United States District Court, S.D. New York
MEMORANDUM AND ORDER
JAMES C. FRANCIS, IV, Magistrate Judge.
The plaintiff, Darren Patrick Sickler, brings this action pursuant to section 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking review of a determination of the Commissioner of Social Security (the "Commissioner") finding that he is not entitled to disability insurance benefits. The parties have submitted cross-motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons set forth below, the plaintiff's motion is granted, the Commissioner's decision is reversed, and the case is remanded to the Social Security Administration for further findings with respect to the period for which the plaintiff is entitled to benefits.
A. Personal History
Mr. Sickler was born on April 8, 1960. (R. at 34). The record indicates that he has some college education. (R. at 36). The plaintiff's last job was as a gas line surveyor. (R. at 37-40, 195); prior to working as a surveyor, he was a glass installer (R. at 41, 195). He lost his most recent job in December 2008 when his employer's contract in South Carolina was not renewed. (R. at 40). As of August 8, 2012, Mr. Sickler lived in an apartment in New Rochelle, New York with his girlfriend and daughter. (R. at 33).
B. Medical History
The plaintiff alleges a disability beginning July 1, 2010 (R. at 14), consisting of back and neck pain and numbness in his left leg. (R. at 66, 90). A June 2005 visit to the South Shore Medical Center emergency department and a June 24, 2010, walk-in visit to Conway Medical Center are the only medical reports on record preceding the plaintiff's alleged onset date. (R. at 277, 472-74). The 2005 visit appears to have been precipitated by an attack of gout (R. at 472-73), while the reason for the 2010 walk-in was an abscess on Mr. Sickler's elbow. (R. at 277). Upon examination in 2010, Mr. Sickler was found to have "grossly normal" extremities with intact range of motion and sensation. (R. at 277). He was discharged shortly thereafter with prescriptions for Keflex and Bactrim. (R. at 279).
On August 25, 2010, the plaintiff met with Dr. Elliott Bettman at the Conway Medical Center complaining of neck and back pain. (R. at 293). Mr. Sickler tested "moderately positive" for straight leg raising. (R. at 293). Dr. Bettman scheduled the plaintiff for MRIs of the cervical and lumbar spine and prescribed Ultram. (R. at 293). The plaintiff underwent the prescribed MRI examinations on September 3, 2010. (R. at 283, 285, 295-96). The cervical spine MRI showed "[m]ultilevel multicolumn degenerative changes" and "left uncovertebral osteophyte and disk complex creating highgrade left and mild to moderate right exiting foraminal stenosis." (R. at 284, 298). The most pronounced abnormality appeared at C5-C6 which showed "[h]igh-grade left exiting foraminal stenosis with moderate right." (R. at 283, 284, 298). The lumbar spine MRI revealed a "L4-L5 broad-based bulge with central and left disk protrusion. This contacts both forming L5 nerve rootlets, displacing the one on the left. Facet hypertrophy contributes to right greater than left exiting foraminal stenosis." (R. at 296).
On October 8, 2010, the plaintiff returned to Conway Medical Center for a follow-up. (R. at 290). Dr. Bettman assessed the MRI of the back as "abnormal" and noted Mr. Sickler's continued complaints of pain. (R. at 290). Mr. Sickler was also diagnosed with gout. (R. at 290). He was discharged with prescriptions for Lorcet, Pravachol, and Benemid. (R. at 290).
Three days later, the plaintiff underwent an orthopedic examination with Dr. Regina Roman, D.O. (R. at 303). Mr. Sickler reported "chronic low back pain, which radiates to his left leg, " numbness and tingling, and "shooting pain to his left foot." (R. at 306). He also complained of left shoulder pain that sometimes radiates to his arm and "involuntary movements of the fingers of the left hand." (R. at 307). The plaintiff stated that he was unable to walk more than half a block before having to rest because of his low back and foot pain. (R. at 307). He further admitted needing assistance in getting his socks and shoes on and stated that his "wife" did the cooking, cleaning, and shopping. (R. at 308). During the physical examination, the plaintiff was observed to have a "slow and antalgic" gait during which he favored his left leg, though he did not utilize an assistive device. (R. at 308). Mr. Sickler was able to get on and off the examination table, utilize a logrolling technique to go from supine to seated, and perform a squat to 50 degree knee flexion while holding the examination table. (R. at 308-09). The plaintiff also underwent range of motion testing and exhibited full cervical spine flexion and extension, though he complained of discomfort with right and left rotation. (R. at 309). Lumbar spine flexion was 70 degrees, with increased discomfort with right lateral flexion and forward flexion. (R. at 309). Straight leg testing was negative bilaterally, but positive unilaterally at 40 degrees on the right side and 30 degrees on the left for low back pain. (R. at 309). Mr. Sickler had full range of motion in his fingers and the ability to manipulate small items. (R. at 309). No muscle atrophy was noted, but Mr. Sickler was unable to heel, toe, or tandem walk due to lower back pain. (R. at 309).
