United States District Court, N.D. New York
LAWRENCE E. KAHN, District Judge.
Before the Court is an action for judicial review of a final decision of the Commissioner of the Social Security Administration ("SSA") denying Plaintiff Ian Hunter ("Plaintiff") benefits. Dkt. No. 6 at 1-3. Both parties have filed briefs. Dkt. Nos. 12 ("Plaintiff Brief"); 16 ("Defendant Brief"). For the reasons discussed below, the case is remanded to the SSA for reassessment in light of the new medical evidence.
A. Factual History
Plaintiff, who was thirty-two years old at the time of the Commissioner's decision, Dkt. No. 10-2 at 29,  has a history of back and upper extremity impairments and mental conditions, Dkt. No. 1 ("Complaint") at 2. Plaintiff held various jobs before October 15, 2009, the date on which he alleges onset of his disability. Dkt. No. 10-2 at 44-45. Plaintiff testified during the hearing before the Administrative Law Judge ("ALJ") that, since he injured his back in 2005, he has experienced constant pain that worsens with movement. Id. at 44, 55-56. Consequently, Plaintiff maintains that his medical conditions preclude him from engaging in any gainful work. Compl. at 2.
Plaintiff injured his back on November 15, 2005, while working as a welder for Mile High Metal Works in Frederick, Colorado, which required him to do heavy lifting. Dkt. No. 10-8 at 7. He was twenty-nine years old at the time. Id . On the date of the accident, Plaintiff complained of back pain, and was diagnosed by Jeffrey T. Paulsen, F.N.P., with a back strain. Id. at 86-87. He was prescribed Toradol and Percocet. Id. at 87. A week later, Plaintiff was authorized to return to work by Jonathan Fisher, PA-C, with restrictions that he lift, push, or pull no more than ten pounds and not engage in repeated bending, twisting, reaching, or prolonged sitting. Id. at 79.
On December 22, 2005, Plaintiff underwent an MRI exam, which revealed "minimal early degenerative disc dessication involving the L4-5 disc and minimal L4-5 neural foraminal narrowing, but no evidence of spinal stenosis." Dkt. No. 10-8 at 6. The test did not exhibit any evidence of disc protrusion. Id . The MRI also revealed degenerative changes of the thoracic spine "most marked at T7-8 where broad based disc protrusion leads to mild foraminal narrowing." Id . Subsequently, Plaintiff underwent weekly physical therapy at Back To Action Physical Therapy from March 13, 2006, to June 8, 2006, which included mechanical traction therapy, stretching and stabilization exercises, and aqua therapy. Id. at 165-91.
On February 11, 2009, Plaintiff visited Brea Bond, M.D., and reported that his back pain had worsened and was now radiating to his legs with occasional numbness in his hips. Dkt. No. 10-7 at 10. In April 2009, Dr. Bond ordered an MRI, which revealed a "prominent disc bulge at C6-7, with narrowing of the spinal canal." Id. at 22. In addition, "mild left paracentral disc bulge [was] present" at T7-8. Id . In her medical source statement from January 12, 2010, Dr. Bond diagnosed Plaintiff with "[b]ack pain with radiation, [c]ervical disc degeneration, [n]eck pain bilaterally, loss of pinpoint touch to bilateral forearms, and lumbar back pain." Id. at 25. She opined that Plaintiff could occasionally lift up to ten pounds, stand or walk up to two hours per day, and sit less than six hours per day. Id. at 34.
On January 28, 2010, the Division of Disability Determination referred Plaintiff for an orthopedic consultative examination, where Plaintiff showed normal gait and needed no assistance changing for the examination or getting on and off the examination table. Id. at 38-42. Plaintiff's hand and finger dexterity were intact, he had five-out-of-five grip strength bilaterally with no cervical or paracervical pain or spasm upon flexing or extension, full range of motion in his left shoulder and mildly decreased motion in the right shoulder, and no significant deficits in his lower extremities. Id. at 40-41. The examiner, Roberto Rivera, M.D., opined that Plaintiff had no limitations in his ability to sit, stand, or walk; mild to moderate limitations in lifting, carrying, and pushing; and that overhead reaching with his right arm was moderately restricted. Id. at 41-42.
B. Procedural History
Plaintiff filed an application for benefits under Title II and Title XVI of the Social Security Act (the "Act") on October 15, 2009, originally alleging a period of disability beginning December 1, 2008. Dkt. No. 10-2 at 21. After a hearing on May 16, 2011, at which Plaintiff amended the alleged onset date to October 15, 2009, the ALJ denied Plaintiff's application. Id. at 17-20. The Appeals Council denied Plaintiff's request for review on May 11, 2012, rendering the ALJ's decision the final decision of the Commissioner. Dkt. No. 6 at 1-3.
C. The ALJ's Decision
The ALJ found that Plaintiff had not engaged in substantial gainful activity since October 15, 2009, the alleged onset date. Dkt. No. 10-2 at 23. The ALJ determined that Plaintiff had the following severe impairments: back pain, upper extremity pain, mood disorder not otherwise specified, bipolar disorder, post-traumatic stress disorder, and a personality disorder. Id. at 24. After reviewing all of the evidence, the ALJ found that through June 29, 2011, the date of the ALJ's decision, Plaintiff did not have an impairment, or combination of impairments, that met, or medically equaled, an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. Id . The ALJ then considered Plaintiff's credibility, the medical opinions, and other evidence of record, and found that Plaintiff retained the residual functional capacity ("RFC") to perform light work as set forth in 20 C.F.R. §§ 404.1527(b) and 416.927(b), with certain limitations. Id. at 25. Comparing Plaintiff's RFC to his past work, the ALJ found that Plaintiff was unable to perform any past relevant work. Id. at 30. The ALJ then found that considering Plaintiff's age, education, work experience, and RFC, and using ...