United States District Court, N.D. Georgia, Atlanta Division
FINAL OPINION AND ORDER
JANET F. KING, Magistrate Judge.
Plaintiff in the above-styled case brings this action pursuant to § 205(g) of the Social Security Act, 42 U.S.C. § 405(g), to obtain judicial review of the final decision of the Commissioner of the Social Security Administration which denied his applications for a period of disability and supplemental security income. For the reasons set forth below, the court ORDERS that the Commissioner's decision be REVERSED and that the case be REMANDED for further proceedings.
I. Procedural History
Plaintiff Claude Queen filed an application for supplemental security income in March 2010, alleging that he became disabled on December 1, 2008. [Record ("R.") at 19, 141-47]. After his application was denied initially and on reconsideration, an administrative hearing was held on July 20, 2012. [R. at 19, 32-73]. The Administrative Law Judge ("ALJ") issued a decision denying Plaintiff's application on August 31, 2012, and the Appeals Council denied Plaintiff's request for review on March 22, 2013. [R. at 1-7, 19-26]. Plaintiff filed his complaint in this court on May 23, 2013, seeking judicial review of the Commissioner's final decision. [Doc. 3].
The ALJ found that Plaintiff has status post nephrectomy (history of renal cell carcinoma of the left kidney), mild chronic obstructive pulmonary disease ("COPD"), and degenerative disc disease of the cervical and lumbar spine, impairments that are "severe" within the meaning of the Social Security regulations. [R. at 21-22]. However, the ALJ found that Plaintiff does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. [R. at 22-23]. The ALJ found that although Plaintiff is unable to perform any past relevant work, there are jobs that exist in significant numbers in the national economy that he can perform. [R. at 25-26]. As a result, the ALJ concluded that Plaintiff has not been under a disability since March 1, 2010, the date the application was filed. [R. at 26].
The decision of the ALJ [R. at 19-26] states the relevant facts of this case as modified herein as follows:
The claimant worked after the application date, but this work activity did not rise to the level of substantial gainful activity. He testified that he briefly attempted to work, although a review of Agency-generated earnings queries does not show any reported earnings.
The claimant was diagnosed with renal cell carcinoma in September 2010, after complaining of blood in his urine. (Ex. 3F at 8). A computerized tomography (CT) revealed a large mass in the left kidney, as well as signs of diverticulosis, fatty infiltration of the liver, and multiple kidney stones. (Ex. 3F at 14). Biopsy of the kidney confirmed the diagnosis of carcinoma, and the claimant underwent surgical removal of the left kidney in February 2011. (Ex. 5F at 29; Ex. 6F at 7). The claimant has been followed after surgery by nephrologists and his primary care doctor, but there is no evidence suggesting that he was treated with chemotherapy and/or radiation. In April 2011, CT scan of the abdomen and pelvis was negative for signs of recurrent malignancy or metastases. (Ex. 6F at 10).
The claimant's medical history is further significant for mild COPD, as evidenced by pulmonary function testing performed in January 2011. (Ex. 13F at 81). A stress test was normal for signs of cardiac disease. (Ex. 13F at 54). Additionally, the claimant has complained of persistent neck and back pain, but diagnostic imaging studies showed only "mild" degenerative changes in the cervical spine in October 2011. (Ex. 13F at 91). CT scan of the lumbar spine at the same time showed moderate to marked degenerative narrowing at T-12 and L-1, but only "borderline" foraminal stenosis. (Ex. 13F at 99). There is no evidence of severe spinal stenosis, ruptured disc, or complications of spinal cord compression such as saddle anesthesia or bowel/bladder incontinence. He was referred to pain management specialists, who have treated the claimant with facet joint injections and oral pain medications. (Ex. 14F, 18F). Based on the available evidence, the claimant has not been referred for surgical consultation due to back pain.
The record indicates that the claimant has been treated over the years for gastroesophageal reflux disease (managed by medications, according to Ex. 6F at 13), diabetes mellitus, hypertension, obesity, and inguinal hernia. He underwent removal of melanoma from his scalp in approximately 2010, but there is no evidence of recurrence or metastases. (Ex. 3F at 20; Ex. 5F at 10, 39). He has not had recurrence of diverticulitis and has not required surgery for the impairment. Finally, there is evidence of obesity, with Body Mass. Index score of 30. (Ex. 13F at 7).
At the hearing, the claimant testified that he is 55 years old and lives with his wife and adult daughter and her two children. His last work was approximately three years ago. He completed up to the tenth or eleventh grade in school and never obtained a GED. There is no history of military service. Previous jobs include general construction, but he alleges that he can no longer work due to pain in his back and legs and breathing problems.
The claimant's doctors gave him a walker which he uses only about 60 percent of the time because he does not want to become dependent on it. He is able to get around inside and outside of his home. Doctors also prescribed a back brace, but he does not wear it due to breathing problems. He rated his pain at eight or nine out of ten in severity. Difficulties include climbing stairs, bending, squatting, kneeling, or crawling. After about 50 feet of walking, he has to sit down and rest. However, the claimant holds a valid driver's license and was able to drive to the hearing unassisted. He is able to groom, bathe, and dress himself without assistance, and he can prepare simple meals. In addition, he is able to do laundry and sweep, and he often accompanies his mother to the grocery store to help her shop. His nephew helps with mowing the lawn, although the claimant can pick vegetables from the garden. He denied any side effects from medications.
With regard to the claimant's degenerative disc disease, CT scans of the cervical and lumbar spine in January 2011 showed mild degenerative changes, without significant spinal stenosis. (Ex. 13F at 81, 97). Findings on physical examination have been largely unremarkable, i.e., negative straight leg raise test, normal gait, and normal neurological examination in February 2012. (Ex. 14F at 4). His renal cancer has not recurred after nephrectomy, nor has he had any recurrence of melanoma in the scalp. (Exs. 3F, 5F). The claimant informed his pain management physicians in April 2012 that his pain was well managed on his current medication regimen, and in June 2012, his doctor noted he was "progressing well and continue[d] to have good pain relief with the current medications prescribed, and minimal to no side effects." ...