Lewis v. Barnhart
| Decision Date | 19 March 2002 |
| Docket Number | Cause No. 3:01cv0403 AS. |
| Citation | 201 F.Supp.2d 918 |
| Parties | David LEWIS, Plaintiff, v. Jo Anne B. BARNHART, Commissioner of Social Security, Defendants. |
| Court | U.S. District Court — Northern District of Indiana |
Eric Schnaufer, Evanston, IN, for plaintiff.
Clifford D. Johnson, Assist. U.S. Atty., South Bend, IN, for defendants.
This cause is before the Court because the Plaintiff, David Lewis, appeals the final decision of the Commissioner of Social Security (the "Commissioner") denying his application for disability insurance benefits (DIB) under Title II of the Social Security Act, 42 U.S.C. §§ 416(i), 423(d), and supplemental security income (SSI) under Title XVI of the Act, 42 U.S.C. §§ 1382, and 1382c. Jurisdiction over Lewis's petition for judicial review is conferred on this Court by 42 U.S.C. § 405(g). In accordance with Local Rule 7.3, this matter is deemed to be before the Court on cross-motions for summary judgment. The Court has carefully considered the submissions of the parties and the 375 page record in this case, and now rules as follows.
On October 27, 1994, Lewis filed for Disability Insurance Benefits (DIB) under Title II of the Social Security Act, 42 U.S.C. §§ 416(i) and 423(d), and for Supplemental Security Income (SSI) under Title XVI of the Act, 42 U.S.C. §§ 1382 and 1382c, claiming disability dating back to February 21, 1993, due to severe back and neck impairments. R. at 43-45. The state agency denied his application initially and on reconsideration. Pl.'s Brief at 1. A hearing was held before an administrative law judge (ALJ) on October 10, 1996, at which Lewis appeared without counsel. Id. The ALJ heard testimony from Lewis and from a vocational expert. Id. at 2. On December 11, 1996, the ALJ ruled that Lewis was disabled from February 21, 1993 until October 6, 1994, but not thereafter. Id. He was therefore entitled to DIB payments for the period from February 21, 1993, to October 6, 1994, but not for SSI. Id. The ALJ determined that Lewis was ineligible for SSI benefits because his closed period of eligibility ended prior to the date on which he filed his application for SSI. ALJ Decision at 8.
Lewis filed for review of the ALJ's Decision, but his review was delayed because the record upon which the decision was based could not be located. Pl.'s Br. at 2, R. at 369. On March 20, 2000, this case was remanded to the ALJ for a new hearing because the Appeals Council was unable to locate or redevelop the evidence, but the file was finally located, and, on October 24, 2000, the case was returned to the Appeals Council. R. at 372. Finally, on April 5, 2001, the Appeals Council denied Lewis's request for review, thus adopting the ALJ's opinion as the Commissioner's final decision, and Lewis appealed to this Court. Id.
At the time of his application, Lewis was thirty-two years old. Pl.'s Br. at 3. He was a high school graduate with work experience as a circuit board assembler, mechanic, and railroad car switch man. Id. At the time of the hearing, Lewis lived in Michigan City, Indiana, with his wife and two children, ten year old twins. Id. In 1990, Lewis was in an automobile accident and suffered a whiplash injury. R. at 179.1 He was off work for three months. Then, on February 21, 1993, Lewis was injured at work when he fell on icy concrete stairs and injured his lumbosacral spine. Pl.'s Mem. at 3. An x-ray showed that he had an acute fracture to the left L4 transverse. R. at 97.
On October 15, 1993, Lewis was still experiencing low-back pain, left leg and bilateral foot pain. R. at 9598. A lumbar discogram showed a degenerated disc at L4, and 40 mg of Depo Medrol was injected. Id. at 96. On November 26, 1993, Lewis's treating physician, Dr. John Collis,2 a specialist in Orthopaedics and Neurosurgery, reviewed the discogram and recommended conservative treatment. Id. at 102. Lewis continued to experience severe pain, and on March 21, 1994, Dr. Collis performed surgery consisting of a lumbar laminectomy and L4 total disc replacement using bank bone. R. at 99 and 102. A follow-up exam with x-rays by Dr. Collis on May 19, 1994 showed "fine healing in the area of the decompression and interbody fusion." Id. at 105. Dr. Collis recommended that Lewis wear a brace for a total of four months, then begin work-hardening exercises. Id.
