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Mitchell v. Colvin

United States District Court, W.D. New York

July 27, 2017

NICOLE CECELIA MITCHELL, Plaintiff,
v.
CAROLYN W. COLVIN, [1] COMMISSIONER OF SOCIAL SECURITY, Defendant.

          PRELIMINARY STATEMENT

          MARIAN W. PAYSON United States Magistrate Judge

         Plaintiff Nicole Cecelia Mitchell (“Mitchell”) brings this action pursuant to Section 205(g) of the Social Security Act (the “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 # 7).

         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 ## 16, 18). For the reasons set forth below, this Court finds that the decision of the Commissioner is supported by substantial evidence in the record and complies with applicable legal standards. Accordingly, the Commissioner's motion for judgment on the pleadings is granted, and Mitchell's motion for judgment on the pleadings is denied.

         BACKGROUND

         I. Procedural Background

         Mitchell protectively filed for SSI/DIB on November 6, 2012, alleging disability beginning on December 29, 2011, as a result of a left knee injury, anxiety, depression, high blood pressure, and a left shoulder injury. (Tr. 213, 218).[2] On December 27, 2012, the Social Security Administration denied both of Mitchell's claims for benefits, finding that she was not disabled.[3] (Tr. 84-85). Mitchell requested and was granted a hearing before Administrative Law Judge Michael W. Devlin (the “ALJ”). (Tr. 125-26, 136-40). The ALJ conducted a hearing on April 30, 2014. (Tr. 40-63). Mitchell was represented at the hearing by her attorney, Mark J. Palmiere, Esq. (Tr. 40, 123). In a decision dated July 3, 2014, the ALJ found that Mitchell was not disabled and was not entitled to benefits. (Tr. 15-39).

         On October 21, 2015, the Appeals Council denied Mitchell's request for review of the ALJ's decision. (Tr. 1-5). Mitchell commenced this action on December 8, 2015, seeking review of the Commissioner's decision. (Docket # 1).

         II. Relevant Medical Evidence

         A. Treatment Records

         1. Brown Square Center

         Treatment notes indicate that Mitchell received primary care treatment from Terri Michele Ragin (“Ragin”), PA, and Colleen T. Fogarty (“Fogarty”), MD, at Brown Square Center. In June 2009, Fogarty ordered images of Mitchell's right and left knee due to ongoing pain. (Tr. 475-77). The images demonstrated medial compartment osteophytic spurring in the left knee and early degenerative changes in the medial compartment with tiny spurring in the right knee. (Id.).

         During an appointment with Ragin on January 28, 2010, Mitchell indicated that Zolpidem, prescribed to manage her depression and anxiety, was not effective, and she requested a trial of Ambien CR. (Tr. 303-05). Ragin agreed to prescribe Ambien, but noted that a depression and anxiety screen would be conducted during the next visit. (Id.).

         On July 14, 2010, Mitchell met with Ragin, who assessed several conditions, including diabetes mellitus, hypertension, and hyperlipidemia. (Tr. 300-02). During the appointment, Mitchell complained of ongoing knee pain and anxiety. (Id.). She indicated that her left knee was sometimes swollen and that her pain was worse with activity and standing. (Id.). She reported having been treated by an orthopedist the previous year, who had recommended physical therapy and a knee brace. (Id.). She requested a referral to a sports medicine specialist. (Id.). Regarding her anxiety, Mitchell described feeling stressed and worried. (Id.). She reportedly did not find the Ambien effective and had tried Paxil in the past without relief. (Id.). She reported previous relief using Xanax. (Id.). She requested a referral for mental health treatment. (Id.).

         Ragin noted tenderness to palpation in the lateral anterior joint of the left knee and crepitus, although range of motion was intact. (Id.). She noted that imaging from the previous year had demonstrated mild degenerative changes. (Id.). She assessed osteoarthritis and instructed Mitchell to continue taking Naprosyn and Ultraset. (Id.). She also referred Mitchell to a sports medicine specialist for evaluation of the knee pain. (Id.). With respect to Mitchell's anxiety, Ragin discontinued Ambien and prescribed Zolpidem and a short course of Xanax. (Id.). She referred Mitchell to a mental health provider. (Id.).

         Mitchell returned on October 20, 2010, for an appointment with Ragin. (Tr. 292-94). Mitchell complained of increasing depression, frustration, and stress. (Id.). She reported experiencing periods of panic characterized by shortness of breath and chest pressure. (Id.). Although Mitchell had begun treatment at Unity, she reported that she would not be able to see a psychiatrist for approximately two months. (Id.). She cried during the appointment and appeared agitated. (Id.). Ragin prescribed Xanax and Zoloft. (Id.).

