United States District Court, W.D. New York
DECISION & ORDER
MARIAN W. PAYSON, Magistrate Judge.
Plaintiff Izella Marie Johnson ("Johnson") brings this action pursuant to Section 205(g) of the Social Security 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 # 17).
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 ## 10, 13). For the reasons set forth below, this Court finds that the decision of the Commissioner is supported by substantial evidence in the record and is in accordance with applicable legal standards. Accordingly, the Commissioner's motion for judgment on the pleadings is granted, and Johnson's motion for judgment on the pleadings is denied.
I. Procedural Background
Johnson protectively filed for SSI and DIB on October 12, 2010, alleging disability beginning on August 1, 2006, due to low back pain and a right ankle injury. (Tr. 162, 166). On December 30, 2010, the Social Security Administration denied Johnson's claims for benefits, finding that she was not disabled. (Tr. 70-71). Johnson requested and was granted a hearing before Administrative Law Judge John P. Costello (the "ALJ"). (Tr. 83-92, 100-05). The ALJ conducted a hearing on January 24, 2012 in Rochester, New York. (Tr. 35-69). Johnson was represented at the hearing by her attorney Jaya Shurtliff, Esq. (Tr. 35, 94-96). In a decision dated March 16, 2012, the ALJ found that Johnson was disabled beginning on December 19, 2011, but was not disabled or entitled to benefits prior to that date. (Tr. 19-30).
On July 26, 2013, the Appeals Council denied Johnson's request for review of the ALJ's decision. (Tr. 1-6). Johnson commenced this action on September 19, 2013 seeking review of the Commissioner's decision. (Docket # 1).
II. Relevant Medical Evidence
A. Treatment Records
1. Strong Memorial Hospital
On April 11, 2005, Johnson was treated in the Emergency Department at Strong Memorial Hospital ("Strong") for complaints of left-side chest pain. (Tr. 334-67). According to the treatment notes, Johnson indicated that she had been experiencing chest pain and dizziness on and off for approximately one month. ( Id. ). Johnson denied any shortness of breath and indicated that the pain usually occurred when she was stressed or upset or after strenuous activity. ( Id. ). Gwy Seo, MD, conducted a bedside examination and assessed a mild cardiac silhouette enlargement. (Tr. 331). The records also indicate that Johnson received a blood transfusion due to heavy menstruation and anemia. (Tr. 334-67).
On February 23, 2007, Johnson returned to Strong's Emergency Department after slipping on ice and falling on her left side. (Tr. 368-409). She also complained of heavy menstruation. ( Id. ). Johnson was again assessed to be anemic and received a blood transfusion. ( Id. ). She complained of left flank and neck pain and was prescribed iron, Flexeril, Vicodin and Motrin. ( Id. ). Images were taken of Johnson's abdomen, pelvis, head, chest, left hip, left humerus and thoracic spine. (Tr. 313-30).
On July 21, 2011, Johnson returned to the Emergency Department complaining of back pain. (Tr. 411-53). She denied any recent injury, but reported suffering from chronic back pain. ( Id. ). According to Johnson, she had been experiencing back pain since she was thirty and was not certain whether an injury or accident had precipitated it. ( Id. ). She also reported that she previously had surgery on her ankle to remove a benign tumor. ( Id. ). Johnson indicated that she had been denied Medicaid, did not have a primary care physician, and treated her pain with Aleve and Tylenol. ( Id. ).
Johnson denied weakness, numbness or paresthesias in her extremities. ( Id. ). Upon examination, she appeared moderately uncomfortable and demonstrated back pain with tenderness and spasm, but no deformity, myalgias, joint swelling or gait problems. ( Id. ). Images were taken of Johnson's lumbar spine, which demonstrated that her sacroiliac joints were symmetrical, her vertebral alignment was normal, and there were no acute fractures. ( Id. ). The images did demonstrate two calcified bodies projecting over the upper pelvis. ( Id. ). The radiologist assessed no acute bone or joint abnormalities of the lumbar spine. ( Id. ). Johnson was given Percocet and Ativan for her pain. ( Id. ). Again, she was assessed to be anemic likely due to a myomatous uterus and was given a transfusion. ( Id. ). Johnson was prescribed iron, Colace and Naproxen. ( Id. ).
