Chaparro v. Colvin
| Decision Date | 19 January 2016 |
| Docket Number | 15 Civ. 2349 (AJP) |
| Citation | 156 F.Supp.3d 517 |
| Parties | Rolando Chaparro, Plaintiff, v. Carolyn W. Colvin, Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Southern District of New York |
Charles E. Binder, Binder and Binder P.C., New York, NY, for Plaintiff.
Shane Patrick Cargo, U.S. Attorney Office, John E. Gura, Jr., New York, NY, for Defendant.
ANDREW J. PECK
, United States Magistrate Judge:
Plaintiff Rolando Chaparro, represented by counsel (Binder & Binder), brings this action pursuant to § 205(g) of the Social Security Act, 42 U.S.C. § 405(g)
, challenging the final decision of the Commissioner of Social Security (the “Commissioner”) denying him Social Security disability insurance benefits (“DIB”). (Dkt. No. 1: Compl.) Presently before the Court are the parties' cross-motions for judgment on the pleadings pursuant to Fed.R.Civ.P. 12(c). (Dkt. No. 15: Chaparro Notice of Mot.; Dkt. No. 20: Comm'r Notice of Mot.) The parties have consented to decision of the case by a United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). (Dkt. No. 19.)
For the reasons set forth below, the Commissioner's motion (Dkt. No. 20) is DENIED, Chaparro's motion (Dkt. No. 15) is GRANTED, and the case is remanded to the Commissioner for further proceedings.
Chaparro applied for DIB alleging disability since January 1, 2009, which he later amended to February 24, 2010. .) Chaparro alleged disability due to lower back pain, neck pain, left shoulder pain, severe headaches, depression, anxiety and panic attacks. (R. 436.) After the Commissioner denied Chaparro's application on initial review (R. 356–61), Chaparro requested a hearing (R. 362–63). On March 12, 2013, Chaparro appeared before Administrative Law Judge (“ALJ”) Katherine Edgell. (R. 291–318.) On June 26, 2013, ALJ Edgell denied Chaparro's application, finding that Chaparro could perform sedentary work as long as he was limited to bending and squatting occasionally and performing only simple tasks. (R. 273–85.) On August 6, 2013, Chaparro requested Appeals Council review. (R. 270.) On February 4, 2015, the Appeals Council denied Chaparro's request for review. (R. 1–4.)
Chaparro, born in 1974, was thirty-five at the alleged onset of his disability. (R. 296.) He has a ninth grade education and previously worked as a porter. (R. 298–99.) Chaparro stopped working because of a lower back injury at work in 2008. (R. 300.) Since then, he has been unable to work because of his depression, lower back pain, neck and shoulder pain and constant headaches. (Id. ) Chaparro weighed 185 pounds at his hearing, down from 340 pounds prior to gastric surgery. (R. 296–97.) Chaparro testified that weight loss did not improve his back pain (R. 305), and described experiencing persistent depression and “high anxiety attacks” (R. 304–05). Chaparro testified that he had difficulty concentrating (R. 316), suffers from headaches every morning, and this pain is aggravated by walking or turning his neck (R. 314–15).
About a year prior to his hearing, Chaparro took the GED exam but failed, which he attributed to memory problems and difficulty concentrating. (R. 299.) Chaparro lived with his wife and children. (R. 306, 449–50.) On a typical day, he tried to assist his wife with household chores, but he could not lift much and his wife did most of the cooking and cleaning. (R. 306, 308.) Chaparro had no difficulty with personal hygiene, helped prepare meals, and drove and shopped, although his wife and children carried the groceries when they went shopping. (R. 308, 450–53.) Chaparro spent most of his days in the house and he would nap during the day. (R. 307, 309.) He could walk about two blocks before needing to sit down for half an hour. (R. 309.) He could sit for fifteen to thirty minutes (id. ), and occasionally could lift his daughter, who weighed twenty pounds, but “[n]ot for a very long time” (R. 307). Chaparro reported that he could follow spoken but not written instructions, cannot stay focused, forgets what he needs to do, and has short term memory loss
. (R. 456–57.)
On March 12, 2009, Chaparro received a neurological evaluation from Dr. David Steiner for workers' compensation purposes. (R. 556–60.) Chaparro appeared alert and fully oriented, with full strength throughout his extremities. (R. 557–58.) Chaparro's general and neurological examination results were unremarkable, including normal motor strength, intact sensation, the ability to walk independently and a full range of motion in his cervical spine and extremities. (R. 557–59.) Chaparro's musculoskeletal examination
results showed tenderness to palpation, guarding and loss of lumbar lordosis1 in Chaparro's lumbosacral2 spine, but unremarkable results in his cervical spine, shoulder and elbows. (R. 559.) Dr. Steiner diagnosed Chaparro with lumbosacral radiculopathy3 and lumbosacral sprain /strain. (R. 556, 560.) Dr. Steiner opined that Chaparro should avoid heavy lifting and should perform home exercises. (R. 560.)
