Ritchie v. Saul

MELANIE M. RITCHIE, Plaintiff, v. ANDREW M. SAUL,¹ Commissioner of Social Security, Defendant.

19cv01378 (DF)

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK

September 29, 2020

MEMORANDUM AND ORDER

DEBRA FREEMAN, United States Magistrate Judge:

In this Social Security action, which is before this Court on consent pursuant to 28 U.S.C. § 636(c), plaintiff Melanie M. Ritchie ("Plaintiff") seeks review of the final decision of defendant Nancy A. Berryhill, former Acting Commissioner of the Social Security Administration ("SSA"), succeeded by Andrew M. Saul, ("Defendant" or the "Commissioner"), denying Plaintiff Supplemental Security Income ("SSI") and Social Security Disability Insurance ("SSDI") under the Social Security Act (the "Act") on the grounds that, for the relevant period, "medical improvement" had occurred, such that Plaintiff's impairments no longer constituted a disability under the Act. Currently before the Court is Plaintiff's motion, pursuant to Rule 12(c) of the Federal Rules of Civil Procedure, for judgment on the pleadings reversing the Commissioner's decision. (Dkt. 17.) Also before the Court is the Commissioner's cross-motion for judgment on the pleadings affirming the Commissioner's decision. (Dkt. 20.)

For the reasons set forth below, Plaintiff's motion is granted to the extent that it seeks remand for further administrative proceedings, and Defendant's cross-motion is denied.

BACKGROUND²

Plaintiff filed an application for SSDI on November 4, 2015 (R. at 161-62) and an application for SSI on December 7, 2015 (id. at 163-69). In both applications, Plaintiff alleged a disability onset date of October 9, 2015 due to exacerbation of lower back pain. (Id. at 161-69.) After Plaintiff's claims were denied initially on January 4, 2016 (id. at 91-98), Plaintiff requested a hearing before an Administrative Law Judge ("ALJ") (id. at 103-05). Plaintiff, represented by counsel, testified by videoconference before ALJ Michael J. Stacchini, at a hearing conducted on October 19, 2017 (the "Hearing"). (Id. at 121-27; see also id. at 27-58.) At the Hearing, the ALJ also heard testimony from Mary Ann Morocco, a vocational expert ("VE"). (Id. at 50-55.)

On March 21, 2018, the ALJ issued a partially favorable decision finding that the Plaintiff was disabled from October 9, 2015 through October 25, 2017, but that Plaintiff's disability ended on October 26, 2017 because of medical improvement. (Id. at 8-26.) Plaintiff sought review of the portion of the decision that held there had been medical improvement as of October 26, 2017 and filed a Request for Review of a Hearing Decision on April 17, 2018. (Id. at 157-60.) The ALJ's decision became the Commissioner's final decision when the Appeals Council denied Plaintiff's request for review on December 10, 2018. (Id. at 1-6.) Plaintiff now challenges the Commissioner's denial of benefits for the period beginning October 26, 2017.

A. Plaintiff's Personal and Employment History

Plaintiff was born on October 28, 1970, such that she was 44 years old as of her alleged disability onset date of October 9, 2015. (Id. at 7.) In her Function Report, Plaintiff indicated that she had received her GED in 1988 and had completed training in 2002 to become a certified nursing assistant ("CNA"). (Id. at 212.) According to Plaintiff, she was employed as a "warehouse worker" from September 2002 through March 2003. (Id. at 213.) In addition, since 2002, she had reportedly worked on and off as a patient care aide and a CNA. (Id.)

At the Hearing, Plaintiff testified that her most recent job was as a part-time home attendant for elderly adults and that she stopped working in June of 2017. (Id. at 37-38.) She explained that, as a home attendant for the elderly, her responsibilities had included "feeding, cooking, [and] washing them down." (Id. at 38.) Plaintiff testified that she stopped working because she "just couldn't work anymore." (Id. at 37.)

Plaintiff testified that she lived with her two children, ages 9 and 14,³ and her sister. (Id. at 35.) When asked what she did with her children for enjoyment, she stated, "[m]y kids will go to the movies, but not with me." (Id. at 36.) Plaintiff testified that she drove and used public transportation, which she described as "[m]edical transportation." (Id. at 38-39.) She further testified that she did not exercise or go out with friends at all. (Id. at 39.) She stated in her Function Report that her hobbies included reading and watching television, and that she typically spent all day engaged in these activities. (Id. at 227.)

B. Medical Evidence

Although the relevant period under review for the purpose of Social Security benefits only runs from October 26, 2017 (the date by which the ALJ concluded that medical improvement had occurred) to the present, the Court will summarize the body of evidence that was before the ALJ when he rendered his decision.

