1

IN THE UNITED STATES DISTRICT COURT

FOR THE WESTERN DISTRICT OF PENNSYLVANIA 

DENNIS L. ECHOLS, )

) Case Number 04-243 ERIE

Plaintiff )

) District Judge Sean J. McLaughlin

vs. ) Magistrate Judge Susan Paradise Baxter

)

JOANNE B. BARNHART, )

Commissioner of Social Security )

Defendant )

MAGISTRATE JUDGE’S REPORT AND RECOMMENDATION

I. RECOMMENDATION

It is recommended that the Motion for Summary Judgment filed by the Plaintiff

[Document # 7] be granted. It is further recommended that the Motion for Summary Judgment

filed by the Defendant [Document # 9] be denied. This matter should be remanded to the Social

Security Administration for further proceedings.

II REPORT

A. Procedural Background

Plaintiff (Echols) brings this action pursuant to Section 216(i), 223 and 1614(a)(3)(A)

respectively of the Social Security Act (the Act), seeking judicial review of a final decision by

the Commissioner of Social Security denying his Application for Disability Insurance Benefits

and Supplemental Security Income Disability payments. After his application was denied by

Notice dated May 20, 2003, Plaintiff requested a hearing which was conducted before an

Administrative Law Judge (ALJ) on December 19, 2003 and at which Echols was represented

by counsel. The ALJ issued a decision denying Echols’ claim for Social Security Disability

Insurance benefits, as well as Supplemental Security Income Disability benefits, effectively

concluding that Echols was not under a “disability” as that term is defined under the Act at any

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1 The Court’s recitation of relevant facts is derived from the transcript of the

administrative record filed by the Commissioner as part of her answer in accordance with §

205(g)of the Act, 42 U.S.C. § 405(g), which is referred to hereinafter as “R.” Additional

citations appear as necessary.

2 Echols is insured for purposes of his claim for Social Security Disability Insurance

benefits only through March 31, 1996. Therefore, to be entitled to Social Security Disability

Insurance benefits, Echols would have had to prove that he became disabled on or before March

31, 1996. 20 C.F.R. § 404.131. However, Echols’ remaining claim for Supplemental Security

Income Disability benefits requires only proof that Echols is under a “disability” at any time up

to and including the date of the ALJ’s decision, and, otherwise, meets certain income and

resource limitations. 20 C.F.R. § 416.202.

2

time prior to the date of the March 23, 2004 claim denial. R. 17.1 Echols sought administrative

review from the SSA’s Appeals’ Council, which was denied by Order of the Appeals’ Counsel

dated June 25, 2004. 

Echols now seeks judicial review pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). He

alleges errors entitling him to a new administrative hearing. The Commissioner disagrees. Both

Echols and the Commissioner have filed a motion and cross-motion, respectively, for summary

judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure and the matter is ripe for

disposition by this Court.

B. Factual Background

Plaintiff Echols was born on September 24, 1953. Echols was fifty years old when the

Commissioner issued her final decision. R. 13. He has a high school education and has past

relevant work experience as a carpenter, dump truck driver, maintenance worker, and bodyshop

worker. R. 69, 74. Echols alleges that he has been unable to work since December 5, 1995 due

to a back injury, with the addition of Hepatitis C in November 2002. R. 68.2

C. Medical Background

In December of 1995, Plaintiff suffered a low back injury while in the course of his

employment. R. 346. Thereafter, Plaintiff began suffering chronic and severe lower back pain

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with some radiation down his legs. R. 347. 

In February 1996, Plaintiff consulted with an Orthopedic Surgeon, Lawson Smart. An

MRI of the lower spine revealed a small central disc herniation at the L5-S1 level with mild

impingement on the thecal sac. Plaintiff was prescribed Indocin, an anti-inflammatory, and

Vicodin, for pain. Dr. Smart also prescribed moist heat and stretching and indicated that

Plaintiff could not return to work, but should check on “light duty possibilities.” R. 191- 192.

On June 11, 1996, Plaintiff was treated at the Pain Clinic by Dr. Macielak, who

concluded that Plaintiff was suffering from a left lower extremity radiculopathy, along with S1

dermatome and secondary to the herniated disc at the L5-S1 level. Dr. Macielak concluded that

Plaintiff was not able to work and prescribed Talwin for pain. Dr. Macielak suggested that

Plaintiff consider a surgical option to address his situation. R. 173 - 176. 

