Pitaroski v. Colvin
| Decision Date | 24 July 2014 |
| Docket Number | Case No. 2:13-cv-00112 |
| Parties | VLASE PITAROSKI Plaintiff, v. CAROLYN W. COLVIN, Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Northern District of Indiana |
This matter before the court on the petition for judicial review of the decision of the Commissioner of Social Security filed by the plaintiff, Vlase Pitaroski, on September 16, 2013. For the following reasons, the decision of the Commissioner is REMANDED.
The plaintiff, Vlase Pitaroski, filed an application for Disability Insurance Benefits on September 14, 2010, alleging disability due to degenerative disk disease of the lumbar spine, degenerative joint disease of the right knee, hypertension, and anxiety. (Tr. 14, 17, 110-111) Pitroski's application initially was denied on November 16, 2010. (Tr. 61) Pitroski's request for reconsideration was denied on February 7, 2011. (Tr. 62) He then filed a request for a hearing on February 24, 2011. (Tr. 7-8) On November 18, 2011, he testified at a hearing in Valparaiso, Indiana, before Administrative Law Judge (ALJ) William Sampson. (Tr. 31-60) Vocational Expert (VE) Thomas A. Grzesik also appeared and testified. (Tr. 31-60) On December 9, 2011, the ALJ issued a decision denying benefits. (Tr. 9-23) Pitaroski filed a request for review of thehearing decision with the Appeals Council on December 27, 2011, but his request was denied on February 6, 2013, making the ALJ's determination the final decision of the Commissioner. (Tr. 1-8) Pitaroski filed this action for judicial review of the final decision of the Commissioner on March 28, 2013.
At step one of the five step sequential analysis used to determine whether a claimant is disabled, the ALJ determined that Pitaroski had not engaged in substantial gainful activity since November 20, 2008, his alleged onset date. (Tr. 14) At step two, the ALJ found that Pitaroski had the following severe impairments: "degenerative disk disease of the lumbar spine and degenerative joint disease of the right knee." (Tr. 14) The ALJ also determined that Pitaroski had the non-severe impairments of hypertension and anxiety. (Tr. 14)
In this section, the ALJ explained his reasons for determining Pitaroski's hypertension and anxiety were not severe. (Tr. 14-16) In March 2011, Pitaroski was noted to have hypertension during an office visit at St. Clare Health Clinic1. (Tr. 14) Pitaroski was advised to go to the emergency room. (Tr. 14) There it was noted that Pitaroski had an episode of anxiety when he was in a crowd of people and developed a pressure-like chest pain. (Tr. 14) Pitaroski's EKG revealed poor R-wave progression and sinus rhythm, and a chest x-ray showed no acute changes. (Tr. 14) The following day, Piatroski had an exercise stress test. (Tr. 14) The test showed a normal hemodynamic response to exercise, and Pitaroski had no exercise-induced arrhythmias. (Tr. 14) In April 2011, at an office visit at St. Clare Health Clinic, Pitaroski's hypertension was noted to be controlled. (Tr. 14) Pitaroski's biggest concern during that visit was his anxiety, and he was referred to the Regional Mental Health Center for an evaluation. (Tr. 14)
Pitaroski attended a psychiatric evaluation in July 2011. (Tr. 15) Dr. Jose Ramirez, M.D., noted that Pitaroski did not appear dangerous to himself and could be managed on an outpatient basis. (Tr. 15) Pitaroski had a global assessment of functioning (GAF) score of 55 during the past 12 months, which is reflective of someone with only moderate difficulty in social, occupational, or school functioning. (Tr. 15) Dr. Ramirez prescribed a trial of Celexa, and Pitaroski agreed to try the medication but deferred therapy because of financial constraints. (Tr. 15)
The ALJ concluded that Pitaroski's mental impairments did not cause more than a minimal limitation on his ability to perform basic mental work activities. (Tr. 15) In the four broad functional areas known as "paragraph B" criteria, Pitaroski had a mild limitation in activities of daily living, a mild limitation in social functioning, a mild limitation in concentration, persistence, and pace, and no episodes of decompensation. (Tr. 15-16) The ALJ determined that Pitaroski's impairments did not meet or medically equal a listed impairment at step three. (Tr. 16)
In the area of daily living, Pitaroski had a mild limitation. (Tr. 15) He lived with his wife and two grown children. (Tr. 15) He was able to do some yard work, but he used a riding lawn mower to cut the grass. (Tr. 15) He spent most of his time at home, refraining from the use of drugs and drinking very little alcohol. (Tr. 15) He maintained his comfort by changing positions between standing and sitting. (Tr. 15) Based on that evidence, the ALJ found that Pitaroski had a mild limitation in activities of daily living. (Tr. 15)