On August 4, 2009, orthopedic surgeon Dr. Arnold Wilson evaluated Chaparro for lower back pain from an April 2008 work injury. (R. 573.) Chaparro reported that he had been injured on the job in 2008, and had been unsuccessfully treated with medications and physical therapy. (Id. ) Examination revealed moderate paravertebral muscle tenderness in Chaparro's lumbar spine. (Id. ) Dr. Wilson reviewed a lumbar spine MRI
for Chaparro, which revealed a disc bulge at L5–S1. (Id. ) Dr. Wilson diagnosed Chaparro with a work related lower back sprain /strain. (Id. ) Physical therapy and medication were continued. (Id. )
On January 27, 2010, Chaparro returned to Dr. Wilson for follow-up. (R. 578.) Dr. Wilson noted that Chaparro remained “symptomatic, out of work, and participating in physical therapy three times a week.” (Id. ) Examination revealed a decreased range of motion and tenderness to palpation in Chaparro's lumbar spine, a positive straight leg raising test on the right and radicular4 pain throughout the right lower extremity. (R.578.) Dr. Wilson diagnosed lumbar radiculitis5
with disc bulging at L5–S1 and requested authorization for a lumbar disc brace for Chaparro. (R.578.) Dr. Wilson prescribed Ultram
and referred Chaparro to pain management. (Id. ) Dr. Wilson opined that Chaparro was “totally disabled.” (Id. )
On March 8, 2010, Chaparro again visited Dr. Wilson. (R. 577.) Chaparro was walking with a cane, and examination revealed tenderness to palpation along the lumbar region and right sciatic notch, as well as pain with straight leg raise on the right. (Id. ) Dr. Wilson again diagnosed lumbar disc bulge at L5–S1 and right-sided radiculopathy
. (Id. )
On April 19, 2010, Dr. Wilson evaluated Chaparro for back pain, and for right shoulder pain resulting from a car accident in September 2008. (R. 499, 576.) Examination revealed diffuse tenderness in Chaparro's right shoulder, painful range of motion, slight weakness and limited range of motion in flexion. (R. 499.) Dr. Wilson also noted that Chaparro was wearing an unloader type lumbar brace. (R. 576.) A lumbar spine examination
found that Chaparro had tenderness to palpation in the lower back and moderate pain with straight leg raising bilaterally. (Id. ) Dr. Wilson recommended epidural steroid injections (id. ), and arthroscopic surgery (R. 499). On April 21, 2010, a cervical spine MRI revealed that Chaparro had bulging discs at C4–5, C5–6 and C6–7. (R. 500.)
Chaparro saw Dr. Wilson on May 7, May 27, July 8 and September 16, 2010. (R. 496–98, 574–75, 1044–45.) On September 21, 2010, Dr. Wilson performed arthrosporic right shoulder surgery on Chaparro with debridement
of the shoulder joint and subacromial decompression. (R. 497–98.)
On October 28, 2010, Chaparro saw Dr. Wilson for follow-up. (R. 571.) On examination, Chaparro had tenderness to palpation in his paralumbar musculature, difficulty with range of motion in all planes, a positive straight leg raising test on the right to forty degrees. (Id. ) Chaparro ambulated with a single point cane. (Id. ) Dr. Wilson referred Chaparro for pain management and continued his physical therapy. (Id. ) At a November 16, 2010 follow-up, Dr. Wilson noted that Chaparro was making normal recovery and not using assistive devices. (R. 494.) Although the arthroscopic site was well-healed, Dr. Wilson noted that Chaparro had limited range of motion and compromised strength in his rotator cuff. (Id. ) Dr. Wilson opined that Chapparo was “totally disabled at this time.” (Id. )
On December 20, 2010, Chaparro saw Dr. Wilson for further follow-up for his lower back pain. (R. 570.) Dr. Wilson stated that Chaparro had “decreased endurance with standing, sitting and walking.” (Id. ) Chaparro walked with a cane and wore a lumbar brace. (Id. ) On examination, Chaparro had pain with forward flexion of his trunk that radiated down his right leg and positive straight leg raise. (Id. ) Dr. Wilson prescribed Tramadol
and opined that Chaparro was “100% disabled at this point in time.” (Id. )
On January 20, 2011, Chaparro visited Dr. Wilson again. (R. 569.) Chaparro reported little change in his condition and that he continued to have lower back pain that radiated down his right lower extremity. (Id. ) On examination, Chaparro had diffuse tenderness in the lumbosacral junction, marked pain with right lower extremity leg raising, and an antalgic6 gait. (R. 569.) He continued to use a cane. (Id. ) A February 4, 2011 follow-up showed improvement in Chaparro's range of motion, although Dr. Wilson again opined that Chaparro was “totally disabled.” (R. 492.) On February 17, 2011, Chaparro told Dr. Wilson that he experienced decreased numbness in his right leg following his first steroid injections. (R. 568.) Examination revealed diffuse lumbosacral tenderness, marked pain with...
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