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Courson v. Commissioner of Social Security

United States District Court, W.D. New York

January 7, 2020

DARREL LOREN COURSON, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          DECISION & ORDER

          LAWRENCE J. VILARDO, UNITED STATES DISTRICT JUDGE.

         On November 9, 2018, the plaintiff, Darrel Loren Courson, brought this action under the Social Security Act (“the Act”). He seeks review of the determination by the Commissioner of Social Security (“Commissioner”) that he was not disabled. Docket Item 1. On May 28, 2019, Courson moved for judgment on the pleadings, Docket Item 6; on September 26, 2019, the Commissioner responded and cross-moved for judgment on the pleadings, Docket Item 13; and on October 17, 2019, Courson replied, Docket Item 15.

         For the reasons stated below, this Court grants Courson's motion in part and denies the Commissioner's cross-motion.

         BACKGROUND

         I. PROCEDURAL HISTORY

         On June 17, 2015, Courson applied for Disability Insurance Benefits. Docket Item 5 at 71. He claimed that he had been disabled since April 23, 2013, due to two spinal fusions, chronic pain, nerve damage, an overactive bladder, incontinence, hemorrhoids, anxiety, and depression. Id. at 71-72.

         On September 23, 2015, Courson received notice that his application was denied because he was not disabled under the Act. Id. at 70. He requested a hearing before an administrative law judge (“ALJ”), id. at 97, which was held on November 7, 2017, id. at 31. The ALJ then issued a decision on February 27, 2018, confirming the finding that Courson was not disabled. Id. at 19-26. Courson appealed the ALJ's decision, but his appeal was denied, and the decision then became final. Id. at 5.

         II. RELEVANT MEDICAL EVIDENCE

         The following summarizes the medical evidence most relevant to Courson's claim. Courson was examined by several different providers, but the opinions of Gordon C. Steinagle, D.O., M.P.H.; Abrar Siddiqui, M.D.; and Stuart Rubin, M.D., are of most significance to the claim of disability here.

         A. Gordon C. Steinagle, D.O., M.P.H.

         On March 17, 2015, Dr. Steinagle, an internist, evaluated Courson. Docket Item 5 at 406. Dr. Steinagle reported that Courson had “chronic, unrelenting radicular pain in both legs and into his feet.” Id. at 407. Courson's “legs [were] also weak and he state[d] that he [was] not steady on his feet.” Id.

         Courson reported that he “need[ed] help with cooking” and with “dressing at times” but that he could “feed and toilet [him]self.” Id. He could “drive very short distances” and “walk up a few stairs” but could not “walk distances.” Id.

         Dr. Steinagle observed that Courson's gait was “antalgic” and he was “unable to perform” a “[h]eel and toe walk.” Id. at 408. He had limited mobility in his lumbar spine, and his straight leg raise was positive bilaterally. Id. Dr. Steinagle also noted a “[r]esting tremor.” Id. Ultimately, Dr. Steinagle concluded that Courson was not “capable of working in a sedentary or light capacity” because he could not “lift 10 lbs. occasionally (up to 1/3 of a day) and/or walk occasionally (up to 1/3 of a day).” Id. at 406-07.

         B. Abrar Siddiqui, M.D.

         On August 17, 2015, Dr. Siddiqui, an internist, evaluated Courson. Id. at 603. Dr. Siddiqui noted that Courson “complain[ed] of [constant] back pain” that was “8/10 in intensity” and “sharp, dull, aching, [and] burning in nature.” Id. The pain “radiat[ed] to both hips and legs [and was] associated with tingling and numbness.” Id. As a result, Courson “stumble[d] sometimes while walking.” Id.

         Dr. Siddiqui observed that Courson “appeared to be in no acute distress.” Id. at 604. Courson was, however, “shaking while walking” and could walk on his heels and toes only “with difficulty.” Id. He was able to squat up to 20 degrees and get up from his chair without difficulty. Id. Courson's “[c]ervical spine show[ed] full flexion, extension, lateral flexion bilaterally, and full rotary movement bilaterally.” Id. at 605. His “[l]umbar spine show[ed] flexion restricted to 15 degrees bilaterally, and rotary movement restricted to 15 degrees bilaterally.” Id. His straight leg raise was “negative bilaterally.” Id. Dr. Siddiqui opined that Courson had “mild to moderate limitations in [his] ability to push, pull, or carry heavy objects.” Id. at 606.

         C. Stuart Rubin, M.D.

         On April 19, 2016, Dr. Rubin, a pain-management specialist, evaluated Courson's medical records. Id. at 702. Based on that review, Dr. Rubin opined that Courson could sit for “[o]ne-half-hour at a time up to seven hours per day with the ability to change position every 15 minutes”; could stand and/or walk for “15 minutes at a time up to one hour a day with [an] appropriate assistive device and safety rails”; could lift, carry, push, and/or pull “0 pounds while standing and up to 15 pounds while sitting”; could reach above shoulder level or below desk level ...


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