In November 1996, Plaintiff returned to the Pain Clinic complaining of increased pain in

his back and leg, with numbness in his left foot. A CT scan dated June 14, 1996 confirmed the

presence of a disc herniation at L5-S1, larger than that revealed by a previous MRI and now

compressing on the nerve root. R. 178, 171. Dr. Macielak opined that Plaintiff was not capable

of work. 

In January 1997, Plaintiff returned to Dr. Macielak, who suggested surgical intervention. 

R. 171. On March 20, 1997, Plaintiff underwent a laminotomy procedure. R. 145 -152. In May

of 1997, Dr. Macielak reported a setback in Plaintiff’s recovery, possibly due to a recurrent disc

herniation or increased nerve root irritation. R. 143. By June of 1997, Plaintiff was still

significantly symptomatic as to his left lower leg pain. An MRI conducted on June 20, 1997

suggested a recurrent disc herniation. R. 141. Plaintiff began physical therapy in July 1997 in

order to increase his strength and range of motion. R. 140. 

Between February 1997 and September 1997, Dr. Macielak consistently indicated in the

medical records that Plaintiff was unable to work. R. 164 - 170.

In September of 1997, a formal physical capacity evaluation performed by John Hilson, a

physical therapist, indicated that Plaintiff had the ability to sit and stand for no more than twenty

to twenty-five minutes with walking limited to moderate distances, lifting abilities measured at

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3 At the ALJ hearing, Plaintiff explained that he stopped seeing Dr. Macielak when he

settled his worker’s compensation case and lost his medical insurance. Plaintiff testified that he

continued to suffer intense back pain every day; his pain was aggravated by activity; his pain

would limit his ability to stand and walk; he could not lift more than ten pounds. This pain

persisted throughout the period leading up to the hearing in December of 2003. 

4 Plaintiff’s Hepatitis C diagnosis was confirmed by needle biopsy on January 24, 2003. 

R. 251 - 252. 

4

twelve to fifteen pounds. The therapist opined that Plaintiff should be encouraged to work

toward a vigorous exercise program. R. 128 - 135.

On September 30, 1997, Plaintiff saw Dr. Macielak who suggested that Plaintiff was

improving but was to remain limited to light duty with no more than twenty pounds maximum

lifting on a part-time basis. R. 162-163. 

Plaintiff was last seen by Dr. Macielak in September 1998 3 when he complained of

increased pain. Plaintiff complained that his pain level intensified as each day wore on

proportional to the amount of activity he performed that day. Dr. Macielak concluded that

Plaintiff was unable to work. R. 164. 

On November 5, 2002, Plaintiff presented to Kristin Templin, his Primary Care

Physician, complaining of nausea, vomiting, syncope, pre-syncope, weakness and fatigue for

more than six months. Blood work revealed that Plaintiff was suffering from Hepatitis C.4 R.

261 -262. Dr. Templin referred Plaintiff to Bruce Dratler, a Gastroenterologist.

On January 10, 2003, Plaintiff consulted with Dr. Dratler, who recommended treatment

of Pegulated Interferon and Rivavarin. Dr. Dratler explained that the side-effects of such

treatment could include increased depression, flu-like symptoms, reduced white blood cell count

and reduced platelet count. Plaintiff chose to proceed with the therapy. R. 246. 

On February 18, 2003, Plaintiff began the treatment. On February 25, 2003, Plaintiff

reported to Dr. Templin that since beginning the Interferon treatments, he experienced fatigue,

tinnitus and pounding headache. He also reported chronic low back pain and intermittent

sciatica. Dr. Templin prescribed Vioxx for back pain and assured Plaintiff that his tinnitus was

secondary to the Interferon therapy. R. 320. 

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5 Anemia is defined as too few red blood cells which may result in insufficient oxygen

to tissues and organs.

5

On March 28, 2003, Plaintiff reported to Dr. Templin of continuing tinnitus, with vertigo

and lightheadedness, at which time Dr. Templin arranged for a second opinion with another

gastroenterologist. R. 319 -320. 