         On January 18, 2011, Mitchell returned for an appointment with Ragin. (Tr. 285-87). Mitchell complained of sleep disturbance and an anxious mood. (Id.). She reported that she had missed some appointments with her counselor and had not yet been evaluated by a psychiatrist. (Id.). According to Mitchell, her therapist had recommended group therapy, but Mitchell was not inclined to participate. (Id.). Ragin refilled Mitchell's prescription for Xanax and Zoloft and advised her to remain compliant with the treatment plan recommended by her mental health provider. (Id.).

         During an appointment with Fogarty on May 19, 2011, Mitchell reported abusing prescription medication, including Percocet and Ambien, due to back pain. (Tr. 273-75). Mitchell indicated that she had attempted mental health treatment, which was not helpful because group therapy had been recommended. (Id.). Mitchell returned the following week for a follow-up appointment with Fogarty. (Tr. 271-72). During the appointment, she presented as irritable and impatient. (Id.). Mitchell was advised to follow up regarding her anxiety in approximately one month. (Id.).

         Treatment notes dated October 7, 2011, indicate that an intern from Unity Mental Health contacted Fogarty's office to express concern regarding Mitchell's increased anxiety attacks and depression. (Tr. 268-69). The intern noted that Mitchell would not be evaluated by a psychiatrist until the end of November and would need medication in the meantime. (Id.). During an appointment that day with Fogarty, Mitchell reported feeling tired and agitated and that Paxil was not alleviating her symptoms. (Id.). Mitchell indicated that she was not aware that she was supposed to have increased her dosage and stated that she stopped taking the medication. (Id.). She reported feeling sad, agitated, irritable, and tired, and that she was no longer taking any mental health medication. (Id.). Fogarty discontinued Zoloft, instructed Mitchell to continue taking Paxil, and prescribed Xanax as needed. (Id.).

         Mitchell returned for an appointment with Ragin on October 19, 2011. (Tr. 352-53). She complained of severe left knee pain and reported that she had visited a walk-in clinic over the weekend due to the pain. (Id.). According to Mitchell, images were taken, but she was not informed of the results. (Id.). Additionally, she was given a prescription for Naproxen. (Id.). She complained that her knee felt as though it was “cracking” and frequently gave out. (Id.). According to Mitchell, she walked a lot for her job, which exacerbated her pain. (Id.). She reported that she had previously participated in physical therapy and had not seen her orthopedist in approximately one year. (Id.).

         Upon examination, Ragin noted mild swelling, crepitus, and clicking in the left knee. (Id.). She noted that Mitchell walked with a limp, but was able to bear weight. (Id.). She reviewed the images taken over the weekend and noted that they demonstrated mild arthritis. (Id.). She recommended that Mitchell use a knee brace and continue to take Naprosyn and Tramadol. (Id.). She referred Mitchell for an MRI to assess for soft tissue damage and to an orthopedist. (Id.).

         Mitchell returned for an appointment with Fogarty on October 26, 2011. (Tr. 350-51). Mitchell continued to suffer from left knee pain and requested a refill for Xanax. (Id.). Fogarty noted that the knee brace that had been prescribed was not covered by Mitchell's insurance and that Mitchell continued to work, despite the fact that Ragin had written a note to excuse her from work. (Id.). Upon examination of the knee, Fogarty noted mild inflammation, full range of motion with pain, mild crepitus, and tenderness to palpation. (Id.). She recommended that Mitchell continue to take Naprosyn and Tramadol while she awaited an MRI and an orthopedic evaluation. (Id.).

         On November 10, 2011, Mitchell attended an appointment with Ragin to review her MRI results. (Tr. 348-49). Mitchell reported that she was scheduled to see an orthopedist at the end of the month. (Id.). She indicated that despite her continued use of medication, she was still in significant pain. (Id.). The MRI of her left knee demonstrated a tear of the anterior horn of the lateral meniscus and a tear of the inner margin of body of medial meniscus. (Id.). It also revealed abnormal signal intensity involving the anterior cruciate ligament due to either degeneration or a sprain, osteoarthritis, moderate size effusion, and a small Baker's cyst. (Id.). Ragin assessed a torn meniscus and indicated that Mitchell might need surgery to correct it. (Id.). Mitchell indicated that the standing and walking requirements of her job exacerbated her pain. (Id.). Ragin advised her to contact her human resources department to determine whether she was eligible for leave. (Id.). Ragin prescribed Amitriptyline to manage pain and ameliorate anxiety and sleep issues. (Id.).

