Jackson v. Kijakazi

Docket Number20-CV-7476 (JLC)
Decision Date03 March 2022
Citation588 F.Supp.3d 558
Parties Shawn JACKSON, Plaintiff, v. Kilolo KIJAKAZI, Commissioner, Social Security Administration, Defendant.
CourtU.S. District Court — Southern District of New York

Josephine Gottesman, Dennis Kenny Law, Newburgh, NY, for Plaintiff.

Daniella Marie Calenzo, Social Security Administration - Off. of the General Counsel, New York, NY, for Defendant.

OPINION AND ORDER

JAMES L. COTT, United States Magistrate Judge:

Table of Contents

I. BACKGROUND...565
B. The Administrative Record...566
1. Jackson's Background...566
2. Relevant Medical Evidence...566
a. Treatment History...566
i. Christopher George, M.D.Primary Care Physician...566
ii. Farrah Ashraf, D.O. – Treating Rheumatologist...567
iii. Surinder P. Jindal, M.D., P.C. – Treating...568
iv. Duyet T. Bui, Doctor of Podiatric Medicine (DPM)Treating Podiatrist...568
v. Brittney Santana, Registered Physician Assistant (RPA) – Treating Provider...569
vi. Patricia Cave, Doctor of Physical Therapy (DPT)Treating Physical Therapist...569
vii. Nurse Practitioner ("NP") June Higgins and Licensed Master Social Worker ("LMSW") Karen LancasterTreating Providers...570
viii. Nurse Practitioner ("NP") Amber Herman and Licensed Master Social Worker ("LMSW") Delilah GonzalezTreating Providers...570
b. Opinion Evidence...571
i. Alex Gindes, Ph.D.Consultative Psychologist...571
ii. Allison Murphy, PM.D. – Consultative Psychiatrist...572
iii. John Caruso, M.D.Consultative Examiner...572
iv. Non-Examining Consultative Opinions...572
3. ALJ Hearing...573
II. DISCUSSION...575
C. Analysis...582
1. The ALJ failed to fully develop the record...583
2. The ALJ did not properly assess medical opinions under the new SSA regulations...585
3. The ALJ's RFC determination was not supported by substantial evidence...587
4. The ALJ's errors were not harmless...588
III. CONCLUSION...589

Plaintiff Shawn Jackson seeks judicial review of a final determination by defendant Kilolo Kijakazi, the Acting Commissioner of the Social Security Administration, denying his application for supplemental security income under the Social Security Act. Jackson has moved to remand for further administrative proceedings, and the Commissioner has cross-moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons set forth below, the Court grants Jackson's motion, denies the Commissioner's cross-motion, and remands the case for further proceedings.

I. BACKGROUND
A. Procedural History

On June 27, 2018, Jackson applied for Supplemental Security Income ("SSI"), alleging a disability onset date of October 1, 2007.2 Administrative Record ("AR"), Dkt. No. 11, at 10.3 The Social Security Administration ("SSA") denied Jackson's claims on November 2, 2018, and Jackson subsequently filed a request for a hearing before an Administrative Law Judge ("ALJ") on December 12, 2018. Id. On September 13, 2019, Jackson appeared and testified before ALJ Robert Gonzalez. Id. at 37–77. Jackson was represented during that hearing by a non-attorney representative, Jessica Lindhorst. Id. at 37. Sugi Y. Komarov appeared as Vocational Expert ("VE"). Id. at 10. During that hearing, the ALJ granted a request by Jackson to amend the alleged onset date to December 28, 2018. Id. at 43–44. In a decision dated December 9, 2019, the ALJ found Jackson to be not disabled and denied his claim. Id. at 7–26. Through his attorney, Jackson sought review of the ALJ's decision by the Appeals Council on February 1, 2020. Id. at 182–85. His request was denied on July 15, 2020, rendering the ALJ's decision final. Id. at 1–3.

