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Martin v. Colvin

United States District Court, W.D. New York

January 26, 2017

RALPH L. MARTIN, JR., Plaintiff,
v.
CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.

          DECISION AND ORDER

          MICHAEL A. TELESCA United States District Judge

         I. Introduction

         Represented by counsel, Ralph L. Martin, Jr. (“plaintiff”) brings this action pursuant to Title XVI of the Social Security Act (“the Act”), seeking review of the final decision of the Commissioner of Social Security (“the Commissioner”) denying his application for supplemental security income (“SSI”). The Court has jurisdiction over this matter pursuant to 42 U.S.C. § 405(g). Presently before the Court are the parties' cross-motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons discussed below, plaintiff's motion is granted to the extent that this matter is remanded to the Commissioner for further administrative proceedings consistent with this Decision and Order.

         II. Procedural History

         The record reveals that in June 2012, plaintiff (d/o/b October 15, 1970) applied for SSI, alleging disability as of June 23, 2011. After his application was denied, plaintiff requested a hearing, which was held before administrative law judge Timothy J. Trost (“the ALJ”) on April 29, 2014. The ALJ issued an unfavorable decision on August 11, 2014. The Appeals Council denied review of that decision and this timely action followed.

         III. Summary of the Evidence

          The medical record reveals that plaintiff sustained a left ankle fracture in June 2011, and subsequently developed problems secondary to a torn right meniscus. A March 19, 2012 MRI of plaintiff's left ankle revealed a healing fracture of the distal fibula, “[v]ery mild tendinopathy and mild tenosynovitis of the Achilles tendon, ” “[m]inimal edema adjacent to the plantar fascia suggesting very mild plantar fascitis, ” “[m]inimal edema adjacent to the lateral margin of the flexor diti minimi muscle, ” and “[s]mall joint effusion.” T. 172. An MRI of plaintiff's right knee taken that same day revealed a “[t]ear of the posterior horn of the medial meniscus extending to the inferior articular surface, ” “[l]inear defects within the articular surface of the patella overlying the apex and medial patellar facet, ” “[m]ild thinning of the articular cartilage in the medial compartment, ” and “[s]mall joint effusion with a moderate-sized Baker's cyst.” T. 174. Plaintiff attended physical therapy as needed throughout the relevant time period. On August 6, 2012, plaintiff's physician Dr. Christopher Ritter opined that plaintiff was totally and temporarily disabled.

         Plaintiff underwent two consulting internal medical examinations at the request of the state agency. The first was performed by Dr. Honbiao Liu on August 31, 2012. On physical examination, Dr. Liu recorded that plaintiff had a normal gait but could not perform heel walking and performed toe walking “with mild difficulty”; squat was 40% of normal; and range of motion (“ROM”) was limited in the right knee and left ankle. Dr. Liu opined that plaintiff had “mild limitation of standing, walking, climbing stairs, bending and kneeling.” T. 181. The second consulting internal medicine exam was performed by Dr. Samuel Balderman on November 15, 2012. On physical examination plaintiff had a “limp favoring the right”; squat was 40% of normal; limited ROM of the left knee and ankle; and limited ROM of the right knee. Dr. Balderman opined that plaintiff had “[m]arked limitation in walking, kneeling, and climbing for three months to allow for recovery from recent knee surgery.” T. 204.

         The record contains mental health treatment notes from February through December 2013, from Shaun Crimmins, LMSW with Mid-Erie Counseling. LMSW Crimmins' treatment notes indicate that plaintiff was diagnosed with mood disorder, not otherwise specified (“NOS”), alcohol dependence, cannabis abuse, and nicotine dependence. Plaintiff had been referred for mental health and substance abuse treatment[1] by the Buffalo COURTS (Court Outreach Unit: Referral and Treatment Services) program, in association with a domestic violence incident in which he “slapped a cigarette out of [his girlfriend's] hand.” T. 289.

         Although LMSW Crimmins' notes did not include results of formal mental status examinations (“MSE”), the notes occasionally noted that plaintiff had a depressed mood but denied suicidal ideation. On May 15, 2013, LMSW Crimmins noted that plaintiff was scheduled for an evaluation with psychiatrist Dr. Sanjay Gupta. On June 17, 2013, plaintiff had apparently been evaluated by Dr. Gupta as he had been prescribed medication for a mental health condition; he reported that he “continued medication compliance but felt that at times, his mind was slowed down.” T. 296. LMSW Crimmins noted that she scheduled plaintiff for another appointment with Dr. Gupta. In July 2013, plaintiff again reported that he “experience[d] sedation due to medication, ” but felt that “his thoughts [had] slowed down and [become] more manageable.” T. 297.

         On September 23, 2013, LMSW Crimmins noted that he “reviewed [plaintiff's] recent psychotropic medication management appointment with Dr. Gupta and [plaintiff] noted that the medication continue[d] to assist with decreasing racing thoughts and helping him to sleep better.” T. 299. On November 11, 2013, plaintiff reported that he was taking Zyprexa (an antipsychotic typically used for treatment of bipolar disorder and schizophrenia), which helped him sleep “but [did] not address racing thoughts during the day.” T. 302. Plaintiff also noted that he had recently seen Dr. Gupta for treatment.

         LMSW Crimmins and Dr. Gupta submitted three letters which are included in the administrative transcript. The first, dated December 24, 2013, indicated that plaintiff was “currently receiving psychiatric treatment” for medication management and counseling relating to a diagnosis of bipolar disorder mixed type. The letter stated that plaintiff “consistently attend[ed] clinic appointments including bi-monthly appointments with Dr. Gupta and appointments with Mr. Crimmins every six weeks.” T. 209. According to the letter, plaintiff “continue[d] to work in treatment to stabilize his mood, to improve symptoms of sleep disturbance and to cope with his adjustment to a decreased physical ability level and being unable to work in his desired profession as well as the financial difficulty that has resulted from his injuries.” Id. Two substantially similar letters were dated February 24, 2014 and April 28, 2014. The latter letter indicated that plaintiff had discontinued taking Zyprexa but was compliant with his new medication regimen prescribing Seroquel, another antipsychotic medication. All three letters gave a phone number for the ALJ to call if any further information and/or medical records were required.

         IV. The ALJ's Decision

         At step one of the five-step sequential analysis, see 20 C.F.R. § 416.920, the ALJ determined that plaintiff had not engaged in substantial gainful activity since June 21, 2012, the application date. At step two, the ALJ found that plaintiff suffered from the following severe impairments: meniscus tear of the right knee, status post arthroscopic surgery, and left ankle fracture. At step three, the ALJ found that plaintiff did not have an impairment or combination of impairments that met or medically equaled a listed impairment. In considering plaintiff's mental impairments, the ALJ found that plaintiff had no restrictions in ...


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