United States District Court, Western District of New York
DECISION & ORDER
MARIAN W. PAYSON MAGISTRATE JUDGE
Plaintiff Wanda Jean Wilson ("Wilson") brings this action pro se pursuant to Section 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security (the "Commissioner") denying her applications for Supplemental Security Income and Disability Insurance Benefits ("SSI/DIB"). Pursuant to 28 U.S.C. § 636(c), the parties have consented to the disposition of this case by a United States magistrate judge. (Docket # 16).
Currently before the Court is the government's motion for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. (Docket # 12). For the reasons set forth below, I hereby vacate the decision of the Commissioner and remand this claim for further administrative proceedings consistent with this decision.
I. Procedural Background
Wilson applied for SSI/DIB alleging disability beginning on May 30, 2007, due to degenerative disc disease with radiating hip pain, migraines, blackouts, diabetes, hypoactive thyroid, high blood pressure, tuberculosis, depression, bipolar and homicidal. (Tr. 222-23). On April 13, 2010, the Social Security Administration denied Wilson's claims for benefits, finding that she was not disabled. (Tr. 92-94). Wilson requested and was granted a hearing before Administrative Law Barry E. Ryan (the "ALJ"). (Tr. 123-24, 166-70). The ALJ conducted a hearing on May 12, 2011. (Tr. 65-91). Wilson was represented at the hearing by her attorney, John Bush, Esq. (Tr. 65, 114). In a decision dated June 20, 2011, the ALJ found that Wilson was not disabled and was not entitled to benefits. (Tr. 10-30).
On March 25, 2013, the Appeals Council denied Wilson's request for review of the ALJ's decision. (Tr. 1-4). Wilson commenced this action on April 25, 2013 seeking review of the Commissioner's decision. (Docket # 1).
III. Relevant Medical Evidence
A. Physical Health Treatment Records
1. Family Health Center
Treatment records from Family Health Center, located in Florida, indicate that Wilson received treatment between July 2006 and October 2009. (Tr. 342-95). Wilson was seen by Christine Mackie ("Mackie"), MD, on July 1, 2006 complaining of back pain. (Tr. 394-95). According to Wilson, the pain radiated down the front of her left leg to her knee. (Id.). Upon examination, Mackie observed that Wilson's lumbosacral spine exhibited abnormalities and that there was pain to palpation on the left side. (Id.). Mackie prescribed Lortab, Flexeril and Augmentin, and advised Wilson to return in one week if her symptoms did not improve. (Id.).
In April 2008, Wilson returned to the Family Health Center for treatment and was diagnosed with hypertension, obesity, diabetes mellitus, neurologic disorder, psychiatric disorders and anemia. (Tr. 391). In September 2008, Wilson attended another appointment complaining of pain in her legs and dizziness. (Tr. 378-82). In December 2008, Wilson arrived at the Family Health Center without an appointment complaining of pain in her back and legs. (Tr. 375). Her physician, Ida J. Gagliardi ("Gagliardi"), MD, advised Wilson to return to the emergency room, stating that Wilson appeared "very ill" and to schedule a follow-up appointment. (Id.).
On December 23, 2008, Wilson returned for the follow-up appointment with Gagliardi. (Tr. 371-74). Treatment notes indicate that Wilson had reported to the emergency room after a fall and had undergone a CT of her head and an x-ray of her lumbar spine. (Id.). According to Wilson, she had suffered from a back injury for the last fifteen years. (Id.). The treatment notes indicate degenerative changes in the L5-S1 of Wilson's spine. (Id.). Wilson reported that she was prescribed Lortab in the hospital and had previously taken only Flexeril. (Id.). Upon examination, Gagliardi noted abnormalities in Wilson's lumbosacral spine, especially upon palpation. (Id.). Gagliardi prescribed Ultram for the pain and Soma Compound for muscle relaxation. (Id.). Gagliardi instructed Wilson to exercise as tolerated. (Id.).
