United States District Court, D. Connecticut
RULING ON THE PLAINTIFF'S MOTION TO REVERSE THE
DECISION OF THE COMMISSIONER AND ON THE DEFENDANT'S
MOTION TO AFFIRM THE DECISION OF THE COMMISSIONER
Robert
M. Spector United States Magistrate Judge.
This
action, filed under § 205(g) of the Social Security Act,
42 U.S.C. § 405(g), seeks review of a final decision by
the Commissioner of Social Security [“SSA” or
“the Commissioner”] denying the plaintiff Social
Security Disability Insurance [“SSDI”] benefits.
I.
ADMINISTRATIVE PROCEEDINGS
On or
about February 25, 2014, the plaintiff protectively filed an
application for SSDI benefits claiming that he had been
disabled since October 5, 2012, due to the following
impairments: back injury; neck injury; tarsal tunnel
syndrome; “painful weeping skin lesions, cysts in
rectum, chronic”; compromised immune system;
Raynaud's syndrome; diabetes; “candida albicans,
chronic”; food and respiratory allergies; and nerve
damage. (Certified Transcript of Administrative Proceedings,
dated October 16, 2018 [“Tr.”] 138, 154;
see Tr. 367-68). The Commissioner denied the
plaintiff's application initially and upon
reconsideration. (Tr. 138-53, 200-04; Tr. 154-69, 206-09). On
September 4, 2014, the plaintiff requested a hearing before
an Administrative Law Judge [“ALJ”] (Tr. 210-11),
and on November 12, 2015, a hearing was held before ALJ Peter
Alexander Borré, at which the plaintiff and a
vocational expert, Howard Steinberg, testified. (Tr. 89-136;
see Tr. 237-56, 259-84, 287-92). On March 17, 2016,
the ALJ issued an unfavorable decision denying the
plaintiff's claim for benefits. (Tr. 170-91). On March
28, 2016, the plaintiff requested review of the hearing
decision (Tr. 296-98), and on May 4, 2017, the Appeals
Council remanded the plaintiff's claim to the ALJ for
another hearing. (Tr. 192-96).
On
October 24, 2017, ALJ Borré held a second hearing, at
which the plaintiff and a vocational expert, Edmond Calandra,
testified. (Tr. 47-88, 324-52, 355-60). On February 28, 2018,
the ALJ issued another unfavorable decision denying the
plaintiff's claim for benefits. (Tr. 9-37). The plaintiff
requested review of the second hearing decision; however, on
July 20, 2018, the Appeals Council denied the plaintiff's
request for review, thereby rendering the ALJ's decision
the final decision of the Commissioner. (Tr. 1-6).
On
September 11, 2018, the plaintiff filed his complaint in this
pending action (Doc. No. 1), and on September 12, 2018, the
Court granted his Motion for Leave to Proceed In Forma
Pauperis (Doc. No. 7). On September 24, 2018, the
parties consented to the jurisdiction of a United States
Magistrate Judge, and the case was assigned to this
Magistrate Judge. (Doc. No. 11). The defendant filed the
Certified Administrative Transcript on November 13, 2018.
(Doc. No. 13). On November 15, 2018, the plaintiff filed his
Motion to Reverse the Decision of the Commissioner (Doc. No.
16), brief in support (Doc. No. 16-1 [Pl.'s Mem.]),
Statement of Material Facts (Doc. No. 16-2), and three
exhibits (Doc. Nos. 16-3-16-5). The defendant filed his
Motion to Affirm the decision of the Commissioner on April 3,
2019 (Doc. No. 22), with brief in support (Doc. No. 22-1
[Def.'s Mem.]), and Statement of Material Facts (Doc. No.
22-2).
For the
reasons stated below, the plaintiff's Motion to Reverse
the Decision of the Commissioner (Doc. No. 16) is DENIED, and
the defendant's Motion to Affirm (Doc. No. 22) is
GRANTED.
II.
