Traci S. v. Kijakazi

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TRACI S.,^[1] Plaintiff, v. KILOLO KIJAKAZI, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.

No. 3:21-cv-01582(VAB)

United States District Court, D. Connecticut

March 17, 2023

RULING AND ORDER ON MOTIONS REGARDING THE COMISSIONER'S DECISION

VICTOR A. BOLDEN, UNITED STATES DISTRICT JUDGE

Traci S. (“Plaintiff”) has filed this administrative appeal under 42 U.S.C. § 405(g) against Kilolo Kijakazi the Acting Commissioner of Social Security (“Defendant” or “the Commissioner”) seeking to reverse the decision of the Social Security Administration (“SSA”) denying her claim for Title II disability insurance benefits under the Social Security Act. Compl., ECF No. 1 (Nov. 29, 2021) (“Compl.”).

Traci S. has moved for an order reversing the decision of the Commissioner, or, in the alternative, an order remanding the case. See Mot. for Order Reversing the Commissioner's Decision, ECF No. 14 (Mar. 29, 2022) (“Pl. Mem.”).

On May 25, 2022, the Commissioner moved to affirm the decision. See Def. Mot. for an Order Affirming the Decision of the Commissioner, ECF No. 16 (May 25, 2022); Def.'s Mem in Supp. of Mot. for an Order Affirming the Commissioner's Decision, ECF No. 16-1 (May 25, 2022) (“Gov't Mem.”).

For the following reasons, Traci S.'s motion is DENIED, and the Commissioner's motion is GRANTED.

I. FACTUAL AND PROCEDURAL BACKGROUND

A. Factual Background

Born in 1971, Traci S. reached the age of forty-one at the time of the alleged onset of her disability. See Tr. of Administrative Proceedings at 214, ECF No. 10 (Jan. 27, 2022) (“Tr.”). Before the alleged onset of her disability, Traci S. worked as a receptionist at a veterinary hospital for seven years and as a window clerk at a post office for approximately seven years. See Tr. at 250. Traci S. has not engaged in substantial gainful activity since her alleged onset date. See id. at 20-32.

The Administrative Law Judge J.K. Harrington (“ALJ Harrington”) found Traci S. to have the following severe impairments: “Pelvic Prolapse Syndrome and Cystocele/Rectocele.” Tr. at 29. The ALJ concluded that Traci S.'s Bell Palsy, Grave's Disease, Glaucoma, Psoriasis, and Anxiety Disorder impairments are “non-severe” because “such impairments establish only a slight abnormality or a combination of slight abnormalities that would have no more than a minimal effect on the claimant's ability to meet the basic demands of work activity.” Id. at 23.

1. Medical History

On March 1, 2011, Dr. George Heading (“Dr. Heading”) completed a medical source statement. He wrote that Traci S. has a limitation of lifting up to ten pounds and can do so two hours out of the day. Id. at 2049. She can reach above her shoulders four hours a day, walk two hours a day, stand two hours a day, and sit six hours a day. Id. She can perform stooping and bending two hours day. Id.

On April 28, 2011, Traci S. underwent pelvic surgery in the form of robotic-assisted laparoscopic myomectomy, trans obturator tape, cystoscopy, and posterior repair with mesh, for diagnoses of symptomatic uterine fibroids, pelvic organ prolapse, and stress urinary incontinence. Id. at 2438.

On September 19, 2011, Dr. James Brunetti wrote a letter on Traci S.'s behalf. Id. at 2337. He wrote that, in November 2010, Traci S. sustained a strain of her pelvic ligaments which resulted in pelvic organ prolapse. Id. “A pelvic ligament strain is very rarely seen. It is usually caused by female organ prolapsing due to childbirth or severe strain. People who are elderly and overweight are usually candidates for this type of injury.” Id. He gave his opinion that Traci S.'s work-lifting caused her to develop this strain. Id. After her surgery, Traci S. developed “a great deal of panic and anxiety.” Id. She has had a total of four surgical procedures and will have lifting restrictions for life. Id. Dr. Brunetti wrote that he has been Traci's primary care physician for 15 years and “she has never been one to complain . . . unfortunately her restrictions will carry throughout her career.” Id.

On November 14, 2011, Dr. Heading wrote a letter on Traci S.'s behalf. He wrote that she underwent reconstructive vaginal surgery with pelvic prolapse syndrome. Id. at 480. This condition “specifically consisted of grade II cystocele, grade II rectocele, and second degree uterine prolapse.” Id. She had symptoms for approximately two years, which include constant pelvic pressure, urinary frequency, and severe constipation requiring insertion of a finger into the vagina to push stool from the rectum. Id. “These anatomic abnormalities represent a hernia of the female anatomy which is unusual to find in a young woman who has not given birth as in Traci's case.” Id. Dr. Heading concluded that in his eighteen years of clinical practice he has only seen such a situation once before. Id.

