United States District Court, N.D. Georgia, Atlanta Division
LEONA E. LAGARES, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner, Social Security Administration, Defendant.
ORDER AND OPINION
ALAN J. BAVERMAN, Magistrate Judge.
Plaintiff Leona E. Lagares ("Plaintiff") brought this action pursuant to section 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 ("the Commissioner") denying her application for Disability Insurance Benefits ("DIB") under the Social Security Act. For the reasons below, the undersigned REVERSES the final decision of the Commissioner AND REMANDS the case to the Commissioner for further proceedings consistent with this opinion.
I. PROCEDURAL HISTORY
Plaintiff filed an application for DIB in April 2010, alleging disability commencing on October 15, 2008. [Record (hereinafter "R") 93, 136]. Plaintiff's application was denied initially and on reconsideration. [R82-83]. Plaintiff then requested a hearing before an Administrative Law Judge ("ALJ"). [R106-07]. An evidentiary hearing was held on December 9, 2011. [R48-81]. The ALJ issued a decision on April 2, 2012, denying Plaintiff's application on the ground that she had not been under a "disability" from the alleged onset date through the date of the decision. [R43-44]. Plaintiff sought review by the Appeals Council, and the Appeals Council denied Plaintiff's request for review on September 24, 2013. [R7].
Plaintiff then filed action in this Court on October 23, 2013, seeking review of the Commissioner's decision. [ See Doc. 1]. The answer and transcript were filed on April 17, 2014. [ See Docs. 7, 8]. On May 19, 2014, Plaintiff filed a brief in support of her petition for review of the Commissioner's decision, [Doc. 11], and on July 21, 2014, the Commissioner filed a response in support of the decision, [Doc. 15]. The matter is now before the Court upon the administrative record, the parties' pleadings, and the parties' briefs, and it is accordingly ripe for review pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3).
II. STATEMENT OF FACTS
Plaintiff was born on March 26, 1956, [R146], and therefore was fifty-two years old at the time of her alleged disability onset date, [R146], fifty-five years old at the time of her administrative hearing, [R48], and fifty-six years old at the time of the ALJ's decision, [R44]. Plaintiff has a high-school education, [R57], and previously worked an assembler of electronics, [R53, 78]. She alleges that she became unable to work as of October 15, 2008, due to back, hand, leg, and foot pain; arthritis; patellar tendinitis; degenerative joint disease of the right knee; carpal tunnel syndrome; diabetes mellitus; and diabetic neuropathy. [R52-53, 55, 59-62, 64-66, 74, 136, 150]. Plaintiff was insured through December 2013. [R144].
B. Plaintiff's Testimony
In her testimony before the ALJ, Plaintiff complained of tingling and numbness in her hands that reduces her ability to grasp her tools, use buttons, and lift things like pots or pans full of water or food, but she stated that she is able to use zippers. [R52, 55-56, 70-72]. She reported that she had carpal tunnel surgery in 2003 but the symptoms returned. [R51-52, 69-70]. She testified that the symptoms caused her to stop working in 2008 and that when she tried to go back in 2010, numbness and tingling kept her from performing satisfactorily. [R54-57]. She stated that her hands numb and cramp after about five or ten minutes of repetitive activity, and she will then rub them together for about two to three minutes until the feeling comes back. [R72-73].
Plaintiff also stated that she had lower-back pain, leg pain, and popping, cracking, and pain in her knee. [R60-62]. She indicated that her knees bother her every day and that her doctor treats them by prescribing medication. [R61]. She reported that when she stands or sits for more than about thirty minutes, her lower back starts to hurt and her feet go to sleep, and that without medication, she did not believe that she could stand for even that long. [R61-63]. Plaintiff also complained of neuropathy that causes numbness on both sides of her feet and in two toes, leg swelling that causes an inability to stand for long periods, and reliance on an unprescribed cane. [R62, 66-67, 74, 76]. She stated that around the house, she hangs on to things for balance, and she tries to stay on her feet because when she walks around, the tingling and burning in her legs subsides. [R67].
