United States District Court, W.D. Wisconsin
SHAWN J. HEIDENREICH, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
OPINION & ORDER
D. PETERSON DISTRICT JUDGE
Shawn Heidenreich seeks judicial review of a final decision
of defendant Nancy A. Berryhill, Acting Commissioner of
Social Security, finding him not disabled within the meaning
of the Social Security Act. Heidenreich contends,
principally, that remand is warranted because the
Administrative Law Judge (ALJ): (1) improperly discredited
his testimony regarding his subjective symptoms of pain and
(2) improperly assigned weight to various medical opinions.
Because the ALJ relied on “significant inconsistencies
in the record” to discredit Heidenreich's
testimony, but failed to adequately connect the evidence to
these perceived inconsistencies, the court will remand the
case for further proceedings.
was born in 1969 and has a high school education. He had a
brief period of employment in 2014, but has not otherwise
worked since 2009. He applied for disability insurance
benefits in September 2012, alleging a disability onset date
of May 27, 2012. His application was denied both initially
and upon reconsideration.
hearing, the ALJ issued a written opinion denying
Heidenreich's claim in full. The Appeals Council denied
his request for review, making the ALJ's decision the
final determination of the Commissioner. Heidenreich now
appeals, seeking judicial review of the ALJ's decision
pursuant to 42 U.S.C. § 405(g).
Relevant medical history
underwent decompression surgeries on the lumbar spine in 2006
and 2010. In May 2012, he sought treatment for continuing
back pain from his primary treating physician, Thomas Reiser,
MD, and an x-ray showed advanced degenerative disc space
narrowing at L 5-S1. On August 8, 2012, Heidenreich visited
Dr. Reiser and complained of “low back pain and right
leg pain.” R. 384. Dr. Reiser
restricted him to lifting 15 to 20 pounds, sitting for 3 to 5
hours, and standing 4 to 6 hours. On October 17, 2012, Dr.
Reiser recommended that Heidenreich undergo decompression and
fusion surgery to address “the fact [that] he continues
to have significant lower back pain.” R.
2013, Heidenreich sought primary care treatment at the St.
Croix Regional Medical Center. First, on January 4, he had a
scheduled office visit to refill his diabetes medication and
told his provider he had a “low back injury” that
caused “burning and numbness in his toes, ” but
that he was waiting for “Workmen's Comp. to approve
surgery.” R. 472. Next, on September
25, he had another office visit in order to refill his pain
medication, Hydrocodone. R. 467. At this
visit he reported suffering persistent, “sharp”
lower back pain. Finally, on October 24, he sought treatment
for “musculoskeletal pain” in his lower back
after being involved in a motor vehicle accident, and was
prescribed muscle relaxants. R. 462.
returned to Dr. Reiser on February 19, 2014, again
complaining of persistent back pain. An x-ray showed no more
than mild degenerative changes since 2012. An April 7, 2014
MRI scan showed moderate-to-severe right and mild left
foraminal narrowing at L5-S1 and some evidence of enhancing
scar tissue at L5-S1. Heidenreich elected to proceed with
surgery and underwent an anterior-posterior fusion at L5-S1
on June 27, 2014. At a surgical follow-up appointment on
August 6, 2014, he complained of ongoing back and left leg
pain. An x-ray indicated that the surgery had achieved
excellent fusion, but a CT scan indicated that a loosening
screw may have been causing mechanical pain.
performing a revision surgery to remove this loose screw, Dr.
Reiser sent two letters to Heidenreich's counsel opining
on his disability status. First, on October 8, 2014, Dr.
Reiser wrote to Heidenreich's attorney stating
Heidenreich was “totally disabled” due to
“instability, persistent pain, severe degenerative disc
disease of lumbar spine L5-S1, [and] failure of prior
surgeries with persistent mechanical back pain necessitating
a fusion.” R. 416. Three weeks later,
on October 29, 2014, he sent another letter revising his
opinion, this time stating Heidenreich met the requirements
of Listing 1.04 due to chronic pain and radiculitis.
revision surgery was performed on November 11, 2014, and the
loose screw was removed from Heidenreich's back. At a
follow-up appointment on November 26, 2014, Heidenreich
reported that his leg pain had improved but that he still had
residual numbness. On February 18, 2015, Dr. Reiser noted
that Heidenreich's x-ray looked satisfactory, motor
strength and sensation were intact, and his straight leg
raise was negative. Based on this, Dr. Reiser recommended
that Heidenreich begin physical therapy (PT).
began PT and reported that while he still had back pain, he
had noticed some improvement post-surgery. At his eighth PT
session, on March 19, 2015, he reported slow improvement but
was still weak, sore, and had a “stiff lumbar
spine.” R. 481. At his sixteenth and
final PT session on April 20, 2015, he had a “very
stiff lumbar spine” and showed “slight
improvement but very minimal, ” leading his provider to
conclude that “PT at this time does not appear to be
beneficial.” R. 493.
held a hearing on June 3, 2015. Heidenreich, represented by
counsel, appeared and testified by telephone. R.
28. Andrew Steiner, MD, an impartial medical expert,
and Beverly E. Solyntjes, an impartial vocational expert
(VE), appeared and testified in person. The ALJ asked
Heidenreich about his work history, daily activities, and the
reasons why he was unable to work.
testified that he had worked as a Computer Numerical Control
operator and furniture assembler in 2008, but was no longer
able to work due to the problems he was having with his legs
and lower back. He stated that he was unable to stand or walk
for more than one hour at a time and could not sit down for
more than 30-45 minutes at a time. R. 34.
Further, after any combination ...