FACTUAL BACKGROUND
At the
time of his alleged onset date of disability, October 5,
2012, the plaintiff was forty-eight years old. (See
Tr. 138, 154). The plaintiff is married and resides with his
wife. (Tr. 54). He dropped out of school when he was a
sophomore in high school, but later obtained a GED and a
certificate in electromechanical assembly. (Tr. 55). At the
time of the second hearing, the plaintiff was fifty-three
years old. (See Tr. 53). The plaintiff's date
last insured is December 31, 2017. (Tr. 138, 154).
A.
MEDICAL HISTORY[2]
1.
THE RELEVANT EVIDENCE PRIOR TO THE PLAINTIFF'S
ALLEGED ONSET DATE
On
October 20, 2006, Dr. Daniel E. Nijensohn evaluated the
plaintiff, who presented to Dr. Nijensohn with a complaint of
“pain at the base of the neck radiating into the right
shoulder without numbness and/or weakness, resolving.”
(Tr. 678). Dr. Nijensohn noted that “[t]he patient has
x-ray and MRI evidence of cervical disc herniation at ¶
4-5 and somewhat less at ¶ 5-6.” (Tr. 678).
Following a physical examination, Dr. Nijensohn “told
him to continue with conservative management including
therapy and medications for as long as [that] works.”
(Tr. 679). On March 6, 2008, Dr. Nijensohn evaluated the
plaintiff again, noting that the plaintiff complained
“of persistent neck pain for the past six months”
and “lower back pain that has been bothering him for
quite a long time[.]” (Tr. 681). X-rays and an MRI of
the lumbar spine revealed “bilateral pars
interarticularis defects at ¶ 5 with Grade I
anterlisthesis and with a right L5-S1 disc protrusion and
degenerative disc disease at ¶ 5-S1 and narrowing of the
L5-S1 interspace.” (Tr. 681). The images also revealed
“bilateral spondylosis with a Grade I spondylolisthesis
at ¶ 5 on S1, and anterolisthesis, with a right
posterolateral intraforaminal local disc protrusion at ¶
5-S1, impinging upon the right L5 nerve root.” (Tr.
681). Dr. Nijensohn recommended that the plaintiff undergo
cervical and lumbar spinal fusion surgeries. (See
Tr. 682).
On
March 13, 2008, the plaintiff underwent an “excision of
herniated discs at ¶ 4-5 and at ¶ 5-6, followed by
anterior interbody cage fusion, and internal fixation with
metal plating and screws.” (Tr. 683). On March 20,
2008, Dr. Nijensohn noted that the plaintiff had “done
quite well” since the surgery and that the plaintiff
ha[d] already noted improvement compared to the way he was
preoperatively.” (Tr. 683). Specifically, the plaintiff
had “a good range of motion of the neck” and good
“[s]trength of the upper extremities[.]” (Tr.
683). Dr. Nijensohn evaluated the plaintiff again on April
17, 2008, at which time he noted that the plaintiff
“recovered beautifully from the standpoint of cervical
spine surgery.” (Tr. 684). Dr. Nijensohn explained that
the plaintiff's “symptoms [were] gone[]” and
that the plaintiff “fe[lt] real well.” (Tr. 684).
The treatment note reflects that the plaintiff continued to
complain of lower back pain and that Dr. Nijensohn believed
it was “the time to proceed with the posterior fusion
of the lumbar spine[.]” (Tr. 684).
On May
1, 2008, the plaintiff underwent, inter alia, a
“transforaminal posterior lumbar interbody
fusion[.]” (Tr. 685). On May 8, 2008, Dr. Nijensohn
evaluated the plaintiff and noted that he had “done
beautifully” following surgery, “already feels
much better, ” “woke up without pain into the
right leg, ” “the sciatica is all gone[, ]”
and “[h]is toes are not numb anymore as they were
before the surgery.” (Tr. 685). Dr. Nijensohn added
that the plaintiff was taking short walks, that his neck also
“fe[lt] great[, ]” and that “he no longer
ha[d] any nerve pains”; he concluded that the plaintiff
was “happy and grateful and quite pleased with his
progress.” (Tr. 685). During a July 17, 2008
examination, the plaintiff stated to Dr. Nijensohn that he
“occasionally hears noises in the lower back.”