         Mitchell attended another appointment with Fogarty on January 12, 2012. (Tr. 346-47). During the appointment she complained of ongoing knee pain, reported that she had been scheduled for knee surgery, and requested pain medication and that Fogarty complete a disability form. (Id.). Fogarty advised her that she would need to consult with her orthopedist who was providing post-operative care. (Id.).

         On June 14, 2012, Mitchell returned for an appointment with Ragin. (Tr. 342-43). She reported that she had had surgery on her left knee in February 2012 and had participated in physical therapy for a time. (Id.). Her orthopedist had scheduled another MRI and had indicated that she might need another surgery. (Id.). She also reported an upcoming appointment at the pain clinic. (Id.). According to Mitchell, her knee pain was worse at the end of the day, despite taking Naprosyn, Ibuprofen, and Tramadol. (Id.). Upon examination, Ragin noted mild swelling and painful range of motion. (Id.). Ragin prescribed Vicodin as needed for severe pain and advised her to follow up with her orthopedist. (Id.).

         An MRI conducted on June 18, 2012, revealed a mucoid degeneration of the ACL, post-operative changes with no definite re-tear, tricompartmental mild chondral wear, a small joint effusion, and a small neck of a Baker's cyst. (Tr. 378-79). On June 28, 2012, Mitchell attended an appointment with Fogarty. (Tr. 340-41). She complained of right knee pain, perhaps as a result of her inability to bear weight on her left knee. (Id.). She also reported that she was not working and was experiencing increased stress. (Id.).

         On February 6, 2013, Mitchell attended an appointment with Ragin. (Tr. 334-35). Ragin assessed Mitchell's depression as moderate. (Id.). She also reported ongoing pain in her left knee. (Id.). By letter dated February 12, 2013, Ragin declined to complete a medical questionnaire in connection with Mitchell's claim for benefits, instead requesting that Mitchell “have an independent medical examination to determine the degree of disability.” (Tr. 383).

         2.University of Rochester Orthopaedics

         On October 29, 2009, Mitchell attended an appointment with Dr. DeHaven (“DeHaven”) with the Orthopaedics Department of the University of Rochester Medical Center complaining of ongoing knee pain for the previous six months. (Tr. 478-79). Mitchell reported pain and cracking that had increased in intensity over the previous two months, which was aggravated by weight bearing and activity. (Id.). She reported that she had attempted physical therapy and NSAIDs for the previous eight weeks without relief. (Id.).

         Upon examination, DeHaven noted moderate effusions bilaterally on Mitchell's knees with decreased range of motion. (Id.). Mitchell demonstrated palpable pain on the medial joint lines and some mild pain on the lateral joint line, with greater pain on the right side. (Id.). Mitchell also complained of patellar crepitus, pain with patellar movement, and lateral patellar subluxation. (Id.). The Lacman, posterior drawer and circumduction tests were all negative, and her sensation was intact. (Id.).

         DeHaven recommended against corticosteroid injections given Mitchell's relatively young age and recent x-rays that did not reveal significant osteoarthritis. (Id.). DeHaven recommended that she continue to take Naproxen and return in one week for imaging. (Id.). Imaging conducted on November 6, 2009, demonstrated no significant changes in the right knee and a small central osteophyte on the left knee, without joint effusion or substantial joint space narrowing. (Tr. 480).

         On November 17, 2011, Mitchell attended an appointment with Gregg Nicandri (“Nicandri”), MD, and Lindsey Caldwell, a medical resident. (Tr. 397-98). Mitchell complained of ongoing left knee pain that had worsened since she had been treated in 2009. (Id.). Mitchell reported difficulty ambulating and was concerned about her ability to return to work. (Id.). She requested a further evaluation following an MRI ordered by her primary care physician. (Id.). Mitchell reported some swelling and occasional popping and locking in her knee. (Id.).

         Upon examination, Mitchell was able to ambulate without assistance, and her lower right extremity demonstrated full range of motion with minimal tenderness. (Id.). Mitchell's left knee had moderate effusion with pain on patellar grind and palpation of the medial and lateral aspects of the patella. (Id.). Mitchell demonstrated pain and crepitus on range of motion of her left knee, although she did demonstrate full range of motion. (Id.). Her MRI revealed diffuse degenerative changes throughout the knee, including the lateral meniscus, the ACL and the chondromalacia of the patella, and joint effusion. (Id.). A cortisone injection was administered at that time, along with a prescription for physical therapy. (Id.).

