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Holdeman v. Saul

United States District Court, W.D. Missouri, Western Division

November 6, 2019

SCOTT TERRILL HOLDEMAN, Plaintiff,
v.
ANDREW M. SAUL, Commissioner of Social Security Administration, Defendant.

          ORDER

          NANETTE K. LAUGHREY United States District Judge

         Plaintiff Scott Terrill Holdeman appeals the Commissioner of Social Security's final decision denying his applications for disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act. For the reasons set forth below, the Court reverses and remands to the Commissioner for further proceedings.

         I. Background

         Holdeman alleges that he became disabled on 12/27/2015 following an injury while working as a plumber. Holdeman alleges that this injury exacerbated his preexisting injuries, and in conjunction with a diagnosis of lupus and aggravation of his mental impairments, he is now unable to return to work. He filed his initial applications for disability insurance and SSI benefits on 5/13/2016. The ALJ held a hearing on 1/17/2018 and subsequently issued a decision denying benefits on 3/6/2018. The Appeals Council declined review in a letter dated 9/17/2018. Holdeman appealed to this Court.

         A. Medical History

         Holdeman's disability claim is based on limitations resulting from degenerative joint disease of the bilateral knees, degenerative joint disease of the right shoulder, history of bilateral carpal tunnel release, lupus erythematosus, alcohol abuse, depression, somatic symptom disorder, anxiety, and post-traumatic stress disorder. Holdeman had previously been involved in two Worker's Compensation cases: a lower back injury in 1995 and an injury to his shoulder in 2010. Holdeman was able to return to work following the first two injuries, but has not worked since his December 2015 injury. He alleges that he was at work lifting a heavy object when he felt a pop in his left knee and spasm in his lower back, resulting in pain radiating from his lower mid-back to the right side and tingling in his right foot. Tr. 572.

         Prior to his last workplace injury, Holdeman saw Dr. Scholsberg, a psychologist, on 7/31/2015 for evaluation and treatment of post-traumatic stress disorder. He was given a PTSD checklist (civilian version, PCL-C) and scored below the cutoff for PTSD with a score of 24. Holdeman complained of unstable mood, anger, agitation, and rage following his father's death in 2012, accompanied by suppressed appetite, sleep disturbances, decreased energy, and anxiety. Consistent with possible bipolar II disorder, Holdeman was offered individual therapy and substance abuse treatment was recommended. Tr. 374.

         On 12/15/2015, Holdeman had a punch biopsy taken for diagnosis related to multiple facial lesions and raised and scaling pink plaques. Tr. 337. Pathology results indicated discoid lupus erythematosus, and Doxycycline was prescribed. Tr. 338-339.

         Following his work injury, Holdeman saw Dr. Arthur Ziporin on 12/28/2015 for lumbar strain. Tr. 566. An examination revealed lumbosacral tenderness at ¶ 3-L4, flexion to 30 degrees, extension to 10 degrees, bilateral side bending to 15 degrees, and negative straight leg raise. He was prescribed Flexeril and referred to physical therapy. Holdeman returned to Dr. Ziporin on 12/31/2015 and 1/8/2016 with complaints that his pain was not better. Exam findings and work restrictions remained the same after both visits. Tr. 576, 579.

         Holdeman received physical therapy treatment on 1/4/2016, 1/6/2016, and 1/8/2016 but was unable to tolerate therapy due to exacerbation of his symptoms, resulting in discontinuation in treatment. Tr. 588, 584, 582.

         A 1/14/2016 MRI of Holdeman's lumbar spine showed mild degenerative disease at ¶ 4-L5 and L5-S1 with facet DJD at ¶ 5-S1 resulting in mild left greater than right foraminal narrowing, as well as a broad-based disc bulge at ¶ 4-L5 and L5-S1 approaching the central L5 and S1 nerve roots without significant mass effect or displacement. Tr. 569-570.

         On 1/28/2016, Holdeman was examined by Dr. Fermin Santos. The examination revealed full range of motion, mild pain with lumbar flexion and extension, and focal tenderness along L2-L3 paraspinal musculature bilaterally, and physical therapy was ordered. Tr. 612, 616.

         On 1/29/2016, Holdeman had a physical therapy evaluation for his lower back pain, and treatment was planned twice weekly for four weeks. Tr. 646. Holdeman subsequently returned to physical therapy for treatment over seven visits, but with minimal change to his range of motion, strength, and functional capacities. Tr. 657.

         A 2/25/2016 examination by Dr. Santos revealed full range of motion, mild pain with lumbar flexion and extension, and focal tenderness along L2-L3 paraspinal musculature bilaterally, resulting in diagnoses which included acute chronic low back pain now localized to L2-L3, lumbar strain, mild degenerative lumbar disc disease, and resolution of lumbar radiculitis. Tr. 612. Two weeks of physical therapy followed by two weeks of work conditioning was ordered. Holdeman attended four additional physical therapy visits before beginning the work conditioning program.

         The conditioning program was set to be for three to four visits weekly for two weeks. Holdeman's back symptoms were noted as improving overall, but bilateral knee and ankle pain caused functional limitations and continuation of treatment was not recommended. Tr. 681.

         A 3/24/2016 examination by Dr. Santos revealed full range of motion, mild pain with lumbar flexion and extension, and focal tenderness along L2-L3 paraspinal musculature bilaterally. Tr. 607. Holdeman was considered at maximum medical improvement and was returned to full duty work status. Tr. 608.[1]

         On 6/13/2016, Holdeman was examined by Dr. Dorzab. Holdeman complained of being more depressed with anxiety and feelings of anger and nervousness. Dr. Dorzab prescribed Prilosec, Paxil, and Xanax. Tr. 379. Holdeman was examined again by Dr. Dorzab on 11/1/2016, revealing mild swelling of both knees with bilateral crepitus, limp favoring left leg, increased warmth of both knees, slight lateral swelling of ankle, and that Holdeman was not taking Paxil on a regular basis. He was instructed to take his medication regularly, and braces were ordered. Tr. 923.

         B. Expert Opinions

         Dr. G.L. Pacci opined, based on a 6/14/1996 examination following a 9/15/1994 work injury resulting in low back pain, that chronic lumbar strain could be permanent and produce permanent work restrictions. Tr. 393. Dr. Pacci noted that an MRI had confirmed signs of discopathy at ¶ 4 and L5 interspaces, which could be explained by intermittent irritation of the thecal sac and mild traction of the nerve roots at the two ...


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