On August 2, 1994, Lewis went to a hospital emergency room complaining of significant pain in his neck with radiation into his left arm. R. at 109. On August 4, Dr. Collis performed cervical spine surgery on Lewis, including cervical discectomies and interbody fusions at C4, C5, and C6. He was given instructions to "Wear a Miami collar for 2 to 4 months, no driving for two months, and no strenuous exertions." Id. at 107.
On October 4, 1994, two months after the second surgery, Dr. Collis examined Lewis and reported that the majority of his cervical pain symptoms had been relieved, however, he still had interscapular pain, and pain in the groin area. R. at 128. He noted that the cervical x-rays "look excellent", that all three grafts are "in site and healing well", and that the x-rays of his lumbar surgery also look excellent. Id. On October 7, 1994, Dr. Collis advised Lewis that he should have a local interscapular injection at the trigger point. Id. at 127. He also advised that it was okay to drive, to wear his collar for three months, and no strenuous activities. Id. It was not advised that Lewis increase all his activities to his tolerance at that time. Id. at 128. Dr. Collis informed Lewis that he should be able to return to his usual work on February 7, 1995. Id.
Dr. Collis examined Lewis again on December 27, 1994. He noted that Lewis's cervical x-rays showed "three perfect disc replacements with solid interbody fusions." R. at 123. The lumbar fusion also looked excellent, with the one weak area he had completely replaced by bone. Id. He stated that Lewis was having much less pain in his neck and arms, but still complained of abdominal pain, and recommended that he see his family doctor or an appropriate specialist. Id. Dr. Collis recommended more vigorous work hardening exercises, but only after consultation about the groin-abdominal pain. Id. He noted that Lewis should be able to return to his regular work by May 1, 1995.
On January 5, 1995, Dr. Collis wrote Lewis an additional letter regarding his December 27 examination, in which he told Lewis that he no longer needed to wear a collar or brace. R. at 122. Dr. Collis told Lewis that he could go back to work if he could find light work. Id. For very strenuous exertion or heavy work, however, Lewis should wait until May 1, 1995. Dr. Collis again recommended work hardening exercises. Id.
On May 25, 1995, Dr. Collis examined Lewis again. R. at 118. Lewis told Dr. Collis at the time that he was having more pains than he could possibly tolerate, that he felt unable to stand for prolonged periods of time, unable to bend, to lift, etc., and that the most relief came from lying down. Id. However, Dr. Collis had examined Lewis' CT scanning, and found that the x-rays looked very good, with no signs of any new disease. Id. at 119. He found that the lumbar area looked perfect, and that the L4 area was solid. Id. In addition, he noted that the cervical x-rays looked quite good, with the C4 and C5 fusions completely solid. He noted that the C6 was "semi-solid" in that the anterior part was solid, but the back part still had some scar tissue. Id. It was Dr. Collis' opinion that Lewis would not need additional surgery, and that the C6 should be solid within the next year or two. Id. Dr. Collis advised that Lewis could return to work any time, and that he might possibly be able to do the same work he had done in the past. Id.
During this same time period, Lewis started going to Doctor Paul Madison, M.D., at the Midwest Pain Clinic in Michigan City complaining of sharp pain and numbness in both shoulders radiating between the shoulder blades, more to the left than to the right. R. at 156. A Thoracic Spine MRI was performed on February 14, 1995, and found to be normal. Id. On April 10, 1995, a Cervical MRI with no paramagnetic enhancement was performed. Id. at 158-9. The report indicates that Lewis had a borderline narrow anterior posterior dimension of the spinal canal between C5-6 and C6-7 down to 1cm, but with no current disc or spur impingement of the otherwise well preserved cervical canal and traversing nerves. Id. The doctor also observed static moderate to severe C5-6 and C6-7 exiting neuroforamen fat narrowing from degenerative disc and possible spur. Id.
On April 12, 1995, Dr. Madison wrote a cervical spine flexion and extension report which indicated solid fusion of the 4th, 5th and 6th cervical vertebral bodies, but incomplete fusion of the 6th and 7th vertebral bodies. Id. at 157. The report states that there is Id. On April 18, 1995, Dr. Madison noted that a study of the lumbar spine with flexion and extension lateral views indicated that there was a continued narrowing of the L4 L5 intervertebral disc space with a posterior anterior osteophyte which may be due to a partial fusion. Id. at 160. The remainder of the disc spaces appeared normal. Id.
On November 16, 1995, and again on October 9, 1996, Dr. Madison diagnosed Lewis as having both cervical and lumbar arachnoiditis with intractable pain. R. at 293 and 173. Dr. Madison recommended that Lewis avoid lifting more than twenty pounds, walking more than 100 feet, prolonged standing...
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