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Williams v. Berryhill

United States District Court, D. Connecticut

September 14, 2018



          Hon. Vanessa L. Bryant, United States District Judge

         This is an administrative appeal following the denial of Plaintiff Lynne C. Williams' application for Title II Social Security Disability and Title XVI Supplemental Security Income benefits.[1] It is brought pursuant to 42 U.S.C. §§ 405(g). Plaintiff has moved for an order reversing the decision of the Commissioner of the Social Security Administration (“Commissioner”). (Dkt. No. 21). The Commissioner opposes this motion. (Dkt. No. 26). For the following reasons, Plaintiff's Motion for an Order Reversing the Commissioner's Decision (Dkt. No. 21-2) is DENIED and Defendant's Motion for an Order Affirming the Commissioner's Decision is GRANTED.

         I. Background

         a. Administrative Proceedings

         On April 8, 2014, Plaintiff applied for disability insurance benefits and for supplemental security income. (R. 248). Plaintiff claims that her disability began on December 16, 2013, when she began experiencing back and radiating leg pain. Both applications were initially denied on August 19, 2014, and again upon reconsideration on May 6, 2015. (R. 134-141, 147-162). Plaintiff then requested a hearing before an Administrative Law Judge (“ALJ”). (R. 163-165). ALJ Ronald J. Thomas heard the case on November 21, 2016. (R. 33-35). ALJ Thomas issued a decision finding that Plaintiff was not disabled within the meaning of the Social Security Act. (R. 10). The Appeals Council denied Plaintiff's request for review; this action followed. (R. 1-4).

         b. Medical History/Chronology

         Plaintiff was under the care of Dr. Richard R. Slater until December 23, 2010. (R. 649). Dr. Slater withdrew from treating Plaintiff because he believed that Plaintiff was seeking controlled substances. (R. 648-649).

         On September 22, 2011, Plaintiff saw nephrologists Anushree Shirali, M.D. and Deepak Kadiyala, M.D for evaluation. (R. 405). Their treatment notes described Plaintiff as a 53-year-old female with a ten-year history of hypertension, hyperlipidemia, remote CVA, obesity[2] and chronic back pain. (R. 405). Plaintiff told Drs. Shirali and Kadiyala that she was formerly an x-ray technician “but stopped due to back pain” (R. 406). Plaintiff had been taking Percocet and Valium for several months preceding her appointment but switched to meloxicam and Motrin shortly before her appointment. Plaintiff stated that her hypertension was a side effect of the meloxicam and that she would prefer to take Percocet. (R. 406). Dr. Kadiyala diagnosed Plaintiff with Chronic Kidney Disease and suggested a Liboderm patch instead of non-steroidal anti-inflammatory drugs (“NSAIDs”) like meloxicam and Motrin. (R. 406).

         Plaintiff presented to the Emergency Room at Yale New Haven Hospital (“Yale”), on February 19, 2013, following a fall on the ice. (R. 403-405). Plaintiff complained of left ankle pain and swelling. (R. 403). An x-ray confirmed an avulsion fracture to the left ankle. (R. 405). Plaintiff received Tylenol for pain. (R. 405).

         Months later, in May 2013, Plaintiff saw a physician at the General Practitioners of Hamden and asked for a note allowing her to “return to work at full capacity.” (R. 647). While there, she complained of prolonged back pain and requested something to aid sleep. The doctor she saw prescribed Diazepam. (R. 647).

         On December 16, 2013, Dr. Pichamol Jirapinyo treated Plaintiff at Yale's Primary Care Center for back pain. (R. 401-403). The doctor recorded Plaintiff's height and weight as 5'7” and 193 pounds giving Plaintiff a BMI of 30.25 kg/m2. (R. 402). Plaintiff complained that her back pain had been occurring for approximately 15 years. She described the pain as sharp, constant, and getting increasingly worse. Plaintiff also experienced numbness and tingling in her legs. (R. 401). She stated the pain affected her daily activity and interrupted with her sleep. (R. 401). Additionally, Plaintiff indicated that she had tried multiple medications as well as several weeks of physical therapy with no improvement. (R. 401). She refused to accept a physical therapy referral. (R. 401). Thus, Dr. Jirapinyo prescribed Tramadol, an opioid pain medication. (R. 402). The Plaintiff stated that morphine, which she received from a friend, provided the only relief. (R. 401). Plaintiff requested morphine, but the doctor refused because alternative options were not yet maximized. (R. 401).

         Following the doctor's refusal to prescribe morphine, Plaintiff returned to Yale's Primary Care Center on January 23, 2014. (R. 524-525). During this visit, Plaintiff denied the scheduled blood work and threw lab slips at the nurse. (R. 524). Plaintiff then pushed her son who was defending the nurse. Security was called to escort Plaintiff out of the office. (R. 524).