(Tr. 686). Dr. Nijensohn advised the plaintiff to “wait
a couple of months before returning back to work[, ]”
but noted that “[t]he most recent x-rays look pretty
good.” (Tr. 686).
Following
an examination on September 25, 2008, Dr. Nijensohn stated
that the plaintiff was “doing excellent and ready to be
discharged from [Dr. Nijensohn's] care.” (Tr. 687).
The plaintiff was set to return to work within days and felt
that he could “handle it.” (Tr. 687). Although
Dr. Nijensohn advised the plaintiff to start work “on a
part-time basis and then increase his activities as
tolerated[, ]” he stated that “[x]-rays of the
cervical and lumbar spine show excellent healing of the
instrumented fusions and no complications or problems.”
(Tr. 687).
Moreover,
on March 25, 2009, the plaintiff completed a tinnitus
questionnaire, on which he answered questions regarding
“head and ear noises[.]” (Tr. 590). He indicated
on the form that he had experienced noises in his head and
ears for two years and that the “quality of
noise” included “ringing, whooshing, steam
escaping, [and] pulsating[.]” (Tr. 590). The plaintiff
indicated also that the noise was constant, varied in
intensity, and occurred in both ears. (Tr. 590). The noise
did not prevent the plaintiff from sleeping; however, he
indicated that the noise was rated at a six on a scale of one
to ten, with ten being “very loud” and seven or
above being “noise that you feel you cannot live
with.” (Tr. 590). The plaintiff explained that stress,
such as lifting something heavy, increased the noises and
that he had a history of noise exposure from work. (Tr. 590).
He noted also that he thought he had hearing loss and that he
had headaches, blurred vision, and “[h]ead or [n]eck
[t]rauma.” (Tr. 590). The plaintiff completed a hearing
test on April 1, 2009, which revealed that his hearing was
within normal limits, but sloping to mild to moderate
sensorineural hearing loss. (Tr. 595).
2.
STAYWELL HEALTHCARE RECORDS
The
plaintiff has an extensive treatment history with Staywell
Healthcare [“Staywell”]. On March 12, 2014, the
plaintiff presented to Staywell and complained of “pain
in his neck and back” and “pain in multiple other
sites throughout his body.” (Tr. 544). Dr. Monika Kaul
evaluated the plaintiff. A review of the plaintiff's
symptoms revealed that he had neck and back pain, but
“[n]o lump or swelling in the neck[, ]” and that
he had “no tinnitus.” (Tr. 545). A physical
examination revealed that the plaintiff had “tenderness
[in the] lumbar area” and that the “[c]ervical
spine showed full range of motion limited.” (Tr. 546).
His gait and stance were normal. (Tr. 546). Dr. Kaul referred
the plaintiff to physical therapy for his neck and back pain
(Tr. 573) and, following an examination on April 11, 2014,
she referred the plaintiff to a neurosurgeon for cervical
pain. (Tr. 547).
The
plaintiff underwent imaging of his spine on April 7, 2014,
which revealed anterior fusion at ¶ 4-C5 and C5-C6, as
well as “[d]egenerative changes with narrowing of the
disc space at ¶ 7-T1 and C6-C7, as well as encroachment
on the neural foramina in the oblique views at ¶ 6-C7 on
the right and C4-C5 and C5-C6 on the left.” (Tr. 716).
This imaging revealed also “[s]tatus post posterior
lumbar fusion and decompression at ¶ 5/S1” but
“[n]o significant degenerative disease above the level
of fusion.” (Tr. 717). The plaintiff underwent a CT
scan of his spine on May 21, 2014, which revealed, inter
alia, the following: unremarkable findings in the
thoracic spine (Tr. 559, 561); and “anterior cervical
and incomplete intradiscal fusion at ¶ 4-C5 and C5-C6[,
]” as well as “[m]ild multilevel neuroforaminal
stenosis involving the right C3-C4, right C4- C5, and
bilateral C5-C6 and C6-C7 neuroforamen, ” but “no
significant central spinal stenosis” in the cervical
spine (Tr. 560).
