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Charles A. v. Berryhill

United States District Court, D. Rhode Island

May 10, 2018

CHARLES A., Plaintiff,
NANCY BERRYHILL, Acting Commissioner, Social Security Administration, Defendant.


          JOHN J. MCCONNELL, JR., United States District Judge.

         Plaintiff filed this action for judicial review of a final decision by the Commissioner of the Social Security Administration denying him Supplemental Security Income (SSI) benefits. ECF No. 1. Before the Court is Plaintiffs Motion to Reverse and/or Remand for rehearing. ECF No. 9. Plaintiffs appeal focuses on the Administrative Law Judge's (ALJ) decision that he had the residual functional capacity (RFC) to perform light work as defined in the regulations. He argues that the ALJ failed to weigh properly the medical opinion evidence and to evaluate Plaintiffs credibility. The Commissioner has moved to affirm the decision. ECF No. 12.

         The Court finds that the ALJ's findings, specifically his decision to disregard Plaintiffs treating physician's opinion, were not supported by substantial evidence in the record. The Court therefore grants Plaintiffs motion and remands the case for reconsideration in light of this order.


         A district court's role in reviewing the Commissioner's decision is limited. "The findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive[.]". 42 U.S.C. § 405(g). The determination of substantiality must be made upon an evaluation of the record as a whole. The Court "must uphold the Secretary's findings ... if a reasonable mind, reviewing the evidence in the record as a whole, could accept it as adequate to support his conclusion." Rodriguez v. Sec'y of Health & Human Servs., 647 F.2d 218, 222 (1st Cir. 1981); see also Ortiz v. Sec'y of Health & Human Servs., 955 F.2d 765, 769 (1st Cir. 1991). The Supreme Court has defined substantial evidence as "more than a mere scintilla." Richardson v. Perales, 402 U.S. 389, 401 (1971). In reviewing the record, the Court must avoid reinterpreting the evidence or otherwise substituting its own judgment for that of the Secretary. See Colon v. Sec'y of Health & Human Servs., 877 F.2d 148, 153 (1st Cir. 1989). The "resolution of conflicts in the evidence is for the Secretary, not the courts." Ortiz, 955 F.2d at 769 (citing Rodriguez, 647 F.2d at 222).


         Plaintiff was forty-five years old on the date of the onset of his disability. He went to school through the ninth grade and was previously employed as a machine operator.

         A. Medical History

         Plaintiffs medical history includes diagnoses for degenerative disc of the lumbar spine, diabetes, obesity, hypertension, and high cholesterol. Dr. Joyce Alves, his primary care family physician, has taken care of Plaintiff during the entire period of his disability and took charge of coordinating his care with specialists when needed. Dr. Alves' treatment notes consistently discuss that Plaintiff suffered from chronic lower back pain, diabetes, and complications related thereto. He occasionally reported feeling anxious and depressed. He was taking multiple medications to address these medical and mental health issues.

         Plaintiff was let go from his job in February 2013; he could no longer do the job because of the pain. From the records, it appears that Plaintiffs care throughout 2013 was geared toward controlling his diabetes with medication. Chronic back pain is noted in his past medical history, ' he took a steady dose of Percocet for this pain throughout the treatment period. Dr. Alves frequently discussed exercise and healthy eating to improve his health; Plaintiff occasionally complied with this advice. He reported that he walked for exercise during August of 2013, but the records show that he was getting minimal or no exercise from September 2013 through February 2014. In December 2013, Plaintiffs wife accompanied him to his appointment and reported to Dr. Alves that he has been irritable, is not sleeping, and is depressed. Dr. Alves screened him and noted that he had severe depression. She prescribed him an antidepressant and Elavil to help him sleep. These symptoms improve in January 2014 as the Elavil was working.

         In treatment notes for visits from November 15, 2013 through February 13, 2014, Dr. Alves specifically noted that Plaintiff was experiencing back tenderness when bending forward, negative straight leg raising, spasms and congestion over the paravertebral muscles in the low lumbar, high sacral area. As of February 13, 2014, Plaintiff reported that he was still looking for a job. In May 2014, Dr. Alves noted that Plaintiff had pain throughout his spine, especially in the thoracic and lumbar areas, moderate chronic congestion. That same month, Dr. Alves noted that Plaintiff "was asked to reconsider back surgery, or an evaluation at the pain clinic. He is unable to live his life as he would like due to his back." She also told him that losing weight was very important to his overall health, but would also likely help his back pain.

         During a May 19, 2014 follow-up visit to address blood work, Dr. Alves noted that Plaintiffs weight was up. He told her that he was not exercising and blamed his back for his weight gain and inactivity. However, on June 4, 2014, Plaintiff reported changes in his diet and exercise routine, ' he was eating healthier and riding his bike every evening on the bike path. He did note back pain while riding. On June 19, 2014, he saw Dr. Alves to complete his disability papers! he told her that he could not work due to his low back pain though a stable dose of narcotics has adequately managed his pain over the years. On examination, Dr. Alves noted congestion over the L/S area, chronic in nature, no midline tenderness. Plaintiff reported that he was exercising three to four times per week. He requested a prescription for an antidepressant to address the mental health issues he was experiencing again. On July 28, 2014, Plaintiff reported that he had numbness in both feet.

         Dr. Alves' opined in an Impairment Questionnaire on August 15, 2014 that, because of his lower back pain, Plaintiff would be limited to sitting 1 hour and standing/walking 1 hour in an 8-hour workday. R. at 632. When sitting, he needed to get up, move around every 30 minutes, and not sit again for 5 to 10 minutes. Plaintiff could never lift or carry anything more than 5 pounds. Dr. Alves opined that Plaintiffs pain, fatigue, or other symptoms were "frequently" severe enough to interfere with attention or concentration. In addition, Plaintiff would miss work more than three times a month. Dr. Alves stated that the above symptoms and limitations were present since February 18, 2013 and were expected to last for at least an additional twelve months.

         On September 17, 2014, he noted that he was experiencing a recent worsening of his chronic low back pain and, at his next visit, he reported that his pain was unchanged, still in the L/S area across the back and occasionally down the left leg such that he would like to try the pain clinic again. He testified at the hearing that he was hesitant to get steroid injections at the pain ...

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