Ragland v. Saul

KEVIN RAGLAND, Plaintiff, v. ANDREW M. SAUL, Commissioner of Social Security,¹ Defendant.

No. 18-CV-8206 (OTW)

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK

March 29, 2021

OPINION & JUDGMENT

ONA T. WANG, United States Magistrate Judge:

I. Introduction

Plaintiff Kevin Ragland ("Plaintiff"), proceeding pro se, brings this action pursuant to section 205(g) of the Social Security Act, 42 U.S.C. §405(g), seeking judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying his application for supplemental security income ("SSI"). Before the Court is the Commissioner's Motion for Judgment on the Pleadings, made pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. To date, Plaintiff has not served or filed any opposition to the motion, nor has he requested an extension of time in which to serve opposition papers. Notwithstanding Plaintiff's failure to respond, I shall consider the merits of the Commissioner's motion. For the reasons set forth below, the Commissioner's Motion for Judgment on the Pleadings is DENIED, and the case is remanded for further proceedings pursuant to 42 U.S.C. §405(g).II. Statement of Facts²

A. Procedural Background

Plaintiff applied for both disability insurance benefits ("DIB") and SSI on April 13, 2015. (Tr. 155, 162). Plaintiff alleged a disability onset date of January 1, 2010, listing impairments of back pain, asthma, "COPD," "[a]tonic bladder problem," and prostate infection. (Tr. 63). Plaintiff later added that since August 2015, he was also suffering from depression and anxiety. (Tr. 187). In a letter dated April 18, 2015, the Commissioner notified Plaintiff that he was not eligible for DIB because he did not work long enough to qualify for DIB. (Tr. 73). Plaintiff received another letter dated July 1, 2015, which notified Plaintiff that his SSI claim was denied because he was not found to be disabled. (Tr. 77, 81).

After Plaintiff requested a hearing on his SSI claim before an Administrative Law Judge ("ALJ"), (Tr. 83), ALJ Sharda Singh conducted a video hearing on April 12, 2017, at which both Plaintiff (represented by counsel) and vocational expert Robert Baker gave testimony. (Tr. 31-62). On October 25, 2017, the ALJ issued a decision finding that Plaintiff was not disabled. (Tr. 14-26). The Appeals Council then granted Plaintiff two extensions of time to submit a statement or provide additional evidence, after which Plaintiff's counsel submitted a five-page brief. (Tr. 7, 9). On July 9, 2018, the Appeals Council subsequently denied Plaintiff's request for review of the ALJ's decision, rendering the Commissioner's decision final. (Tr. 1-3). Plaintiff then filed an action for review in this Court on September 5, 2018. (ECF 1).

B. Social Background

Plaintiff was born in 1966 and previously worked as a painter from 2005 through 2008. (Tr. 162, 180). Before that, Plaintiff worked various manual labor jobs. (Tr. 180). After having difficulty finding work as a painter, Plaintiff stopped working in 2008 and lived for two years as an apartment superintendent. (Tr. 46). Plaintiff left the apartment in 2010 and was homeless until 2015. (Id.) In 2015, a homeless shelter helped Plaintiff find an apartment in Middletown, New York with the aid of government assistance. (Tr. 44, 46-47). At the time of the ALJ hearing in 2017, Plaintiff was living by himself in the second-floor Middletown apartment. (Tr. 44-45).

Plaintiff reported that he watched television and read when he could, but that he often needed to move around, including walking outdoors, to alleviate his pain. (Tr. 49). Plaintiff said he did his own cooking and laundry, but a friend helped clean his apartment due to Plaintiff's difficulty in bending over. (Tr. 53).

C. Medical Record³

1. Orange Regional Medical Center ("ORMC")

Treatment records from various doctors' visits at the Orange Regional Medical Center were submitted on behalf of Plaintiff.

On May 27, 2013, Plaintiff was seen by Dr. Kurt K. Kloss because of a recent episode of dysuria,⁴ which was noted to be a recurrent problem. (Tr. 249). Dr. Kloss recorded that Plaintiff was "[p]ositive for dysuria, hesitancy, urgency, and frequency," and that "[a]ll other systems reviewed . . . [were] negative." (Id.)

On September 14, 2013, Plaintiff was seen by Dr. Steven Piriano for another episode of dysuria and abdominal pain. (Tr. 254). Plaintiff described his pain as being at a seven out of ten. (Id.) Plaintiff was "positive" for abdominal pain, abdominal distention, dysuria, hesitancy, urgency, frequency, decreased urine volume and difficulty urinating, and "[a]ll other systems reviewed [were] negative." (Tr. 255). Dr. Piriano also noted a history of prostatitis and the following impressions:

1. Massive distention of the urinary bladder which extends out of the pelvis into the lower abdomen. The urinary bladder was also markedly distended on the prior exam of 2011. Correlate clinically for bladder outlet obstruction. 2. Bullous emphysematous changes in both lung bases, grossly unchanged compared to the prior exam. 3. Remainder of the examination is unremarkable.

