Gilpin v. Comm'r of Soc. Sec.

1

DENISE NICOLE GILPIN, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.

No. 23-cv-6758 (LJL)

United States District Court, S.D. New York

November 27, 2024

OPINION AND ORDER

LEWIS J. LIMAN UNITED STATES DISTRICT JUDGE

Plaintiff Denise Nicole Gilpin (“Plaintiff”) brings this action pursuant to 42 U.S.C. § 405(g) seeking judicial review of a final decision of the Commissioner of Social Security (“Defendant” or the “Commissioner”) denying Plaintiff's application for Disability Insurance Benefits for lack of disability. Dkt. No. 1. Plaintiff moves for judgment modifying or reversing the decision of the Commissioner, Dkt No. 13, and the Commissioner cross-moves for judgment affirming the decision of the Commissioner, Dkt. No. 14. For the following reasons, Plaintiff's motion is granted, and Defendant's motion is denied. The case is remanded to the Commissioner for further proceedings.

BACKGROUND

The following facts are taken from the administrative record (the “Record”) filed in connection with this action. Dkt Nos. 9, 9-1, 9-2, 9-3 (“Ad Rec.”).^[1] The Record contains Plaintiff's medical history, information she provided in support of her applications for benefits opinions from several medical and psychological examiners the transcript of Plaintiff's hearing before the ALJ, and the ALJ's decision.

I. Background

Plaintiff was born in 1974 and was forty-six years old at the alleged onset date (“AOD”) of her disability on October 18, 2020. Id. at 188. She is a resident of Poughkeepsie, New York and earned a bachelor's degree from Marist College in 2011. Id. at 189, 229, 716. Before her AOD, Plaintiff worked as a store manager, an administrative assistant, and as a receptionist. Id. at 212, 222.

Plaintiff's disability claim is based on five alleged impairments: polyarthritis, fibromyalgia, neuropathy, lumbar degenerative disc disease, and schizoaffective disorder. Id. at 15. Plaintiff reports that she developed schizoaffective disorder when she was 28 years old and was hospitalized for it in 2003, 2012, and 2020. Id. at 820-21. The 2020 hospitalization coincides with the alleged onset of her disability. See id. at 266, 331.

At that time, Plaintiff was laid off from her job as a receptionist. Id. at 211, 237. Plaintiff states that she lost her job because of her “condition(s),” and her mother specifies that she was terminated “for always[s] being late” while she was “in crisis.” Id. Plaintiff has not worked since her AOD. Id. at 39, 211. She received offers to work as a package handler at a FedEx facility and as a receptionist at a nursing home, but declined both offers. Id. at 39-40. She expressed a desire to find a clerical job that will allow her to work in an office setting on a part-time basis. Id.

Plaintiff reports living in an apartment alone and taking care of herself without assistance. Id. at 35, 40-41, 242-45. She also reports no difficulty in day-to-day activities such as cooking, cleaning, driving, visiting with friends, doing laundry, and shopping. Id. Plaintiff's mother reports that when Plaintiff is “stable” and on medications she can do such chores, but when “in crisis” she has substantial difficulty. Id. at 231-38.

II. Medical Background

A. Physical Impairments (Polyarthritis, Fibromyalgia, Neuropathy, Lumbar Degenerative Disc Disease).

Plaintiff was treated for her physical impairments by Steven B. Jacobs, D.O. Plaintiff's medical records indicate she visited Dr. Jacobs at least eight times between October 6, 2020- just before her AOD-to October 7, 2021. Id. at 303-29. As part of the agency's review of Plaintiff's application, Plaintiff was also seen by Dr. Kautilya Puri, M.D., for a consultative examination on September 7, 2021. Id. at 725-29.

1. Treatment Records from Dr. Jacobs

The earliest record of Plaintiff's treatment with Dr. Jacobs made available to the ALJ comes from a visit on October 7, 2020. Dkt No. 9 at 327-29. During this visit, Plaintiff reported “diffuse muscle aches” and intermittent pain throughout her body. Id. at 327. Dr. Jacobs reported Plaintiff was suffering from fibromyalgia and migraine. Id. at 329. To help alleviate these conditions, Dr. Jacobs prescribed bupropion and acetaminophen. Id. On October 29, 2020, Plaintiff presented with leg pain, and Dr. Jacobs assessed Plaintiff as having polyarthritis of “unclear etiology.” Id. at 324-26. Dr. Jacobs did not issue a new prescription at this time, instead recommending Plaintiff take Advil. Id.

Plaintiff returned to Dr. Jacob's office on December 7, 2020, complaining of bilateral leg pain, a burning sensation in her feet, numbness, and weakness. Id. at 321-23. Dr. Jacobs noted Plaintiff suffered from neuropathy of unclear etiology. Id. at 323. Plaintiff began taking gabapentin to help alleviate her symptoms. See, e.g., id. at 318-19. Plaintiff returned for a follow-up visit with Dr. Jacobs on January 11, 2021. Id. at 318-20. Dr. Jacobs noted that Plaintiff's neuropathy had improved with gabapentin. Id.