On April 9, 2003, Plaintiff was examined by Dr. Thomas Shaw-Stiffel at the UPMC

Center for Liver Disease. Dr. Shaw-Stiffel noted that Plaintiff’s liver biopsy revealed chronic

Hepatitis with piecemeal necrosis, balloon degeneration, and bridging fibrosis. The doctor

noted that Plaintiff was tolerating the Interferon treatments poorly and was suffering fatigue,

dizziness, nausea, headache and generalized flu-like symptoms following each weekly Interferon

injection for about two to three days in duration. Dr. Shaw-Stiffel prescribed Trazadone for

Plaintiff’s insomnia and mood alteration, and prescribed an increased dosage of Zoloft and

Ultram for Plaintiff’s musculoskeletal aches and pains. R. 294 -295. 

On May 12, 2003, Plaintiff was seen at the UPMC Center for followup. Plaintiff had

developed anemia5, continued to suffer headaches, nausea with occasional vomiting, and fatigue. 

Dr. Shaw-Stiffel prescribed Aranesp or Procrit for the anemia and confirmed that the length of

Interferon therapy was to be forty-eight weeks (with Plaintiff having completed his twelfth

week). R. 285 - 286. 

On June 16, 2003, Plaintiff was again seen at the UPMC Liver Center (in his sixteenth

week of Interferon therapy). Plaintiff reported headache, shortness of breath with activity,

nausea, vomiting, abdominal pain, and fatigue. Dr. Shaw-Stiffel reported that Plaintiff was

beginning to show a virologic and biochemical response to the Interferon therapy, but that

Plaintiff was suffering complications with anemia. R. 280 -281. 

On August 25, 2003, Plaintiff was seen at the UPMC Liver Clinic (in his twenty-fifth

week of Interferon therapy). Plaintiff reported headaches, blurred vision, shortness of breath,

nausea, alternating diarrhea and constipation, decreased appetite, dizziness and fatigue. Plaintiff

had lost thirteen pounds since June. Dr. Shaw-Stiffel noted that Plaintiff’s Interferon treatment

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 Neutropenia is a marked decrease in the white blood cells.

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was now complicated by neutropenia6 along with the anemia. R. 271 -272. 

By letter dated December 18, 2003, Dr. Shaw-Stiffel summarized Plaintiff’s condition

for counsel. Dr. Shaw-Stiffel stated that Plaintiff had reached the fortieth week of his Interferon

therapy with a desired biochemical and virologic response. The doctor indicated that with the

completion of treatment he hoped Plaintiff would achieve a cure and that if Plaintiff cleared the

virus, he had an excellent prognosis. The doctor also indicated that Plaintiff continued to suffer

from a number of side effects including insomnia, nausea, diarrhea, headache, severe fatigue and

depression, most likely related to the Interferon therapy (although the Rivavarin therapy had

caused the anemia and contributed to the severe fatigue). The doctor stated that many of these

symptoms would likely resolve after the Interferon therapy was complete. Plaintiff was referred

to a neurologist and pain management specialist for his continuing back pain. R. 324. 

D. The Administrative Law Judge’s Decision

A disability hearing was conducted on December 19, 2003. Plaintiff and a vocational

expert testified at this hearing. R. 340-365. 

On March 23, 2004, the ALJ issued his decision. The ALJ made the following findings

which are listed verbatim from his decision:

1. The claimant meets the nondisability requirements for a period of

disability and Disability Insurance Benefits set forth in Section 216(i) of

the Social Security Act and is insured for benefits only through March 31,

1996.

2. The claimant has not engaged in substantial gainful activity since the

alleged onset of disability.

3. The claimant’s back injury, status post surgery and hepatitis C with

current Interferon treatment are considered “severe” based on the

requirements in the Regulations 20 C.F.R. §§ 404.1520(c) and

416.920(b).

4. These medically determinable impairments do not meet or medically

equal one of the listed impairments in Appendix 1, Subpart P, regulation

No. 4. 

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5. The claimant’s allegations regarding his limitations are not totally

credible for the reasons set forth in the body of the decision. 

6. The claimant has the residual functional capacity for light exertion with a

sit/stand option.

7. The claimant is unable to perform any of his past relevant work.

8. The claimant was a “younger individual between the ages of 25 and 49" at

the alleged date of onset, and is currently 50 and approaching advanced

age.

