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Roach v. Colvin

United States District Court, D. Delaware

February 24, 2017

DARLENE R. ROACH, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          Oderah C. Nwaeze, Esq., Wilmington, DE, Attorney for Plaintiff.

          Charles M. Oberly, III, United States Attorney, Wilmington, DE; Dina White Griffin, Special Assistant United States Attorney, Philadelphia, PA, Attorneys for Defendant.



         Plaintiff Darlene R. Roach appeals the decision of Defendant Carolyn W. Colvin, the Acting Commissioner of Social Security, denying her application for Social Security Disability Benefits ("SSD") under Section 216(i) and 223(d) of the Social Security Act, and for Supplemental Security Income ("SSI") under Section 1614(a)(3)(A) of the Social Security Act. Pending before the Court are the parties' cross-motions for summary judgment. (D.I. 9, 10, 12, 13). For the reasons set forth below, the Court: (1) grants Plaintiffs motion in part to remand this matter for a new hearing and decision; (2) denies Plaintiffs request that this Court find her disabled; (3) denies the Commissioner's motion; and (4) remands this matter to the Commissioner for a new hearing and decision consistent with this memorandum opinion.


         Plaintiff first filed her application for SSD and SSI on January 15, 2010, alleging disability as of July 2, 2007. (D.I. 1 at ¶ 5, 6). That claim was denied initially and Plaintiff timely requested a hearing before an Administrative Law Judge ("ALJ"). (D.I. 1 at ¶ 7). After the requested hearing, the ALJ issued a decision denying benefits. (D.I. 1 at ¶ 9). On October 8, 2013 the Appeals Council vacated the ALJ's decision and remanded the case for further proceedings. (D.I. 1 at ¶ 11). On remand, the ALJ found that Plaintiff was not entitled to SSD and SSI benefits, and the Appeals Council denied Plaintiffs request for review. (D.I. 1 at¶ 13, 15). Plaintiff then filed an appeal to this Court. Plaintiff was forty years old when she filed for SSI. (D.I. 7 (hereinafter "Tr.") 51). She completed the twelfth grade, and worked as a cashier, general clerk and a fast food worker. Id. Plaintiff alleges disability due to neck injuries, back injuries, and arthritis. Id.

         A. Disability Determination Process

         Title XVI of the Social Security Act provides for the payment of disability benefits under the SSI program. 42 U.S.C. § 1382(a). A "disability" is defined for purposes of SSI as the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months. See 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3). A claimant is disabled "only if her physical or mental impairment or impairments are of such severity that she is not only unable to do her previous work but cannot, considering her age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." 42 U.S.C. § 423(d)(2)(A); Barnhart v. Thomas, 540 U.S. 20, 21-22 (2003).

         In determining whether a person is disabled, the Commissioner is required to perform the five-step sequential analysis set forth at 20 C.F.R. § 404.1520. Plummer v. Apfel, 186 F.3d 422, 427-28 (3d Cir. 1999). If a finding of disability or non-disability can be made at any point in the sequential process, the Commissioner should not review the claim further. 20 C.F.R. § 404.1520(a)(4).

         B. Medical Evidence

         At the onset of her disability, on January 2, 2007 (Tr. 152-53), Plaintiff was thirty-three years old and had a GED. (Tr. 74-75, 109). Plaintiff has relevant work experience as a cashier, a general clerk, and a fast food worker. (Tr. 98, 121). Plaintiffs detailed medical history is contained in the record, but the Court will provide a brief summary of the pertinent evidence.

         Plaintiff first began treatment for lower back pain in December 2002 after seeing Dr. Balu, a pain management specialist. (Tr. 494). Plaintiff received posterior lumbar spinal joint steroid block injections and "reported significant pain relief following the procedure. (Tr. 547). In March 2003, Plaintiff received transforaminal epidural steroid injections and again reported "significant pain relief following this procedure. (Tr. 543). In June 2003, Dr. Balu performed a lumbar discography and Plaintiff reported a pain level of 6/10. (Tr. 534-35).

         In November 2006, Plaintiff presented to Nanticoke Memorial Hospital following a motor vehicle accident. (Tr. 437-38). Plaintiff complained of low back pain and underwent pelvic and lumbar x-rays. (Tr. 440). These exams revealed that there was no acute fracture or dislocation, the pelvic rim and obturator rings were intact, and both hip joints were intact. Id. The attending physician notes indicated that Plaintiff appeared to be in mild distress and had painless range of motion in her neck and extremities. She was diagnosed with lumbar strain, told to apply ice and heat, remain active and prescribed Motrin and Vicodin. (Tr. 433-34, 442).

         On January 3, 2007, Plaintiff returned to Dr. Balu for low back pain evaluation. (Tr. 482). An examination revealed bilateral paraspinal lumbar spasms, facet loading and decreased range of motion. Id. An MRI on January 5, 2007 showed a broad based annular bulge with foraminal narrowing. (Tr. 555-56). Plaintiff continued seeing Dr. Balu between January and June 2007 complaining of increasing back pain. Dr. Balu continued to treat Plaintiff by giving her pain injections, which gave temporary pain relief. (Tr. 475, 481, 507, 511).

         In June 2007, Plaintiff was involved in a second motor vehicle accident and went to Nanticoke Memorial Hospital complaining of neck pain. (Tr. 466-67). The attending physician noted that because the accident had minimal force, there was minimal possibility of significant injury. (Tr. 466). Plaintiff underwent an x-ray of her cervical spine, which revealed no fracture or dislocation. (Tr. 467). From June 2007 to December 2007, Plaintiff continued to see Dr. Balu, who opined that her condition was unchanged and could be treated conservatively (Tr. 470-73), but that she was "unable to return to any gainful employment." (Tr. 586).

         In February 2008, at an appointment with Dr. Balu, Plaintiff stated that she had worsening pain and right hand numbness. (Tr. 469). An MRI of Plaintiff s cervical and lumbar spine showed no herniation and only mild stenosis. (Tr. 709-10). Dr. Balu recommended conservative care and told Plaintiff to continue taking Vicodin, which she had been taking since 2002. (Tr. 469, 494).

         In September 2009, Plaintiff underwent an initial orthopedic evaluation by Dr. Freedman. (Tr. 576). Dr. Freedman noted that, since Plaintiffs last appointment with Dr. Balu in December 2008, she had received no treatment and was only taking Tylenol for her pain. (Tr. 576). Dr. Freedman opined, based on a full examination and x-rays he ordered of Plaintiff s lumbar and cervical spine, that she had a full range of motion, that the seated root test caused some back pain, and that her x-rays were "basically negative." Id. In November 2009, Dr. Freedman noted that mild bulging of Plaintiff s lumbar spine was present, but that her reflexes were good, her motor strength was intact and she had a negative seated root test. He recommended continuing her conservative treatment plan and in December prescribed her a home cervical traction unit. (Tr. 572-74).

         In April 2010, Plaintiff had x-rays, which indicated that her sacroiliac joints were intact with normal bone mineralization. (Tr. 600). Plaintiff returned to Dr. Balu in June 2010 after complaining of back pain. (Tr. 686). Dr. Balu performed a posterior lumbar joint radiofluoroscopic steroid block of the bilateral facet joints, which reduced some of Plaintiff s pain. (Tr. 784, 791). In August 2010, Dr. Balu completed a Spinal Impairment Questionnaire and reported treating Plaintiff for facet pain and radiculopathy in the cervical and lumbar spine. (Tr. 591). Dr. Balu stated that ...

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