         Plaintiff next appeared at Yale in the Emergency Room on March 4, 2014 reporting suicidal ideation. (R. 516-524). She admitted to spending her state benefits check on card games and alcohol. (R. 517). She stated that she drank vodka from the bottle for two days before arriving at the hospital. (R. 517). Plaintiff also admitted to feeling bad about herself for several months because she was unemployed and had a poor relationship with her father. (R. 517). Plaintiff was willing to undergo alcohol treatment. (R. 522). Her Global Assessment of Functioning Score (GAF Score), which assesses the effect of psychiatric illness on a person's functional skills and abilities, was 51 out of 100. (R. 522).

         Three weeks later, on March 28, 2014, Plaintiff returned to the Primary Care Center. (R. 389-392). Dr. Jirapinyo met with Plaintiff. Plaintiff informed the doctor that her pain was still constant. (R. 390). Dr. Jirapinyo noted that Plaintiff was in the obese range based on a recorded height of 5'6” and weight of 191 pounds. (R. 390). The doctor noted Plaintiff's BMI to be 30.88 kg/m2. (R. 390). The doctor was not certain whether spinal stenosis or osteoarthritis caused the Plaintiff's back pain. (R. 391). The doctor ordered an MRI to evaluate Plaintiff's back. (R. 391).

         The MRI took place on April 22, 2014, and showed multiple bulging discs, some with stenosis and contact with nerve roots. (R. 369). Plaintiff saw Dr. Perdigoto to review the MRI. (R. 385). Dr. Perdigoto stated the pain was likely degenerative disease and that Plaintiff had epidural lipomatosis, which was possibly correlated with her obesity. (R. 386). Plaintiff stated that she was having difficulty working because she was unable to stand or sit for prolonged periods of time due to her pain. (R. 385). The epidural lipomatosis can lead to progressive neurological deficits, so Dr. Perdigoto referred Plaintiff to orthopedics. (R. 386). The doctor increased the Tramadol prescription from 50mg to 100mg. (R. 386). Dr. Perdigoto issued a letter following the visit stating that Plaintiff has a degenerative disc disease and epidural lipomatosis, rendering her unable to work. (R. 370).

         On May 24, 2014, just one month after the MRI, an ambulance escorted Plaintiff to the Yale New Haven Emergency Room. (R. 430-439). The ambulance arrived after Plaintiff woke up naked, in complete disarray. Plaintiff's son indicated that she was extremely intoxicated the night before. (R. 431). The report showed Plaintiff was drinking two pints of vodka per day, three days per week, and using crack cocaine. (R. 435). The Plaintiff also admitted to taking “handfuls” of the prescribed Tramadol. (R. 431). Plaintiff refused detoxification. She left the hospital upon being clinically sober. (R. 432).

         Plaintiff returned to Yale on May 30, 2014 after making suicidal comments. (R. 471-478). The report stated that Plaintiff “had been drinking earlier, got into an altercation wither her husband, and made comments about ‘blowing her brains out.'” (R. 473). Additionally, Plaintiff was “belligerent, combative and yelling at staff.” (R. 473). Plaintiff ultimately denied suicidal plans and staff decided she was non-suicidal. (R. 475).

         On August 13, 2014, Plaintiff presented to Yale Primary Care Center for “pain uncontrolled on current regiment” and refills of her anti-hypertensives and cholesterol medications. (R. 552-555). The report indicated Plaintiff had been using double the prescribed amount of Tramadol and was in need of more medication. (R. 552). Additionally, Plaintiff stated that no medication eased her pain except morphine. The supervising physician added to the report that Plaintiff refused to discuss any type of therapy or medication besides narcotic treatment. (R. 554). The supervising physician declined to prescribe morphine. (R. 522).

         Plaintiff returned to Primary Care Center on October 8, 2014 with lumbar pain. (R. 555-559). Dr. Alison Romegialli assessed Plaintiff. (R. 555). Plaintiff indicated that the pain was better when she leaned forward, but that she laid flat the majority of the time. (R. 556). Additionally, Plaintiff showed significant weight gain over the past few years due to inactivity and reported an inability to perform household chores. (R. 556). The doctor indicated lower lumbar tenderness and a limited range of motion, but no neurological deficits. (R. 557). Furthermore, the doctor referred Plaintiff to a pain specialist and a neurologist. (R. 559).

         On January 12, 2015, Dr. Kolene McDade assessed Plaintiff at the Primary Care Center. (R. 570-573). The examination affirmed the continued back pain as well as a gait problem. (R. 571). The doctor stated that Plaintiff's description of her pain was out of proportion to the MRI results. (R. 572).

