Augustin v. Berryhill

375 F.Supp.3d 135

Nirlande AUGUSTIN, Plaintiff,

v.Nancy A. BERRYHILL, Acting Commissioner of Social Security Administration, Defendant.

Civil Action No. 18-10761-PBS

United States District Court, D. Massachusetts.

Filed April 23, 2019

Richard F. Landrigan, Costello & Landrigan, Somerville, MA, for Plaintiff.

Sean D. Santen, Social Security Administration-Office of the General Counsel, Boston, MA, for Defendant.

MEMORANDUM AND ORDER

Saris, C.J.

INTRODUCTION

Plaintiff Nirlande Augustin brings this action under 42 U.S.C. § 405(g) for judicial review of a final decision denying her applications for Social Security Disability Insurance and Supplemental Security Income benefits. She claims that the Administrative Law Judge ("ALJ") erred by failing to find that she has a listed impairment, misweighing the medical opinions, and improperly concluding she can perform light office work.

For the following reasons, the Court ALLOWS Plaintiff's motion to reverse the Commissioner's decision (Docket No. 12) and DENIES Defendant's motion to affirm the Commissioner's decision (Docket No. 13).

FACTUAL BACKGROUND

The following facts are taken from the administrative record. Plaintiff is a single, 62-year-old female. R. 40. She lives with one of her children in Everett, Massachusetts. Id. Her claim for disability benefits is based on her sickle cell disease, breast cancer, and left shoulder subtotal tear/avascular necrosis. R. 19-20.

I. Educational and Work History

Plaintiff earned a high school diploma and received some vocational training. R. 40. She worked as a legal secretary at New England Life until the mid-1980s. R. 165. She stopped working due to her sickle cell disease, moved to Florida, and received disability benefits for ten years. Id. She worked from 2000 to 2010 as a legal secretary at a Miami law firm. Id. During 2011, 2012, and 2014, she was self-employed as a part-time French translator and personal care attendant and companion for elderly clients. R. 45-46, 165. After her diagnosis of breast cancer in 2015, she moved from Miami back to Boston for her medical care. R. 426.

II. Medical History

At age sixteen, Plaintiff was diagnosed with sickle cell disease. Id. She began taking folic acid and iron around this time, though not consistently. R. 440. During the twenty-nine years she lived in Miami, she was hospitalized about ten times. Id. For example, in February 2015, she was hospitalized for chest, back, knee, and arm pain associated with her sickle cell disease. R. 426.

In March 2015, Plaintiff was diagnosed with breast cancer. R. 342. On April 29, 2015, she underwent a right modified radical mastectomy to remove the cancer. R. 374-75. There were no immediate complications from the procedure, and her surgeon indicated one week later that she exhibited full range of motion of her entire arm. R. 340-41.

On June 27, 2015, after moving to Boston, Plaintiff went to the Lawrence Memorial Hospital emergency room complaining of shortness of breath and right-sided chest pain. R. 382, 384. She informed the attending physician that she had been doing reasonably well since her surgery two months earlier. R. 386. The physician found that she was severely anemic. R. 382. Her symptoms improved after she was rehydrated and transfused with two units of blood. Id. She remained in the hospital for three days. Id.

Plaintiff met with oncologist Dr. Dejan Juric at the Massachusetts General Hospital ("MGH") on July 17, 2015 to discuss her breast cancer. R. 405-06. She reported some fatigue and intermittent tightness in her right chest wall, but denied any frank pain, shortness of breath, dyspnea on exertion, bone pain, or joint pain. R. 405. She declined chemotherapy to reduce her risk of recurrence because she worried that, in conjunction with her sickle cell disease, the chemotherapy would render her completely unable to function. R. 51, 406.

Plaintiff saw a hematologist at MGH, Dr. Rachel Rosovsky, on December 7, 2015 for her sickle cell disease. R. 440-43. She told Dr. Rosovsky that her energy levels were "okay" but had decreased over the past two years. R. 441. She reported no pain. R. 441-42. Plaintiff said she was not consistently taking her folic acid and iron to treat her sickle cell disease and did not know how many sickle cell crises she had per year. Id.

Three weeks later, Plaintiff returned to Dr. Rosovsky. She reported that she had been taking her iron and folic acid daily since the last visit and that she was okay but felt fatigued often. R. 436. Plaintiff refused to take any pain medication stronger than Motrin. R. 439. Dr. Rosovsky encouraged Plaintiff to start taking a prescription drug called Hydra for her sickle cell disease, which she said she would consider. Id.