On November 2, 2010, Dr. Jim Liao, a Medical Consultant for the Social Security Administration, reviewed the plaintiff's medical files, but did not examine Mr. Sickler personally. (R. at 314). Dr. Liao recorded his findings in a Physical Residual Functional Capacity Assessment. (R. at 314). He concluded that the Mr. Sickler could "[o]ccasionally lift/or carry" 20 pounds, "[f]requently lift and/or carry" ten pounds, and was "unlimited" in his ability to "[p]ush and/or pull". (R. at 315). Dr. Liao also found that Mr. Sickler could stand and/or walk (with normal breaks) for a total of about six hours in an eight hour workday and sit (with normal breaks) for a total of about six hours in an eight hour workday. (R. at 315).
Dr. Liao also found the plaintiff's "[a]lleged chronic back pain and lt pain" to be credible. (R. at 316). The report noted Mr. Sickler's foraminal stenosis and "lt radiculopathy" in the comments section. (R. at 316).
From early February 2011 to April 2011, the plaintiff frequently visited the Family Practice of Kingston, often with the same complaints. On February 11, 2011, the plaintiff sought care for lower back pain and poor circulation in his legs. (R. at 388). Mr. Sickler reported left-side weakness, numbness, tingling, and involuntary movements in both upper and lower extremities. (R. at 390). The supervising physician, Dr. Raymond Harvey, noted Mr. Sickler's antalgic gait, pain while in motion, and lumbar stenosis. (R. at 391). A week later the plaintiff was seen by Dr. Geniene Wilson. (R. at 383). Dr. Wilson scheduled Mr. Sickler for an MRI. (R. at 386). On February 25, 2011, the plaintiff again sought relief for his chronic back pain. (R. at 376). Mr. Sickler's pain medication prescription was renewed and a consultation with a neurosurgeon was scheduled. (R. at 379).
On February 26, 2011, the plaintiff underwent an MRI on his lumbar spine. (R. at 393). The MRI revealed "[s]uperimposed L3-4 and L4-5 disc herniations" with stenosis being most severe at those levels. (R. at 394). It further showed Mr. Sickler's "Cauda Equina is bunched together... at L3-4 and L4-5"; narrowing and signal loss at L1-2, L2-3, and L4-5; and central and/or foraminal stenosis ranging in severity from mild to severe at L1-2, L2-3, L3-4, L4-5, and L5-S1. (R. at 393-94).
On March 15, 2011, the plaintiff saw Dr. Wilson, again reporting back pain and stating that his medication was losing effectiveness. (R. at 371). Mr. Sickler also reported that sometimes his "leg gives out on him". (R. at 373). He was scheduled for a neurology appointment and prescribed Fentanyl patches to help his back pain. (R. at 374). The plaintiff returned two weeks later on March 29, 2011, for his back pain. (R. at 366). During the physical examination, Mr. Sickler tested positive on a bilateral straight leg test. (R. at 369). On April 21, 2011, the plaintiff returned to Dr. Wilson, stating that his back pain "[h]urts [w]orse". (R. at 361). Dr. Wilson diagnosed Mr. Sickler with neuropathy. (R. at 364).
On June 3, 2011, the plaintiff attended a consultation with Dr. Farag Aboelsaad for a possible transforaminal epidural injection. (R. at 342). Mr. Sickler described his pain as being "located in the lower back, more in the left than the right. It is also going down more in the left lower extremity than in the right lower extremity... [with] numbness in the left lower extremity". (R. at 342). Mr. Sickler also stated that his pain increases with activity. (R. at 342). Dr. Aboelsaad noted that the plaintiff displayed a very slow gait, inability to walk on heels or toes, and "sensation diminished in the left lower extremity more than the right to light touch." (R. at 343). A transforaminal epidural steroid injection was scheduled thereafter to help with Mr. Sickler's back pain. (R. at 343).
On June 10, 2011, the plaintiff underwent an MRI of his cervical spine. (R. at 347). It revealed "[s]evere left sided foraminal stenosis from uncovertebral joint hypertrophy at C5-6". (R. at 348).
On June 23, 2011, the plaintiff received his epidural injection. (R. at 338-41, 345-46). Later that day, Mr. Sickler had a follow-up with Dr. Darryl DiRisio to review his recent cervical spine MRI. (R. at 336-37). In a letter addressed to Dr. Wilson, Dr. DiRisio reported that Mr. Sickler was having difficulties with his hands as he was frequently dropping things and was unable button his shirt. (R. at 336). He was also experiencing a fair amount of neck pain. (R. at 336). Dr. DiRisio found Mr. Sickler's intrinsic hand strength to be "okay." (R. at 336). The plaintiff did experience pain while performing a Phalen's type maneuver but had a negative Tinel's sign, coupled with excellent strength in all four extremities and a "perfectly fine" gait. (R. at 336). Dr. DiRisio believed Mr. Sickler's symptoms pointed to Lyme disease as the cause of his pain. (R. at 336-37). Dr. DiRisio's report did not mention Mr. Sickler's recent epidural or how it might have affected Mr. Sickler's pain or range of motion. Lastly, Dr. DiRisio stated that he did not feel "operative conditions exist right now until these other issues are sorted out." (R. at 336-37).
