United States District Court, W.D. New York
MARTHA F. YEOMAS, Plaintiff,
CAROLYN W. COLVIN, COMMISSIONER OF SOCIAL SECURITY, Defendant.
DECISION & ORDER
MARIAN W. PAYSON, Magistrate Judge.
Plaintiff Martha F. Yeomas ("Yeomas") brings this action 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 application for Supplemental Security Income Benefits ("SSI"). 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 # 8).
Currently before the Court are the parties' motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. (Docket ## 9, 10). 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
Yeomas applied for SSI on November 5, 2010, alleging disability beginning on January 1, 2000, due to a lower back injury, arthritis, high blood pressure, diabetes, asthma and chronic obstructive pulmonary disease ("COPD"). (Tr. 156, 160). On March 16, 2011, the Social Security Administration denied Yeomas's claim for benefits, finding that she was not disabled. (Tr. 55). Yeomas requested and was granted a hearing before Administrative Law John P. Costello (the "ALJ"). (Tr. 84, 85-92, 93-97). The ALJ conducted a hearing on February 14, 2012 in Rochester, New York. (Tr. 9-45). In a decision dated March 21, 2012, the ALJ found that Yeomas was not disabled and was not entitled to benefits. (Tr. 65-75).
On April 2, 2013, the Appeals Council denied Yeomas's request for review of the ALJ's decision. (Tr. 3-8). Yeomas commenced this action on May 30, 2013 seeking review of the Commissioner's decision. (Docket # 1).
II. Relevant Medical Evidence
A. Treatment Records
1. Paul K. Maurer, MD
Treatment notes indicate that Yeomas began treating with Paul K. Maurer ("Maurer"), MD, in January 2002. (Tr. 397). According to the notes, on January 1, 2002, Yeomas was admitted to Rochester General Hospital ("RGH") after she visited the Emergency Department complaining of low back pain with radiation and numbness to both of her legs. ( Id. ). According to the notes, Yeomas reported that her symptoms presented after she had a significant coughing spell. ( Id. ). An MRI revealed a herniated disc at L4-5. ( Id. ). Yeomas's symptoms improved and she underwent physical therapy before being discharged. ( Id. ).
Maurer reviewed Yeomas's records and recommended against surgery because she had improved, but advised Yeomas that he would reevaluate if there were any neurological changes. (Tr. 396). On January 23, 2002, Yeomas failed to attend a scheduled appointment with Maurer. ( Id. ). On February 9, 2002, Yeomas was evaluated by Maurer. (Tr. 395). Yeomas demonstrated ongoing symptoms, including a halting and cautious gait and lower extremity pain in both her legs. ( Id. ). Based upon her symptoms, Maurer recommended surgery due to a "fairly dramatic compression of the spinal sac at the L4-5 region." ( Id. ). On March 5, 2002, Maurer performed a bilateral decompressive lumbar laminectomy with discectomy at L4-5. (Tr. 394).
On October 28, 2002, imaging was conducted to evaluate a possible recurrent disc herniation at L4-5. (Tr. 392). According to Margaret H. Ormanoski, DO, the scans demonstrated that there were no vertebral body compression fractures or spine misalignment. ( Id. ). The scans revealed a minimal diffuse disc bulge at L3-4 with a mild mass effect upon the central canal with no neural foraminal narrowing or focal disc protrusion or extrusion. ( Id. ). At L4-5, post-operative changes were observed consistent with Yeomas's previous surgery. ( Id. ). In addition, the images revealed scar tissue around the thecal sac and the L5 nerve roots and a minimal bulging disc, but no evidence of recurrent disc herniation. ( Id. ).
According to Maurer, at L5-S1, there was a diffuse disc bulge and a mild mass effect upon the thecal sac and the S1 nerve root, posterior element degenerative change including ligamentum falvum and facet joint hypertrophy, but no neural foraminal narrowing. (Tr. 393). After reviewing the imaging results, Maurer opined that no significant recurrent disc herniation or stenosis were present and that the images demonstrated expected post-operative changes. (Tr. 391). Based upon those results, Maurer did not recommend surgery. ( Id. ).
Yeomas returned to Maurer in January 2003 with improvement in her lower extremity symptoms, but complaints of pain in her lumbar spine. (Tr. 390). Maurer indicated that Yeomas's symptoms suggested that she was suffering from a mechanical dysfunction, rather than a neural compressive issue. ( Id. ). Maurer indicated that he would be reluctant to recommend surgery and that more conservative options should be explored. ( Id. ). Maurer recommended that Yeomas wear a "Warm-N-Form" back support daily for four weeks. ( Id. ). Maurer discontinued Yeomas's Vicodin prescription and prescribed Darvocet. ( Id. ).
On June 5, 2003, Yeomas attended a follow-up appointment with Maurer. (Tr. 388). Yeomas continued to experience "significant discomfort" due to mechanical back pain. ( Id. ). Given her ongoing discomfort, Maurer considered further surgery, but cautioned that it would not be a "cure all" and that Yeomas might continue to experience discomfort. ( Id. ). Maurer also counseled Yeomas about her use of Vicodin. ( Id. ).
