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Caffrey v. Berryhill

United States District Court, W.D. Wisconsin

May 3, 2018

RICHARD CAFFREY, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          OPINION AND ORDER

          BARBARA B. CRABB, District Judge

         Plaintiff Richard Caffrey is seeking review of a final decision denying his claim for disability insurance benefits under the Social Security Act. 42 U.S.C. § 405(g). Plaintiff contends that he has been disabled since January 1, 2004 because of numerous impairments, including back, knee, ankle and hand pain, depression and obesity. The administrative law judge concluded that even though plaintiff has several severe and non-severe impairments, he is not disabled because he can perform the full range of light work. As explained below, I am remanding this case because the administrative law judge did not give an adequate explanation for discounting the opinion of plaintiff's treating provider, failed to discuss plaintiff's need for a walking cane and failed to conduct a proper credibility analysis.

         The following facts are drawn from the administrative record (AR).

         FACTS

         A. Social Security Application

         Plaintiff Richard Caffrey filed for disability insurance benefits and supplemental security income on August 20, 2013, contending that he was disabled because of a variety of problems, including, but not limited to, his heart, back, knees, ankle and hands. AR 196-205. He was 50 years old at the time of his application. AR 26. After his application was denied initially and on reconsideration, he requested a hearing before an administrative law judge. A video hearing was held before Administrative Law Judge Charles J. Thorbjornsen, on April 29, 2016, AR 34-71, at which plaintiff was represented by counsel. On August 23, 2016, the administrative law judge concluded that plaintiff was not disabled. AR 15-33. In July 2017, the Appeals Council denied plaintiff's request for review, AR 1, making the hearing decision the final decision of the commissioner.

         B. Overview of Medical Problems and Treatment

         1. Heart

         Plaintiff's medical record contains treatment notes for heart problems, starting in 2004. In October 2004, plaintiff was recovering from a myocardial infarction with a subsequent stent. Between 2004 and 2016, plaintiff suffered occasional chest pain and difficulty breathing with exertion. AR 307-17, 378-90, 750-67. Stress tests and other exams between 2005 and 2016 showed no exercise-induced ischemia, but showed a perfusion defect in the inferior and distal aspects of the inferolateral wall and a mildly reduced ejection fraction. AR 297-377, 750-67. Plaintiff also suffered from high blood pressure that was not well-controlled. AR 751. In 2016, he was directed to take a low dose of aspirin for prevention purposes. Id.

         2. Back, knee and ankle pain

         Plaintiff has suffered low back pain for several years and had back surgery on his lumbar spine in 2004. AR 400. Since then, he has continued to suffer from back pain, with the pain sometimes being insignificant and causing no tenderness, AR 295 (June 2013), and sometimes significant, shooting down his legs and causing numbness in his lower extremities. AR 407-08 (May 2014). In June 2013, plaintiff reported insignificant back pain, but ongoing bilateral knee pain and left ankle pain and swelling. AR 295. At an exam in May 2014, he reported back pain in the lumbar area and numbness and tingling in his legs and feet. AR 406. His strength was measured at 5/5 in both lower extremities and he had a negative straight leg raising test on the right. AR 408. He had a positive response on a straight leg raising test on his left leg at approximately 30 degrees. Id.

         In May 2014, plaintiff had magnetic resonance imaging of his lumbar spine that showed a disc protrusion at ¶ 5-S1 with foraminal narrowing bilaterally, some lateral recess stenosis at ¶ 4-L5 with a mild disc protrusion and facet joint and ligamentum flavum hypertrophy. AR 400. On June 25, 2014, plaintiff was given an epidural steroid injection at ¶ 5-S1 at the recommendation of his primary care physician. Id.

         In October 2014, plaintiff showed poor deep tendon reflex 1 over 4 bilaterally and approximately 30 degrees positive straight let test on the left. AR 408. He also had moderate tenderness with palpation to the left paraspinal muscle groups of lower lumbar region. His doctor noted that plaintiff's gait was a bit stiff from back pain and that plaintiff showed obvious discomfort and difficulty sitting for any short period of time and needed to change positions because of his back pain. AR 411.

         Plaintiff continued to complaint of back pain and numbness in 2015 and 2016. In March 2015, he was given a prescription for a walking ...


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