Victoria M. v. Kijakazi

1

VICTORIA M.,^[1] Plaintiff, v. KILOLO KIJAKAZI, Defendant.

No. 3:21-cv-1575 (VAB)

United States District Court, D. Connecticut

March 24, 2023

RULING AND ORDER ON MOTIONS REGARDING THE COMMISSIONER'S DECISION

VICTOR A. BOLDEN UNITED STATES DISTRICT JUDGE

Victoria M. (“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 denying her claims under Title II and Title XVI of the Social Security Act. Compl. ¶ 6, ECF No. 1.

Plaintiff has moved for an order reversing the Commissioner's decision or, in the alternative, remanding the case for a new hearing, while the Commissioner has moved for an order affirming the decision. See Pl.'s Mot. for an Order Rev'ing the Decision of the Comm'r or in the Alternative Mot. for Remand for a Hr'g, ECF No. 12 (“Pl.'s Mot.”); Pl.'s Mem. in Supp. of Pl.'s Mot., ECF No. 12-1 (“Pl.'s Mem.”); Def.'s Mot. for an Order Aff'ing the Decision of the Comm'r, ECF No. 14 (“Comm'r's Mot.”); Def.'s Mem. in Supp. of her Mot., ECF No. 14-1 (“Def.'s Mem.”).

For the following reasons, Plaintiff's motion is GRANTED, and the Commissioner's motion is DENIED. The decision of the Commissioner is VACATED and REMANDED for further proceedings consistent with this Ruling and Order.

On remand, the ALJ is instructed to develop the record further by attempting to obtain assessments from Plaintiff's treating providers regarding her mental residual functional capacity.

I. FACTUAL AND PROCEDURAL BACKGROUND

A. Factual Background

Plaintiff alleges that she is disabled based on a combination of conditions, including mental illness, hypertension, related chronic kidney disease, degenerative spinal conditions that cause lower back pain, visual impairment, and obesity. Tr. of Administrative Proceedings at 33, ECF No. 24 (“Tr.”) (Tr. of Oral Hr'g.); Pl.'s Mem. at 1.

On March 29, 2019, Plaintiff filed a protective Title II application for a period of disability and disability insurance benefits, alleging disability beginning on February 16, 2018. Tr. at 12. Plaintiff the filed an application for supplemental social security income (“SSI”) on April 12, 2019. Id. at 216 (Ex. B3D, Application for Supplemental Security Income).

Plaintiff was forty-seven years old at the time of the alleged onset of her disability, February 16, 2018. See id. at 22 (ALJ Decision (Mar. 4, 2021)).^[2]She has a high school education and, before her alleged onset date, worked as a house cleaner, a home health aide, and a cashier checker. Id. at 21, 34, 299 (Ex. B1E, Disability Report - Form SSA-3368). Plaintiff has not been employed since September 2017. Id. at 295.

On August 14, 2019, Plaintiff's application was initially denied. Id. at 96 (Ex. B3A Disability Determination Explanation - Initial). Her application was then denied on rehearing on November 13, 2019. Id. at 119 (Ex. B5A, Disability Determination Explanation -Reconsideration).

On October 29, 2020, Plaintiff received a hearing before ALJ Ryan Alger. Id. at 29-51.

On March 1, 2021, the ALJ issued a decision. He found that Plaintiff had the following medically determinable severe impairments: seizures, degenerative disease of the lumbar spine, obesity, and major depressive disorder. Id. at 14 (ALJ Decision). The ALJ also found that Plaintiff had a non-severe vision disorder. Id. Nonetheless, the ALJ concluded that Plaintiff was not disabled and denied her application for benefits. Id. at 23.

On April 20, 2021, Plaintiff filed a request for review of the ALJ's decision by the Appeals Council. Id. at 206 (Ex. B12B, Request for Review of Hearing Decision). That request was denied on September 29, 2021. Id. at 1 (Appeals Council Decision).

1. Plaintiff's Testimony

Plaintiff testified at the hearing that she currently lives with her adult daughter, who cooks and cleans for her. Id. at 35. Plaintiff does not drive and relies on her son for transportation to medical appointments. Id.

Plaintiff testified that she struggles with back pain but cannot take ibuprofen for pain relief because of the risk to her kidneys. Id. at 36. She also takes medication for her depression, which she sometimes finds helpful. Id. She sometimes does not take the medication, however, because voices in her head told her not to take it. Id.

Plaintiff stated that she cannot walk or sit for more than about fifteen minutes without experiencing pain in her legs. Id. at 37-38. She also testified that she can stand for about twenty minutes on a good day. Id. 38.

On good days, Plaintiff testified, she can sit up in bed and watch television or do a crossword puzzle, while on bad days she will remain in bed all day. Id. She testified that about half her days qualify as good days, and half are bad. Id.

