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Wagner v. Colvin

United States District Court, W.D. New York

February 27, 2017



          HON. MICHAEL A. TELESCA United States District Judge

         I. Introduction

         Represented by counsel, Roberta Wagner (“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 her application for supplemental security income. 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 for further administrative proceedings consistent with this Decision and Order.

         II. Procedural History

         The record reveals that in October 2012, plaintiff (d/o/b August 27, 1965) applied for SSI, alleging disability as of January 1, 1999. After her application was denied, plaintiff requested a hearing, which was held before administrative law judge Connor O'Brien (“the ALJ”) on June 25, 2014. The ALJ issued an unfavorable decision on November 3, 2014. The Appeals Council denied review of that decision and this timely action followed.

         III. Summary of the Evidence

         The record reveals that plaintiff treated with Dr. Maureen Perry during the relevant time period.[1] Treatment notes indicate that plaintiff was on antidepressant medication as well as medication to control her diabetes. Notes of physical examinations, however, were unremarkable. Plaintiff also attended treatment at Sawgrass Pain Treatment Center (“Sawgrass”), where she received epidural injections approximately every three months. Physical examinations performed by Dr. Christopher Galton at Sawgrass indicated that plaintiff reported tenderness, demonstrated decreased range of motion (“ROM”) of the lumbosacral spine, and occasionally had positive straight leg raise (“SLR”) tests. Plaintiff was prescribed Gabapentin for pain and reported improvement with the epidural injections. Imaging of plaintiff's lumbar spine showed mild degenerative changes without significant central canal or neural foramina narrowing, as well as posterior central disc protrusion at T10-T11 level, causing mild central canal narrowing.

         On April 10, 2013, Dr. Perry completed a medical source statement regarding plaintiff's physical capabilities. Dr. Perry, who noted that plaintiff had been her patient “for many years, ” opined that plaintiff's impairments were severe enough to interfere with the attention and concentration required to perform simple work-related tasks on a frequent basis. According to Dr. Perry, plaintiff could walk one city block without rest or significant pain; could sit 30 minutes at one time and stand 15 minutes at one time, but could not sit, stand, and/or walk at all during an eight-hour workday; she would need a job which permitted shifting positions at will from sitting, standing, or walking; and she would need to take unscheduled breaks from the workday every hour for 10 minutes. Dr. Perry opined that plaintiff could occasionally lift up to 10 pounds, but could never lift anything heavier. Dr. Perry concluded that plaintiff was incapable of working eight hours per day, five days per week on a sustained basis, and she would be absent from work more than four times per month.

         Plaintiff also received mental health treatment at Unity Mental Health during the relevant time period. On mental status examination (“MSE”), plaintiff at times demonstrated preoccupied thought processes or thought processes characterized by guilt or helplessness; anxious, depressed, and irritable mood; and superficial insight. Plaintiff was diagnosed with major depressive disorder, recurrent, of moderate severity, and prescribed Trazodone (a sedative and antidepressant), Wellbutrin (a smoking cessation aid and antidepressant), Lunesta (a sedative), and Abilify (an antipsychotic commonly used to treat schizophrenia, bipolar disorder, and depression).

         In a Disability Determination Explanation which included a mental RFC assessment dated September 17, 2012, state agency reviewing psychologist Dr. L. Blackwell opined that plaintiff was moderately limited in maintaining attention and concentration for extended periods, completing a normal workday and workweek without interruptions from psychologically based symptoms, and performing at a consistent pace without an unreasonable number and length of rest periods. Dr. Blackwell concluded, based on a review of plaintiff's file, that plaintiff had no restrictions in activities of daily living; mild difficulties in maintaining social functioning; and moderate difficulties maintaining concentration, persistence, or pace.

         IV. The ALJ's Decision

         At step one of the five-step sequential evaluation, see 20 C.F.R. § 416.920, the ALJ determined that plaintiff had not engaged in substantial gainful activity since October 17, 2012, the application date. At step two, the ALJ found that plaintiff suffered from the following severe impairments: degenerative disc disease of the lumbar spine; degenerative joint disease of the bilateral hips and knees; diabetes mellitus; vitamin D deficiency; hyperlipidemia; status post fracture of the right foot; depression; and obesity. At step three, the ALJ found that plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of any listed impairment.

         Before proceeding to step four, the ALJ determined that, considering all of plaintiff's impairments, plaintiff retained the RFC to perform sedentary work as defined in 20 C.F.R. § 416.967(a), except that she could not climb a rope, ladder, or scaffolding; could not balance on narrow, slippery, or moving surfaces; could occasionally stoop, crouch, climb stairs, kneel, and crawl; could tolerate up to occasional exposure to extreme cold, extreme heat, wetness, humidity, and occasional exposure to concentrated airborne irritants; could “focus on work tasks for 2 hour periods, but required up to three, short, unscheduled, less-than-5-minute breaks in addition to the regularly scheduled daily breaks”; and could work to meet daily goals, but not maintain an hourly, machine-driven, assembly line production rate.

         At step four, the ALJ found that plaintiff could not perform any past relevant work. At step five, the ALJ found that considering plaintiff's age, education, work experience, and RFC, jobs existed in the national economy which plaintiff ...

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