On July
7, 2014, the plaintiff presented to Staywell where Dr. Anna
Timell completed an examination. (Tr. 706-07). The plaintiff
complained of “back pain, pain travel on his shoulders
and neck, also ha[d] problems with his metatarsal
arch[.]” (Tr. 706). A review of the plaintiff's
neurological system revealed that he had “dysethesias,
numbness and tingling in the [left] forearm, [right] hand and
arm in varying locations and at varying times, occasionally
has sharp pain in the [right] 3rd and 4th fingertips.”
(Tr. 706). Dr. Timell noted that the plaintiff
“appeared uncomfortable” at the appointment. (Tr.
706). She noted also that the plaintiff's “[n]eck
demonstrated a decrease in suppleness[, and that] he had good
lateral rotation, [but] poor flexion and extension.”
(Tr. 706). Dr. Timell stated that the plaintiff had
“[a]bnormal movement of all extremities [and a] trigger
nodule [at the] upper [right] trapezius.” (Tr. 707).
She diagnosed the plaintiff with cervicalgia and muscle
spasm, for which she prescribed medications. (Tr. 707).
In
August 2014, Dr. Timell examined the plaintiff again and
noted that he had a “rigid back[, ]” but that his
motor strength was normal and he rose “to heels and
toes well.” (Tr. 736- 37). She diagnosed the plaintiff
with, inter alia, lumbar spondylosis and prescribed
a Lidoderm patch. (Tr. 737). On December 31, 2014, the
plaintiff contacted Dr. Timell and stated to her that he was
“upset at not being able to get the help that he feels
he needs.” (Tr. 742). Dr. Timell noted that,
“[a]fter some discussion, ” they “agreed
[she] could help [the plaintiff] by writing a letter to
support his SSD application.”[3] (Tr. 742). The plaintiff
underwent an MRI of his thoracic spine in November 2014,
which revealed (1) “T5-T6 mild left paracentral disc
herniation, without canal narrowing[, ]” and (2)
“T7-T8 tiny left paracentral disc herniation, without
canal narrowing.” (Tr. 750). He also underwent an MRI
of his cervical spine in November 2014, which showed (1)
“[s]tatus post C4-C6 anterior fusion[, ]” (2)
“C3-C4 mild central disc herniation[ with] [n]o central
canal narrowing[, ]” and (3) “C3-C4 mild
spondylotic right neural foraminal narrowing[, ] ¶ 5-C6
mild spondylotic right greater than left neural foraminal
narrowing[, and] ¶ 6-C7 mild bilateral spondylotic
neural foraminal narrowing.” (Tr. 752).
The
plaintiff returned to Dr. Timell on June 4, 2015 and
complained that his “[l]egs are getting weaker, having
difficulty walking[, ]” and that he wanted “his
progressive disability documented for an upcoming SSD
hearing.” (Tr. 743). Under the review of systems, Dr.
Timell noted that the plaintiff had “neck and low back
pain, especially if he tries to look down, or if he stands
very long or tries to do household chores.” (Tr. 743).
She added that the plaintiff “reported he can no longer
mow his own lawn, ” and that “the pain appears to
vary in intensity and sometimes puts him down on the
floor.” (Tr. 743). She noted also that the plaintiff
reported “muscle twitching and sensory disturbances
[and] report[ed] burning pain in his [left] foot.” (Tr.
743). A physical examination revealed that the
plaintiff's “[c]ervical spine did not show full
range of motion - [right] anterior neck scar[ and] limited
lateral rotation.” (Tr. 744). Examination of the
plaintiff's lumbar spine “did not demonstrate full
range of motion - all movement occur[red] above the level of
his fusion, there was marked para-thoracic muscle spasm above
the surgical scar with spontaneous twitching after attempted
lateral flexion.” (Tr. 744). The plaintiff
“walked well on heels and toes” but
“ambulated antalgically with a stiff [left] knee and
out-toeing, no Trendelenberg”; however, Dr. Timell
opined that “the etiology of his gait disturbance [was]
unclear to [her].” (Tr. 744).