Plaintiff testified that, because of her pain management issues, she would have to miss significant time at work if she had a full-time job. Id. at 42.

Plaintiff also testified that she struggles to be around strangers for too long. Id. at 40. As a result of these issues, she last went grocery shopping in person a year and a half before her hearing. Id. She testified that she would bring someone with her when she went shopping because she struggles to lift things and because she might have to leave the store to avoid being around people. Id. at 41-42.

2. Medical History

On November 2, 2017, Plaintiff met with behavioral health clinician Hope Taylor, where she reported challenges with self-care and with staying out of bed when she gets overwhelmed. Id. at 361 (Ex. B1F, LifeBridge Community Services Progress Note). Counselor Taylor noted that Plaintiff presented as slightly disheveled, but calm and pleasant. Id.

Plaintiff continued to see Counselor Taylor for behavioral health appointments through December 2018. Id. at 353. At some of these visits, Plaintiff reported depressed mood, decreased grooming, and periods of staying in bed triggered by environmental stressors. See id. at 360 (Nov. 16, 2017, and Nov. 30, 2017), 359 (Jan. 11, 2018), 358-59 (Jan. 25, 2018), 357 (Apr. 6, 2018), 356 (Apr. 12, 2018, and Apr. 26, 2018), 353 (Oct. 18, 2018 and Dec. 6, 2018). At other visits, she reported greater success in getting out of bed and managing challenges in her life. See id. at 358 (Feb. 22, 2028), 355-56 (May 17, 2018), 355 (June 7, 2018, and July 5, 2018), 354 (Sept. 6, 2018).

On December 1, 2017, Plaintiff presented for a primary care visit with complaints of a headache that had lasted for the past two days, as well as tingling and numbness in her hands. Id. at 409 (Ex. B2F, Optimus Healthcare Office Treatment Records). She also reported a backache related to retrolisthesis. Id. at 411.

On January 17, 2018, Plaintiff had a follow-up appointment for chronic kidney disease and was assessed with normal renal function, minimal proteinuria, and hypertensive chronic kidney disease. Id. at 720-21 (Ex. B9F, Park City Primary Office Treatment Records).

On January 24, 2018, Plaintiff presented to Dr. Allen Schlein with complaints of lower back pain since 2013. Id. at 719. Dr. Schlein assessed Plaintiff with chronic lumbar strain, instructed her in posture control, and told her to lose weight. Id.

On February 8, 2018, Plaintiff had an appointment for a physical therapy evaluation and plan of care. Id. at 889 (Ex. B13F, Yale New Haven Health Information Technology Medical Report). The appointment notes indicate that Plaintiff had ongoing back pain, which was aggravated by standing, sitting, walking, and bending. especially while walking, and that she noted increased pain with sitting, difficulty sleeping, and difficulty standing to cook or do laundry. Id. at 890. The notes reference an x-ray from October 2017, which showed grade one retrolisthesis of the L4 vertebra over the L5 vertebra. Id. She was assessed with postural deficits, impaired trunk and hip range of motion, impaired core strength, impaired lower extremity strength, impaired flexibility to the bilateral hamstring and hip flexor, as well as the upper quadrant, impaired spinal segmental mobility, and soft tissue hypertonicity at the lumbar spine. Id. at 892.

On March 16, 2018, Plaintiff presented to primary care with complaints of headaches and heartburn. Id. at 401. Notes from this appointment indicate that an x-ray from December 2017 continued to show a grade one retrolisthesis of L4 over L5, as well as L3 anterior osteophyte. Id. The notes also indicate that Plaintiff had failed physical therapy and that an MRI had been reordered. Id.

On April 2, 2018, Plaintiff had an appointment with an ophthalmologist, Dr. Annette Hoo, at which Plaintiff reported blurred vision both near and at distance. Id. at 509 (Ex. B4F, Dr. Annette Hoo Progress Notes). Dr. Hoo reported a noticeable decline in her vision without correction. Id. Plaintiff was assessed with bilateral disc cupping asymmetry, ocular hypertension, defects in the nerve of the fiber layer, hyperopia, astigmatism, and presbyopia, as well as corneal hysteresis. Id. at 510.

On May 22, 2018, Plaintiff presented to neurology with headaches and seizures. Id. at 714. The appointment notes indicate that Plaintiff had been seizure-free since 2015, but that she had stopped taking one of her prescribed medications six months ago for no real reason. Id. Plaintiff reported that she didn't think the medication was helping with her headaches. Id.

On May 31, 2018, Plaintiff had a neuro-ophthalmology appointment, where she presented with blurry vision, a visual field defect, strabismus, and generalized tonic-clonic seizures with occipital cerebral infarction. Id. at 537.

On October 19, 2018, Plaintiff underwent a total...