In the area of social functions Pitaroski had a mild limitation. (Tr. 15) He was able to attend some social functions, including weddings and graduations, and was able to attend medical appointments while behaving in a socially appropriate manner. (Tr. 15) At a consultative medical examination, Pitaroski appeared to be cooperative. (Tr. 15) At the psychiatric evaluation,Pitaroski interacted in a pleasant and appropriate manner, despite complaining of bouts of anxiety. (Tr. 15) Based on that evidence, the ALJ found Pitaroski had a mild limitation in social functioning. (Tr. 15)
In the area of concentration, persistence, or pace, Pitaroksi had a mild limitation. (Tr. 15) Pitaroski testified that he had a panic disorder. (Tr. 15) He further testified that when he had a panic attack, he would have to leave the store or the crowded environment that he was in and withdraw so that he could be alone. (Tr. 15) However, Pitaroski was able to attend the consultative examination, follow the proceedings without the need to be redirected, his speech was noted to be fluent, and his memory appeared to be preserved. (Tr. 15) Based on that evidence, the ALJ found that Pitaroski had a mild limitation in concentration, persistence, and pace. (Tr. 15)
In the final area of episodes of decompensation, Pitaroski experienced no episodes of decompensation of an extended duration. (Tr. 15) Because Pitaroski's medically determinable mental impairment caused no more than mild limitations in the first three functional areas and no episodes of decompensation of an extended duration in the fourth area, it was deemed nonsevere. (Tr. 16)
The ALJ then assessed Pitaroski's residual functional capacity (RFC) as follows: "the claimant has the residual functional capacity to perform the full range of medium work as defined in 20 CFR 404.1567(c)." (Tr. 19) In determining Pitaroski's RFC, the ALJ discussed all of Pitaroski's symptoms and the extent the symptoms reasonably could be accepted as consistent with the objective medical evidence and other evidence. (Tr.16) In doing so, the ALJ followed a two-step process: first determining whether there could be a medically acceptable basis for his complaints, and second evaluating the "intensity, persistence, and limiting effects of the claimant's symptoms" to determine if they limited his work ability. (Tr. 16-17)
The ALJ summarized Pitaroski's medical treatment for his symptoms consistent with degenerative disk disease of the lumbar spine and degenerative joint disease of the right knee. (Tr. 17) Pitaroski first sought treatment for back and knee pain in July 2010, and went to St. Anthony Medical Center. (Tr. 17) Radiology studies from that treatment only revealed early degeneration in the lumbar spine of the multiple upper lumbar disks, and the radiology studies of the knees revealed degenerative change and moderate narrowing of medial right knee joint and minimal narrowing of the lateral right and both sides of the left knee joint. (Tr. 17) In August 2010, Pitaroski went to St. Clare Health Clinic where he was diagnosed with mild effusion in his right knee, but he had no instability or tenderness upon palpation. (Tr. 17) He was prescribed Naprosyn. (Tr. 17)
During a consultative examination in October 2010, Dr. Rahmany Mohammed, M.D., noted that despite Pitaroski's complaints of low back pain and knee pain, Pitaroski was able to walk with a steady gait, did not use an assistive device, and could stoop and squat without difficulty, walk heel to toe and tandemly, and stand from a sitting position without difficulty. (Tr. 17) Dr. Mohammed also found that Pitaroski did not have any edema, stiffness, effusion, or atrophy in his lower extremities. (Tr. 17) Pitaroski had full range of motion in his cervical, thoracic, and lumbar spines, as well as full range of motion in each joint of his hips, knees, ankles, and feet. (Tr. 17)
In December 2010, Pitaroski returned to St. Clare Health Clinic complaining that he hardly could sit for a long time due to the pain in his back and knee. (Tr. 17) He was diagnosed with degenerative disk disease of the lumbar spine and degenerative joint disease of the knees. (Tr. 17) He was prescribed Celebrex and instructed to discontinue using Naprosyn. (Tr. 17) Pitaroski was advised to follow up for a Depo-medrol injection with Dr. Frederick Klepsch. (Tr. 17) During2011, Pitaroski continued his treatments at St. Clare Health Clinic, where it was noted that he was not taking any medications for pain while he was awaiting the results of his Medicaid application. (Tr. 17)
Dr. Klepsch completed a Medical Source Statement. In his opinion, Pitaroski was capable of low stress work. (Tr. 17) Pitaroski also would require an absence from work one day per month. (Tr. 17) Pitaroski was supposed to keep his legs elevated above the waist 25-30% of the workday because of knee and ankle edema, but this limitation was considered excessive by the ALJ when compared to the progress notes of Dr. Klepsch. (Tr. 18-19) The progress notes were devoid of any directive to Pitaroski to elevate his legs. (Tr. 18) Pitaroski...
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