On
October 29, 2015, Dr. Timell completed a form on which she
opined about the plaintiff's ability to do physical
activities. (Tr. 753-55). She indicated that the
plaintiff's diagnoses were cervical spondylosis, lumbar
spondylosis, and diabetes, and that his prognosis was
“poor.” (Tr. 753). Dr. Timell opined that the
plaintiff could walk one city block without rest, that he
could sit continuously for forty-five minutes, and that he
could stand continuously for thirty minutes. (Tr. 753). In an
eight-hour workday, Dr. Timell believed the plaintiff could
sit for “about 4 hours” and
“stand/walk” for “about 2 hours.”
(Tr. 753). She added that the plaintiff needed a job that
permitted shifting positions “at will from sitting,
standing or walking[, ]” and that he would need to take
unscheduled breaks every thirty minutes and rest for about
fifteen minutes before returning to work. (Tr. 753-54). Dr.
Timell opined that the plaintiff could occasionally lift and
carry up to ten pounds during the workday; however, he could
never lift and carry more than ten pounds. (Tr. 754). Dr.
Timell indicated that the plaintiff had “significant
limitations in doing repetitive reaching, handling, or
fingering[.]” (Tr. 754). Specifically, Dr. Timell noted
that the plaintiff could do the following: use his hands to
grasp, twist, and turn objects for ten percent of an
eight-hour workday; use his fingers for fine manipulations
for fifty percent of an eight-hour workday; and use his arms
for reaching, including overhead reaching, for ten percent of
an eight-hour workday. (Tr. 754). In addition, Dr. Timell
opined that the plaintiff could never bend, twist, crouch,
climb stairs, or climb ladders, and that he should avoid
exposure to extreme cold and cigarette smoke. (Tr. 755). She
thought that the plaintiff's condition would not be
likely to produce good days and bad days, and in response to
a question asking how often the plaintiff's impairments
would cause him to the absent from work, Dr. Timell answered,
“[C]an't work.” (Tr. 755).
On
February 11, 2016, Dr. Timell saw the plaintiff for a
follow-up appointment after the plaintiff went to the
emergency room the previous week due to back
pain.[4] (Tr. 767-70). Dr. Timell noted that the
plaintiff presented “with a litany of indigant
complaints about doctors who haven't helped him,
apparently a consulting MD has told [SSA] that [the
plaintiff] is not disabled.” (Tr. 767). The plaintiff
denied depression, but noted that he has “always been
melancholy[.]” (Tr. 768). Under “review of
symptoms, ” Dr. Timell noted neck pain and low and
thoracic back pain. (Tr. 768). She noted also
“[s]ensory disturbances [left] arm radicular pain to
the index finger, [right] arm radicular pain to 4th and 5th
fingers; [left] radicular pain radiating to 4th and 5th toes;
all pain also assoc[iated] with paresthesias.” (Tr.
768). The plaintiff appeared at the appointment
“wearing a soft neck colla[r].” (Tr. 769). A
physical examination revealed that both the cervical and
lumbosacral spine “did not demonstrate full range of
motion.” (Tr. 769). In his lumbosacral spine, the
plaintiff “had marked [right] parathoracic muscle
spasm, he also had virtually no lateral flexion in thoracic
or lumbar spines.” (Tr. 769). The plaintiff's
strength was normal, he was able to walk on his heels and
toes, had “no arm drift[, ]” normal grip, and
normal interossei. (Tr. 769). The plaintiff's gait and
stance were abnormal, as he limped with his right leg; his
reflexes were abnormal, as his “[right] biceps jerk
[greater than] [left].” (Tr. 769). Dr. Timell
prescribed Cyclobenzaprine for the plaintiff's neck pain
and referred the plaintiff for a nerve conduction study of
his upper and lower extremities. (Tr. 770). The doctor who
performed the nerve conduction test concluded that
“[t]here is no definitive electrodiagnostic evidence
for a neuropathy or radiculopathy in the arms or legs.”
(Tr. 803).