On January 18, 2007, Yeomas had an MRI of her lumbar spine. (Tr. 385). The radiologist opined that the imaging demonstrated mild degenerative disc disease at L4-5 and L5-S1 that had progressed from the prior images. ( Id. ). In addition, he noted surgical changes at L4-5 with posterior decompression of the thecal sac and no central canal stenosis. ( Id. ). A diffuse disc bulge with a small central disc protrusion abutting the bilateral S1 nerve roots was evident at L5-S1. ( Id. ). Additionally, the radiologist noted a mild diffuse disc bulge at T12-L1 that was not present on previous images. ( Id. ). In June 2011 the Social Security Administration requested that Maurer complete a medical questionnaire evaluating Yeomas, but Maurer declined to complete the questionnaire because he had not treated her since 2007. (Tr. 384).
2. RGH Records
Treatment records indicate that Yeomas received treatment at RGH's TWIG clinic beginning in February 2009. (Tr. 263). During that month, Yeomas attended two appointments complaining of low back pain and right shoulder pain. (Tr. 263-64, 299). Yeomas reported that she had previously undergone back surgery with Maurer and had experienced pain in her right shoulder since the surgery. ( Id. ). Treatment notes indicate that the straight leg test Yeomas had was positive on the right and negative on the left. ( Id. ). The notes also indicate that an examination of her shoulder was limited due to her complaints of pain. ( Id. ). Yeomas missed her follow-up appointments in March and April. (Tr. 265-67).
In April 2009, Yeomas returned to the clinic complaining of low back pain. (Tr. 268). The notes indicate that Yeomas requested a refill of her pain medication and that she had failed to obtain an epidural injection. (Tr. 268, 298). In May 2009, Yeomas was advised to follow-up with Maurer for her ongoing back pain. (Tr. 270, 298). In June 2009, Yeomas returned to the clinic with continued complaints of chronic lower back pain, as well as pain in her right toe. (Tr. 271-72). The notes also indicate that Yeomas had been diagnosed with diabetes. (Tr. 271). Yeomas continued to attend medical appointments in July, August, October and December and received ongoing treatment and monitoring of her diabetes. (Tr. 273-79).
In January 2010, Yeomas attended an appointment at the clinic complaining of continued pain in her back and abdomen, requested Vicodin and indicated that she wanted to be placed on disability. (Tr. 280). Yeomas underwent a hysterectomy in June 2010. (Tr. 281-82, 308). On December 3, 2010, Yeomas presented in the RGH Emergency Department with complaints of back pain. (Tr. 330-31). Yeomas reported that she had been experiencing pain for approximately two days and had suffered similar episodes in the past, but had not received recent treatment. ( Id. ). An examination demonstrated pain in Yeomas's lower back with movement, but no decreased range of motion. ( Id. ). Yeomas was given a prescription for Naprosyn and Norco and advised to follow-up with her doctor. ( Id. ).
On January 8, 2011, Yeomas returned to the Emergency Department complaining of low back pain that she had been experiencing for a week. (Tr. 332-33). Yeomas was able to ambulate without difficulty, although she had decreased range of motion in her back. (Tr. 332). On January 19, 2011, the TWIG clinic provided Yeomas with a note stating that she could lift no more than ten pounds and that she needed assistance with her housework. (Tr. 422). On January 26, 2011, Yeomas attended an appointment at the TWIG clinic complaining of back pain. (Tr. 284). Upon examination, Yeomas demonstrated very tender lumbar spine with decreased range of motion. ( Id. ). Yeomas was prescribed Flexeril, Naprosyn and Vicodin and advised that if her symptoms did not improve she would need to follow-up with neurosurgery. (Tr. 285). She was also instructed to resume her medications for diabetes and high blood pressure. ( Id. ). Yeomas was provided a note from Physician's Assistant Stacey Gombetto ("Gombetto") excusing her from work until January 31, 2011, after which she could return to work without limitations. (Tr. 370-71).
On April 12, 2011, Yeomas was referred to Maurer for an assessment of her ongoing back pain. (Tr. 372). On May 13, 2011, Yeomas presented in the RGH Emergency Department complaining of back pain. (Tr. 374, 409-21). Yeomas indicated that her symptoms started after she had carried a "couple loads of laundry" up the stairs. (Tr. 412). Yeomas reported experiencing similar "flare ups" every couple months. ( Id. ). An examination demonstrated back pain with movement. ( Id. ). Yeomas was advised to follow-up with her doctor and to consider physical therapy for her back pain. (Tr. 413). She was prescribed Norco and discharged. (Tr. 374, 414). On June 27, 2011, Yeomas returned to the Emergency Department complaining of difficulty breathing. (Tr. 401-08).
