United States District Court, E.D. Kentucky, Central Division at Lexington
JERALDINE LEAR, Plaintiff.
CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.
MEMORANDUM OPINION AND ORDER
KAREN K. CALDWELL, Chief District Judge.
This matter is before the Court for consideration of cross-motions for summary judgment. (DE 12 & 13). The plaintiff, Jeraldine Lear, brought this action pursuant to 42 U.S.C. § 405(g) to obtain judicial relief of an administrative decision of the Commissioner of Social Security denying her claim for Supplemental Security Income ("SSI") benefits. The Court, having reviewed the record, will remand the Commissioner's decision for the reasons set forth below.
1. Treatment History
Lear injured her back while working as a licensed practical nurse ("LPN"). [TR 33-35]. Specifically, her injury occurred in June 2002 while lifting a patient from a wheelchair. [TR 33, 275].
Shortly after suffering her injury, Lear sought treatment from neurosurgeon Dr. George Raque, Jr. [TR 275]. Lear routinely saw Dr. Raque from 2002 until 2005. [TR 275, 288]. Initially, Dr. Raque ordered an MRI scan of her back, and the MRI revealed that Lear had an annular tear and spondylothesis at L5-S1; however, Dr. Raque did not recommend surgery because the tear occurred on the front of her spine and would have required transabdominal surgery-a technically difficult and risky procedure. Hikmet Turan Suslu et al., One-stage Surgery Through Posterior Approach for L5-S1 Spondyloptosis, J. Croniovertebral Junction & Spine, (July-Dec. 2011), available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3486007/. Dr. Raque noted that there was not "anything simple from a surgical standpoint that w[ould] help her" and advised that Lear's treatment comprise of "conservative measures." [TR 277]. Lear's condition appeared to improve throughout her physical therapy ("PT") sessions and with piriformis injections; however, the strain of day-to-day activities combined with her nursing duties caused Lear's back to deteriorate to the point that Dr. Raque concluded that Lear could not "go back to direct patient care activities and is limited to sedentary work." [TR 274-76].
Dr. Raque referred Lear to Dr. Anjum Bux. [TR 288]. Starting in August 2005, after Lear's condition worsened despite continued PT and piriformis injections, Lear saw Dr. Bux for pain management. [TR 288]. Dr. Raque recommended continuous treatment from Dr. Bux. [TR 285].
Lear later received treatment from Dr. Mohammad Shahzad. [TR 332]. Dr. Shahzad, a primary care physician, is Lear's treating physician. [TR 37]. Dr. Shahzad began caring for Lear in 2007 and has treated Lear for neck and back pain; difficulty swallowing; cough and congestion; muscle jerking, numbness, tingling, and visual disturbances; the flu; and a urinary tract infection. [TR 332-36, 350]. Dr. Shahzad completed Lear's Residual Functional Capacity ("RFC") Questionnaire, and determined that Lear could sit for less than two hours in an eight-hour working day, stand and walk for less than two hours in an eight-hour working day, and occasionally lift less than ten pounds. [TR 413-14].
Dr. Shahzad referred Lear to Dr. Maria Pavez. [TR 350]. Dr. Pavez, a neurologist, treated Lear for her back and neck pain, muscle jerking, numbness, tingling, and visual disturbances. [TR 350]. Lear worried that her symptoms might be consistent with Multiple Sclerosis ("MS"). [TR 351]. Lear expressed this concern because her elder sister has MS. [TR 351]. Dr. Pavez scheduled Lear for a brain MRI, cervical spine MRI, and additional testing, but the results of these tests did not indicate that Lear suffered from MS. [TR 350].
2. Procedural History
Lear filed her claim for SSI and disability insurance benefits ("DIB") on July 27, 2010, alleging an onset date of June 1, 2003. [TR 173, 179]. The agency denied her application initially and again after reconsideration. [TR 115, 119, 126, 129]. Lear requested review by an ALJ, and a hearing was held on August, 27, 2012. [TR 27-54].
At the hearing, Lear withdrew her claim for DIB. [TR 28]. She testified to her symptoms and daily routine. [TR 29-50]. Lear noted that coping with her lower back and neck pain is debilitating and time consuming and she frequently has to "lay flat on the bed with [her] knees up at [a] 90 degree angle on pillows and alternate heat and ice and let the medication work until [her back] just eases up." [TR 50].
The ALJ's Notice of Decision followed the five-step sequential process; however, the ALJ's decision is notably sparse. For example, the ALJ's decision is devoid of specifics concerning Lear's education and work experience despite Lear's testimony that she completed high school, completed her LPN degree, and worked as an LPN from the time she graduated from the program until her injuries prevented her from working any longer. [ Compare TR 14-21 (the ALJ's Decision), with TR 31-32 (Lear's testimony)].
At the first step, the ALJ determined that Lear has not engaged in substantial gainful activity since her alleged onset date of June 1, 2003. [TR 16]. At the second step, the ALJ found that Lear suffered from the following sever impairments: "chronic low back and neck pain secondary to degenerative disc disease and chronic obstructive pulmonary disease." [TR 16]. At the third step, the ALJ determined that Lear does not have an impairment or ...