1. Evidence Pre-Dating the Relevant Period

Plaintiff has a history of chronic back pain, apparently dating back to at least 2011. (Id. at 324; see also id. at 64-65.) The records suggest that she may have had some early benefits from physical therapy, but that in October of 2015, she reported a relapse of severe back pain. (Id. at 324.) On October 1, 2015, Plaintiff saw her primary care physician, Dr. Muhammad Chowdhury, who prescribed pain medicine and a muscle relaxant, and referred Plaintiff to an orthopedic and pain management specialist. (Id.) Plaintiff, however, reported that she continued to have persistent pain and was unable to walk around or stand up. (Id.) On October 8, 2015, Plaintiff presented to the Emergency Department of St. Luke's Cornwall Hospital for the pain in her lower back, radiating down her right leg. (Id. at 317-22.) She stated that she could not recall any precipitating factor, but that she woke up and felt severe pain when trying to get out of bed. (Id. at 324.) Dr. Chowdhury admitted Plaintiff to the hospital. (Id. at 321-22.) A musculoskeletal exam showed positive results, bilaterally, on a straight leg raise test⁴ and thatPlaintiff had pain with movement from lying down to sitting. (Id. at 319.) Plaintiff's MRI results were recorded as follows:

1. Large broad-based left paracentral disc herniation⁵ encroaches upon both S1 nerve roots, left greater than right, with mild central stenosis⁶ at L5-S1; 2. Right paracentral/foraminal protrusion at L4-L5 encroaches upon the right L5 and right exiting L4 nerve roots; 3. Mild exaggerated lordosis⁷ without acute fracture or pars defect."⁸

(Id. at 345-46.) Dr. Chowdhury wrote in the Emergency Department records that Plaintiff was "[u]nable to ambulate," that she had "[s]evere disabling back pain with radiculopathy," that her "pain [was] refractory with oral medications," and that she had "chronic back pain [that had been] stable until [the prior] week," but that, since then, Plaintiff's pain was "not getting controll[ed] with oral medications." (Id. at 323.) Dr. Chowdhury also stated, in an Assessment and Plan, that Plaintiff had "suddenly developed severe pain in the low back . . . and [was] not getting better at all with the pain management as well as steroid." (Id. at 325.)

While in the hospital, Plaintiff was seen by Dr. Juan Cuartas, an orthopedist; Dr. Syed Nasir, a neurologist; and Dr. Syed Hosain, a pain-management specialist. (Pl. Mem., at 4; see also R. at 331-40.) Dr. Cuartas noted that Plaintiff's pain was "mostly axial pain due to the injured and abnormal disc at 5-1." (R. at 331.) He further indicated that Plaintiff's treatment in the past had included "[NSAIDs,] narcotics[,] and relaxants" in addition to "oral steroids." (Id. at 327.) Dr. Nasir noted that Plaintiff's outpatient MRI "show[ed] no change from 2011," and that Plaintiff's pain was worse with movement. (Id. at 333.) Dr. Hosain indicated that analgesic medications were likely to be of little help, and that, while muscle relaxants were prescribed, physical modalities would be more effective in the long term. (Id. at 340.)

Plaintiff was kept on bedrest and was administered intravenous pain medication, muscle relaxants, an NSAID, and an intravenous steroid. (Id. at 341.) Plaintiff gradually improved and was able to move around, albeit "with pain," and was discharged on October 11, 2015, with medication. (Id.)

On October 13, 2015, Plaintiff saw a physiatrist, Dr. Rakesh Patel, at Crystal Run Healthcare ("Crystal Run"). (Id. at 389.) Dr. Patel reported that Plaintiff had had lower back pain since 2011, but denied any inciting event, such as "trauma, [a] fall, [or an] accident," and also reported "heavy lifting for her work (CNA)." (Id.) He wrote that Plaintiff's "[p]ain [was] progressively worse over the years, with recent severe exacerbation limiting work duties," and that Plaintiff had "limited ambulation due to pain" and had a "cane at home." (Id.) He further reported that Plaintiff was "[i]ndependent in most ADL [activities of daily living]," but"require[d] assistance for lower body dressing." (Id.) Dr. Patel prescribed Oxycodone⁹ and Gabapentin,¹⁰ and referred Plaintiff to a pain-management specialist at Crystal Run, Dr. Thomas Booker, for epidural injections. (Id. at 392.)

Plaintiff went to Dr. Chowdhury for a follow-up appointment on November 19, 2015. (Id. at 462.) Dr. Chowdhury reported that, at that point, Plaintiff was "using a walking cane [] for back pain," which "still radiate[d] to the back of the thigh as well as leg" and was then "radiating up to the back of knee." (Id. at 462-63.)

Plaintiff saw Dr. Patel for follow-up appointments on December 8, 2015 and January 7, 2016. (Id. at 364-76.) He noted that Plaintiff had recently been in the hospital for pain and had been provided Oxycontin.¹¹ (Id. at 371.) He noted that her pain level was a "7/10," and that her pain was "exacerbated by bending forward, [with] no relieving factors." (Id. at 372.) He furthernoted that Plaintiff had been "prescribed Vicodin¹² and Naproxen¹³ by Dr. [C]howd...