The
plaintiff underwent a CT scan of his lumbar spine on March 4,
2016, which revealed postoperative changes “at L5-S1
status post laminectomy and posterior fusion. Grade 1
anterolisthesis of L5 on S1. Left L5 pedicle screw traverses
the superior endplate with tip noted along the L4-L5 disc
space. Hypertrophic changes of the posterior facets results
in moderate right and mild left L5-S1 neural foraminal
stenosis.” (Tr. 799).
On
April 11, 2016, Dr. Timell noted that, during a physical
examination, the plaintiff “[sat] comfortably on the
exam table, [and] move[d] about the room normally.”
(Tr. 777). She also referred the plaintiff for a
neurosurgical consultation to “advise if removal of the
[left] pedicle screw would be advisable” (Tr. 777), as
the plaintiff worried that the position of the screw might be
the cause of his “ongoing intermittent sharp back pain
that brings him to his knees” (Tr. 775).
During
a physical examination on April 13, 2017, Dr. Timell noted
that the plaintiff “did not demonstrate full range of
motion” in his thoracolumbar spine and had
“[left] para-thoracic muscle spasms.” (Tr. 878).
The plaintiff had the ability to stand on his heels and toes
and had normal motor strength. (Tr. 878-79). However, Dr.
Timell noted that the plaintiff had an abnormal gait and
stance and that he walked with a cane in his left hand. (Tr.
879). Dr. Timell determined that the plaintiff's
“deep tendon reflexes” were abnormal. (Tr. 879).
On July
27, 2016 and August 29, 2017, Susan Murray, MA, LPC, LADC,
the plaintiff's mental health treatment provider,
submitted letters discussing the plaintiff's mental
health treatment “in lieu of confidential psychiatric
records[.]” (Tr. 823; Tr. 815). Ms. Murray noted that
the plaintiff's current diagnosis was “Major
Depressive Disorder, recurrent, severe, without psychotic
features” (Tr. 815, 823), and that the plaintiff was
prescribed Cymbalta and Buspirone (Tr. 815, 823), as well as
Wellburtin SR (Tr. 823) to treat his condition. In the August
2017 letter, Ms. Murray noted that the plaintiff continued to
participate in weekly, individual therapy and that he had
participated in a “six-week psycho-educational group
for Chronic Pain Management[.]” (Tr. 823). She added
that the plaintiff “participated actively in his
treatment and made appropriate clinical progress.” (Tr.
823).
3.
YALE NEW HAVEN HEALTH RECORDS
Throughout
the relevant period, the plaintiff also sought treatment with
Yale New Haven Health [“Yale”]. On September 21,
2016, the plaintiff presented to Yale with complaints of
“low back pain.” (Tr. 825). A physical
examination of the plaintiff revealed “full strength
throughout bilateral upper and lower extremities, normal
tone. Able to heel and toe walk without difficulty. Full
painless range of motion of the bilateral lower extremities.
No. pain with bilateral hip range of motion. No. trochanteric
bursa tenderness.” (Tr. 827). The examination revealed
also that the plaintiff “ambulate[d] without antalgic
gait” and “[did] not require assistive device for
ambulation.” (Tr. 828). The physician's assistant
who evaluated the plaintiff referred the plaintiff for a bone
scan to check for pseudoarthrosis.[5] (Tr. 828).
A
physical examination on November 30, 2016 revealed the
following with respect to the plaintiff's head and neck:
“[n]o restriction in cervical flexion, extension,
rotation, or lateral bending”; “[n]o pain with
cervical flexion, extension, rotation, or lateral
bending”; “[n]o tenderness to palpation over
posterior cervical spine or trapezius muscles”;
“[n]egative Spurling's maneuvers”; and
“[n]egative Lhermitte's sign.” (Tr. 831). The
examination revealed the following regarding the
plaintiff's “spin/ribs/pelvis”: “[n]o
tenderness to palpation over the spine or buttocks”;
“[n]o previous incisions”; “[n]o
restriction in thoracolumbar flexion, extension, rotation, or
lateral bending”; “[n]o pain in back or legs with
flexion or extension”; and “[n]o elevation of
shoulders or pelvis.” (Tr. 831). Regarding the
plaintiff's extremities, the examination revealed the
following: “[n]ormal peripheral pulses with no edema,
swelling, varicosities, or lymphadenopathy”;
“[n]ormal alignment and muscle tone with no masses,
asymmetric atrophy/hypertrophy, tenderness to palpation,
ligamentous instability, or crepitus/effusions/subluxations
of the major joints”; and “[n]egative straight
leg raising tests.” (Tr. 831). The examination revealed
also that the plaintiff had no difficulty heel and toe
walking; however, he “require[d] an assistive device
for ambulation” and had an antalgic gait. (Tr. 831).
