United States District Court, N.D. Illinois
MEMORANDUM OPINION AND ORDER
SUSAN E. COX, Magistrate Judge.
Plaintiff Cosme Velazquez ("Mr. Velazquez") seeks judicial review of the final decision of the Commissioner of Social Security Administration ("Commissioner"), Carolyn W. Colvin, denying his application for Social Security Disability Insurance ("SSDI") benefits under Title II of the Social Security Act, 42 U.S.C. §§ 216(i), 223. Mr. Velazquez filed a motion for summary judgment seeking reversal of the Commissioner's decision [dkt. 15]. For the reasons stated herein, this Court grants Mr. Velazquez's motion.
I. PROCEDURAL HISTORY
On January 29, 2010, Mr. Velazquez applied for SSDI benefits alleging disability as of January 1, 2007. He later amended his date of disability to August 29, 2008. Mr. Velazquez stated that he could no longer work because he suffered from diabetes mellitus, neck, shoulder and back pain, a left wrist, forearm, and hand injury, and vision problems. On June 14, 2010, his claim was denied in full. On June 29, 2010, Mr. Velazquez completed a request for reconsideration. The SSA regional commissioner affirmed the June 14, 2010 denial of benefits. Mr. Velazquez requested a hearing before an Administrative Law Judge ("ALJ"). On May 9, 2011, ALJ Jose Anglada ("ALJ Anglada") conducted an administrative hearing regarding Mr. Velazquez's disability benefits claim. ALJ Anglada issued an unfavorable decision on May 27, 2011. Thereafter, Mr. Velazquez filed a request for review of ALJ Anglada's decision with the Appeals Council, which was denied. Pursuant to 42 U.S.C. § 405(g), Mr. Velazquez now requests judicial review of his denial of SSDI benefits by this Court.
II. STATEMENT OF FACTS
Mr. Velazquez was fifty-six years old and had an eleventh grade education from Mexico when he appeared before ALJ Anglada on May 9, 2011. For twenty-seven years, the majority of his working career, he worked for Vulcan Materials, which is a facility that takes limestone out of the ground, heats it in industrial kilns to convert it to lime, and sells the finished product to steel mills. Mr. Velazquez started at Vulcan Materials as a laborer in 1979, and worked in that capacity for a number of years before becoming a foreman. He was then promoted to plant manager, a position he held for the next fourteen years. Mr. Velazquez was the only plant manager who worked his way up from a laborer, and to his knowledge, the only plant manager without a college degree. According to Mr. Velazquez, new management took over and he was let go in 2006. Mr. Velazquez applied for disability benefits on January 29, 2010 based on the following medical impairments: diabetes, hypertension, neck and shoulder pain, left wrist, forearm and hand injury, and non-proliferative retinopathy.
B. Mr. Velazquez's Medical Impairments
The record contains evidence of the following medical impairments: shoulder, and neck pain, back pain, permanent impairment of the left wrist, forearm and hand, diabetes mellitus, evidence of diabetic retinopathy, neuropathy and renal problems, hypertension, fatigue, and calf pain. The facts pertaining to each are discussed below.
1. Shoulder, Neck and Back Impairments
The record reveals that Mr. Velazquez was treated at various medical institutions from June 2009 through the end of 2010 for his shoulder, neck and back pain. He saw physician Steven Clar at Alivo Medical Center in June 2009 for bilateral numbness and tingling in the third through fifth digits of his hands, forearms, and shins and limited movement in his right shoulder. Following this treatment, his Alivo medical records show continued neck and shoulder pain.
On February 24, 2010, Mr. Velazquez went to Stroger Hospital's emergency room with complaints of neck and shoulder pain and numbness to his fingers. An x-ray showed mild degenerative changes in his lower cervical spine. An MRI taken in April 2010 also revealed multilevel cervical spondylosis,  mild uncovertebral joint disease narrowing the left and right neural foramens at C3-C4 and C4-C5, a disc bulge and left uncovertebral joint disease narrowing the left neural foramen at C5-C6, and minimal disk bulge, and mild left neural foraminal narrowing relate to osteophyte formation, at C6-C7.
In June 2010, Mr. Velazquez's visited the pain clinic at Ambulatory & Community Health Network of Cook County (ACHN) and he reported that his pain on that day was a four out of ten and he was experiencing neck pain that was radiating into both hands with an increase in numbness and tingling. The treatment plan included physical therapy and visits to the pain clinic for cervical radiculopathy.
In August 2010, after completing two months of physical therapy, he reported that his pain decreased from, at its absolute highest, a seven out of ten to a five out of ten. He also stated he felt happy that the pain was better controlled.
By September 2010, however, Mr. Velazquez had to be fitted for a home traction unit due to continued and escalating complaints of pain. Dr. Clar's November 2010 report contained findings of clinical evidence for bilateral cervical radiculopathy as well as diabetic peripheral neuropathy. Dr. Clar's notes showed Mr. Velazquez was started on Gabapentin and Elavil, which along with a home traction unit and home exercises had decreased his pain from a seven out of ten to a five out of ten.
2. Permanent Left Hand, Wrist, and Forearm Injury
In January of 1994, Mr. Velazquez sustained a severe fracture to his left wrist and forearm caused by an injury during the course of his employment with Vulcan. In February 1996, Doctor Robert Groya reported that Mr. Velazquez had reached maximum medical improvement, but had permanent loss of function. Dr. Robert Groya's report opined that Mr. Velazquez had permanently lost 85% of the function of his left wrist, hand and elbow. Subsequent to this injury, Vulcan provided Mr. Velazquez with assistance in completing the paperwork required by his position as plant manager.
Dr. Wen Yang from Alivo Medical Center documented Mr. Velazquez's diabetes as uncontrolled with a possibility of neuropathy explaining the numbness in his hands and legs on June 19, 2009. Insulin was prescribed, and his diabetes was again reported as uncontrolled on June 25, 2009. Over the next few months, the records show improving blood sugar levels with twice a day insulin injections. Mr. Velazquez consistently reported multiple hypoglycemic episodes per month during this time. Further, in March 2010 there is a note that his insulin may need to be increased to control his blood sugar levels. In September 2010, he was assessed by ACHN as a fifty-five year old man with poorly controlled diabetes and hypertension.
4. Diabetic Conditions: Eye Disease, Nerve Damage, and Kidney Impairment
On December 10, 2009, Dr. Yang diagnosed Mr. Velazquez with a retinal hemorrhage and referred Mr. Velazquez to an ophthalmologist. He went to the Specialty Care Center Eye Clinic through ACHN in February 2010. Eventually, in May 2010, he went to the Illinois Eye Institute where his listed ocular conditions included "[m]oderate NPDR". Mr. Velazquez underwent surgery on both eyes to correct the issues associated with his diabetic retinopathy in June and September 2010. He also had multiple laboratory tests done which reported high creatinine levels in his urine. Although a December 7, 2010, renal ultrasound came back unremarkable,  subsequent medical records indicate a diagnosis of "probable chronic renal failure" from December 17, 2010. ...