(Tr. 257).

On December 11, 2013, Plaintiff was seen by Dr. Vohra for abdominal pain and other similar symptoms he had raised during his prior visits. (Tr. 271). Dr. Vohra noted the following:

1. Wall thickening of the rectosigmoid junction rectum. 2. Indeterminate lesion in mid pole of the left kidney[.] 3. Abnormal appearance the pelvis. There is an irregular lobular bladder wall thickening with edema. Primary consideration must be given to epithelial neoplasm or cystitis. 4. Large bulla noted at the right lung base.

(Tr. 284).

Plaintiff was next seen by Dr. Plexousakis on February 15, 2014. (Tr. 296). He complained of urinary retention, "hematuria, mild lower abdominal pain, and vomiting for the past 2 days," and was admitted to the hospital for genitourinary abnormalities. (Tr. 296, 299, 306). Dr. Plexousakis noted "[m]assive distension of the urinary bladder with wall thickening and large blood clots," and diagnosed Plaintiff with hematuria.⁵ (Tr. 318). Plaintiff underwent anoperation performed by Dr. Steven J. Rowe on February 16, 2014. (Tr. 324). Dr. Rowe performed a cystoscopy, clot evacuation, and bladder biopsy. (Id.) A Foley catheter was inserted and "left in postoperatively" given the Plaintiff's massive bladder distention. (Tr. 325). Pursuant to the bladder biopsy, Plaintiff was further diagnosed with "[u]rothelial mucosa with chronic cystitis, focal acute cystitis, and associated reactive changes." (Tr. 326). On February 18, 2014, he was discharged. (Tr. 325).

On December 24, 2014, Plaintiff was seen by Dr. Rose Anna Roantree. (Tr. 328). He complained of "chronic lower back pain that [was] mild in severity and ha[d] been intermittent since onset several years ago." (Id.) He was given Motrin and discharged the same day. (Tr. 331). On February 12, 2015, he returned to ORMC, again presenting with dysuria for 7 days. (Tr. 343). Less than two months later, on April 4, 2015, he presented again with urinary retention and an inability to insert his catheter. (Tr. 356). Plaintiff was tested and several abnormalities were detected in his basic metabolic panel, hepatic function panel, CBC differential, and urinanalysis. (Tr. 348-49). Plaintiff was diagnosed with urinary retention and a urinary tract infection, and he received a Foley catheter. (Tr. 349-350). He was discharged the same day and told to follow up with a urologist. (Tr. 351). On July 28, 2015, he presented with similar symptoms and was diagnosed with hematuria. (Tr. 471).

On September 2, 2016, Plaintiff was admitted to ORMC after presenting with a severe abscess and cellulitis in his left arm. (Tr. 497-98). Various doctors at the medical center examined him, the abscess was drained, and he was discharged and provided with medication on September 7, 2016. (Tr. 499-532). On September 9, 2016, it was noted in Plaintiff's chart that the abscess was worsening, was relieved by "nothing," and was worsened by draining orsqueezing. (Tr. 540). Plaintiff underwent an incision and drainage procedure to treat the abscess on September 9, 2016. (Tr. 543).

2. Crystal Run Health Care ("CRHC")

On March 3, 2015, Plaintiff presented for a urinary tract infection after experiencing pain and burning and was seen by Dr. Rowe. (Tr. 399). Dr. Rowe noted that Plaintiff's pertinent history included self-catheterization. (Id.). Plaintiff rated his pain as being a six out of ten. (Tr. 399). Plaintiff was diagnosed with a urinary tract infection, directed to finish his course of antibiotics, and further directed to schedule a follow-up exam in 6 months. (Tr. 401).

On March 16, 2015, Plaintiff presented with lower back pain and an atonic bladder that had an onset date of February 17, 2015. (Tr. 238-247). He was again seen by Dr. Singh, who noted Plaintiff's current medications, which included cefadroxil, ciprofloxacin, and a rubber catheter with directions to administer the self-catheter every four to six hours. (Tr. 244). Plaintiff was examined, completed two health questionnaires indicating pain of seven out of ten and moderate depression, and was referred to Dr. Yeon for a consultation. (Tr. 243-44, 386).

On March 19, 2015, Plaintiff had an orthopedic consultation with Dr. Yeon due to his lower back pain. (Tr. 386). His pain at the time was at a six out of ten. (Tr. 386). Dr. Yeon noted that "[x]-rays show multilevel disc degeneration [and] loss of height with osteophyte formation," diagnosed Plaintiff with lumbar radiculopathy and possible stenosis spondylosis, ordered physical therapy, and prescribed Naprosyn, Neurontin, and Zanaflex. (Tr. 388).

On April 7, 2015, Plaintiff presented with a case of chronic obstructive pulmonary disease ("COPD") that began two days earlier and was seen by Dr. Hulse.⁶ (Tr. 381). Plaintiff'ssymptoms included chest pressure and discomfort, dyspnea with exertion, excessive sputum, productive cough,...