Jackson timely commenced this action on September 11, 2020, seeking judicial review of the Commissioner's decision pursuant to 42 U.S.C. § 405(g) and/or 42 U.S.C. § 1383(c)(3). Complaint ("Compl."), Dkt. No. 1. The Commissioner answered Jackson's complaint by filing the administrative record on April 1, 2021. Dkt. No. 11. On July 1, 2021, Jackson moved for remand and submitted a memorandum of law in support of his motion. Notice of Motion, Dkt. No. 16; Memorandum of Law in Support of Plaintiff's Motion ("Pl. Mem."), Dkt. No. 17. The Commissioner cross-moved for judgment on the pleadings on August 31, 2021, and submitted a memorandum in support of her motion. Notice of Motion, Dkt. No. 20; Memorandum of Law in Support of the Commissioner's Cross-Motion ("Def. Mem."), Dkt. No. 21. On September 20, 2021, Jackson submitted reply papers. Reply Memorandum of Law in Opposition to Defendant's Motion for Judgment on the Pleadings and in Further Support of Plaintiff's Motion for Remand for Further Administrative Proceedings ("Pl. Reply"), Dkt. No. 22. The parties have consented to my jurisdiction for all purposes under 28 U.S.C. § 636(c). Dkt. No. 28.

B. The Administrative Record
1. Jackson's Background

Jackson was born on December 20, 1980. AR at 98. At the time of the hearing, he was 38 years old and living with his mother in Poughkeepsie. Id. at 56. Jackson is a father; his son lives with the son's mother. Id. Jackson has a history of trauma, including witnessing the death of a friend as a result of gunfire in 2001. Id. at 466. He was arrested twice, in the late 1990's and again in 2003, and struggled with drug and alcohol abuse since he was a young teenager. Id. at 464–68. In January 2018, Jackson was successfully discharged from rehabilitation at Turning Point treatment facility. Id. at 1028.

Physically, Jackson suffers from polyarthritis, as well as Osgood-Schlatter's disease in both his knees. Id. at 417, 420. On February 7, 2017, Jackson injured his right foot. AR at 305. His left shoulder is a source of pain; he dislocated his shoulder from which he continues to experience pain and was diagnosed with a small Hill-Sachs deformity. Id. at 661–63. He generally suffers from stiffness and pain in his joints due to these conditions. Mentally, Jackson was diagnosed with depression, anxiety, and post-traumatic stress disorder ("PTSD"). Id. at 477–78.

Jackson received his GED in 2006. Id. at 104. He had prior temporary work experience as a prep cook and dishwasher. Id. at 48–49. He was in HVAC training in 2018, but was unable to complete the program due to his injury. Id. at 57.

2. Relevant Medical Evidence
a. Treatment History

i. Christopher George, M.D. – Primary Care Physician

Dr. Christopher George began treating Jackson on June 6, 2017 at Hudson River Community Health ("HRCH"). AR at 434. Jackson suffered from joint pain, a shoulder dislocation, arthritis, a fractured ankle, and a toenail fungus infection ; he had been taking Omeprazole and Tramadol and was in physical therapy. Id.4 Dr. George observed that Jackson was in "no acute distress," with "normal" range of motion ("ROM") in extremities and "diffuse joint pain." Id. Dr. George found that Jackson suffered from gastroesophageal reflux disease ("GERD"). Id. at 435.5 He refilled Omeprazole. Id. On September 25, 2017, Dr. George found "diffuse hand, shoulder bilateral and right foot pain," with "no joint crepitation." Id. at 430. Jackson also tested ANA positive. Id. Dr. George prescribed Prednisone and Meloxicam, and referred Jackson to rheumatologist Dr. Farrah Ashraf. Id.6

On January 24, 2018, Jackson returned to Dr. George after his discharge from Turning Point rehabilitation. Id. at 424, 1028. He presented with "no acute distress" and "normal ROM" in his extremities, Dr. George noted "perilumbar tenderness, diffuse joint tenderness no swelling" and referred Jackson to Orthopedic Associates for pain in shoulder and foot. Id. at 424–25. In a follow-up, Dr. George assessed Jackson with polyarthritis (to be treated by Dr. Ashraf) and onychomycosis (for which he referred Jackson to podiatrist Eric Sims). Id. at 420.