On April 17, 2012, Dr. Brunetti wrote a medical source statement in which he noted Traci S.'s uterine and pelvic wall prolapse and rectal prolapse, with spasms and chronic pain. Id. at 2037.

On June 21, 2012, Dr. Heading wrote a letter on Traci S.'s behalf. Id. at 2038. He explained that she underwent a repeat surgery on May 3 because “she now developed bilateral . . . inguinal (groin) hernia in addition to her previous condition of pelvic prolapse. Id. She cannot perform any lifting at this point under any circumstances.” Id.

On July 16, 2012, Dr. Heading again wrote that “it continues to be my recommendation that she [does] not engage in any lifting activities.” Id. at 2039.

On July 18, 2012, Traci S. was seen for outlet dysfunction constipation and anal spasm. Id. at 2040.

On August 15, 2012, Dr. Heading again wrote that “it continues to be my recommendation that she refrain from all lifting.” Id. at 2040.

On September 17, 2012, Dr. Heading again wrote “it continues to be my recommendation that she refrain from all lifting.” Id. at 2041.

On October 22, 2012, Dr. Bellapianta wrote a letter to Dr. Brunetti, in which he noted that after her pelvic surgery, Traci S. has had spasms affecting her adductor muscles and groin that are possibly caused by peripheral neuritis. Id. at 2395. She also has severe spasming of her perilumbar spine muscles. Id.

On November 14, 2012, Traci S. was noted to be having therapy for spinal muscle spasm. Id. at 2445.

On January 9, 2013, Traci S. was noted to be prescribed Zoloft and diazepam. Id. at 2480.

On February 6, 2013, Dr. Heading wrote that it continues to be his clinical impression that Traci S. “cannot return to work secondary to [illegible] prolapse recurrence.” Id. at 2042.

On July 15, 2013, Traci S. was noted to have prolapse and that her vaginal spasms remain. Id. at 2483.

On September 3, 2013, Traci S. had a follow-up for Graves' disease. Id. at 1356. Since November, she gained approximately fifteen pounds, associated with profound fatigue, exhaustion, insomnia, and daytime somnolence. Id. She cut back on coffee and recently quit smoking. Id. She has had occasional palpitations that she thinks may be related to panic attacks, and Zoloft is alleviating some of her symptoms. Id. She tried to eat healthy and improved her sleep quality. Id. She became positive for diaphoresis, headaches, diarrhea and constipation, and Palpitations. Id.

On December 24, 2013, state agency reviewer Dr. Abraham Bernstein gave his opinion that Traci S. has no severe medical impairments. Id. at 118.

On December 30, 2013, Traci S. had a consultative examination with Dr. Nancy Kelly, Psy.D. Id. at 511. She had a cooperative demeanor, but was occasionally stuttering upon entering the evaluation. Her mood and affect were anxious. Id.

At this examination, Traci S.'s recent and remote memory were mildly impaired due to distractibility in the evaluation setting. Id. at 513. She recalled 0/3 words after five minutes, but remembered 3/3 immediately. There was no evidence of limitation in following and understanding simple directions or performing simple work tasks independently, maintaining a regular schedule, making appropriate decisions, or relating adequately to others. Id. She may have had mild limitations learning new tasks and moderate limitations performing complex tasks independently. Id. Traci S. may have had moderate limitations maintaining concentration and appropriately dealing with stress. Id. “The results of the evaluation appear to be consistent with stress-related problems that may significantly interfere with the claimant's ability to function on a daily basis.” Id.

On January 7, 2014, state agency reviewer Adrian Brown, Ph.D., gave his opinion that Traci S. has moderate difficulty maintaining concentration, persistence, and pace, and mild difficulty maintaining social functioning and performing activities of daily living. Id. at 119.

Traci S. was moderately impaired in the ability to carry out detailed instructions and maintain attention and concentration for extended periods Id. at 120-121.

On February 18, 2014, Traci S. had her first appointment with Dr. Lynn Morris, who noted diagnoses of Graves' disease, glaucoma, anxiety, and hyperhidrosis of axilla. Id. at 2202.

On February 26, 2014, Traci S. was noted to have prolapse and pelvic spasm. She will continue taking Valium. Id. at 2469.

On March 27, 2014, the United States Office of Personnel Management issued a noticed that Traci S. is “disabled from [her] position as a Window Clerk due to pelvic prolapse syndrome, cystocele and rectocele.” Id. at 1754.

On April 17, 2014, state agency reviewer Janine Swanson, Psy.D., gave her opinion that Traci S. has mild difficulty maintaining concentration, persistence, and pace, and difficulty maintaining social functioning and performing activities of daily living. Id. at 130.

On May 8, 2014, state agency reviewer ...