         Mitchell returned for an appointment with Nicandri and another medical resident on December 29, 2011. (Tr. 399-400). Mitchell reported that the injection had provided relief for approximately two weeks and that physical therapy was not alleviating her pain. (Id.). She wanted to discuss surgical options. (Id.). A physical examination revealed an obvious effusion of the left knee and, although she retained range of motion, her gait was hindered by a limp. (Id.). Nicandri recommended arthroscopic left knee surgery to address the lateral meniscus and the patellar cartilage. (Id.). He prescribed Vicodin to manage Mitchell's pain until surgery. (Id.).

         Nicandri performed surgery on Mitchell's left knee on February 13, 2012. (Tr. 401-03). Following surgery, Nicandri recommended that Mitchell remain non-weight bearing for approximately six weeks and start a rehabilitation program to increase her range of motion. (Id.).

         On February 15, 2012, Mitchell attended an unscheduled appointment with Nicandri because her surgical site was bleeding. (Tr. 404). Upon examination, Nicandri noted that her surgical incision was well-healed with no active bleeding. (Id.). He assessed appropriate post-surgical discharge and instructed her to continue with post-operative exercises and to begin physical therapy as instructed. (Id.).

         Mitchell returned on February 22, 2012, for her scheduled post-operative appointment. (Tr. 405). She complained of pain and, upon examination, demonstrated full extension and flexion to 95 degrees. (Id.). She was instructed to continue physical therapy to improve her range of motion and to follow up in approximately one month. (Id.).

         On March 15, 2012, Mitchell returned for a follow-up appointment with Nicandri. (Tr. 406-07). Mitchell complained of continued pain, although she demonstrated “excellent range of motion, ” with full extension and flexion to 130 degrees. (Id.). Mitchell reported that she continued to maintain her non-weight bearing status, although she admitted to placing weight on her left leg occasionally at home. (Id.). Nicandri noted significant tenderness to palpation, although Mitchell was neurovascularly intact. (Id.). Nicandri recommended that she continue to avoid bearing weight on her left leg for two more weeks and continue her range of motion exercises. (Id.). He also prescribed a brace and advised her to follow up in two to three weeks. (Id.).

         Approximately two weeks later, Mitchell returned for an appointment with Nicandri. (Tr. 410-11). Despite instructions to remain non-weight bearing, Mitchell reported she had not been compliant. (Id.). Mitchell continued to suffer significant pain and was still taking narcotic pain medication. (Id.). Upon examination, Nicandri noted a knee effusion and tenderness to palpation with good range of motion. (Id.). He noted that she had been compliant with physical therapy and offered a cortisone injection to relieve the pain and inflammation in her knee. (Id.). The injection was administered without complication, and Nicandri advised Mitchell to continue using the knee brace. (Id.).

         A note dated October 12, 2012, indicated that Mitchell's next appointment with Nicandri was rescheduled for January 31, 2013, so that her progress could be better evaluated after treatment at the URMC Sawgrass Pain Clinic. (Tr. 564). On January 3, 2013, Wenjing Zeng authored a note on behalf of Nicandri. (Tr. 393). The note indicated that Mitchell would be undergoing a series of injections and would be unable to work for at least five weeks, after which she would be reevaluated. (Id.). On January 31, 2013, Nicandri apparently completed a form indicating that Mitchell was not able to return to work, had not yet reached maximum improvement, and would be reevaluated on April 18, 2013. (Tr. 394-95).

         On September 12, 2013, Mitchell attended an appointment with Taylor Buckley (“Buckley”), MD. (Tr. 412). During the appointment, Mitchell reported that she had been attending appointments at the pain management clinic, but was frustrated by the clinic's willingness to prescribe opioid medications. (Id.). She also reported continued physical therapy with minimal progress. (Id.). Buckley noted that Mitchell previously had surgery on her knee, as well as corticosteroid and Hyalgan injections. (Id.). Upon examination, Buckley noted tenderness to palpation, and pain and crepitus with range of motion. (Id.). Buckley did not recommend any new intervention, but instructed Mitchell to continue with pain management treatment and physical therapy. (Id.).

         3. Sawgrass Pain Treatment Center

         On June 19, 2012, Mitchell attended an appointment with Joel L. Kent (“Kent”), MD, at the Sawgrass Pain Treatment Center. (Tr. 252-54). Mitchell reported that she had undergone a left knee arthroscopy in February 2012 and that her pain had been worsening since then. (Id.). According to Mitchell, she experienced pain while resting, which was aggravated by activity, including climbing stairs, bending, and adjusting positions during sleep. (Id.). Mitchell reported that she could alleviate her pain by lying down, taking medications, or applying heat or a TENS unit. (Id.). She described her pain as sharp, with numbness and tingling sensations. (Id.). She reported swelling, redness, and clicking of the left knee with increased activity. (Id.). ...


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