9. The claimant has a “high school education.”

10. The claimant has no transferable skills from semi-skilled work previously

performed decision.

11. [omitted in original]

12. Although the claimant’s exertional limitations do not allow him to

perform the full range of work, based on the testimony of the Vocational

Expert and using Medical-Vocational Rules 202.13 and 202.21 as a

framework for decision-making, there are a significant number of jobs in

the national economy that he could perform.

13. The claimant has not been under a “disability” as defined in the Social

Security Act, at any time through the date of this decision.

R. 16-17 (internal citations omitted).

E. Standards of Review

The Social Security Act provides limited judicial review of a final decision of the

Commissioner (effectively that of the ALJ where, as in this case, the Appeals Council has

denied the applicant’s request for review). In reviewing the Commissioner’s decision, this court

may not decide facts anew, reweigh the evidence, or substitute this court’s judgment for that of

the Commissioner or, by extension, the ALJ. See Herron v. Shalala, 913 F.3d 329, 333 (7th Cir.

1994). Rather, this court must affirm a decision if it is supported by substantial evidence and

the ALJ has made no error of law. 42 U.S.C. § 405(g); Hartranft v. Apfel, 181 F.3d 358, 360

(3d Cir. 1999). Substantial evidence is “ ‘such relevant evidence as a reasonable mind might

accept as adequate to support a conclusion.’ ” Pierce v. Underwood, 487 U.S. 552, 564-65

(1988) quoting Consolidated Edison v. NLRB, 305 U.S. 197, 229 (1938). See also Jones v.

Barnhart, 364 F.3d 501, 503 (3d Cir. 2004). Plaintiff contends that the ALJ’s decision is not

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supported by substantial evidence. 

A disability is defined under the Act as the “inability to engage in any substantial gainful

activity by reason of any medically determinable physical or mental impairment . . . which has

lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C.

§ 423(d)(1)(A) (Supp. 2002); 20 C.F.R. § 404.1505(a) (2002). A claimant is unable to engage in

substantial gainful activity when “his physical or mental impairment or impairments are of such

severity that he is not only unable to do his previous work, but cannot, considering his age,

education and work experience, engage in any other kind of substantial gainful work which

exists in the national economy[.]” 42 U.S.C. § 423(d)(2)(A).

The Commissioner must perform a five-step sequential evaluation process to make

disability determinations under the regulations. See 20 C.F.R. § 416.920. If the claimant fails to

meet the requirements at any step in the process, the Commissioner may conclude that the

claimant is not disabled under the Act. The ALJ must determine, in order: (1) whether the

claimant is currently engaged in substantial gainful activity; (2) if not, whether the claimant has

a severe impairment; (3) if so, whether the claimant’s severe impairment meets or equals the

criteria of an impairment listed in 20 C.F.R pt. 404, subpt. P, app. 1; (4) if not, whether the

claimant’s impairment prevents him from performing his past relevant work; and (5) if so,

whether the claimant can perform any other work which exists in the national economy in light

of his age, education, work experience and residual functional capacity. See 20 C.F.R. §§

404.1520, 416.920; Sykes v. Apfel, 228 F.3d 259, 262-63 (3d Cir. 2000). 

In this case, the ALJ evaluated the case under these guidelines and determined, at step

five, that Plaintiff Echols could perform work in the national economy. R. 17. Specifically, the

ALJ concluded that: (1) Echols was not currently employed in substantial gainful activity; (2)

that he has an impairment or a combination of impairments considered “severe” pursuant to the

requirements of 20 C.F.R. § 404.1520(c) and 416.920(b); (3) that these impairments did not

meet the criteria for listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1; (4) that

Echols retained the residual functional capacity to perform a significant range of light work; and

(5) that there were other jobs in the national economy that Echols could perform. R. 16-17. 

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7 Plaintiff also argues that the ALJ has not adequately analyzed all the medical evidence

in relation to Plaintiff’s liver condition. However, because this Court is recommending the

remand of this matter, we need not specifically address this argument.

9

Plaintiff has the burden of establishing that he is disabled under the Act. See 20 C.F.R.

§§ 404.1512, 416.912.

