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Mault v. Colvin

United States District Court, W.D. New York

March 24, 2017

DOUGLAS D. MAULT, JR., Plaintiff,


          HON. MICHAEL A. TELESCA, United States District Judge

         I. Introduction

         Represented by counsel, Douglas D. Mault, Jr. (“plaintiff”) brings this action pursuant to Titles II and XVI of the Social Security Act (“the Act”), seeking review of the final decision of the Commissioner of Social Security (“the Commissioner”) denying his applications for disability insurance benefits (“DIB”) and 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 case is remanded to the Commissioner for further administrative proceedings consistent with this Decision and Order.

         II. Procedural History

         The record reveals that in May 2011, plaintiff (d/o/b July 4, 1979) applied for DIB and SSI, alleging disability as of May 18, 2010. After his applications were denied, plaintiff requested a hearing, which was held before administrative law judge Eric L. Glazer (“the ALJ”) on December 6, 2012. The ALJ issued an unfavorable decision on January 14, 2013. The Appeals Council denied review of that decision and this timely action followed.

         III. Summary of the Record

         The record reveals that plaintiff suffered a work-related lower back injury on April 5, 2010. At the time, plaintiff worked as a stock department manager at Walmart, but he was fired from his job on approximately May 18, 2010. The record indicates that plaintiff was fired because he was unable to perform his required job duties subsequent to his injury.[1] Plaintiff treated with Dr. Steven Celotto, a neurologist, in the aftermath of the injury until approximately December 2010. Dr. Celotto consistently noted a 100% disability during his treatment of plaintiff.

         Plaintiff was referred for pain management by his primary treating physician, Dr. Juliette Nwachukwu, and began treating with neurological pain specialist Dr. Eugene Gosy in February 2011. Dr. Gosy consistently noted that plaintiff had an antalgic gait on the left side. In the first few months of his treatment with Dr. Gosy, plaintiff demonstrated mild tenderness at ¶ 5 bilaterally, absent lumbar retroflexion, and anteflexion at 30 degrees. In treatment through April 2012, plaintiff was consistently noted to have negative straight leg raise (“SLR”) tests and full or near-full strength of the upper and lower extremities. Earlier treatment notes indicated that plaintiff struggled with daily activities, while more recent notes stated that he was able to maintain his activities of daily living. Plaintiff did report to Dr. Gosy, however, that his pain levels were exacerbated quickly when he attempted to assist his wife with household tasks.

         Dr. Gosy noted that an EMG study completed December 30, 2010 showed radiculopathy at ¶ 4-L5 and L5-S1. Additionally, an MRI of the lumbar spine performed May 3, 2010 indicated mild bulges without stenosis at ¶ 2-3, L3-4, and L5-S1, as well as a “mild bulge with a slight left lateral component [at L4-5" . . . [with no obvious effacement of the left L4 nerve root” and “mild facet arthropathy” with no stenosis. T. 187. Plaintiff underwent epidural injections for pain, which he reported did not improve his pain. In August 2011, Dr. Gosy noted that after plaintiff received a facet block injection, he “developed spasms for a period of 10 days associated with hypersensitivity.” T. 383.

         Throughout his treatment of plaintiff, Dr. Gosy noted that plaintiff's complaints were consistent with his history of injury and consistent with Dr. Gosy's objective findings. Dr. Gosy consistently rated plaintiff at 66% temporary impairment. Dr. Gosy's most recent treatment note, dated April 26, 2012, stated that plaintiff's “pain patterns remained unchanged, ” his pain was “exacerbated with activity and improved with rest, ” and his “combination of medications [which included narcotic pain medication, muscle relaxant medication, and anticonvulsant medication] [was] helpful in reducing his pain to a level of 2-5/10 with rest.” T. 365. Dr. Gosy noted that plaintiff “ambulate[d] slowly with a mildly antalgic gait with straight cane assist, ” lumbar lordosis was diminished and plaintiff wore a hard plastic lumbar brace, and plaintiff's skin demonstrated “hypersensitivity without any skin changes of the lumbar region.” T. 367.

         Also on April 26, 2012, nurse practitioner (“NP”) Christine Moley, who worked with Dr. Gosy, completed a form indicating that plaintiff had the following work restrictions: he could not stand or walk for longer than 30 minutes at a time; he could not sit for more than 30 minutes at a time; he could not lift greater than 20 pounds; and he was restricted to “[l]ite duty work only.” T. 364. Those same restrictions were also stated in Dr. Gosy's treatment note of the same date, and Dr. Gosy noted that the restrictions would be in effect “indefinitely.” T. 367.

         On July 13, 2011, Dr. Samuel Balderman completed a consulting internal medicine examination at the request of the state agency. Dr. Balderman noted that plaintiff's gait was normal, he appeared to be in no acute distress, he could not walk on heels or toes “due to pain, ” squat was 10% of full, stance was normal, plaintiff used no assistive devices, and he needed no help changing or moving on or off the examination table. On physical examination, Dr. Balderman noted limited range of motion (“ROM”) of the lumbar spine with flexion to 20 degrees and paraspinal tenderness “to extremely light touch, ” but otherwise unremarkable findings. Dr. Gosy opined that plaintiff had “mild limitation in bending and lifting, ” noting that his “MRI report should be reviewed for clinical correlation, ” and finding that plaintiff “show[ed] symptom magnification [i.e., exaggeration of complaints] during [the] evaluation.” T. 315.

         On February 13, 2012, Dr. Patrick Hughes performed an independent medical examination (“IME”) of plaintiff for workers compensation purposes. Dr. Hughes noted normal strength, negative SLR test bilaterally, and hypalgesia (decreased sensitivity to painful stimuli due to interruption of the nerve path) of the left foot to the mid tibia. Dr. Hughes opined that plaintiff had a “moderate 50% partial disability, ” had reached maximum medical improvement (“MMI”) for purposes of workers compensation, and could return to light duty with “[n]o sitting, standing, or walking for more than 30 minutes at a time or lifting more than 20 pounds.” T. 398. Two earlier IMEs, completed in July 2010 and January 2011 by Dr. John Ring and Dr. Melvin Brothman, respectively, found marked temporary or partial disability. Both of these physicians restricted plaintiff to sedentary work on a temporary basis.

         IV. The ALJ's Decision

         Initially, the ALJ found that plaintiff met the insured status requirements of the Social Security Act through December 31, 2015. At step one of the five-step sequential evaluation, see 20 C.F.R. §§ 404.1520, 416.920, the ALJ determined that plaintiff had not engaged in substantial gainful activity since May 18, 2010, the alleged onset date. At step two, the ALJ found that plaintiff suffered from the severe impairments of degenerative disc disease of the lumbar and cervical spines, degenerative changes of the hip, and chronic obstructive pulmonary disorder (“COPD”). 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 the full range of light work as defined in 20 C.F.R. §§ 404.1567(b), 416.967(b). At step four, the ALJ found that plaintiff could perform past relevant work as a manager of a retail store. Accordingly, the ALJ found plaintiff not disabled and did not proceed to step five.

         V. ...

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