On January 4, 2016, Plaintiff met with Dr. Anne Moulton, her primary care physician at MGH. R. 434-35. Plaintiff reported no pain, though she appeared tired. R. 434. She also saw Dr. Rosovsky the same day. R. 426-30. She reported feeling weak all over and had taken 600mg of Motrin the evening before to prevent a sickle cell crisis. R. 427. She stated that she was taking folic acid and iron more regularly. Id. Dr. Rosovsky again recommended that Plaintiff start taking Hydrea.¹ R. 430. Plaintiff was transferred to the emergency department to receive a transfusion of one unit of red blood cells, but she left later that night before receiving the transfusion. R. 423, 431.

On February 29, 2016, she visited a nurse practitioner complaining of fatigue, feeling like she was going to pass out after basic tasks, and right arm numbness. R. 462. The nurse practitioner noted that Plaintiff was inconsistently taking her folic acid. R. 463-64. She arranged for Plaintiff to receive a blood transfusion. R. 463.

On April 1, 2016, Plaintiff visited Dr. Juric to discuss her breast cancer. R. 452-54. She reported significant fatigue and intermittent chest wall tightness but no pain. R. 452-53. Dr. Juric counseled her to take Hydrea regularly for her sickle cell and advised her to undergo chemotherapy to reduce the risk of cancer recurrence ; again, she declined both. R. 454.

Plaintiff met with Dr. Rosovsky the same day. R. 455-60. She told her she was tired all the time and took naps a lot but her fatigue was better than before. R. 456. She noted that she was still inconsistent in taking her folic acid and iron. Id. Dr. Rosovsky strongly encouraged her again to take Hydrea, but Plaintiff decided not to do so. R. 460.

Plaintiff returned to Dr. Juric on July 15, 2016. R. 477-80. He again tried to convince Plaintiff to undergo chemotherapy to reduce her risk of breast cancer recurrence, but she declined. R. 477. He also emphasized the importance of taking Hydrea daily for her sickle cell disease. Id. At the appointment, she reported significant fatigue and intermittent chest tightness. R. 478. Dr. Juric noted that Plaintiff was restricted in her ability to perform physically strenuous activity but that she was ambulatory and able to carry out work of a light or sedentary nature, such as light house work and office work. Id.

Five days later, Plaintiff followed up with Dr. Rosovsky. R. 469-75. She said she was feeling "quite well," although she was still not consistent with her medications. R. 470. She reported occasional back or neck pain and said she took Motrin when this occurred, which helped the flare-ups subside within three days. Id. She said she was still tired, though not all the time, and that her fatigue was better. Id. She said that she took occasional naps during the day, but not as often as before. Id. She denied any pain, except for an occasional slight twinge in her left shoulder with movement. Id. She reported shortness of breath with one flight of stairs only when her sickle cell disease flared up. Id. Dr. Rosovsky again strongly recommended that Plaintiff take Hydrea. R. 475.

Plaintiff saw Dr. Moulton on August 23, 2016 for left arm pain she first noticed while putting on coats in the late winter. R. 476. She told Dr. Moulton that her arm hurt whenever she reached for anything and that she had been unable to sleep on her left side for a month. Id. Her arm hurt much more when she was moving than when she was at rest. Id. She was not dropping anything because of the pain, and ibuprofen helped "a little." Id. Dr. Moulton ordered an MRI of Plaintiff's left shoulder. Id. The MRI revealed avascular necrosis of the humeral head and a subtotal tear of the anterior fibers of the supraspinatus. R. 465. At an appointment a few months later, Plaintiff reported pain at an eight out of ten but refused medication and did not want to see orthopedics. R. 484. She stated that she had a similar issue with her other shoulder twenty years earlier. Id.

Plaintiff visited Dr. Juric again on October 4, 2016. R. 480-84. She reported some fatigue, intermittent chest wall tightness, and some left shoulder pain, but no other bone or joint pain. R. 482. Dr. Juric again discussed the utility of taking Hydrea to control her sickle cell disease, but Plaintiff refused to do so. R. 480. He again noted that Plaintiff was able to carry out work of a light or sedentary nature. R. 482.

On October 17, 2016, Plaintiff followed up with Dr. Rosovsky. R. 485-92. She reported feeling "quite well" but noted that she was tired all the time and took occasional naps during the day. R. 487. Dr. Rosovsky recorded her fatigue as "moderate to severe." R. 488. Plaintiff told Dr. Rosovsky that she was taking her folic acid and iron every day. R. 487. She stated that she took Motrin when she had neck and back pain that signaled a flare-up of her sickle cell disease. Id. Dr. Rosovsky again strongly advised Plaintiff to start Hydrea, which Plaintiff said she would continue to consider. R. 491.

III. Medical Opinions

In an undated letter, Dr. Moulton stated that Plaintiff has sickle cell disease"with all of the secondary manifestations," "exceedingly painful" aseptic necrosis of her left shoulder, "extreme fatigue," and "pain and...