United States District Court, D. Kansas
BERNARD E. HONEYCUTT, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security Administration. Defendant.
MEMORANDUM AND ORDER
DANIEL D. CRABTREE, District Judge.
Under 42 U.S.C. § 405(g), plaintiff Bernard Honeycutt seeks judicial review of the final decision of the Commissioner of the Social Security Administration ("Commissioner") denying his application for benefits under Title II and Title XVI of the Social Security Act, as amended. Plaintiff has filed a brief seeking judicial review of the Commissioner's decision. (Doc. 18) The Commissioner has filed a brief in opposition (Doc. 24) and submitted the administrative record. (Doc. 10) When plaintiff filed his reply brief (Doc. 27), this matter became ripe for determination. Having reviewed the administrative record and the briefs of the parties, the Court reverses the decision of the Commissioner, orders that judgment shall be entered pursuant to the sixth sentence of 42 U.S.C. § 405(g), and remands the case to the agency for further proceedings consistent with this Order.
I. Factual Background and Procedural History
Plaintiff applied for a period of Social Security Disability ("SSD") benefits under Title II of the Social Security Act and Supplemental Security Income ("SSI") under Title XVI of the Social Security Act on August 11, 2009. (R. 29) In both applications, plaintiff alleged disability beginning on July 31, 2009. ( Id. ) The Social Security Administration denied plaintiff's claims on March 31, 2010 (R. 53-61), and again denied them upon reconsideration on September 21, 2010. (R. 29) Plaintiff then requested a hearing before an Administrative Law Judge ("ALJ"), who held a hearing on July 7, 2011. ( Id. ) On September 14, 2011, the ALJ issued a decision denying plaintiff's applications for SSD and SSI benefits because the ALJ determined that plaintiff was not disabled under sections 216(i), 223(d), or 1614(a)(3)(A) of the Social Security Act. (R. 38); 42 U.S.C. §§ 416(i), 423(d), 1382(a)(3)(A).
Plaintiff filed an appeal with the Appeals Council on December 6, 2011. (R. 22-24) The Appeals Council denied plaintiff's request for review on May 22, 2012. (R. 1-3) Plaintiff has exhausted the proceedings before the Commissioner and now seeks judicial review of the Commissioner's final decision denying him SSD and SSI benefits.
II. Medical History
The administrative record contains (1) emergency room records from Wesley Medical Center, (2) inpatient records from Hunter Health Clinic, (3) physical therapy records from Wesley Medical Center, (4) treatment notes from spinal specialist Dr. Alan Albarracin, (5) consultative examination reports from Dr. Aaron Lewis, (6) consultative examination reports from Dr. Brent Adams, (7) a medical interrogatory and medical source opinion from Dr. Robert Thompson, and (8) a Physical RFC assessment from Dr. Harold Keairnes.
1. Wesley Medical Center-ER Visit
Plaintiff went to Wesley Medical Center on September 29, 2009, when he experienced an onset of neck pain. (R. 318) On August 3, he returned to Wesley Medical Center because the pain persisted and he had run out of Lortabs. ( Id. ) Plaintiff had no history of neck injury or previous neck problems, but wore a soft cervical collar. ( Id. ) Plaintiff exhibited a decreased range of motion in the neck, but showed no evidence of fracture or dislocation of the cervical spine. (R. 327) Imaging studies revealed "[m]ultilevel degenerative change within the cervical spine, most significant at C5/C6, " resulting in "mild/moderate central canal stenosis and right greater than left neuroforaminal narrowing." ( Id. ) The treating physician referred plaintiff to Hunter Health Clinic for continuing care. (R. 326)
2. Hunter Health Clinic
Plaintiff made visits to Hunter Health Clinic on August 4, 11, and 18 of 2009, and again on September 10, 2009. (R. 331-34) Plaintiff described neck pain radiating down his arm, which failed to improve with neck exercises and wearing a cervical collar. (R. 333) The treating physician continued to prescribe pain medication and referred plaintiff to Dr. Alan Albarracin, a spine specialist. ( Id. )
3. Wesley Medical Center-Physical Therapy Discharge Summary
Plaintiff's physical therapy outpatient progress notes from Wesley Medical Center show that new medication had greatly improved his pain. (R. at 342) Plaintiff reported that he had found a new job and planned to return to work as a cook. ( Id. ) Plaintiff apparently did not return for physical therapy after September 24, 2009.
