from Dr. Dubowitch

Dr. Stuart G. Dubowitch is an orthopedist with Regional Orthopedic Professional Association. He first treated Plaintiff prior to 2001, when he performed arthroscopic surgery on Plaintiff's right knee. (R. at 321.) In 2002, Dr. Dubowitch evaluated Plaintiff for bilateral knee pain, and informed Dr. Wolfe that Plaintiff's pain had progressed over the past months and continued to worsen. (R. at 321.) Dr. Dubowitch treated Plaintiff again from July through September of 2008. (R. at 346-352.) After comparing Plaintiff's 2001 CT scan with a lumbar MRI performed in ...


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