United States District Court, D. Colorado
ALFRED H. SONNENFELD, JR., Plaintiff,
v.
COMMISSIONER, Social Security Administration, Defendant.
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 ...