Sonnefeld v. Commissioner, Social Security Administration

          OPINION and ORDER

          Marcia S. Krieger United States District Judge.

         THIS MATTER comes before the Court on Plaintiff Alfred H. Sonnenfeld's^[1] appeal from the Commissioner of Social Security's (the “Commissioner”) final decision denying his application for Disability Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401-33, and Supplemental Security Income under Title XVI of the Social Security Act, 42 U.S.C. §§1381-83c. Having considered the pleadings and the record, the Court

         FINDS and CONCLUDES

         I. Jurisdiction

         Mr. Sonnenfeld filed a claim for disability insurance benefits pursuant to Titles II and XVI in August 2013, asserting that his disability began approximately five months earlier. After his claim was initially denied, Mr. Sonnenfeld filed a written request for a hearing before an Administrative Law Judge (the “ALJ”). This request was granted and a hearing was held in August 2015.

         The ALJ's Decision applied the five-step social security disability claim evaluation process: (1) Mr. Sonnenfeld had not engaged in substantial gainful activity after April 18, 2013; (2) he had the severe impairments of a left transhumeral amputation and left ankle/foot degenerative joint disease with neuropathic pain; (3) he did not have an impairment or combination of impairments that met or medically equaled any of the impairments listed in 20 C.F.R. Part 404, Subpt. P, App'x 1; and (4) Mr. Sonnenfeld had the residual functional capacity (“RFC”) to perform light work as set forth in 20 C.F.R. § 416.967(b)^[2] with various limitations, and he could perform jobs that he previously held. The Decision did not proceed to “Step 5” of the social security disability analysis; instead, based on its Step 4 conclusion, the Decision determined that Mr. Sonnenfeld was not and had not been under a disabled under the Social Security Act.

         The Appeals Council denied Mr. Sonnenfeld's request for review of the Decision, making the Decision the Commissioner's final decision for purposes of judicial review. Krauser v. Astrue, 638 F.3d 1324, 1327 (10th Cir. 2011). Mr. Sonnenfeld's appeal was timely brought, and this Court exercises jurisdiction to review the Commissioner of Social Security's final decision pursuant to 42 U.S.C. § 405(g).

         II. Relevant Material Facts

         Mr. Sonnenfeld claims the onset of disability on April 18, 2013. An automobile accident in 1977 caused severe injuries on his left side of his body. As a result of the accident, his left arm was amputated, and significant injuries to his left leg and foot required ongoing treatment over many years. At the time of his application for benefits, Mr. Sonnenfeld asserted that he suffered severe impairments of a left transhumeral amputation and left ankle/foot degenerative joint disease with neuropathic pain.

         Prior to his application, Mr. Sonnenfeld worked as a tax preparer, employee benefits counselor, financial analyst, insurance auditor, order manager, and ledger accountant. Mr. Sonnenfeld's last period of employment apparently was as a customer service representative, which employment ended in April 2013.

         Treatment:

         In March 2014, Mr. Sonnenfeld was seen by Dr. Marshall Meier, M.D. Dr. Meier noted that Mr. Sonnenfeld appeared to have difficulty explaining what symptoms he was experiencing and how they might have changed. Dr. Meier's records reflect, however, that Mr. Sonnenfeld had complaints about pain in his previously-injured left foot that had worsened during recent years. Mr. Sonnenfeld also experienced swelling in his lower left leg and foot, and that he sometimes was required to sit down and elevate his leg in order to provide relief. However, Mr. Sonnenfeld did not exhibit any discomfort or disability getting on or off the examination table and/or moving around the examining room. Dr. Meier opined that Mr. Sonnenfeld was able to stand for two-to-four hours, he could perform postural activities on an occasional basis, and he could lift up to twenty pounds, both occasionally and frequently.

         Mr. Sonnenfeld also was seen by Dr. Amy M. Tubay, M.D. on three occasions in 2014. The first encounter occurred in February, when the records state that Mr. Sonnenfeld saw Dr. Tubay for treatment for “chronic sequelae” (complications) associated with his prior leg trauma. The record of this visit reflects Dr. Tubay thought that Mr. Sonnenfeld's condition “[p]robably qualifies him for disability.” The February 2014 documentation also states that “[Mr. Sonnenfeld] will pursue disability claim with a specialist & will return with any paperwork he thinks I can help him with.” In April, 2014, the records reflect Mr. Sonnenfeld's extremity weakness, numbness in extremities, and stable leg paresthesia (burning or prickling sensation). Mr. Sonnenfeld had a third appointment with Dr. Tubay on December 8, 2014. That day, Dr. Tubay completed a single page document stating that she was treating Mr. Sonnenfeld and that he needed to elevate his feet every two hours for 30 minutes. No. explanation for the prescription was provided.

         Mr. Sonnenfeld consulted Dr. Angelo Giarratano, D.P.M., in April and May 2015, to address the pain and other symptoms in his left leg. Treatment records reflect that he reported severe pain in his leg, but that he was in no acute distress at the time of his appointment. Mr. Sonnenfeld had an abnormal gait secondary to foot drop, limited range of motion and strength but no sensation in his left foot. Dr. Giarratano diagnosed idiopathic neuropathy in Mr. Sonnenfeld's left foot and prescribed medication. He also ordered x-rays of Mr. Sonnenfeld's foot. In a subsequent visit, Dr. Giarratano noted that Mr. Sonnenfeld experienced reduced sensation in his lower left leg as well as a slight shortening of ...