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Lisa Knepple-Hodyno v. Michael J. Astrue

September 10, 2012


The opinion of the court was delivered by: Dora L. Irizarry, U.S. District Judge:


Plaintiff Lisa Knepple-Hodyno ("Plaintiff") filed an application for disability insurance benefits under the Social Security Act (the "Act") on November 27, 2006 alleging a disability that began on June 7, 2006. Plaintiff's application was denied, and, on reconsideration, Plaintiff appeared and testified at a hearing held before Administrative Law Judge David Z. Nisnewitz ("ALJ") on July 1, 2008. By decision dated December 29, 2008, the ALJ concluded that Plaintiff was not disabled within the meaning of the Act. On November 29, 2010, the ALJ's decision became the Commissioner's final decision when the Appeals Council denied Plaintiff's request for review.

Plaintiff filed the instant appeal seeking judicial review of the denial of benefits, pursuant to 42 U.S.C. § 405(g). The Commissioner moved for judgment on the pleadings, pursuant to Fed. R. Civ. P. 12(c), seeking affirmation of the denial of benefits. (See Comm'r Mot. for J. on the Pleadings, Dkt. Entry 9.) Plaintiff cross-moved for judgment on the pleadings, seeking reversal of the Commissioner's decision and remand. Plaintiff contends that the ALJ failed to:

(i) weigh the treating physicians' opinions and develop the record properly; and (ii) evaluate

Plaintiff's credibility properly. (See Pl. Mem. of Law in Supp. of Pl.'s Cross Mot. for J. on the Pleadings, Dkt. Entry 12 ("Pl. Mem.").)

For the reasons set forth below, the Commissioner's motion is denied, Plaintiff's motion is granted, and the matter is remanded for further administrative proceedings consistent with this opinion.


A. Non-medical and Testimonial Evidence

On July 1, 2008, Plaintiff, represented by counsel, appeared and testified at a hearing concerning her disability claim. (R. 18-89.)*fn1 Plaintiff, born in 1958, completed one year of college. (R. 128, 161.) From 1983 until the onset of her alleged disability in 2006, Plaintiff worked as a medical assistant and an office manager in a doctor's office. (R. 154.) Plaintiff's daily duties included assisting the doctor with medical procedures, preparing patients for treatments, checking patient's vital signs, data entry and various administrative functions. (Id.) This job involved seven hours of standing/walking, no sitting, two hours of climbing and frequently lifting up to ten pounds. (R. 154-55.) Plaintiff was laid off from her job in July 2006 because her employer knew that she was experiencing pain in her lower back radiating down to her feet, and would need surgery. (R. 21-23.)

At the time she applied for disability benefits, Plaintiff's daily routine included light chores, such as preparing meals, dusting, laundry and vacuuming. (R. 170.) Plaintiff could walk for a half of a block before feeling discomfort and for an additional half of a block with difficulty. (R. 29-30.) Plaintiff underwent spinal stenosis surgery in July 2007, after which she felt "slightly" better. (R. 28.) However, Plaintiff fell in March 2008 and sustained a herniated disk. (R. 32.) She did not require additional surgery following the fall, but she was referred to pain management and prescribed Tylenol Extra Strength. (R. 34, 42.)

Vocational Expert Andrew Pasternak ("VE") also testified at the hearing. (R. 87-88.) The VE explained that Plaintiff's previous work was as a medical assistant, which is a light exertional skilled job, and an office manager, which is a sedentary skilled job. (R. 87.)

B. Medical Evidence

1. Medical Evidence Prior to Alleged Onset Date

On October 6, 2005, Dr. Raymond Keller took lumbar spine x-rays, which showed evidence of grade 1 spondylolisthesis of L4-5 and degenerative disc disease in L4-5 and L5-S1, but that alignment and curvature of the spine were unremarkable, and vertebral body heights were intact. (R. 314.)

