United States District Court, D. Delaware
Lewis D. Willis, Plaintiff;
Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant.
Gary W. Lipkin, Esq., Wilmington, DE, Attorney for Plaintiff.
Charles M. Oberly III, United States Attorney, Wilmington, DE; Patricia A. Stewart, Special Assistant United States Attorney, Wilmington, DE, Attorneys for Defendant.
RICHARD G. ANDREWS, District Judge.
Plaintiff, Lewis Duane Willis, appeals the decision of Defendant Carolyn W. Colvin, the Acting Commissioner of Social Security (the "Commissioner"), denying his application for Social Security disability insurance benefits ("DIB") under Title II of the Social Security Act (the "Act"). 42. U.S.C. §§ 401-434. This court has jurisdiction pursuant to 42 U.S.C. §405(g), which grants original jurisdiction to the District Courts to review a final decision of the Commissioner.
Presently pending before the Court are cross-motions for summary judgment filed by Willis and the Commissioner. (D.I. 10, 12). The case was referred to the United States Magistrate Judge, who issued a Report and Recommendation (D.I. 16) recommending that Willis' motion be denied and the Commissioner's motion be granted. Willis filed objections (D.I. 17) to which the Plaintiff has responded. (D.I. 18). I review the objections de novo. For the reasons set forth below, the Court grants Willis' motion, denies the Commissioner's motion, and remands for further proceedings.
A. Procedural History
Willis filed his application for DIB on April 15, 2009, alleging disability beginning on February 22, 2009, due to back pain and hemophilia. ("Transcript" (hereafter "Tr.") at 21)). Willis' application was initially denied and a video hearing was held before an Administrative Law Judge on December 20, 2010. (Tr. 21). The ALJ determined that Willis was not disabled in a decision dated February 10, 2011. (Tr. 21-29). Willis requested a review of the ALJ's decision on February 24, 2011. (Tr. 17, 220-25). The Appeals Council denied the Request for Review on August 3, 2012, making the ALJ's decision the Commissioner's final decision. (Tr. 1-5). Willis filed this lawsuit on October 1, 2012. (D.I. 1 at 1-3).
B. Plaintiff's Medical History, Condition, and Treatment
At the time of the ALJ's decision, Willis was 47 years old and defined as a "younger person" under 20 CFR § 404.1563(c). (Tr. 21, 28). Willis has a high school education and has past relevant work experience as an electrician. (Tr. 21, 28, 178, 179, 182).
Willis' detailed medical history is contained in the record, but the Court will provide a brief summary of the pertinent evidence. Willis suffers from a herniated disc, hemophilia, back pain, left leg pain, and shoulder pain. (Tr. 177, 190). Willis' back and leg pain dates back to 2003 when he was injured in a motorcycle accident. (Tr. 262).
Willis has been treated for back, leg, and shoulder pain by his treating physician, Dr. Robert F. Kopecki, D.O., since 2005. (Tr. 262). On April 2, 2008, an MRI of Willis' lumbar spine showed dextroscoliosis, lower thoracic and diffuse lumbar disc dessication with annular bulge, and bilateral foraminal narrowing in the spine. (Tr. 260, 261). On July 2, 2008, Willis complained of right shoulder pain to Dr. Kopecki, who subsequently ordered an MRI which was performed on November 10, 2008. (Tr. 258, 335). The MRI of Willis' right shoulder indicated a Hills-Sach deformity and an irregularity of the superior labrum with a possible underlying superior labral tear. (Tr. 258-59). On March 18, 2009, Dr. Brian J. Galinat, M.D., whom Willis had been seeing for his shoulder pain since November 2008, performed an arthroscopic rotator cuff repair and extensive debridement on Willis. (Tr. 321-22). In April 2009, during a follow-up to his shoulder procedure, Willis reported continued shoulder pain, describing it as worse than before the surgery. (Tr. 315).
In a May 2009 letter, Dr. Kopecki noted that Willis' hemophilia would make any surgery or epidural injection risky. (Tr. 262). Further, Dr. Kopecki noted that he favored long-term disability for Dr. Kopecki. (Tr. 262). In August 2009, Dr. Kopecki wrote another letter indicating that Willis' back pain had worsened. (Tr. 519). Dr. Kopecki also determined that Willis' disability was permanent and that he could not perform full time work. (Tr. 520). During this time, Dr. Kopecki completed a multiple impairment questionnaire ("MIQ") dated August 4, 2009. (Tr. 523-30). In the MIQ, Dr. Kopecki diagnosed Willis with chronic lower back pain resulting from severe lumbar disc disease and leg pain due to the 2003 ...