On February 4, 2009, Gagliardi administered a Toradol injection to Wilson's right hip. (Tr. 366). Wilson returned for another appointment with Gagliardi on February 24, 2009. (Tr. 368-69). During the appointment, Wilson complained of a lump in her neck. (Id.). Upon examination, Gagliardi noted no abnormalities, but noted some adenopathy and kyphosis. (Id.). On February 17, 2009, an x-ray was taken of Wilson's cervical spine. (Tr. 357, 416). The images demonstrated degenerative changes at C5-6, but no evidence of compression deformity or sublaxation. (Id.).
On March 9, 2009, Wilson attended another appointment with Gagliardi complaining of lower back and leg pain. (Tr. 363-64). Wilson reported that she had fallen two weeks earlier because of weakness in her legs and had struck her right knee during the fall. (Id.). Upon examination, Gagliardi noted that Wilson's lumbosacral spine exhibited abnormalities that extended into both legs. (Id.). She prescribed Gabapentin for the pain and advised Wilson to go to the emergency room if the condition worsened. (Id.).
Approximately one month later, on April 20, 2009, Wilson returned to Gagliardi with continued complaints of back and left leg pain. (Tr. 360-62). Gagliardi administered an injection of Toradol to Wilson's right hip and prescribed Ultram for pain. (Id.).
Wilson returned to Family Health Center complaining of back pain on July 28, 2009. (Tr. 355-56). Wilson was seen by nurse practitioner Nancy Buthman ("Buthman"). (Id.). Wilson reported that she had fallen three times in the last couple of months, complained of "clumsiness" on her left side and of muscle spasms at night, affecting her sleep. (Id.). Buthman noted no abnormalities in Wilson's knees and renewed the prescription for Ultram for pain management. (Id.). Wilson returned for another appointment with Buthman on August 26, 2009, complaining of continued back pain. (Tr. 348-49). Buthman again prescribed Ultram for pain. (Id.). During an October 21, 2009 visit, at Wilson's request, Buthman discontinued Ultram and prescribed Naprosyn and Flexeril for pain management. (Tr. 343-44).
2. St. James Mercy Hospital
Treatment notes indicate that Wilson went to the emergency room at St. James Mercy Hospital on December 28, 2009, complaining of chronic back pain, knee pain, left shoulder pain and migraine headaches. (Tr. 337-39). Wilson reported that she uses a cane to ambulate, had recently relocated from Florida, and did not have a local physician. (Id.). Wilson was given a prescription for Diclofenac and advised to contact Elaine Burritt to establish a primary care provider. (Id.).
3. Spencer P. Annabel, MD and Elaine C. Burritt, NP
Treatment notes indicate that Wilson commenced treatment with Spencer P. Annabel ("Annabel"), MD, and his nurse practitioner, Elaine C. Burritt ("Burritt") on January 11, 2010. (Tr. 324-27). During the first appointment, Wilson explained that she had recently relocated to New York in November 2009, after leaving an abusive relationship in Florida. (Id.). Wilson had been referred to Annabel's care after an emergency room visit on December 28, 2009. (Id.). Wilson reported her medical history, including uncontrolled hypertension, a lumbar disc herniation in 1992, chronic low back pain with muscle spasms since 1992, insulin-dependent diabetes, a pre-2006 history of cocaine use, potential seizure disorder since 2008, bipolar disorder with schizophrenia, tendencies to paranoia, panic attacks with blackouts and post-traumatic stress disorder ("PTSD"). (Id.). Wilson reported that she had been without her medications since leaving Florida in November 2009 and that she was receiving mental health treatment at Steuben County Mental Health. (Id.).
The notes indicate that Wilson had previously reported to the emergency room complaining of chronic headaches, knee pain and shoulder pain. (Id.). Wilson reported that she previously had a disc herniation in her back and had undergone surgery to correct it. (Id.). Despite the surgery, Wilson reported that she continued to experience back spasms, along with pain in her knees and chronic ankle swelling. (Id.). Burritt noted that Wilson walked with a cane, had a broad-based gait and sat "guarded" in her chair with frequent position changes. (Id.).
Burritt formulated a treatment plan for Wilson's hypertension, hyperlipidemia, metabolic syndrome, and diabetes. (Id.). With respect to her back pain, Burritt noted that Wilson described significant muscle spasms and suspected that Wilson suffered from degenerative arthritis in her back. (Id.). Burritt advised Wilson that she did not want to prescribe narcotics or controlled substances to control her pain and instead prescribed Robaxin and suggested Tylenol if needed. (Id.).