During Plaintiff's next visit on February 19, 2021, Dr. Jacobs assessed Plaintiff with “stable” fibromyalgia, and noted Plaintiff “feels well.” Id. at 314, 316. Plaintiff reported lumbar pain during her follow-up appointment on June 1, 2021, leading Dr. Jacobs to prescribe Plaintiff acetaminophen and codeine. Id. at 311-12.

Plaintiff's final visit with Dr. Jacobs before her ALJ hearing was on October 6, 2021. Id. at 305-07. She presented with kidney issues that Dr. Jacobs assessed as likely the result of an infection. Id. During this visit, Dr. Jacobs ordered, among other tests, a CT scan which was performed the following day. Id. at 307. The results of this scan showed that Plaintiff had “[m]ild broad-based disc bulges noted at ¶ 3-4 through L5-S1.” Id. at 304.

Plaintiff reported that she has not sought out nor received any additional treatment for her physical impairments between her last visit with Dr. Jacobs and the date of her ALJ hearing on May 10, 2022. Id. at 33, 44, 330.

2. Plaintiff's Self-Report

Plaintiff reports that she feels pain every day in her lower back, legs, arms, feet, hands, and around her neck. Id. at 42. The pain comes and goes, but she has noticed that it is present in the morning when she gets up. Id. at 42. If she bends over, for example to brush her teeth, she has a hard time straightening up. Id. at 43. Because of her neuropathy, she is not able to stand or walk for more than two hours consecutively and needs to rest after walking a couple of miles. Id. at 246. Plaintiff also reports difficulty keeping a firm grasp on heavier objects, causing her to “drop things a lot.” Id. at 44. She is currently on medication for neuropathy and is taking natural supplements for her fibromyalgia and arthritis. Id. at 42-43.

3. Consultative Examination by Dr. Puri

During the initial review of Plaintiff's SSDI application, a consultative examination (“CE”) was performed by Kautilya Puri, M.D., on September 7, 2021. Id. at 725-29. Dr. Puri noted Plaintiff's history of neuropathy, fibromyalgia, aching pains throughout her body, and her lower back condition. Id. at 725. During the examination, Dr. Puri observed that Plaintiff did not need an assistive device to move, was able to walk on her heels and toes “without difficulty,” and did not need any assistance during the examination. Id. at 726.

Plaintiff's examination was largely normal, except for lumbosacral back tenderness on palpation and movement, non-trigger point areas of tenderness, and trigger points for her neck, shoulders, arms, ribs, back, and legs. Id. at 727. Dr. Puri concluded Plaintiff suffered from fibromyalgia and disc disease that caused pain, but the doctor went on to note that she had “no objective limitations” to her fine or gross motor activity, gait, or activities of daily living. Id. at 727-28. Dr. Puri did conclude Plaintiff had “mild limitations” to squatting, bending, stopping, kneeling, and lifting weights. Id. at 728. Dr. Puri also recommended Plaintiff be seen by an orthopedic doctor and a psychiatrist. Id.

B. Mental Impairment (Schizoaffective Disorder)

Evidence of Plaintiff's mental impairment, schizoaffective disorder, comes primarily from treatment notes from her primary mental health care provider, Spectrum Behavioral Management Services, between 2015 and 2022. Additional evidence comes from records of Plaintiff's emergency room visit and subsequent admission to MidHudson Regional Hospital in October-November 2020, as well as Plaintiff's and her mother's reports of her symptoms.

1. Pre-AOD Records from Spectrum Behavioral Management Services.

The Record contains records from over sixty visits to Spectrum Behavioral Management Services between June 2015 and March 2022.^[2] Id. at 730-848. From June 2015 through May 2021, Plaintiff was seen exclusively by Nurse Practitioner (“NP”) Hani Khalil. Id. at 730-818. Starting in June 2021, Plaintiff was seen by both NP Khalil and Licensed Clinical Social Worker (“LCSWR”) Yogesh M. Shingala. Id. at 820-48. Plaintiff's last reported visit with LCSWR Shingala was on August 12, 2021, and from that time until her hearing in 2022, she was seen only by NP Khalil. Id. at 835, 847-48.

In the first session documented on the Record, on June 19, 2015 Plaintiff complained to NP Khalil that she felt “restless” and “uncomfortable” on her current prescription regimen. Id. at 731. Plaintiff nonetheless confirmed to NP Khalil that her condition was generally good. Id. NP Khalil's notes state there were no apparent signs of Plaintiff experiencing hallucinations or paranoia. Id. While describing Plaintiff as “slightly restless in seat [sic]” and “look[ing] tired and distracted,” NP Khalil's examination found Plaintiff's associations “intact,” thinking logical, and...