F. Discussion

Plaintiff argues that the ALJ failed to adequately consider and explain his rejection of

competent medical evidence supporting the claim. Plaintiff argues that the ALJ did not engage

in a complete analysis in regard to Plaintiff’s lower back pain.7

As to Plaintiff’s lower back pain, the ALJ refers to treatment records which he

concludes: 1) indicate that Plaintiff was able to perform light work as early as February 1996

and 2) suggest that Plaintiff could perform a full range of light work within six months of his

March 1997 surgery (as indicated in the Functional Capacity Assessment dated September

1997). R. 12 - 17. In reaching the conclusion that Plaintiff retains the residual functional

capacity for light exertion with a sit/stand option, the ALJ indicates:

... I have given primary weight to the opinions of the claimant’s treating surgeon

and the claimant’s current treating physician. Although the claimant incurred an

injury just a few months prior to the date he was last insured for benefits on

March 31, 1996, the early records show that the claimant’s physician was of the

opinion the claimant could pursue light work by February 1996, even if he could

not return to his more exertionally demanding job as a construction carpenter. 

Indeed, even one month after he was last insured, the clamant was being advised

to maintain an appropriate level of activity and continue with his exercise

program. Once the clamant elected to undergo a surgical option, he was released

to perform light work within six months of the surgery. A comprehensive

functional capacity assessment, competed in September 1997, concluded that the

clamant could perform a full range of light work. For several years following the

clamant’s last office visit in 1998, he did not consult a physician at all. Even

when the claimant sought health care in 2002, his back condition was not

mentioned as problematic. 

R. 14. 

In his motion for summary judgment, Plaintiff points out that there is medical evidence

that Plaintiff could not return to work which the ALJ does not mention in his decision. These

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include: 1) Dr. Smart’s February 13, 1996 report that Plaintiff should remain off of work until

his next appointment on February 27, 1996 (R. 193) and his subsequent referral to a pain clinic

and direction to remain off work until discharge by the pain clinic (R. 189 - 190); 2) Dr.

Macielak’s treatment notices of September 30, 1997 interpreting the Functional Capacity

Assessment as demonstrating Plaintiff’s capacity to perform light duty with a maximum twenty

pound lifting requirement on a limited basis (R. 162 - 163); and 3) Dr. Macielak’s seven

consistent recommendations that Plaintiff was unable to work from February 18, 1997 though

September 22, 1997 (R. 164 - 170). 

The opinion of claimant’s treating physician that he cannot return to work is entitled to

substantial weight. Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981). An ALJ must explain

reasons for rejecting uncontradicted medical evidence. Schaaf v. Matthews, 574 F.2d 157 (3d

Cir. 1978). See also Kent v. Schweiker, 710 F.2d 110, n.5 (3d Cir. 1983) (“While the ALJ is, of

course, not bound to accept physicians’ conclusions, he may not reject them unless he first

weighs them against other relevant evidence and explains why certain evidence has been

accepted and why other evidence has been rejected.”). Remand is appropriate in cases where the

ALJ has failed to offer a clear explanation why medical evidence was rejected. Altman v.

Commissioner of Social Security, 124 Fed.Appx. 748 (3d Cir. 2005). See also Kennedy v.

Richardson, 454 F.2d 376 (3d Cir.1972) (it was error for an ALJ to reject uncontradicted

medical evidence without a clear statement of the reasons for doing so). 

Accordingly, Plaintiff’s motion for summary judgment should be granted and this matter

should be remanded. 

III. CONCLUSION

For the foregoing reasons, it is recommended that the Motion for Summary Judgment

filed by the Plaintiff [Document # 7] be granted. It is further recommended that the Motion for

Summary Judgment filed by the Defendant [Document # 9] be denied. This matter should be

remanded to the Social Security Administration for further proceedings.

In accordance with the Magistrates Act, 28 U.S.C. § 636(b)(1)(B) and (C), and Local

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Rule 72.1.4 B, the parties are allowed ten (10) days from the date of service to file written

objections to this report. Any party opposing the objections shall have seven (7) days from the

date of service of objections to respond thereto. Failure to timely file objections may constitute a

waiver of any appellate rights

S/ Susan Paradise Baxter 

SUSAN PARADISE BAXTER

Chief United States Magistrate Judge

Dated: August 26, 2005

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