United States District Court, W.D. New York
DECISION AND ORDER
MICHAEL A. TELESCA, District Judge.
Represented by counsel, Abraham Quinones ("Plaintiff") brought this action pursuant to Title II of the Social Security Act ("the Act"), seeking review of the final decision of the Commissioner of Social Security ("the Commissioner") denying his application for Disability Insurance Benefits ("DIB"). The Court has jurisdiction over this matter pursuant to 42 U.S.C. § 405(g).
II. Procedural History
On April 18, 2011, Plaintiff filed a claim for DIB, alleging disability since March 8, 2010, due to low back pain and neurological symptoms in his legs following an accident at work. T.163. After the claim was denied, Plaintiff requested an administrative hearing. T.64; 73-84; 85-87. On May 15, 2012, Plaintiff and his attorney appeared before Administrative Law Judge Michael W. Devlin ("the ALJ") for a hearing in Rochester, New York. See T.41-63. Peter Manzi, a vocational expert, also testified.
On August 3, 2012, the ALJ issued a decision finding that Plaintiff was not disabled under the Act. T.30-36. Plaintiff submitted additional medical records to the Appeals Council, which denied Plaintiff's request for review on September 13, 2012, making the ALJ's decision the final decision of the Commissioner. T.1-5; 24-26.
This timely action followed. Presently before the Court are the parties' cross-motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure.
III. Summary of the Relevant Medical Evidence
A. Records Submitted to the ALJ
On May 10, 2010, Plaintiff reported to Lifetime Health Medical Group with complaints of lower back pain. See T.235-37. Plaintiff told attending physician Dr. Richard Dudrak that he had injured his lower back while he was lifting a heavy item at work on May 8, 2010. Plaintiff previously had back pain, but at the time of the incident, he had a sudden onset of pain radiating down his left leg. Plaintiff had positive straight leg raising test, and Dr. Dudrak assessed left lower back strain. For purposes of Workers' Compensation benefits, Dr. Dudrak stated that Plaintiff could return to his job as a laborer on May 17, 2010, with no restrictions.
On October 4, 2010, Plaintiff saw orthopedic surgeon Andrew Wensel, M.D., complaining of continued back pain following his May 2010 injury. See T.290-91. His symptoms were aggravated by walking, sitting, standing, using the bathroom, bending, and lying down. Physical therapy, chiropractic care, and other treatments had not been helpful. Plaintiff had a positive straight leg raise on the left. Plaintiff's MRI showed the following: degenerative discs at L2-L3 and L4-L5; a herniated disc at L4-L5 completely effacing the lateral aspect of the spinal central canal and the course of the lateral roots; and degenerative spondylosis at multiple levels of the lumbar spine. Dr. Wensel recommended a left L4-L5 discectomy since Plaintiff's symptoms had persisted despite conservative care. Plaintiff underwent surgery with Dr. Wensel on December 8, 2010. T.257.
Plaintiff saw Dr. Wensel in follow-up on December 20, 2010; December 30, 2010; and January 27, 2011. See T.286-88. At that time, Plaintiff was taking ibuprofen for pain. Dr. Wensel stated that Plaintiff "may have the ability to return to work but overall probably has a significant chance of having a reinjury of his back given his lumbar disk problem currently." T.286.
Due to his ongoing pain complaints, Plaintiff sought treatment at the University of Rochester Medical Center's Pain Management Clinic from April 2011, through January 2012, where he saw pain management specialists Drs. Nagendra Upadhyayula and Armando Villareal, as well as Nurse Practitioner Michelle Duggan ("N.P. Duggan"). See T.292-301, 329-38. On April 7, 2011, Plaintiff complained of focal tenderness over the lumbar spine at approximately L1 through L5 into the S1 region. His lumbar spine exhibited a full ROM and straight leg raising tests were negative.
Plaintiff underwent facet injections on April 14, 2011 and May 9, 2011, for his right lumbar facet arthropathy. At his May 25, 2011 visit with Dr. Upadhyayula, Plaintiff reported that on most days following the injections he had no pain. T.295. Dr. Upadhyayula assessed post-laminectomy syndrome, and primary axial pain with radicular features to the anterior aspect of his thigh very intermittently, worse with ambulation. T.295. On June 28, 2011, Plaintiff reported continued improvement with aquatherapy, but complained of increased pain with traditional physical therapy. T.338.
In July 2011, independent medical examiner ("IME") Hossein Hadian, M.D. examined Plaintiff at the request of his Worker's Compensation insurance carrier. See T.306-12. Plaintiff complained of lower back pain radiating to his right leg. He had a near-normal gain, full muscle strength and a full range of motion ("ROM"), and normal reflexes and sensations throughout his arms. Plaintiff's hips and legs had full ROM with no tenderness; his cervical spine had full ROM with no spasms, trigger points, or tenderness; and his lumbar spine exhibit a limited ROM with marked spasms and tenderness. T.309-10. Straight leg raising tests were positive bilaterally. Dr. Hadian assessed lumbar spondylosis without myelopathy and secondary myofascial pain, and lumbar facetogenic pain. Dr. Hadian opined that Plaintiff was temporarily 25% disabled for Worker's Compensation purposes, and that he could return to work that did not require him to lift more than 15 pounds or engage in repetitive movements that would put stress on his lower lumbar spine. T.311.
On June 29, 2011, Plaintiff was treated by N.P. Duggan at the Pain Management Clinic. See T.293. He was progressing in his aquatherapy, but still experienced pain with traditional physical therapy. N.P. Duggan's examination revealed pain on palpation over the surgery scar, pain in the bilateral facet region, pain on the left when ...