On January 13, 2010, an x-ray was taken of Wilson's lumbosacral spine. (Tr. 329). This image did not demonstrate any vertebral compression, destruction or osteopenia. (Id.). The images did reveal chronic degenerative disc disease at L5-S1 with prominent anterior spurs from the inferior end-plate of L5, but no significant disc space narrowing. (Id.).
On January 27, 2010, Wilson attended a follow-up appointment with Burritt. (Tr. 320-23). Wilson reported that she continued to experience chronic pain, but reported some relief in her muscle spasms as a result of the Robaxin. (Id.). Burritt monitored Wilson's diabetes, hypertriglyceridemia and hypertension-related health issues. (Id.). On February 16, 2010, Wilson returned for another appointment with Burritt. (Tr. 316-19). During the appointment, Burritt monitored Wilson's compliance with prescribed treatment for her various medical impairments. (Id.). Wilson reported increasing knee pain and pain in her neck. (Id.). According to Burritt, Wilson appeared uncomfortable and shifted in her chair frequently. (Id.). Wilson complained that she was unable to do much walking due to the continued pain in her legs and back. (Id.). Burritt opined that Wilson's back pain appeared to be arthritic in origin and prescribed a trial of Mobic. (Id.). Burritt stressed, and Wilson agreed, that she needed to avoid using opiates to manage her chronic pain. (Id.).
On May 7, 2010, Wilson attended another appointment with Burritt. (Tr. 548-52). During the appointment, Wilson complained of headaches and back pain. (Id.). Burritt observed that Wilson appeared uncomfortable and shifted in her chair frequently. (Id.). According to Burritt, the symptoms described by Wilson were characteristic of a migraine, and Burritt prescribed Atenolol and Maxal and instructed Wilson to call if she did not improve. (Id.). Treatment notes indicate that Wilson was being treated for tuberculosis by Dr. Picco. (Id.). Wilson informed Burritt that she had been advised to apply for disability based upon her physical and mental impairments, but hoped to be able to train for sedentary employment that would permit her frequent positional changes to accommodate her musculoskeletal disease. (Id.).
Wilson returned for an appointment with Burritt on June 14, 2010. (Tr. 543-47). During the appointment, Wilson complained of ongoing chronic back problems that prevented her from physical activity. (Id.). According to Wilson, she experienced difficulty sleeping due to the pain. (Id.). Burritt noted that Wilson had a long-standing history of degenerative disc disease and chronic back pain. (Id.). Burritt again observed that Wilson appeared to be in pain and that she frequently shifted in her chair. (Id.). Burritt noted that Wilson's back pain might be aggravated by her weight gain. (Id.). Due to medical issues, Burritt discontinued prescriptions for anti-inflammatory medications and advised Wilson to avoid any over-the-counter anti-inflammatories and prescribed Voltaren gel for her back pain. (Id.). At a follow-up appointment on July 27, 2010, Burritt prescribed Ryzolt for Wilson's back pain. (Tr. 538-42).
Wilson's next documented appointment with Burritt occurred on December 17, 2010. (Tr. 606-10). During the appointment, Wilson appeared uncomfortable and used the arm rests on her chair in order to sit and stand. (Id.). Burritt noted that Wilson continued to suffer from chronic back pain and stressed the importance of low back exercises. (Id.). Burritt continued Wilson's prescriptions for Ryzolt and Gabepentin. (Id.).
On February 11, 2011, Wilson returned for an appointment with Burritt. (Tr. 611-15). During the appointment, Wilson reported significantly increased back pain, along with bilateral hip and leg pain. (Id.). Burritt noted that Wilson had a history of back pain after she suffered a back injury at work in 1992. (Id.). According to Burritt, Wilson's last x-ray revealed degenerative disease. (Id.). Burritt suggested that the increased back pain might be weather-related because Wilson suffered from degenerative arthritis in her back; she suggested that Wilson undergo an MRI. (Id.).
