United States District Court, D. Connecticut
RULING RE: MOTION TO REVERSE THE COMMISSIONER'S
DECISION (DOC. NO. 27)
C. Hall United States District Judge.
Ismael Alamo (“Alamo”) brings this action under
title 42 section 405(g) of the United States Code, appealing
from the final determination of the Commissioner of Social
Security (“the Commissioner”) denying his
applications for disability insurance benefits and
supplemental security income. Motion to Reverse the Decision
of the Commissioner (“Pl.'s Mot.”) (Doc. No.
27). The Commissioner cross-moves for an order affirming that
decision. Defendant's Motion to Affirm the Decision of
the Commissioner (“Def.'s Mot.”) (Doc. No.
reasons set forth below, the Motion to Reverse the Decision
of the Commissioner is GRANTED, and the
Motion to Affirm the Decision of the Commissioner is
DENIED. The case is remanded to the ALJ for
proceedings consistent with this decision.
August 18, 2012, Alamo was involved in a serious accident
while riding an all-terrain vehicle. Stipulation of Facts
(Doc. 27-1) at 2. Alamo was taken to Hartford Hospital where
he was diagnosed with a subdural hemorrhage, fractures of the
third through seventh ribs on the right, a transverse process
fracture at the L1 level, and a right frontal contusion. R.
375. The trauma unit subsequently added the additional
diagnoses of traumatic brain injury and subdural hematoma.
Alamo was discharged on August 27, 2012, with instructions to
follow up with the Trauma Clinic at Hartford Hospital. R.
was seen at the Trauma Clinic on September 5, 2012 and
September 12, 2012. On both occasions, Alamo complained of
continued pain and was provided medications.
next medical record is from February 10, 2014. Stipulation of
Facts ¶ 5.
was seen on February 10, 2014, at First Choice Health Centers
by APRN Brittany Enz. R. 409-411. She noted that Alamo was
homeless and was recently approved for medical insurance.
Id. She further noted a history of traumatic brain
injury and back pain. She ordered spinal X-rays, which were
taken on February 10, 2014. The radiologist concluded that
the X-rays showed “[n]o evidence for acute injury or
significant degenerative change. Mild curvature to the lower
thoracic spine. Sacralization of L5 bilaterally which could
be the source of chronic pain.” R. 416.
returned to APRN Enz on February 17, 2014. He continued to
complain of pain and was prescribed medication. APRN Enz also
referred Alamo to pain management, MRI testing, and physical
therapy. R. 407.
February 24, 2014, Alamo underwent MRI testing. The cranial
MRI was interpreted as unremarkable. R. 412. The lumbar MRI
noted that “there may be sacralization of L5 seen on
the axial sequences” and, at ¶ 4-5 “[t]here
is a disk desiccation and a mild annular disk protrusion with
a small central annular tear and/or contained
extrusion.” R. 414.
was seen again by APRN Enz on March 18, 2014. R. 422-423.
APRN Enz changed Alamo's prescription after Alamo
complained that his medication was ineffective. APRN Enz
noted that she would complete the disability paperwork and
noted the importance of a functional capacity evaluation. She
referred Alamo to Easter Seals to complete this evaluation.
At a follow up appointment on April 8, 2014, APRN Enz noted
that Easter Seals was unable to complete the evaluation. R.
420. She further noted that she would help “in any ways
[sic] I could” with Alamo's disability application.
returned to APRN Enz on July 24, 2014, and August 21, 2014.
R. 448, 446. At the July 2014 appointment, Alamo informed
APRN Enz that he failed to attend a neurology appointment at
the UCONN Health Center. APRN Enz urged Alamo to reschedule
the appointment. APRN Enz also referred Alamo to “Pain
Medicine” due to Alamo's chronic pain. R 447.
was seen by Dr. Qassem Kishawi at the Woodland Anesthesiology
Pain Management Center of the St. Francis Medical Center on
September 8, 2014. Alamo complained to Dr. Kishawi of severe
low back pain. On examination, Dr. Kishawi found Alamo to be
in “moderate distress.” R. 461. He further noted
that “[e]xam of the lower extremities for motion,
sensory, reflex, vascular exam and range of motion is
otherwise unremarkable.” R. 461. Dr. Kishawi noted that
Alamo suffers from “lumbar spinal stenosis” and
ordered a lumbar epidural steroid injection. R. 462.
this time, Alamo attended three physical therapy sessions at
Mt. Saini Center for Rehabilitation/Sports. R. 459. Alamo was
initially evaluated on September 4, 2014. The medical
diagnosis was “sacralization of the lumbar
vertebra” and the therapy diagnosis was
“decreased active [range of motion in the] lumbar
spine, spasm in the low back region, difficulty with IADL
[independent activities of daily living].” R. 459. The
record further noted that Alamo “still has difficulty
in bending in all directions in the lumbar spine.” It
was also noted that Alamo had missed most of the physical
therapy sessions; he was therefore discharged from physical
therapy on October 20, 2014.
returned to APRN Enz at First Choice on September 23, 2014,
and October 23, 2014. R. 444, 442. In these appointments,
Alamo discussed cortisone injections, physical therapy, and
pain management at St. Francis. Despite this treatment, Alamo
continued to complain of back pain. Id. Physical
examinations were notable only for “lumbar pain and
limited range of motion.” Id.
Alamo returned to First Choice on December 16, 2014, he was
seen by Dmitry A. Drapach, D.O. R. 440. Dr. Drapach noted
that physical examinations reflected no changes from the
prior visit. Alamo continued to complain of pain, and Dr.
Drapach adjusted his medications. Id.
February 23, 2015, Alamo was seen by a neurologist at the
UCONN Health Center. R. 463. In the consultation, Alamo
complained of headaches and chronic back pain. The reporting
physician noted that he would follow up after a cranial MRI.
The report noted that Alamo had the correct medication to
treat his headaches and that he would not make changes until
after an MRI. The report concluded “[b]ackache
management per primary care.” R. 465.
report from UCONN Health Center is the last contemporary
medical chart note in the record. Stipulation of Facts ¶
Record contains a May 23, 2016 letter from Torise Baker,
Alamo's full time care-taker. She reported that Alamo
requires constant supervision and suffers from mood swings.
there is a July 6, 2016 letter from Wendy Epps, M.Ed, LADC.
R. 467. Epps had provided therapy services to Alamo since
August 2014. Epps reported that Alamo suffers from PTSD and
recommended that Alamo seek medical attention to address
these issues. R. 467.
record also contains reports from two examining physician
consultants and four non-examining consultants. At the
request of the State Agency, Alamo underwent two
examinations. On April 26, 2014, Dr. Andrew B. Pleshkevich,
Ph.D., conducted a psychological examination. Dr. Pleshkevich
noted that Alamo's affect “was depressive and he
appeared to be in noticeable pain.” R. 426-427.
Alamo's score on the Mini-Mental States Exam indicated no
impairment. R. 427. On the WAIS-IV test, Alamo demonstrated a
Full Scale IQ of 89 (low average). Although Alamo scored
Average or Low ...