4. Dr. Alan Albarracin
Plaintiff visited Dr. Albarracin on November 20, 2009 for pain management. (R. 367) Dr. Albarracin prescribed plaintiff Lortab 10 mg. ( Id. ) Treatment notes indicate that the medication controlled plaintiff's pain adequately with no adverse side effects. ( Id. ) The medication also appeared to improve plaintiff's functional capacity. ( Id. ) A physical examination showed some restrictions in range of motion and tenderness and mild muscle spasticity in the right arm. ( Id. ) The examining physician observed no evidence of sensory or motor deficit. ( Id. )
5. Consultative Examination-Dr. Aaron Lewis
Dr. Lewis performed a consultative examination on February 27, 2010. (R. 344-48) Plaintiff reported neck pain that radiated to the left-upper extremity, which was aggravated by coughing and sneezing. ( Id. ) Physical therapy had produced only minimal improvement. (R. 345) Plaintiff reported that he woke up four times per night due to neck discomfort. ( Id. )
Significant findings from the physical examination included no postural abnormalities, normal gait, normal grip strength, perceived dexterity, and negative Tinel and Phalen. (R. 346) Dr. Lewis also noted decreased range of motion of the cervical spine and the lumbar spine- straight leg raising was limited to 30 degrees on the right and 50 degrees on the left. ( Id. ) Plaintiff had no asymmetrical reflex, sensory or motor deficits but did have mild to moderate difficulty with orthopedic maneuvers. ( Id. ) X-rays showed mild spondylosis at C5-6 and similar changes at C4-5 while the remaining disc spaces "appear adequately maintained." (R. 348)
There is one inconsistency in Dr. Lewis' report. At page two of his report, Dr. Lewis states "[p]araspinous muscle spasm is not noted." (R. 346) But at the conclusion of his report, Dr. Lewis notes that "[t]here is limited range of motion today and cervical parspinous muscle spasm. " (R. 347) (emphasis added) The Court does not find this inconsistency to be significant in light of the ALJ's broader findings.
6. Consultative Examination-Dr. Brent Adams
Dr. Adams performed a consultative examination on November 18, 2010. (R. 401-05) Plaintiff again reported pain in his neck and left-upper extremity, rating the pain 9/10 at its worst, and 6-7/10 at its best. (R. 403) Plaintiff also reported that his left arm goes numb in the evenings about three times per week. ( Id. )
The physical examination showed that plaintiff could forward flex fully and extend his neck. (R. 402) Plaintiff had a positive Spurlings' examination to the left upper extremity, and full lateral gaze to the left and right sides. ( Id. ) He exhibited full passive painless range of motion of his shoulders, elbows, and wrists. ( Id. ) Dr. Adams recorded 5/5 ratings for plaintiff's finger abduction and adduction, grip strength, wrist flexion and extension, elbow flexion and extension, and shoulder abduction. ( Id. ) Dr. Adams did note, however, that plaintiff had "[d]ecreased sensation in the left C6 distribution, " but "[o]therwise sensation intact and symmetric C5 through T1 bilaterally." ( Id. ) Plaintiff's reflexes were symmetric. ( Id. )
Dr. Adams examined an MRI of plaintiff's cervical spine, though he acknowledged it was "a fairly poor MRI." ( Id. ) The MRI appeared to show a left paracentral disc herniation, which was "impinging on the nerve root" and appeared "to be fairly significant in nature." ( Id. ) Dr. Adams also noted "degenerative discs at every other level in [plaitiff's] cervical spine." (R. 404) "Specifically at the C3-C4 level [plaintiff] has a central protrusion" that is "fairly small in nature" and "does not appear to be impinging upon any of the nerve roots." ( Id. ) Dr. Adams felt that there was a "fairly good" likelihood that a "simple ACDF at the ...