United States District Court, D. Connecticut
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. ...