Hornbaker v. Berryhill

          MEMORANDUM OPINION AND ORDER

         Plaintiff Summer A. Hornbaker (“Hornbaker”) began the case at bar by filing a complaint pursuant to 42 U.S.C. 405(g). In the complaint, she challenged the final decision of the Acting Commissioner of the Social Security Administration (“Commissioner”), a decision based upon the findings of an Administrative Law Judge (“ALJ”).

         Hornbaker maintains that the ALJ's findings are not supported by substantial evidence on the record as a whole.^[1] Hornbaker so maintains because her residual functional capacity was erroneously assessed.^[2] Because it is not clear how the ALJ could weigh the medical opinions as he did in making the assessment, a remand is warranted.

         Hornbaker alleged in her applications for disability insurance benefits, supplemental security income payments, and disabled widow's benefits that she became disabled in January of 2014. She alleged that she became disabled, in part, because of back pain and chronic obstructive pulmonary disease (“COPD”).

         The record reflects that in April of 2013, Dr. Mark Tait, MD, (“Tait”) performed a consultative examination of Hornbaker. See Transcript at 542-544. He diagnosed her with low back pain with mild to moderate degenerative joint disease in the lumbar portion of her spine.

         On June 23, 2015, Dr. Shannon Brownfield, MD, (“Brownfield”) performed a consultative examination of Hornbaker. See Transcript at 668-672. Although his penmanship is difficult to decipher, he appears to have found that she had a full range of motion in her joints and cervical spine. Her range of motion in her lumbar spine, though, was limited to approximately seventy-five percent with pain. Hornbaker walked with a stooped gait, but she could walk without an assistive device and could walk on her heels and toes. Brownfield diagnosed, inter alia, moderate low back pain with degenerative disc disease and moderate COPD. He opined that she had moderate to severe limitations in lifting, stooping, and maintaining prolonged positions, and moderate to severe limitations in exertion.

         On November 5, 2016, Hornbaker sought emergency room care at the Fulton County Hospital for complaints of pain in her head, neck, and shoulders. See Transcript at 735-753. Testing was performed, and the following diagnosis was made: “[m]ultilevel moderate to severe cervical degenerative change predominately involving C5-C6 and C6-C7 with neural foraminal stenosis as above.” See Transcript at 745-746.

         An MRI of Hornback's cervical spine was performed on November 29, 2016. The physician who interpreted the results found, in part, the following: “[m]ultilevel degenerative changes of the spine ..., most significant at the C4-C5, C5-C6, and C6-C7 levels with areas of moderate to severe spinal canal stenosis with some associated flattening and compression of the cervical spinal cord, ” and “[a]dditional areas of neural foraminal stenosis ...” See Transcript at 808.

         Hornbaker was thereafter seen by Dr. Steven Cathey, MD, (“Cathey”) for a neurosurgical consultation. Cathey examined Hornback and offered the following assessment in a letter dated December 6, 2016:

... As you recall, [Hornbaker] is filing for long-term disability benefits through Social Security for chronic mechanical neck pain with associated paresthesia in both upper extremities. Physical therapy actually exacerbated the problem. Her pain is poorly controlled by medication, specifically tramadol.

A recent MRI of her cervical spine reports multilevel degenerative changes. Unfortunately, [she] did not bring the films with her so I have not had an opportunity to review them firsthand.

... I would certainly like to review her MRI scan firsthand before making additional recommendations. ... Based on today's exam, I suspect she is disabled with regard to future gainful employment. ...

See Transcript at 772.

         Cathey thereafter obtained the MRI of Hornbaker's cervical spine. He reviewed the results and offered the following assessment in a letter dated December 19, 2016:

... Hornbaker's MRI scan of her cervical spine arrived today in the office for review. While she does have a degree of multilevel canal stenosis, there is no significant ...