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Heidenreich v. Berryhill

United States District Court, W.D. Wisconsin

April 16, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          OPINION & ORDER


         Plaintiff 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.


         A. Procedural background

         Heidenreich 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.

         After a 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).

         B. Relevant medical history

         Heidenreich 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.[1] 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. 382.

         Throughout 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.

         Heidenreich 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.

         Before 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. R. 438.

         The 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).

         Heidenreich 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.

         C. Administrative hearing

         The ALJ 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.

         Heidenreich 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 ...

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