Nagy v. Commissioner, Social Security Administration

          OPINION AND ORDER REVERSING THE COMMISSIONER'S DECISION

          Marcia S. Krieger Chief United States District Judge

         THIS MATTER comes before the Court on the Plaintiff's Complaint (# 1), the Plaintiff's Opening Brief (# 15), the Defendant's Response (# 16), and the Plaintiff's Reply (# 19). For the following reasons, the Commissioner's decision is reversed and the matter is remanded for further proceedings.

         I. JURISDICTION

         The Court has jurisdiction over an appeal from a final decision of the Commissioner under 42 U.S.C. § 405(g).

         II. BACKGROUND

         A. Procedural History

         Thomas Nagy seeks judicial review of a final decision by the Commissioner denying his claim for disability insurance benefits (DIB) and supplemental security income (SSI) under the Social Security Act. In March 2014, Mr. Nagy filed for DIB and SSI, claiming he became disabled in May 2011. Tr. at 158-73. His application was denied at all administrative levels and he now appeals to this Court.

         B. Factual Background

         The Court summarizes only the medical evidence relevant to its decision. Here, the dispositive issue concerns the weight given to the medical opinions as to Mr. Nagy's functional capacity. At the time of his alleged onset of disability, Mr. Nagy was 42 years old. Tr. at 158. He was previously employed as a pipe fitter, warehouse worker, and wire mesh fabricator. Tr. at 199. He has a history of musculoskeletal problems in his back and knees.

         In May 2014, Dr. Rebecca Bub conducted a consulting examination of Mr. Nagy. Tr. at 268-77. Though she conducted a thorough exam of all of Mr. Nagy's systems, the relevant findings come from her musculoskeletal exam. Tr. at 273-75. She observed normal range of motion in his cervical spine, hip joints, ankle joints, left shoulder joint, elbow joints, wrist joints, and finger joints. Tr. at 273-74. She also observed significant discomfort while examining his dorsolumbar spine, which had a lower range of motion. Tr. at 274. Moving to his knees, she found discomfort while determining his range of motion, more so in the right knee than the left. Tr. at 274. Ms. Nagy had a positive anterior drawer and Lachman test on the right knee, but a negative McMurray sign bilaterally. Tr. at 274. Examining his right shoulder, Dr. Bub observed limited range of motion and significant discomfort; Ms. Nagy had a positive Neer test and Hawkins test. Tr. at 274. Finally, though she noted lumbar paraspinal muscle tenderness, there was no spinous process tenderness to palpation. Tr. at 275.

         Dr. Bub also reviewed x-ray images of Mr. Nagy's lumbosacral spine and right knee. Tr. at 276. Her impression was mild to moderate lumbar spondylosis without evidence of acute fracture or subluxation and, as to the knee, mild degenerative changes within the medial and patellofemoral compartments without evidence for acute fracture or dislocation. Tr. at 276.

         Based on these observations, she diagnosed Mr. Nagy with back pain, knee pain, and shoulder pain from a torn rotator cuff. Tr. at 276-77. She recommended physical therapy and exercise for his back, and an MRI and follow-up with a surgeon for his knee and shoulder. Tr. at 276- 77. She then opined that Mr. Nagy (1) could sit between four and six hours per workday; (2) can stand only two hours per workday; (3) should walk at least two hours per workday; (4) could lift and carry “25 pounds and 5 pounds, frequently and occasionally, respectively”;^[1] (5) could bend, stoop, squat, crouch, or crawl occasionally; and (6) could manipulate with his fingers and arms occasionally. Tr. at 277.

         In March 2014, Dr. Carlos Rodriguez, a conducted a consulting psychiatric examination of Mr. Nagy. Tr. at 261-62. Dr. Rodriguez diagnosed Mr. Nagy with a history of post-traumatic stress disorder (PTSD), major depression, and anxiety disorder. Tr. at 261-62. In this exam, however, Dr. Rodriguez largely recounted Mr. Nagy's subjective complaints and proceeded to draw conclusions and make recommendations. In June 2016, Dr. Rodriguez again examined Mr. Nagy and, this time, made a more thorough record of his examination. Tr. at 360-65. Dr. Rodriguez found Mr. Nagy oriented to person, place, time, and situation, but with deficits in attention, calculation abilities, working-memory capabilities, auditory-memory capabilities, and social judgment. Tr. at 361. He exhibited great difficulty in the Serial Seven Subtraction cognitive task. Tr. at 361. Dr. Rodriguez observed that Mr. Nagy's responses suggest the presence of low average to borderline intellectual functioning. Tr. at 361-62. Dr. Rodriguez noted that Mr. Nagy experienced multiple PTSD symptoms, including nightmares and flashbacks, as well as intrusive and disturbing thoughts about the death of his son, the genesis of his PTSD. Tr. at 362-63. Dr. Rodriguez found that Mr. Nagy presented with evidence of panic attacks, onset by increased anxiety in the company of others or in crowds. Tr. at 363. Based on these observations, Dr. Rodriguez echoed his 2014 conclusions, adding panic disorder with agoraphobia. Tr. at 364. He then opined that Mr. Nagy's ability to engage in basic work-related activities including memory, understanding, sustained concentration, persistence and pace, social interaction, and adaption are moderately to significantly impaired. Tr. at 365.

         Dr. Rodriguez also completed a mental residual functional capacity (RFC) evaluation. Tr. at 366-68. He opined that Mr. Nagy was moderately impaired in his ability to remember locations and work-like procedures, understand and remember very short and simple instructions, carry out very short and simple instructions, make simple work-related decisions, ask simple questions or request assistance, and travel in unfamiliar places or use public transit. Tr. at 366-67. He opined that Mr. Nagy was at least markedly limited in every other area of the evaluation: understanding and memory, sustained concentration and persistence, social interaction, and adaption. Tr. at 366-67. ...