4. Pasquale Picco, MD
Treatment records indicate that Wilson was treated for tuberculosis by Pasquale Picco ("Picco"), MD, between January 28, 2010 and June 17, 2010. (Tr. 524-35). Picco prescribed Isoniazid and monitored Wilson's progress. (Id.).
B. Mental Health Treatment Records
1. Lee Mental Health
Wilson received mental health treatment at Lee Mental Health between 2007 and 2009. (Tr. 478-98). On May 23, 2007, Wilson was taken to the hospital after she exhibited strange behavior while working at a convenience store. (Tr. 478-79). Wilson reported that she felt disoriented and started imagining things, such as maggots in her bed, being pregnant and being blind. (Id.). She got down on the floor and barked at customers. (Id.). Wilson reported that she was aware of her odd behavior and eventually requested assistance from police officers. (Id.). At the Ruth Cooper Center, she appeared alert and oriented, and her urine screen was negative for narcotics. (Id.). Wilson reported that she previously had used cocaine, but that she had been sober for eight months. (Id.). She was diagnosed with anxiety disorder, not otherwise specified, rule out panic disorder, cocaine dependence, uncertain remission and assessed a Global Assessment of Functioning ("GAF") of 65. (Id.). Wilson was discharged with instructions to follow-up with Lee Mental Health Center. (Id.).
On August 11, 2008, Wilson was evaluated for treatment at the Lee Mental Health Center. (Tr. 480). Wilson reported that she had recently been discharged from inpatient treatment and that she continued to suffer from excessive worry, aggressive and violent behavior, lapses in memory and paranoia. (Id.). Wilson reported prior cocaine use to alleviate her mental symptoms and that she had been physically and sexually abused as a child. (Id.). Wilson also reported that she experienced command auditory hallucinations. (Id.). According to Wilson, she had conversations with the voices that she heard. (Id.). Wilson also reported that she had "shut down" after the deaths of two of her children and her mother and that she did not talk for a long time. (Id.).
Treatment notes indicate that Wilson was admitted to the Lee Mental Health Center Crisis Stabilization Unit into inpatient treatment between October 9, 2008 and October 12, 2008 for homicidal ideation against her live-in boyfriend. (Tr. 481-84). Upon admission she was diagnosed with adjustment disorder, but at discharge was diagnosed with PTSD and cocaine dependence. (Id.). Wilson reported a history of auditory hallucinations, violent tantrums, mood swings, insomnia, poor concentration and racing thoughts. (Id.). During her stay, Wilson participated in therapeutic activities and reported improved mood. (Id.). Wilson was not placed on psychotropic mediations. (Id.). She was assessed a GAF of 65 and discharged with instructions to follow-up with the Lee Mental Health Center. (Id.).
On October 22, 2008, Wilson attended an appointment with Vinod Bhandari ("Bhandari"), MD, who diagnosed Wilson with bipolar disorder, not otherwise specified, cocaine dependence versus cocaine abuse, in remission, rule out PTSD, and assessed a GAF of 55. (Id.). She was assessed to have a classic history of bipolar disorder of mild to moderate severity. Bahandari prescribed Trileptal. (Id.).
On January 8, 2009, Wilson attended an appointment with Christopher Healey ("Healey"), MD. (Tr. 497-98). Healey opined that Wilson's mental status was normal and that she was in a "very entangled relationship" with an abusive boyfriend. (Id.). Wilson did not have any acute symptoms of psychosis, mania, hypomania or delirium, although she exhibited some depressive symptoms and appeared more irritable than sad. (Id.). Healey assessed a GAF of 55 and recommended that she continue to receive mental health treatment from a consistent provider. (Id.).
Wilson continued to receive mental health treatment at the Center between December 2008 and September 2009. (Tr. 485-96). During treatment, Wilson reported that she had moved and was no longer living with her ex-boyfriend. (Id.). Wilson slept on the couch or floor at friends' houses. (Id.). Wilson also reported that she had begun using a cane to ambulate due to her back pain. (Id.). Wilson was prescribed Prozac and Abilify. (Id.). At one point during the treatment, Wilson reported that she had gotten into a physical altercation with her roommate and that her daughter provided her food. (Id.). During her ...