United States District Court, S.D. New York
CAROLINE N. WILLIAMS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
ORDER AND OPINION
RONALD L. ELLIS, Magistrate Judge.
Plaintiff Caroline N. Williams ("Williams") brings this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for supplemental security income and disability insurance benefits. The parties have consented to this matter being decided by a United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). The Commissioner and Williams have moved separately for judgment on the pleadings pursuant to Federal Rules of Civil Procedure 12(c). For the reasons stated below, the Court GRANTS Williams's motion and REMANDS this case for further proceedings.
A. Administrative Proceedings
Williams applied for supplemental security income ("SSI") and disability insurance benefits ("DIB") on July 7, 2010, alleging that she became disabled on August 10, 2009. (Administrative Record ("R.") at 20.) Williams was most recently employed as a security guard at Madison Security Group and had previously worked both as a counselor for disabled children and as an inventory clerk. (R. at 98.)
Following a hearing before an Administrative Law Judge ("ALJ''), Williams's application was denied on April 26, 2012. (R. at 20.) The ALJ found that Williams was not disabled within the meaning of the Social Security Act from August 10, 2009, through the date of the ALJ's decision. ( Id. ) Williams appealed the ALJ's ruling. On June 7, 2013, the Appeals Council denied Williams's application for review. (R. at 1-4.) The Appeals Council found no reason under the rules to review the ALJ's decision, finding that her arguments did not provide a basis for changing the ALJ's decision. ( Id. ) The ALJ's decision thus constitutes the final decision of the Commissioner.
B. Procedural History
On August 2, 2013, Williams filed the instant action seeking review of the ALJ's decision. (Doc. No. 2.) She moved for judgment on the pleadings on March 20, 2014. (Doc. No. 13.) Williams argues that the ALJ's decision is legally erroneous and unsupported by substantial evidence. ( Id. ) On June 19, 2014, the Commissioner responded with a cross-motion for judgment on the pleadings. (Doc. No. 21.) The Commissioner argues that substantial evidence supports the ALJ's decision denying Williams DIB and SSL ( Id. ) Additionally, the Commissioner contends that the ALJ applied the correct legal standard in reaching his decision. ( Id. )
C. The Administrative Record
Williams was born on April 12, 1955. (R. at 97.) She injured her right wrist on August 10, 2009, after a workplace accident where she slipped and fell. (R. at 98.) She had surgery on that wrist on November 12, 2010. (R. at 113.)
1. Medical Records
a. Bronx Lebanon Hospital Center (August 2009 - May 2011)
Following her accident on August 10, 2009, Williams went to Bronx Lebanon Hospital Center ("Bronx Lebanon"), where she complained of right-wrist pain. (R. at 518-22.) An x-ray showed a possible fracture of the wrist. (R. at 523.) Doctors prescribed Motrin and Diovan for pam. (R. at 521.)
On August 24, Williams saw Dr. Sepideh Baghian, who specializes in orthopedic hand surgery. (R. at 523.) She complained of pain in her right wrist, but said there was no numbness or tingling. ( Id. ) Dr. Baghian's evaluation showed that Williams was neurologically intact, but had some tenderness over the ulnar side of her wrist. ( Id. ) Dr. Baghian diagnosed Williams with a right-wrist contusion and placed her in a short-arm cast. ( Id. )
On October 8, Williams saw Dr. Peter Lesniewski, an orthopedic doctor, to remove her cast. (R. at 524.) Williams was neurologically intact and had a good range of motion, but continued to have some tenderness over her right wrist. ( Id. ) MRI results were negative for distal radial joint injuries and a triangular fibrocartilage complex tear. ( Id. ) Dr. Lesniewski recommended that Williams attend physical therapy and wear a wrist splint during the day for support. ( Id. )
On November 10, Williams saw Dr. Baghian for a follow-up appointment. She reported that her pain and symptoms had subsided significantly, but she complained of some pain and limitations in the range of motion of her right wrist. (R. at 526.) Dr. Baghian's evaluation revealed that Williams was neurologically intact, her grip strength was four out of five, and the suspected ulnar fracture had healed. ( Id. ) Dr. Baghian referred Williams to six weeks of occupational therapy so that she could return to work. ( Id. )
Williams saw Dr. Baghian again on December 10. (R. at 527-28.) A progress note indicated that Williams had begun occupational therapy on November 10. (R. at 527.) Dr. Baghian noted that Williams had to complete a minimum of six weeks of occupational therapy before being cleared to return to work. ( Id. )
On December 22, Williams complained to Dr. Baghian that she had developed numbness and tingling in her right hand, especially at night. (R. at 528-30.) Although x-rays showed no abnormalities, Dr. Baghian gave her an injection of kenalogand lidocainein her right wrist. (R. at 528.) She also prescribed anti-inflammatory medication and instructed Williams to wear a thumb splint. (R. at 530.)