Plaintiff stated that she is in the house "all the time." [R68]. She testified that she sits down for an hour or two to watch television and then stands up again for about half an hour to dust and do dishes. [R68-69]. She reported that she cannot be stationary and needs to be walking. [R69]. Plaintiff also stated that approximately three days of every five are good days and that on the good days, she can go grocery shopping with her husband, do laundry, and dust. [R75-76]. She stated that on the bad days, she relies on her husband to do those things, and that approximately twice per week, she does not feel well and will lie down for as much as an hour. [R75-76].
C. Administrative Records
In an undated disability report, Plaintiff stated that in or around September 2010, she began experiencing increased pain in her feet and increased tingling in her hands. [R173]. She reported that she had trouble bending to wash her feet, that her arms hurt when she washed her hair, and that she was having increased difficulty walking without help. [R175].
In a pain questionnaire dated December 9, 2010, Plaintiff complained of pain in her hands, legs, feet, and joints. [R183]. Plaintiff reported that the pain radiated into her shoulders, elbows, and legs, and that she had difficulty holding items in her hands. [R183]. Plaintiff also indicated that she had problems sitting and standing for prolonged periods and walking long distances. [R183].
In an undated disability report, Plaintiff indicated that in or around January 2011, her legs began tingling more, and her ability to concentrate decreased. [R188]. She stated that her husband helps her bathe because she cannot lift her hands or arms over her head to wash her back, that her husband does the driving because her feet go numb when she drives, and that her husband prepares the meals because she cannot stand more than five minutes in one place. [R190]. She also indicated that her husband cleans the house. [R190].
D. Medical Records
On September 3, 2008, Plaintiff presented to John R. Schnell, M.D. for initial consultation. [R204]. In his notes, Dr. Schnell indicates that Plaintiff reported right-knee pain starting on July 8, 2008, but that she denied any history of injury or trauma. [R204]. The notes further indicate that Plaintiff reported moderate pain into the anterior aspect of the knee, especially when going up and down stairs, and that she could not squat due to pain. [R204]. Physical examination revealed an antalgic gait,  moderate tenderness over the patella and patellar tendon, moderate pain with extension of the knee against resistance, but "no obvious signs of systemic illness, trauma, atrophy, deformity, or infection"; non-tender calves, quadriceps, hamstrings, and medial and lateral joint lines; stable ankle joints; no pain with hip range of motion; no evidence of effusion in the right knee; normal circulation; normal sensation to light touch; and intact motor function. [R204]. It was noted that Plaintiff's medications included Darvocet,  Zetia,  and Lantus. . Dr. Schnell diagnosed moderate right-knee patellar tendinosis and degenerative joint disease, ordered x-rays to rule out degenerative arthritis, and recommended physical therapy. [R204-05]. X-rays of Plaintiff's right knee taken on September 8, 2008, revealed a moderate degree of osteoarthritis and a small joint effusion. [R200].
On November 3, 2008, Plaintiff presented to John R. Ehret, M.D. to establish care and receive treatment for sinus symptoms. [R220]. Dr. Ehret noted that Plaintiff's current medications included Zetia, Vasotec,  Lantus, Byetta,  and Amaryl.
On December 3, 2008, Plaintiff returned to Dr. Ehret for treatment of her diabetes. [R218]. Dr. Ehret assessed benign essential hypertension and type II diabetes mellitus, and he increased Plaintiff's Vasotec dosage. [R219].
On January 8, 2009, Plaintiff presented to Dr. Ehret to discuss changes in her diabetes medication. [R216]. Plaintiff indicated that she could no longer afford Lantus. [R216]. Dr. Ehret assessed type II diabetes mellitus-uncomplicated, uncontrolled. [R216]. He stopped Plaintiff's use of Lantus, Byetta, and Amaryl, and started her on Humulin 70/30 insulin injections. [R217].
On July 16, 2009, Plaintiff again presented to Dr. Ehret for discussion of her medication. [R215]. She was continued on Humulin 70/30 injections. [R215].
On November 16, 2009, Plaintiff again presented to Dr. Ehret for follow-up on her diabetes and hypertension. [R213]. Dr. Ehret assessed hypertension, ...