         Plaintiff's next visit to Primary Care occurred on August 26, 2015, where she saw Dr. Mohsin Chowdhury for “worsening back pain” and a renewal of Tramadol. (R. 657-666). The report showed that Plaintiff had canceled the appointments for neurology and pain management that were previously scheduled at Dr. Romegialli's suggestion. (R. 657). Plaintiff also refused to try aquatherapy, stating she was afraid of water. (R. 657). The doctor renewed the Tramadol prescription. (R. 660).

         On March 29, 2016, Dr. Robert Morrison of the Connecticut Heart Group, PC evaluated Plaintiff for a cardiovascular consultation after an abnormal EKG. (R. 885-886). Plaintiff's height, weight and BMI were 5'6”, 213 pounds, and 34.38 kg/m2 respectively. (R. 885). The doctor ordered a stress test and an echocardiogram. (R. 885). Additionally, Dr. Morrison instructed Plaintiff to discontinue tobacco use. (R. 885).

         Plaintiff returned to the Emergency Room at Yale on April 3, 2016, reporting back pain and abdominal pain. (R. 737-741). The doctor gave Plaintiff a Licodaine patch and she returned home after her symptoms improved. (R. 741). Plaintiff came back to the Emergency Room on April 12, 2016. (R. 742-746). Plaintiff stated she suffered from the same back pain for years that her pain was not changing. (R. 742).

         On May 2, 2016, Plaintiff saw Dr. Romegialli at the Primary Care Center for follow-up. (R. 677-680). Plaintiff specified that she needed narcotics for her back pain. (R. 680). When Dr. Romegialli attempted to counsel Plaintiff on the best remedies, Plaintiff interrupted and asked if the doctor would prescribe her opioids. (R. 680). When the doctor refused to prescribe narcotics, Plaintiff left the office. (R. 680).

         Plaintiff had an abnormal echocardiogram at the Connecticut Heart Group office on May 18, 2016. (R. 890-892). A stress test occurred on June 17, 2016. (R. 889). The Plaintiff's shortness of breath caused the test to end after two minutes. (R. 889). The doctor noted that Plaintiff was at immediate risk for a cardiovascular event due to her performance on the stress test. (R. 889).

         A left heart catheterization and coronary angiography occurred at Yale, on July 18, 2016. (R. 887-888). A surgical consultation for a coronary artery bypass graft with Dr. Viswa Nathan took place on July 21, 2016. (R. 895-897). The catheterization revealed triple coronary artery disease and Dr. Nathan suggested coronary artery bypass x 3 to be done the following day. (R. 895-896). Following the bypass surgery, Plaintiff remained in the hospital until July 27, 2016. (R. 780- 784). After being discharged, Dr. Joseph Gallego noted that Plaintiff returned home and drank half a pint of vodka. (R. 814-815).

         The next day, Plaintiff attempted to appear at the hearing before ALJ Thomas but had a syncopal episode in the lobby and an ambulance transported her to Yale. (R. 804-833). Plaintiff remained hospitalized until August 1, 2016 due to evolving pneumonia. (R. 826). Antibiotics were prescribed. (R. 809). During her stay, Plaintiff discussed with Dr. Jonathan Siegfried her ideation that the hospital was keeping her only for the institution's and employees' financial benefit. (R. 813).

         Plaintiff saw Dr. Chowdhury at the Primary Care Center to follow-up on August 12, 2016. (R. 879-882). Plaintiff stated her dissatisfaction with some of the doctors that have evaluated her, then began complimenting others as the “best doctors” she has ever had. (R. 879). Dr. Chowdhury, concerned by her split behavior, suggested a mental health evaluation. Plaintiff refused. (R. 879). The doctor also noted that her exercise tolerance was improving. (R. 879).

         Dr. Nathan evaluated Plaintiff on August 23, 2016. (R. 899-901). The doctor indicated Plaintiff's height, weight and BMI were 5'5”, 218 pounds, and 36.28 respectively. (R. 900). Dr. Nathan strongly advised Plaintiff to be on a strict diet. (R. 900). On a follow-up dated October 11, 2016, Dr. Nathan saw Plaintiff again. At this visit, Plaintiff weighted 208 pounds and her BMI dropped to 34.78. Dr. Nathan advised Plaintiff to “lose a few more pounds.” (R. 914-915).

         Plaintiff returned to the Primary Care Center on November 9, 2016 to discuss back pain with Dr. Graham Taylor. (R. 916-919). Plaintiff's weight remained at 208 pounds. (R. 917). The doctor discussed with Plaintiff his reasons for not prescribing her an opioid. (R. 916). Plaintiff refused all other suggested treatments. (R. 916). On or around November 14, 2016, Plaintiff had a second lumbar MRI. (R. 910). There was no significant change when compared to the original MRI. (R. 907). Plaintiff then went to Yale on December 6, 2016 and explained that narcotics remained the only medication that could relieve her pain. (R. ...

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