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RUSH Post-hearing Brief, 1500 Page File or Less
Date: February 14, 2019
Claimant: Name, SSN
ALJ: Honorable Judge Name
Hearing Date: February 2, 2019
Introduction: At the hearing held on February 2, 2019, your honor held the file open for 10 days to receive and submit records from Hospital Name. The records have been received and summarized below.
Title II Filing Date: 11/01/2017
Date Last Insured: 12/31/2020
Alleged Onset Date (AOD): 10/1/2017
Age: 43 years, 11 months at AOD and currently 45 years, 6 months
Date Last worked: September 1, 2017 (2D).
Prior ALJ application or reopening issue: No
Severe Impairments: Lumbar Spine multi-level Degenerative Disc Disease with Radiculopathy status-post fusion at L1-2; Congestive Heart Failure; Morbid Obesity (BMI at 45); and Generalized Anxiety Disorder.
Medications as of 2/2019: Percocet, Lopressor, Nitroglycerin, and Zoloft.
DAA Issues: No
A DDS nonexamining consultant in May 2018 finds Claimant has severe congestive heart failure and obesity (1A). The nonexamining source further finds Claimant can perform a limited range of medium work. However, the consultant did not have a significant amount of evidence available to review. Subsequent to this review, Claimant reports worsening back pain with positive straight leg raise tests in 10/2018 and 12/2018 (14F/31, 35, and 39). Moreover, a lumbar spine x-ray confirms disc extrusion and 50 percent narrowing at L1-2; disc bulge and protrusions at L3-4 and L4-5; and disc bulge, protrusion, and moderate narrowing of the neural foramina with contact of the left S1 nerve root at L5-S1 (17F/2). Therefore, Claimant undergoes a lumbar spine posterior left L1-2 fusion on 1/2/2019 (18F/1). Unfortunately, evidence indicates ongoing pain radiating down bilateral legs subsequent to the surgery (14F/45 and post-hearing evidence from Hospital Name). In 1/2019, he is morbidly obese with BMI at 45 (14F/42). This evidence was not considered by the nonexamining consultant.
Post-Hearing Evidence: Hospital Name, 1/19/2019
Hospital Name: Claimant underwent a L1-2 fusion on 1/2/2019. However, he twisted his back and felt a “pop” with recurrent left leg pain. On 1/19/2019, a post-operative examination shows decreased sensation to pinprick of the left leg with antalgic gait. The post-operative lumbar spine MRI shows “recurrent central to left paracentral focal protrusion…indenting the thecal sac” at L1-2. Moreover, the MRI shows scar tissue and postoperative fluid collection at the laminectomy site. The L3-4, L4-5, and L5-S1 discs continue to have narrowing and indention into the thecal sac, which is likely contributing to current complaints and/or result in significant symptoms in the near future. Based on the post-operative lumbar spine MRI and current symptoms, the surgeon recommends a redo of the L1-2 fusion. Claimant is prescribed narcotic pain medication.
Holding: Claimant is disabled based on the effects of his severe impairments singly and in combination. Claimant is morbidly obese with pain stemming from lumbar spine radiculopathy status-post fusion and congestive heart failure. He is reasonably anxious about his declining health and inability to work and requires anti-anxiety medication. In sum, Claimant’s exertional and nonexertional functional limitations preclude work on a regular and continuous basis.
Thank you for the opportunity to submit post-hearing evidence and your consideration in this case.
Terri M. David is a Social Security Disability (SSD) professional and former SSA/Office of Hearings Operations (OHO) Senior Attorney Adjudicator.
Terri began as an Attorney Decision Writer in Nashville, TN in 2004. She was promoted in 2006 to a position at headquarters in falls Church, VA, where she adjudicated disability claims at the reconsideration level. While there, she began her career as an ODAR/OHO trainer and mentor to new adjudicating attorneys and decision writers.
In 2007, Terri worked as a Senior Attorney Adjudicator in Houston, TX. There, an opportunity to create training material and provide training to new attorneys and law interns became possible and increased exponentially based on her extensive training in Falls Church, VA. She went on to become a National Decision Writer Trainer in 2008, teaching the basics of the 5-Step Sequential Evaluation and persuasively writing legally defensible Administrative Law Judge (ALJ) decisions.
Terri began working as a Senior Attorney Adjudicator Trainer in 2010. She trainer new and experienced senior attorneys on how to improve adjudicating disability claims at the hearings level, prior to an ALJ hearing.
Terri M. David’s SSD training is focused on efficiently and accurately adjudicating disability claims and writing persuasive ALJ decisions. Now, Terri shares years of valuable experience as an adjudicator, trainer, and decision writer through training concentrated on expediting and winning cases, understanding SSD law, and efficiently maneuvering the SSD claims process.