2. Westside Health Services
Treatment records indicate that Johnson began treating with Assaf Yosha ("Yosha"), MD, at Westside Health Services on December 21, 2011. (Tr. 455-57). During that appointment, Johnson reported that she had not previously had a primary care physician due to her uninsured status and received treatment through emergency room visits. ( Id. ). She complained of chronic low back pain, which she reported had started in the early-2000's. ( Id. ). Johnson also reported that she had fallen off a motorcycle during the 1970's. ( Id. ). According to Johnson, she used to experience only intermittent pain due to exacerbations, but her pain was now worsening and constant. ( Id. ). She reported that she sometimes used a cane to ambulate, but it was unclear to Yosha whether this was due to back pain or right heel pain. ( Id. ). Johnson reported that she treated her pain with Aleve or Advil and had made an appointment with Unity Spine Center for February 2012. ( Id. ). Johnson indicated that the pain was in her lower back and sometimes radiated to her legs, with occasional left leg paresthesia. ( Id. ).
Johnson also complained of menorrhagia and anemia, explaining that she experienced unusually heavy menstrual cycles and that she had received approximately four blood transfusions. ( Id. ). Johnson reported that her anemia caused her to be fatigued and dizzy and that that she was routinely prescribed iron, but was unable to afford it. ( Id. ). She indicated that previous imaging had demonstrated that she had fibroids. ( Id. ).
Upon examination, Yosha noted a spasm along the lower thoracic and perilumbar regions with no spinal tenderness. ( Id. ). According to Yosha, Johnson demonstrated an antalgic gait because she did not bear weight on her right heel. ( Id. ). Johnson was unable to perform the heel or toe walk due to give-away. ( Id. ). According to Yosha, Johnson's range of motion in her spine was limited due to pain. ( Id. ).
Yosha reviewed images of Johnson's spine, abdomen and pelvis that had been taken in 2007, as well as an additional image of her abdomen taken in July 2011. ( Id. ). Yosha assessed anemia, low back pain and suggested that Johnson be screened for diabetes. ( Id. ). Yosha prescribed Ferrous Sulfate and determined to monitor the fibroids, but noted that a hysterectomy might be necessary. ( Id. ). Yosha prescribed Mobic and Flexeril for her low back pain. ( Id. ).
Johnson returned for an appointment with Yosha on January 11, 2012, complaining of continued back pain. (Tr. 460-61). She reported that she had received a blood transfusion in the Emergency Department in late December 2011. ( Id. ). According to Johnson, she continued to be fatigued and had experienced one episode of chest pain the prior week, but generally had better energy. ( Id. ). She reported that the Flexeril and Mobic were improving her back pain. ( Id. ). She also reported that she had been evaluated by a gynecologist, who had performed an endometrial biopsy. ( Id. ). Johnson indicated that the procedure would have to be repeated and that an ultrasound would be performed to assess her fibroids. ( Id. ).
3. Unity Spine Center
On February 1, 2012, Johnson attended an appointment with Joanne Wu ("Wu"), MD, at the Unity Spine Center. (Tr. 463-66). Johnson reported that she had experienced chronic back pain since a motorcycle accident in the 1970's and that she had an application for disability benefits pending. ( Id. ). Johnson explained that she had been unemployed since 1979 due to her back pain. ( Id. ). Johnson reported that she had primarily received care through emergency room visits due to lack of insurance. ( Id. ). According to Johnson, her pain is a constant, dull, aching pain, but without saddle anesthesia, limb weakness or numbness. ...