United States District Court, D. Kansas
MEMORANDUM AND ORDER
KATHRYN H. VRATIL, District Judge.
Andre Lamar Guliford appeals the final decision of the Commissioner of Social Security to deny disability benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq. For reasons set forth below, the Court reverses the judgment of the Commissioner and remands for further proceedings.
I. Procedural Background
On August 30, 2010, plaintiff applied for disability benefits, alleging a disability onset date of January 8, 2008. See Transcript Of Administrative Record ("Tr.") (Doc. #10) filed December 3, 2013 at 158-65. Plaintiff's benefit application was denied initially and on reconsideration. On March 22, 2012, following a hearing, an administrative law judge ("ALJ") concluded that plaintiff was not under a disability as defined in the Social Security Act. See Tr. at 9-25. On July 15, 2013, the Appeals Council denied plaintiff's request for review. Tr. at 1-6. Plaintiff appealed the final decision of the Commissioner to this Court. The decision of the ALJ stands as the final decision of the Commissioner. See 42 U.S.C. § 405(g), (h).
II. Factual Background
The following is a brief summary of the evidence presented to the ALJ.
Plaintiff was born on November 30, 1968 and was 42 years old on March 31, 2011 - the date he was last insured. He has a high school education and two years of college.
In January of 2008, physicians diagnosed plaintiff with cancer of the head and neck. Plaintiff applied for disability benefits and the Commissioner awarded benefits retroactive to November 19, 2007. The Commissioner later found that as of April 1, 2010 plaintiff's health had improved so that he was able to work. Plaintiff's benefits terminated on June 30, 2010.
On August 30, 2010, plaintiff filed an application to reinstate benefits, alleging that he was disabled due to head and neck cancer and neuropathy in his feet caused by chemotherapy. Plaintiff stated that he had tried to work after his benefits stopped, but that nerve damage to his feet make it painful to stand or walk, and that he also suffers from short-term memory loss. Tr. 68.
A. Medical Evidence
On January 4, 2008, physicians admitted plaintiff to Midwest Regional Medical Center to evaluate a right neck mass. A biopsy revealed that plaintiff had squamous cell carcinoma of the head and neck. On January 17, 2008, plaintiff sought treatment from Dr. Dennis Moore at the Cancer Center of Kansas. On March 3, 2008, Dr. Eric Bunting, an ENT specialist, confirmed the diagnosis of metastatic head and neck squamous cell carcinoma. Plaintiff underwent chemotherapy and radiation.
On October 15, 2008, plaintiff's treating radiologist, Dr. Jon Anders, noted that plaintiff had completed radiation treatment and that he had a "favorable response to radiation therapy and chemo." Tr. 413-414, 416-417. On October 30, 2008 plaintiff returned to the Cancer Center for follow-up treatment and showed "a gratifying response to treatment." Tr. 418. On December 11, 2008, the Cancer Center clinic staff determined that plaintiff continued to do well and showed no evidence of disease progression. On January 8, 2009, Dr. Bunting found that plaintiff showed "no evidence of disease following chemo[/]radiation therapy for squamous cell carcinoma of the tonsil." Tr. 428.
On February 7, 2009, plaintiff went to the Cancer Center for follow-up. He described some symptoms which appeared to be very much like Lhermitte's Syndrome, but which were "not too bothersome for him." Plaintiff showed no evidence of recurrence of cancer. Tr. 420. On February 19, 2009, a CT scan of plaintiff's neck showed no lymph modes exceeding 5 to 6 mm in diameter and no compromise of the airway. Tr. 422.
On July 1, 2009, Dr. Moore saw plaintiff and found that he was doing well but had missed some appointments. On January 25, 2010, Dr. Moore examined plaintiff for follow-up of his cancer. Dr. Moore noted that plaintiff "still has problems with neuropathy and innovating the feet bilaterally extending from mid feet distally which is worse in the winter but which generally is not limiting in terms of his function." Tr. 430, 446.
On March 10, 2010, Dr. James Henderson examined plaintiff and noted that he had diminished sensation in his toes bilaterally but that it did not affect his gait or station. Further, Dr. Henderson found that "reflexes are absent [and] he has difficulty walking on his toes. Continued surveillance is warranted." Tr. 434.
On March 30, 2010, Dr. Carol Eades, M.D., completed a physical residual functional capacity ("RFC") assessment. Tr. 437-44. Dr. Eades diagnosed neuropathy in the feet after chemotherapy. TR 437. She set out limitations as follow:
Exertional: Stand and/or walk (with normal breaks) for a total of about six hours in an 8-hour workday; Postural: Occasionally climbing ladder/rope/scaffolds (Neuropathy in feet s/p chemo); Environmental: Avoid Concentrated Exposure to Hazards (machinery, heights, etc.) (Neuropathy in feet s/p chemo).
Tr. 438-41. Dr. Eades opined that plaintiff "has some limitations in his work." Tr. 444.
On May 13, 2010, plaintiff visited the St. Joseph Clinic complaining of a lump on the back of his neck and numbness and pain in his feet. The treating physicians, Dr. Stephen Sittnick, D.O. and Dr. Doug Neef, M.D., found no new or abnormal lesions and told plaintiff to return if the condition worsened. Tr. 458. On June 14, 2010, plaintiff returned to see Dr. Sittnick, complaining of numbness and tingling in his feet when standing for long. Tr. 455. Dr. Sittnick diagnosed chronic neuropathy in plaintiff's feet secondary to nerve damage due to chemotherapy, and prescribed Neurontin. Tr. 457.
On July 13, 2010, plaintiff returned to Dr. Sittnick. Plaintiff reported constant numbness and tingling in his feet and pain when standing for an hour and with weather changes. Plaintiff told Dr. Sittnick that "disability needs a letter for [his] condition." Tr. 452. He also indicated that Neurontin was too expensive and that he wanted to try another medication. Dr. Sittnick prescribed Amitriptyline. Tr. 453.
On August 16, 2010, plaintiff returned to the Cancer Center. Dr. Moore noted that plaintiff "is now nearly 3 years out from his original diagnosis and continues to do well." Dr. Moore recommended an evaluation to address plaintiff's neuropathy. Tr. 445.
On September 3, 2010, plaintiff told Dr. Sittnick that he had tried Amitryptyline but that it caused side effects. Tr. 450. Dr. Sittnick discontinued Amitryptyline. He offered to prescribe Gabapentin ...