The plaintiff's strength, sensation, and reflexes were
all normal.[6] (Tr. 831-32).
The
plaintiff underwent an MRI of his lumbar spine on April 11,
2017, which revealed “[s]tatus post lumbar fusion and
decompression at ¶ 5/S1 with severe right neural
foraminal narrowing at that level. No. focal disc herniation
identified. No. significant narrowing of the central
canal.” (Tr. 870-71). On June 27, 2017, the plaintiff
underwent an x-ray of his entire spine, which revealed
“bony consolidation across the disc space at ¶
4-C5 and partially so at ¶ 5-C6 posteriorly.” (Tr.
872). The x-ray revealed also that there was “[n]o
significant abnormality” and “no significant
degenerative changes” of the thoracic spine. (Tr. 872).
The x-ray showed that one of the pedicle screws in the
plaintiff's lumbar spine “appeare[d] to breach the
superior plate of L5” and that there was “[m]ild
anterolisthesis of L4-L5 on S1.” (Tr. 872). The imaging
report concluded that “there has been no significant
interval change.” (Tr. 872). Dr. Luis Enrique Kolb
discussed surgical and non-surgical options with the
plaintiff on June 27, 2017 and August 8, 2017, following
which the plaintiff opted to continue non-surgical
interventions. (Tr. 857-61).
4.
CONSULTATIVE EXAMINATIONS
On
March 26, 2014, Dr. Yacov Kogan performed a consultative
examination of the plaintiff for Connecticut Disability
Determination Services. (Tr. 551-56). The plaintiff reported
to Dr. Kogan “a history of chronic, intermittent and
migratory pain affecting the entire posterior torso and the
upper and lower extremities bilaterally and diffusely for
several years.” (Tr. 551). Dr. Kogan noted the
plaintiff's two spinal fusion surgeries and that the
plaintiff had received cortisone injections in both feet for
tarsal tunnel syndrome. (Tr. 551). The plaintiff stated to
Dr. Kogan that “he has self diagnosed Raynaud's
after comparing his symptoms to his wife's symptoms who
has the diagnosis, but he has never received the diagnosis by
a physician.” (Tr. 551). He reported also “a
history of chronic and daily symptoms of congestion, sore
throat, watery eyes, sneezing, subjective fevers, and
wheezing with mild shortness of breath[, ]” which the
plaintiff attributed to various allergies. (Tr. 551). The
plaintiff told Dr. Kogan that “he has had a perianal
cyst for about 6 months” and that “[t]he cyst
hurts to touch.” (Tr. 551). Finally, the plaintiff
noted “a history of diabetes mellitus[, ]” which
“has been diet controlled” and for which the
plaintiff “has never taken any medications[.]”
(Tr. 552).
Following
a physical examination, Dr. Kogan provided a medical source
statement. (Tr. 553-54). He stated that “there are no
range of motion deficits and no neurological deficits that
limit sitting, standing, walking, bending, lifting, carrying,
reaching or fine finger manipulations”; however, such
activities “are mildly limited due to generalized
musculoskeletal pain.” (Tr. 554). Dr. Kogan concluded
that “there is no evidence of Raynaud's in the
fingers or toes[, ]” and that there were “no
active rashes appreciated.” (Tr. 554). He added that
there was “no congestion, no rhinorrhea, no
lacrimation, no sneezing, [and that] the oropharynx [was]
clear without erythema, there [was] no submandibular or
cervical lymphadenopathy[, and] [t]he lungs [were] clear to
auscultation bilaterally.” (Tr. 554). Lastly, Dr. Kogan
determined that there was “no evidence of functional
limitation stemming from ...