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BAKER v. BARNHART

May 7, 2003

CARROLL M. BAKER, PLAINTIFF,
v.
JO ANNE B. BARNHART, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT



The opinion of the court was delivered by: Martin C. Ashman, United States Magistrate Judge.

MEMORANDUM OPINION AND ORDER

Plaintiff Carroll M. Baker seeks judicial review of the final decision of the Commissioner of Social Security ("Commissioner") that she was not entitled to Disability Insurance Benefits ("DIB")*fn1 pursuant to 42 U.S.C. § 405 (g)*fn2 Before this Court are Plaintiff's motion for summary judgment, which seeks a reversal or remand of the denial of her claim, and the Commissioners motion for summary judgment, which seeks to uphold its decision. Both parties have consented to have this Court conduct any and all proceedings in this case, including the entry of final judgment. See 28 U.S.C. § 636 (c); Local R. 73.1(b). For the reasons set forth below, this Court reverses the Commissioner's final decision and remands this case for further proceedings.

I. Procedural History

On February 9, 2000, Baker applied for DIB, alleging disability since February 21, 1999. (R. at 72.) After the application was denied both initially and on reconsideration, Baker requested a hearing before an administrative law judge ("ALJ"). (R. 45-48, 56.) The ALJ's hearing was conducted on April 25, 2001, where Baker, who was represented by counsel, and a vocational expert testified. (R. at 19-43, 56.) On August 28, 2001, the ALJ issued his decision that Baker was not disabled. (R. at 10-17a.) This decision became the final decision of the Commissioner on March 14, 2002, when the Appeals Council denied Baker's request for review. (R. at 4-6.) See 20 C.F.R. § 422.2 10(a). Baker now seeks judicial review of that decision.

II. Facts and Medical History

Baker was born on February 26, 1954, and was forty-seven years old at the time of the ALJ's decision. (R. at 23, 72.) Baker completed the ninth grade, and has a variety of past work experiences. (R. at 24, 90, 98-103.) She has worked as a solderer, a home health care attendant, a sorter in a factory, and a car porter for a rental company. (R. at 90, 98-103.) Baker's last job was as a hotel housekeeper. (R. at 98.)

While working at this last job, Baker slipped and fell in February 1999. (R. at 25-26.) She was taken to an emergency room, where she was seen for ankle pain. (R. at 26, 156.) Dr. Miller, an emergency room doctor, diagnosed Baker with a moderate sprain, and Baker complained the next day of right lower leg pain. (R. at 26.)

Baker began a course of physical therapy, but complained of lower back pain while walking. (R. at 200-18.) In March 1999, mild degenerative changes were observed in a cervical spine x-ray, along with well-preserved disc spaces. (R. at 158.) Baker was discharged from therapy on May 13, 1999, when she was found to have met all her objective goals and to be functionally well. (R. at 218.) However, Baker still complained of subjective back pain. (Id.)

In June 1999, an MRI study revealed a herniated*fn3 disk at L4-L5. (R. at 159.) In December 1999, Dr. Raghu Singh, a neurologist, performed an operation on Baker's spine to treat radiculopathy)*fn4 (R. at 27, 231.) This elective back surgery consisted of a microlumbar hemilaminectomy*fn5 at L4-L5 on the left, a forarninotomy*fn6 at L4-L5 on the left, and the removal of a herniated disk at L4-L5. (R. at 229-31.)

In February 2000, Baker was involved in an automobile accident. (R. at 28.) In March 2000, Dr. Suresh Mahawar performed a consultative examination on Baker in connection with her disability claim. (R. at 240-43.) Dr. Mahawar noted Baker's medical history and her complaints of a history of back pain. (R. at 243.) Mahawar found Baker could bend forward 78° out of 90°. (R. at 240.) He also found Baker had no muscle atrophy in any of her extremities. (R. at 241.) He found her gait to be mildly antalgic*fn7 without a cane, and that she should be able to walk 100 to 200 feet without assistance. (Id.) He also found she was able to bear weight. (Id.) Dr. Mahawar found that Baker had severe difficulty walking on her toes and hopping on one leg, and mild difficulty walking on her heels and rising from a squat. (Id.) He diagnosed Baker as having chronic neck pain with a history of cervical radiculopathy, and chronic lower back pain with mild degenerative joint disease and a history of lumbar radiculopathy. (Id.) Dr. Mahawar's examination also revealed no abnormalities in Baker's extremities. (R. at 242.) Baker was found to be neurologically intact with normal strength and sensation. (Id.)

In April 2000, Dr. Singh performed a computed tomography (CT) scan of Baker's spine. (R. at 244-45.) This scan was interpreted as "grossly normal," and also showed a herniated disk at L4-L5. (R. at 244.) In May 2000, Dr. Singh diagnosed Baker as having low back pain with radiculopathy, along with weak reflexes and sensory loss in the L5 dermatome.*fn8 (R. at 254.) Dr. Singh also found that the straight leg raising test was positive; that Baker could bend forward 70° out of 90° and that Baker had muscle spasms along the lumbosacral spine. (R. at 253-54.) In June 2000, Dr. Singh performed a second surgery on Baker to remove her recurrent herniated disk. (R. at 256-58.)

In March and June 2000, Baker's medical evidence was reviewed by state agency physicians Virgilo Pilapil, M.D., and Reynaldo Gotanco, M.D. (R. at 116-23.) They concluded Baker could lift twenty pounds occasionally and ten pounds frequently, as well as sit, stand, and walk for a total of six hours in an eight-hour workday. (R. at 117, 123.) The physicians also concluded that Baker was occasionally limited from climbing ropes, stairs, ramps, ladders and scaffolds. (R. at 118.) They noted that Baker had no muscle atrophy in any of her four extremities.*fn9 (R. at 123.)

In March 2001, Dr. Singh (Baker's physician) assessed Baker's ability to work. (R. at 262-69.) Dr. Singh reported the following findings:

• Baker could lift as much as five pounds;

• Baker could stand and/or walk for thirty minutes to an hour in an eight-hour day;
• Baker could sit for a total of one to two hours in an eight-hour day;
• Baker could sit thirty minutes to an hour at a time;
• Baker should never climb, balance, stoop, crouch, kneel or crawl; and
• Baker had limited abilities to reach, handle, push, and pull. (R. at ...

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