On January 19, 2012, Yeomas slipped and fell on ice. (Tr. 424). Notes indicate that she went to the Emergency Department and received a prescription for Vicodin. ( Id. ). On January 24, 2012, Gombetto provided a note that restricted Yeomas from lifting more than ten pounds for at least eight weeks due to a back injury. (Tr. 423).
3. Genesee Mental Health Center
The record contains treatment notes from Genesee Mental Health Center ("GMHC") beginning in March 2011. (Tr. 431-34). Yeomas reported that she was living in a halfway house and had previously received mental health treatment at Project Restart, where she was currently receiving chemical dependency treatment. ( Id. ). The notes indicate that Yeomas previously received mental health treatment at GMHC. ( Id. ). Yeomas reported symptoms of depression, including sadness, anhedonia, tearfulness, lack of focus and sleep, decreased appetite and frequent nightmares. ( Id. ). According to Yeomas, these symptoms occur during her "sporadic periods of sobriety." ( Id. ). Yeomas reported a history of cocaine and marijuana dependency. ( Id. ). Richard D. Locey ("Locey"), LMSW, diagnosed Yeomas with depressive disorder, not otherwise specified and cocaine dependence, and assessed a Global Assessment of Functioning ("GAF") of 58. ( Id. ). Locey opined that Yeomas would benefit from individual therapy and that her prognosis was good. ( Id. ). Locey recommended that Yeomas undergo a psychiatric evaluation and receive ongoing medication management. ( Id. ).
On March 5, 2012, Yeomas returned for an appointment with Locey. (Tr. 440). Treatment notes indicate that Yeomas continued to maintain her sobriety and was attending GED classes twice a week. ( Id. ). Yeomas reported minimal issues with pain. ( Id. ). On March 19, 2012, Yeomas returned for another appointment with Locey. (Tr. 438). During the appointment, Yeomas reported that she had relapsed and used crack cocaine before her previous visit. ( Id. ). On March 20, 2012, Yeomas attended an appointment for evaluation of her medication. (Tr. 436). Treatment notes indicate that she was prescribed Celexa and Neurontin and that she was making positive progress on that medication. ( Id. ).
B. Medical Opinion Evidence
1. Harbinder Toor, MD
On December 9, 2009, state examiner Harbinder Toor ("Toor"), MD, conducted a consultative internal medicine examination of Yeomas. (Tr. 233-38). Yeomas reported chronic pain in her right shoulder that caused difficulties pushing, pulling, lifting and reaching. ( Id. ). In addition, Yeomas reported lower back pain that was sharp and constant, radiating to her right leg and causing difficulty standing, walking, sitting, bending and lifting. ( Id. ). Yeomas reported that she was sometimes able to cook, clean, do laundry, shower, bathe and dress herself, and that she watches television and reads. ( Id. ).
Upon examination, Toor noted that Yeomas had a slightly abnormal gait with limping towards the right side and demonstrated moderate back pain. ( Id. ). Yeomas declined to perform the heel and toe walk and could squat twenty percent of full. ( Id. ). She used no assistive devices and had difficulty getting on and off the exam table and changing for the exam because of pain in her shoulder. ( Id. ). She was able to rise from her chair without difficulty. ( Id. ).
Toor noted that Yeomas's cervical spine showed full flexion, extension, lateral flexion bilaterally and full rotary movement bilaterally. ( Id. ). Toor identified no scoliosis, kyphosis or abnormality in her thoracic spine. ( Id. ). Toor found that Yeomas's lumbar flexion was limited to twenty degrees, extension zero degrees, lateral flexion thirty degrees, and rotation thirty degrees with pain in the back. ( Id. ). The straight leg raise was positive on both sides at twenty degrees when supine and sitting with pain in the back. ( Id. ). Toor noted pain in her right shoulder with forward elevation to eighty degrees, abduction eighty degrees, and internal and external rotation with pain in the shoulder. Toor found full range of motion in the left shoulder, elbows, forearms and wrists. ( Id. ). He also found full range of motion in the hips, knees and ankles bilaterally, but noted that internal and external rotation of the right hip caused pain. ( Id. ). Toor assessed strength as five out of five in the upper and lower extremities with numbness to light touch in the right leg. ( Id. ). Toor found Yeomas's hand and finger dexterity to be intact and her grip strength to be five out of five bilaterally. ( Id. ). Toor also reviewed an x-ray of Yeomas's lumbosacral spine that indicated a transitional L5 vertebral body, but was otherwise unremarkable. ( Id. ).
Toor diagnosed Yeomas with osteoarthritis in the right shoulder, lumbar disc disease with back pain, balancing problem with numbness in right leg, hypertension, asthma, COPD, depression and diabetes. ( Id. ). He opined that Yeomas had moderate limitations for standing, walking, sitting and lying down and that she had moderate to severe limitations for bending and heavy lifting. ( Id. ). Toor also assessed moderate difficulty pushing, pulling and reaching with her ...