On February 2, 2010, Williams complained to Dr. Baghian about occasional pain, but reported significant improvement following the injection and medication prescribed at her last visit. (R. at 531-32.) She had stopped going to occupational therapy before completing the prescribed six weeks because therapy initially exacerbated her symptoms. ( Id. ) Dr. Baghian noted that Williams's symptoms had significantly decreased in intensity and that Williams was wearing her thumb splint as directed. ( Id. ) She advised Williams to return to occupational therapy. ( Id. )
On April 15, Williams returned to Bronx Lebanon to request another referral for occupational therapy because she had completed six weeks of the recommended program. (R. at 533.) On April 26, she told Dr. Baghian that she had returned to occupational therapy, and Dr. Baghian noted that she appeared to be making progress. (R. at 534.)
On June 10, Williams told Dr. Baghian that the occupational therapy had resulted in improvement and she was ready to return to work. (R. at 536.) Dr. Baghian noted that there was minimal tenderness over Williams's right wrist near the base of her thumb, and some grip strength weakness, but that she was neurologically intact. ( Id. ) Dr. Baghian asked Williams to obtain a note from her occupational therapist so that he could clear her to return to work, but there is no record that she was ever cleared to return to work. ( Id. ) In a progress note dated August 19, Dr. Baghian reported that Williams needed to continue therapy in order to return to her pre-injury level of activity, and provided Williams with another referral for occupational therapy. (R. at 435.)
On September 27, Williams complained to Dr. Baghian that she had pain in her right wrist, and requested surgery. (R. at 537-38.) Dr. Baghian reported that he would schedule surgery to relieve the pressure on the tendons. ( Id. )
On November 8, Williams saw Dr. Eric Rosier at Bronx Lebanon Orthopedic Clinic for a preoperative medical evaluation. (R. at 539-41.) On November 10, Dr. Rosier cleared Williams for surgery. (R. at 542-44.) On November 12, Williams had an incision of the tendon sheath to relieve pressure surrounding the tendons on the thumb side of her wrist. (R. at 544-45.) There were no complications from the surgery. ( Id. )
Williams saw Dr. Joshua Auerbach, an orthopedic doctor, on December 6, because of pain in the base of her neck. (R. at 547-48.) An MRI of Williams's spine showed broad-based disc herniation and disc bulges.( Id. ) Dr. Auerbach noted that there was no sign of significant spinal canal stenosis. ( Id. ) He recommended physical therapy and prescribed anti-inflammatory medications. ( Id. )
Williams saw Dr. Auerbach again on April 18, 2011, and complained of neck pain going down towards her left arm. (R. at 569.) She indicated that her symptoms had not improved despite therapy and pain medication. ( Id. ) Dr. Auerbach diagnosed possible cervical radiculopathywith multiple disc herniations. (R. at 569.) For Williams's neck pain symptoms, Dr. Auerbach recommended a cervical epidural steroid injection, which he administered on May 11. (R.at571-72.)
b. Community Medical Care New York (August 2009 - March 2011)
On August 10, 2009, Dr. Ahmed Riaz, a primary care physician, treated Williams at Community Medical Care New York ("Community Medical") for pain in her right-wrist. (R. at 24.) Williams was alert and oriented. ( Id. ) An x-ray of Williams's right wrist revealed a ...