Zoeller v. Berryhill

          RULING AND ORDER

          DONNA F. MARTINEZ, UNITED STATES MAGISTRATE JUDGE

         The plaintiff, Shirley Anne Zoeller, seeks judicial review pursuant to 42 U.S.C. § 405(g) of a final decision by the Commissioner of Social Security ("Commissioner") denying her applications for social security disability insurance benefits and supplemental security income. The plaintiff asks the court to reverse the Commissioner's decision. (Doc. # 23.) The Commissioner, in turn, seeks an order affirming the decision. (Doc. # 26.) For the reasons set forth below, the plaintiff's motion is granted and the defendant's motion is denied.^[1]

         I. Administrative Proceedings

         On July 23, 2014, the plaintiff filed applications alleging that she had been disabled since September 13, 2013. (R^[2] at 397.) The plaintiff's applications were denied initially on September 27, 2014, and upon reconsideration on January 26, 2015. (R. at 302, 318.) She requested a hearing before an Administrative Law Judge ("ALJ") and on June 21, 2016, a hearing was held at which the plaintiff and a vocational expert testified. (R. at 198.) On August 16, 2016, the ALJ issued a decision denying the plaintiff's applications. (R. at 198.) The ALJ's decision became final on June 19, 2017, when the Appeals Council declined further review. (R. at 188.) This action followed.

         II. Standard of Review

         The court may reverse an ALJ's finding that a plaintiff is not disabled only if the ALJ applied the incorrect legal standards or if the decision is not supported by substantial evidence. Brault v. Soc. Sec. Admin., 683 F.3d 443, 447 (2d Cir. 2012). In determining whether the ALJ's findings "are supported by substantial evidence, 'the reviewing court is required to examine the entire record, including contradictory evidence and evidence from which conflicting inferences can be drawn.'" Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012) (quoting Mongeur v. Heckler, 722 F.2d 1033, 1038 (2d Cir. 1983)). "Substantial evidence is more than a mere scintilla. . . . It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Brault, 683 F.3d at 447 (quotation marks and citations omitted).

         III. Statutory Framework

         The Commissioner of Social Security uses the following five-step procedure to evaluate disability claims:

First, the [Commissioner] considers whether the claimant is currently engaged in substantial gainful activity. If he is not, the [Commissioner] next considers whether the claimant has a "severe impairment" which significantly limits his physical or mental ability to do basic work activities. If the claimant suffers such an impairment, the third inquiry is whether, based solely on medical evidence, the claimant has an impairment which is listed in Appendix 1 of the regulations. If the claimant has such an impairment, the [Commissioner] will consider him disabled without considering vocational factors such as age, education, and work experience.... Assuming the claimant does not have a listed impairment, the fourth inquiry is whether, despite the claimant's severe impairment, he has the residual functional capacity to perform his past work. Finally, if the claimant is unable to perform his past work, the [Commissioner] then determines whether there is other work which the claimant could perform.

Rosa v. Callahan, 168 F.3d 72, 77 (2d Cir. 1999).

         IV. Plaintiff's Medical History^[3]

         The medical evidence submitted to the ALJ begins in February, 2013. At that time, an MRI of the plaintiff's lumbar spine revealed “interval development of Grade II anterolisthesis^[4]due to severe facet arthropathy”^[5] at ¶ 4-5 with “progressive very severe central canal stenosis^[6]. . . . Mild central and foraminal neural narrowing at ¶ 3-4” was also noted. (R. at 794.) The plaintiff received physical therapy in July 2013 for her ”constant 8-10/10 pain in her back with difficulty sitting, bending and lifting.” (R. at 795.) On exam, she displayed reduced motor strength in her lower extremities and limited range of motion in her lumbar spine. (R. at 797.)

         Also in July, the plaintiff visited her podiatrist, Dr. Thomas Domanick, for follow up of recurrent and chronic pain overlying her second and third toe deformity. She was diagnosed with symptomatic hammer digit syndrome in her right second and third toes.^[7] (R. at 509.) The following month, she had a similar presentation. (R. at 510-11.)

         On July 15, 2013, the plaintiff presented to Dr. Francis Alcedo, an internist and plaintiff's primary care provider, with a specialty in internal medicine, with an exacerbation of her spinal stenosis. Dr. Alcedo noted that she had difficulty walking. (R. at 42.) He prescribed a trial of prednisone for the spinal stenosis-related back pain. (R. at 544.)

         In the fall, the plaintiff stopped working. She alleges an onset of disability as of September 13, 2013, the last date she engaged in substantial gainful activity.

