United States District Court, S.D. New York.
MEMORANDUM AND ORDER
JAMES C. FRANCIS, IV, Magistrate Judge.
The plaintiff, Lucy Maria Garner, brings this action pursuant to section 405(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking review of a determination of the Commissioner of Social Security (the "Commissioner") finding that she is not entitled to disability insurance benefits. The parties have submitted cross-motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons set forth below, the plaintiff's motion is granted in part, the defendant's motion is denied, the Commissioner's decision is vacated, and the case is remanded to the Social Security Administration (the "SSA") for further proceedings consistent with this opinion.
A. Personal History
Ms. Garner was born on December 21, 1964. (R. at 136). The record indicates that she has a college education. (R. at 191). The plaintiff's last job was as a laundry attendant, prior to which she was a family service worker. (R. at 191, 214). She left her most recent job in 2010 when she was fired. (R. at 65). As of May 24, 2012, Ms. Garner lived in an apartment in New York City with her children. (R. at 38, 64).
B. Medical History
1. Medical Evidence Before September 8, 2010
The plaintiff alleges a disability beginning September 8, 2010, consisting of back and neck pain, which contributes to headaches and pain in her extremities. (R. at 190). She began treatment with Dr. Navageni Rao around 2005. (R. at 348, 351). From 2005 until 2009, Dr. Rao treated Ms. Garner for symptoms arising from pain in the neck, lower back, upper back, and knees; treatment included medication, physical therapy, and lidocaine injections. (R. at 270-72, 274, 276-77, 279-80, 287, 291, 351-52, 369-71, 396, 401-03, 407, 410-11, 428-29). X-rays from August 2005 showed a normal lumbar spine and no evidence of significant arthritic changes of the cervical spine. (R. at 294-95). An MRI in September 2006 indicated a posterior disc herniation at L4-L5, with a slight impingement on the thecal sac. (R. at 291). Ms. Garner stopped treatment with Dr. Rao in May 2009 and did not resume it until after her claim was submitted.
On April 15, 2009, Ms. Garner sought treatment at Harlem Hospital Center and was treated by Dr. Roger Smoke. She reported confusion, headaches, and pain in her back, shoulders, elbows, lower back, and right foot. (R. at 318). Dr. Smoke's primary diagnosis was obesity. (R. at 319). The plaintiff was seen again on July 15, 2009 for the same symptoms. (R. at 321).
2. Medical Evidence from September 8, 2010 to May 24, 2012
i. Dr. Louis Tranese
On June 15, 2011, Ms. Garner filed applications with the SSA for Social Security Disability Insurance Benefits ("SSD") and Supplemental Security Income Benefits ("SSI"), alleging that she had been disabled since September 8, 2010. (R. at 136, 140). On September 6, 2011, the plaintiff was examined by Dr. Louis Tranese, a consulting physician to whom she was referred by the SSA. (R. at 300). Ms. Garner reported neck and lower back pain. (R. at 300). At the time, the plaintiff was five feet, six inches tall and weighed 293 pounds. (R. at 301). During the examination, she was able to change and get on and off the examination table without assistance, and her station and gait were normal. (R. at 301). She was able to walk on her heels and toes while holding the examination table and squat to forty percent of her range. (R. at 301). She exhibited limited range of motion through her cervical and lumbar spine. (R. at 301-02). Her cervical spine showed full flexion, but extension was limited to thirty degrees with bilateral cervical and paracervical tenderness that extended into the superior trapezial region. (R. at 301). Her thoracic and lumbar spine showed full extension, but flexion was limited to seventy degrees with complaint of generalized bilateral lumbar paraspinal tenderness, more so on the right than the left. (R. at 302). She exhibited full muscle strength and range of movement throughout her arms and legs, full bilateral grip strength, and intact hand and finger dexterity. (R. at 301-02). The plaintiff told Dr. Tranese that she cooked, cleaned, did laundry, and shopped, and that she did not require assistance with personal care. (R. at 301).
Dr. Tranese diagnosed Ms. Garner with discogenic low back pain with radicular symptoms, a reported lumbar disc herniation, and chronic neck pain. (R. at 302). Dr. Tranese assessed the plaintiff's physical limitations and restrictions and drew the following conclusions: the plaintiff had (1) moderate restrictions in heavy lifting and forward bending; (2) mild-to-moderate restrictions in stair climbing and long distance walking; (3) moderate restriction with squatting and kneeling; and (4) mild restriction with sitting or standing for long periods. (R. at 302). He did not opine as to what level of work she would be able to perform. On September 16, 2011, K. Saunders, a disability analyst for the SSA, completed a residual functioning capacity ("RFC") assessment by reviewing the plaintiff's file. (R. at 304-09). She concluded that the plaintiff could occasionally lift or carry up to twenty pounds, frequently lift or carry ten pounds, stand and walk at least six hours in an eight-hour workday, and sit about six hours in an eight-hour workday. (R. at 305). The analyst found that the plaintiff could push and pull without restriction, frequently balance, and occasionally climb, stoop, kneel, crouch, or crawl. (R. at 305-06). The analyst opined that the plaintiff retained the capacity for light work. (R. at 309).
ii. Dr. Roger Smoke
On October 3, 2011, Dr. Smoke examined Ms. Garner for the first time since 2009. (R. at 321, 324). Ms. Garner reported back pain, headaches, anxiety, and fatigue. (R. at 324). Dr. Smoke diagnosed morbid obesity and other musculoskeletal symptoms. (R. at 324).
On November 22, 2011, Dr. Smoke completed a Multiple Impairment Questionnaire. (R. at 447-54). He reported treating Ms. Garner yearly since 2009. (R. at 447). He diagnosed morbid obesity and back pain, pain upon movement of the shoulders and elbows, and tenderness of the trapezial muscles. (R. at 447). Dr. Smoke noted that Ms. Garner's diagnostic tests were done elsewhere, and he did not assess her RFC. (R. at 449-53).
iii. Dr. Nagaveni Rao
On October 5, 2011, Dr. Rao examined Ms. Garner for the first time since 2009. (R. at 418). The plaintiff complained of neck pain, low back pain, and left knee pain. (R. at 418). She also had pain radiating to her left upper extremities, headaches, and cracking sounds when she moved her neck. (R. at 418). Dr. Rao noted that Ms. Garner's September 2006 MRI showed a posterior disc bulge on L4-L5 slightly impinging on the thecal sac, and that xrays were negative for abnormalities at that time. (R. at 418). She noted that the plaintiff had not been working for one year but was looking for a job. (R. at 418). Dr. Rao recommended Aleve or Advil for the pain as well as a muscle relaxant. (R. at 418). Dr. Rao also ordered x-rays of the cervical and lumbar spine and an EKG to rule out cardiac pathology. (R. at 422). It is not clear from the record whether the x-rays were taken. (R. at 418).
On October 19, 2011, Ms. Garner had a follow up appointment with Dr. Rao. (R. at 415). Ms. Garner indicated that her neck pain was getting worse and radiating down her left upper extremity. (R. at 415). She also complained that her medication was making her drowsy. (R. at 415). Dr. Rao advised the plaintiff to stop taking Tylenol with Codeine and her muscle relaxer and switch to ...