On June 30, 2011, the plaintiff saw Dr. Wilson for a follow-up concerning the results of recent bloodwork. (R. at 349). Mr. Sickler again reported significant back pain and stated that the epidural injection was "not helping much." (R. at 352). Dr. Wilson diagnosed both cervical and lumbrosacral spinal stenosis and recommended that Mr. Sickler see a neurologist to consider neck surgery. (R. at 352).
On February 22, 2012, the plaintiff sought assistance for his back pain at Sound Shore Medical Center in Westchester, New York. (R. at 423). Mr. Sickler was prescribed Fentanyl patches and instructed to follow up regarding his back pain. (R. at 430). On February 27, 2012 the plaintiff saw Dr. Cristian Brotea at the Westchester Spine Institute. (R. at 475). The plaintiff completed a questionnaire in which he indicated constant back pain that was getting worse and noted "legs give out[;] have fallen". (R. at 475). Dr. Brotea's accompanying handwritten notes are illegible. (R. at 477-78).
On March 29, 2012, the plaintiff underwent an MRI on his lumbar spine. (R. at 485). The MRI showed multilevel spinal canal stenosis at levels L1-2 ("mild"), L2-3 ("mild"), L3-4 ("mild to moderate"), and L4-5 ("moderate to marked"). (R. at 486). Mr. Sickler also had a cervical spine MRI on April 3, 2012. (R. at 487). It showed "[n]o significant spinal canal stenosis". (R. at 487).
On July 12, 2012, the plaintiff was seen by Dr. Eric Mariuma, a neurologist. (R. at 481). Dr. Mariuma found that Mr. Sickler's symptoms suggested radiculopathy and noted signs of femoral neuropathy in the left leg with "associated sensory loss and quadriceps weakness". (R. at 483). On August 24, 2012, Dr. Mariuma completed a Residual Functional Capacity Questionnaire on behalf of the plaintiff. (R. at 491). He opined that Mr. Sickler was incapable of walking a full city block without pain and could not sit or stand for more than ten minutes without having to stand up or move. (R. at 491). Dr. Mariuma further indicated that, in an eight-hour workday, Mr. Sickler could sit or stand less than two hours a day, could only walk approximately five to ten minutes at a time, and could only rarely lift less than ten pounds in a work environment. (R. at 491-92). Dr. Mariuma noted that Mr. Sickler was constantly in pain and would miss more than four days of work a month. (R. at 492).
C. Procedural History
On July 29, 2010, Mr. Sickler applied for disability insurance benefits and supplemental security income, and on June 17, 2011, he filed a second application for a period of disability, disability insurance benefits, and supplemental security income. (R. at 14). He alleged that his disability began on December 19, 2008. (R. at 14). The claims were initially denied on September 21, 2011. (R. at 14). The plaintiff submitted a written request for hearing on October 17, 2011. (R. at 14).
The hearing was held by Administrative Law Judge ("ALJ") Katherine Edgell on August 8, 2012. (R. at 29). At the hearing, the plaintiff, who was represented by counsel, amended the disability onset date to July 1, 2010. (R. at 14). Mr. Sickler testified that he drops things, that his legs give out on him, and that he is unable to tie his own shoes because his pain prevents him from bending down long enough. (R. at 45). Mr. Sickler went on to explain that he had moved to New York from South Carolina for financial reasons. (R. at 47). Mr. Sickler stated that he and his family had "pretty much ended up homeless", that he could not receive consistent medical treatment from doctors in South Carolina because he did not have health insurance or the money to pay for his medical treatment out-of-pocket. (R. at 46-47).
When describing a normal day, the plaintiff stated that his wife helps him shower and get dressed, that he spends his days watching TV and sleeping, and when he does leave the house, it takes him about 45 minutes to get down the stairs. (R. at 52-53). During the hearing, Mr. Sickler had a cane with him, which he reportedly uses "all the time"; prior to receiving the cane from his physical therapist, he had been using a walking stick for the previous one and one-half to two years. (R. at 53, 56).
The plaintiff went on to state that he could lift "[m]aybe four pounds, " that he could stand for ten minutes, and that he could sit for ten to fifteen minutes. (R. at 54). Mr. Sickler stated that his leg is weak and constantly numb, enough so that his doctor was able to "put a needle in about six, eight inches long, " without his feeling pain. (R. at 57). As a result of his pain and weakness, Mr. Sickler is unable to do any household chores or go grocery shopping and only gets three to four hours of sleep nightly. (R. at 58, 62). When Mr. Sickler does reach down to get something, it takes "about seven, ten minutes" to get back up again. (R. at 60).
ALJ Edgell issued a decision on October 23, 2012, finding that the plaintiff was not disabled. (R. at 11-22). The Appeals Council denied Mr. Sickler's request for review of the ALJ's decision (R. at 1-6), rendering the ALJ's determination the final decision of the Commissioner.
A. Determination of Disability
A claimant is disabled under the Social Security Act and therefore entitled to disability benefits if he can demonstrate, through medical evidence, that he is unable to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than [twelve] months." 42 U.S.C. § 423(d)(1)(A); see also Hahn v. Astrue, ...