On February 8, 2006, Plaintiff underwent an MRI, which showed degenerative disc and more striking apophyseal joint disease bilaterally at L4-5, with a resultant grade 1 anterior spondylolisthesis of L4 upon L5. (R. 235.)

Plaintiff saw Dr. Paul Kuflik of the Spine Institute of New York on March 29, 2006. (R. 233-34.) Dr. Kuflik reported that Plaintiff appeared quite uncomfortable, though she had a normal gait and was able to heel and toe walk. (R. 233.) Based on his examination and an MRI Plaintiff brought with her to the appointment, Dr. Kuflik diagnosed "quite severe" spinal stenosis and spondylolisthesis and opined that Plaintiff probably would not obtain lasting relief without surgery. (Id.) On April 11, 2006, Dr. Norman Schoenberg examined Plaintiff and also diagnosed her with spinal stenosis and spondylolisthesis, as well as degenerative disk disease and osteoarthritis. (R. 363.)

2. Medical Evidence on or after Alleged Onset Date

On July 24, 2006, Plaintiff was examined by Dr. Richard Gasalberti, a clinical instructor with New York University. (See R. 400-03.) Dr. Gasalberti noted that Plaintiff complained of lower back pain that gets worse when sitting, standing, walking and bending, but that she wished to avoid surgery. (R. 400.) Dr. Gasalberti reported that Plaintiff had mild lumbar scoliosis, was able to flex her trunk to 70 degrees with lateral rotation to 10 degrees, and a straight leg raising test was positive at 50 degrees. (R. 402.) He recommended electromyography ("EMG") and nerve conduction studies of the lower extremities, use of a corset for comfort and support, physical therapy and epidural steroid injections. (R. 402-03.)

Plaintiff saw Dr. Gasalberti again on August 10, 2006. (R. 408-09.) Plaintiff reported that her pain was about an eight on a ten-point scale. (R. 408.) X-rays revealed that Plaintiff suffered from mild degenerative disease and an EMG study showed clinical lumbar raidculopathy. (Id.) Plaintiff's straight leg raising was negative, trunk flexion was to 75 degrees and paraspinal spasms were evident on deep palpation. (Id.) Dr. Gasalberti again diagnosed chronic lower back pain, mild spondylosis, apophyseal joint degenerative disease bilaterally and disc bulging at L5-S1. (Id.) He also diagnosed clinical lumbar radiculopathy, facet syndrome, sacroiliac joint pain, sacroilitis and mild degenerative joint disease of the sacroiliac joints. (Id.) Dr. Gasalberti reiterated his diagnosis following an August 15, 2006 examination. (R. 410.)

On February 27, 2007, at the direction of the Commissioner, Plaintiff submitted to a consultative orthopedic examination by Dr. Steven Calvino. (R. 458-61.) Plaintiff reported excruciating lower back pain radiating into her legs. (R. 458.) Plaintiff also claimed that she had numbness throughout her bilateral lower extremities down to her feet. (Id.) Dr. Calvino found that Plaintiff had a normal gait and was able to walk on her heels and toes without difficulty. (R. 459). She needed no help getting on and off the examination table and she rose from her chair without difficulty. (Id.) Forward flexion of Plaintiff's lumbar spine was limited to 30 degrees during the examination, but Dr. Calvino observed Plaintiff flexing to 90 degrees after the examination when she picked up papers off the floor. (R. 460.) She had full lateral flexion and rotation of the lumbar spine, and she had no spinal or paraspinal tenderness or spasm in the thoracic and lumbar areas. (Id.) Dr. Calvino diagnosed Plaintiff with chronic low back pain, and concluded that Plaintiff's prognosis was excellent and she had no restrictions. (Id.)

On March 3, 2007, Plaintiff underwent another MRI. (R. 462.) Dr. Kuflik reviewed the MRI and found that it revealed grade II spondylolisthesis, severe central canal stenosis, a left paracentral disc herniation at L5-S1, impinging upon the left ventral aspect of the ...

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