When Dr. George examined Jackson on August 17, 2018, he found "limited ROM" in his left shoulder, crepitation to shoulder, right foot pain, and left knee pain and stiffness. Id. at 416. Dr. George also noted a "clicking popping sound heard" while examining Jackson's extremities. Id. He assessed Jackson as having Osgood-Schlatter's disease in his left knee and "severe persistent" GERD symptoms. Id. at 417.7 Dr. George referred him to Digestive Disease Center, which returned findings to him in a surgical pathology report in September 2018. Id. at 417, 579. By February 4, 2019, Dr. George noted "normal ROM" in Jackson's extremities, and that he was in "no acute distress," though suffered from pain to left shoulder, a fractured right foot, pain with walking, and pain to his right knee. Id. at 576. He prescribed more physical therapy. Id. On August 2, 2019, Dr. George found "no acute distress," "normal ROM" in the extremities, and no joint tenderness or swelling. Id. at 785.

ii. Farrah Ashraf, D.O. – Treating Rheumatologist

Dr. Farrah Ashraf of the Premier Medical Group of Hudson Valley first examined Jackson on January 25, 2018, and continued to see him through August 27, 2019. AR at 787–96. At his first assessment, Jackson's spinal contour was normal with full ROM in his upper extremities, but his shoulders had "stiffness bilaterally" with the left greater than the right, and his metatarsophalangeal joints were "tender and swollen bilaterally." Id. at 787. Dr. Ashraf suggested Jackson try Daypro and discontinue Meloxicam. Id. at 788.8 On February 16, 2018, Dr. Ashraf noted "full ROM" in both upper and lower extremities, and that "Daypro [was] starting to help." Id. at 789. At a May 18, 2018 appointment, Jackson "was doing really well" but his hands and knees were stiff due to biking and exercising. Id. at 791. Dr. Ashraf noted mild tenderness in Jackson's upper extremities, and crepitus and stiffness in...

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6 cases
  • Martinez v. Kijakazi
    • United States
    • U.S. District Court — Southern District of New York
    • December 4, 2023
    ... ... “However, ... the Court need not remand the ... case if the ALJ only committed harmless error, i.e., where ... the ‘application of the correct legal principles to the ... record could lead only to the same conclusion.'” ... Jackson v. Kijakazi, 588 F.Supp.3d 558, 579 ... (S.D.N.Y. 2022) (quoting Zabala v. Astrue, 595 F.3d ... 402, 409 (2d Cir. 2010)) ...          Here, ... the ALJ asked the VE to opine as to whether a person of ... Martinez's RFC could “perform any unskilled ... ...
  • Williamson v. Comm'r of Soc. Sec.
    • United States
    • U.S. District Court — Eastern District of Texas
    • August 30, 2023
    ... ... 489, 500 (S.D.Miss. 2021) (citing Pearson v ... Comm'r, 2021 WL 3708047, at *5 (S.D.Miss. Aug. 11, ... 2021); Kilby v. Kijakazi, No. 4:20-CV-03035, 2022 WL ... 1797043, at *4 (S.D. Tex. Mar. 15, 2022). The most important ... factors in this analysis are ... Tex. Mar ... 14, 2022), R. & R. adopted 2022 WL 1004241 (N.D. Tex ... Apr. 4, 2022); Jackson v. Kijakazi, 588 F.Supp.3d ... 558, 585 (S.D.N.Y. 2022) (holding that the ALJ's ... explanation is not sufficient where he cited to some ... ...
  • Apr. P. v. Comm'r of Soc. Sec.
    • United States
    • U.S. District Court — Western District of New York
    • August 23, 2023
    ... ... Michelle J. v. Comm'r of ... Soc. Sec., No. 1:21-CV-306, 2023 WL 2623587, at *4 ... (W.D.N.Y. Mar. 24, 2023); see Jackson v. Kijakazi, ... 588 F.Supp.3d 558, 585 (S.D.N.Y. 2022) (“Courts ... frequently remand an ALJ's decision when it ignores or ... ...
  • Faure v. Comm'r of Soc. Sec.
    • United States
    • U.S. District Court — Southern District of New York
    • August 7, 2023
    ... ... constitutes a failure to fully develop the record. See ... Jackson v. Kijakazi , 588 F.Supp.3d 558, 583 (S.D.N.Y ... 2022) (finding the ALJ must make “every reasonable ... effort” to obtain medical ... ...
  • Request a trial to view additional results

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