         On September 16, 2013, the plaintiff visited Dr. Richard Blum, an orthopedic surgeon, for evaluation of her spinal stenosis. He noted that she “was doing quite well with a little discomfort.” She displayed a normal straight leg raise on examination. Dr. Blum observed that her spinal stenosis at ¶ 4-5 was the problem and that any surgery would be extensive, likely involving fusion. (R. at 1100.)

         In September 2013, the plaintiff had additional physical therapy for her spinal stenosis. (R. at 717.) Her pain pre-treatment was rated 6/10 and post treatment was rated 4/10. She reported that she felt better after her last session, but had some continued tingling and numbness in the second toe of her left foot. (R. at 717-18.)

         On October 4, 2013, the plaintiff returned to Dr. Blum complaining of numbness in the fourth and fifth toes of her left foot. On exam, her pinprick sensation was intact. Dr. Blum stated that “[s]he has severe spinal stenosis of the lower lumbar spine.” (R. at 1101.)

         Also in October 2013, the plaintiff went to Dr. Vito Errico, a radiologist, for an MRI. Her record states that she had spinal stenosis-induced back pain that had been bothering her consistently since the first week of July 2013, and occasional foot numbness. On examinations, her motor function was intact. Dr. Errico noted that her MRI showed spondylolisthesis^[8] which was likely the cause of her back pain. Epidural steroid injections were recommended. (R. at 512.) On the same day, Dr. Charles Moore, of Yale New Haven Health, noted that the plaintiff had no neurological deficits and had normal sensation. He saw that she could balance on one leg, heel-walk, toe-walk, and walk tandem. (R. at 724.)

         At the end of October 2013, the plaintiff was discharged from physical therapy with on-going issues of right foot and calf numbness as well as right leg weakness. Clinical impairments of hypermobility and poor stability were noted. (R. at 798-99.)

         Also at the end of October, the plaintiff presented to Connecticut Retina Consultants with loss of vision, blurriness and cloudiness. She reported having a harder time recovering from bright light in both eyes. There was no edema and trace waxy disc pallor was noted. “Left greater than right areolar granular atrophy” was observed as well as “no recurrence of iritis.” Her retinal pigmentosis^[9] appeared clinically stationary. She was continued on Restasis.^[10] (R. at 556-57.)

         On November 5, 2013, the plaintiff had an epidural steroid injection for lumbar radiculopathy and back pain. (R. at 513.)

         In November of 2013, the plaintiff experienced a severe increase in pain and weakness in her both legs which made it difficult for her to stand and walk. The pain had gotten slightly better since restarting physical therapy, but not significantly, and she felt that she had taken huge steps backwards. (R. at 828.) On exam, she displayed weakness in multiple lower extremity muscle groups. (R. at 829.) She continued physical therapy. (R. at 832.)

         The plaintiff returned to Dr. Blum, her orthopedist, on November 21, 2013 with continued complaints of pain in her lower back. She had suffered an adverse reaction to a cortisone injection. She had numbness in the left gluteal area, rectum, down the left leg, and in the foot. She was able to walk on her heels and toes. (R. at 1102.)

         In December 2013, the plaintiff reported to her physical therapist that both her feet felt like she was walking on water. She rated the pain in her hips and legs at 6/10. (R. at 836.)

         In physical therapy later that month, the plaintiff said that she felt generally the same. On exam, she displayed reduced motor strength in several muscle groups including only 3 strength in her left hip with abduction and extension, 4/5 internal and external rotation, and 4/5 strength with knee extension. (R. at 728). She was making progress, but both her feet were still numb. (R. at 729.) The plaintiff reported that ambulating in grocery stores increased her symptoms. (R. at 732.)

         On January 12, 2014, the plaintiff presented to Advanced Radiology with increased lower back pain and left buttock pain. Her updated MRI showed “marked” narrowing of the L4-5 disc space with first degree spondylolisthesis at that level. The report noted that “[a]t L4-5 also marked bilateral facet joint arthropathy with associated marked central and bilateral recess stenosis. Moderate bilateral foraminal stenosis is also seen at ¶ 4-5.” The diagnosis was “[m]arked spinal stenosis L4-5.” (R. at 570.)

         The plaintiff continued physical therapy in February 2014. She displayed 4-5/5 strength in her extremities and was described as doing “fair.” (R. at 863.)

         By the end of March 2014, she had met her physical therapy goal of ambulating for 30 minutes, but still experienced pain walking around a grocery store. (R. at 740.)

         In April 2014, the plaintiff returned to the eye doctor for treatment of her retinal pigmentosis and other eye impairments. ...