Laureano v. Comm'r of Soc. Sec.

Decision Date26 September 2018
Docket Number1:17-cv-01347 (SDA)
PartiesCirila A. Laureano, Plaintiff, v. Commissioner of Social Security, Defendant.
CourtU.S. District Court — Southern District of New York


Plaintiff Cirila Laureano ("Laureano" or "Plaintiff") brings this action pursuant to § 205(g) of the Social Security Act ("the Act"), 42 U.S.C. § 405(g), challenging the final decision of the Commissioner of Social Security, denying her application for Supplemental Security Income ("SSI") and Disability Insurance Benefits ("DIB").1 (Compl., ECF No. 2.) Presently before the Court is the Commissioner's motion, pursuant to Fed. R. Civ. P. 12(c), for judgment on the pleadings, (Notice of Mot., ECF No. 14 & Mem. L., ECF No. 15), Plaintiff's statement in opposition to Commissioner's motion (Opp., ECF No. 18), and the Commissioner's reply memorandum of law in support of judgment on the pleadings. (Reply Mem. L., ECF No. 19.)

For the reasons set forth below, the Commissioner's motion is DENIED and the case is remanded for further proceedings.

I. Procedural Background

Laureano filed for SSI and DIB benefits on April 3, 2012, alleging a disability onset date of February 29, 2012 in both applications. (Administrative R. ("R."), ECF No. 11-3, at 332, 334.) Following an initial denial of benefits on July 6, 2012 (R. 112), Laureano had a hearing before Administrative Law Judge ("ALJ") Hilton R. Miller on October 3, 2013. (R. 70-81.) ALJ Miller issued a decision on January 31, 2014 denying Laureano's benefits applications. (R. 91-101.) On July 15, 2015, the Appeals Council granted Laureano's request for review and remanded the case to the ALJ, finding that the ALJ did not provide sufficient rationale for his residual functional capacity (RFC) determination.2 (R. 107-09.) ALJ Miller held a second hearing on October 6, 2015. (R. 70-81, 28-66.) ALJ Miller denied Laureano's benefits application for the second time on November 27, 2015. (R. 23.) The ALJ's decision became the Commissioner's final decision when the Appeals Council denied review on January 27, 2017. (R. 1.) This action followed.

II. Non-Medical Evidence And Laureano's Testimony

Born on May 10, 1957, Laureano was 54 at the onset date and 58 years old at the time of the 2015 hearing. (R. 332.) Laureano lives with her daughter in the New York metropolitan area. (R. 34, 36.) She has a third grade education from the Dominican Republic and speaks very little English. (R. 31.) Laureano most recently worked as a home health aide prior to claiming disability and, prior to that, was employed as a factory hand packer. (R. 384.)

Laureano testified that she suffered from severe multi-level lumbar and cervical discdisorders, herniation, multiple cervical and lumbar disc bulges, severe depression, fibromyalgia and high cholesterol. (R. 32.) Laureano further testified that she is unable to work because she "cannot do any heavy lifting[,]" "can hardly walk[,]" and needs a brace to sleep. (R. 33.) Laureano testified that she could lift 2-3 pounds; occasionally use public transportation alone for medical appointments; wash small items like her coffee cup as needed; style her own hair; and put on clothing, unless experiencing severe pain in which case her daughter provided help. (R. 33-36, 39.)

III. Medical Evidence Before The ALJ
A. January-May 2012 Treatment Records

In January 2012, Laureano was seen by Dr. Martha Valdivia at Groupo Medico Dominicano for right shoulder pain and bilateral knee pain. (R. 565.) At the time, Laureano was assessed with fibromyalgia and joint pain and was taking the pain medication Savella. (Id.) Upon examination, Dr. Valdivia found decreased range of motion in Laureano's shoulders and decreased range of motion below the knees, but no instability. (Id.) Dr. Valdivia prescribed additional medication for joint pain and advised Laureano to follow up in three months. (R. 566.) Dr. Valdivia also referred Laureano to neurology for follow-up regarding her fibromyalgia. (Id.)

On February 28, 2012, Laureano underwent an MRI of her lumbar and cervical spine.3 (R. 472.) The lumbar spine MRI showed "L4-5 right paracentral herniation with impingement uponboth the traversing and exiting L4-5 nerve roots, and disc bulges at L3-4 and L2-3 with thecal sac impingement at both levels." (Id.) The cervical spine showed "straightening of cervical curvature; very small posterior midline herniation at C3-C4; small posterior herniation at C4-C5; retrolisthesis4 and posterior bulge at C5-C6; and a posterior herniation at C6-C7." (Id.)

On April 13, 2012, Laureano saw Dr. Valdivia for a follow-up appointment. (R. 567-68.) Laureano reported that she had had an MRI showing that two discs were out of place and that her back pain was severe. (R. 567.) Dr. Valdivia indicated that Laureano had decreased range of motion of the lumbar spine and positive straight leg raising.5 (Id.) Dr. Valdivia continued Laureano's medications for fibromyalgia and referred her to psychiatry for depression and anxiety due to her difficulty dealing with her pain issues and lack of improvement. (R. 568.)

On April 18, 2012 Dr. Kyla Blatt conducted a neurological consultation and referred Laureano to the pain service due to intractable back pain. (R. 429.) Several days later, on April 21, 2018, Dr. Valdivia referred Laureano to physical therapy for her lower back pain, noting that it was recommended by "Neurology." (R. 432-33) On April 23, 2012, Dr. Armando Ruiz conducted a physiatry6 consultation. (R. 446-48.) Upon examination, Dr. Ruiz found that Laureano hadnormal range of motion in her upper and lower extremities but antalgic gait7 and pain in the right hip when flexing. (R. 446.) Dr. Ruiz also found that Laureano's cervical spine flexion was within normal limits, but noted tenderness of the paraspinal lumbar sacral areas. (Id.) Dr. Ruiz assessed that Laureano could walk one block, stand five to ten minutes and sit for thirty minutes. (Id.)

The same day, Laureano underwent a physical therapy evaluation at Uptown Care Management.8 (R. 441-44.) Laureano indicated that she had difficulty bending; lifting objects from the floor; standing for more than ten minutes; sitting for more than thirty minutes and moderate difficulty negotiating stairs. (R. 441.) Laureano continued to receive physical therapy two to three times per week for the next five weeks. (R. 430, 435, 440, 449-54.)

On May 21, 2012, Dr. Ruiz again evaluated Laureano, noting that she had experienced little relief of her lower back pain. (R. 436-39.) Dr. Ruiz's finding regarding Laureano's range of motion and muscle spasms remained the same, though he noted pain in her right hip, as well as a positive straight leg raise on her right side. (R. 437.) Dr. Ruiz again assessed that Laureano could walk one block, stand five to ten minutes and sit for 30 minutes, and noted that she should not do any lifting. (R. 437, 439.) The same day, Dr. Ruiz wrote a letter stating that Laureano was still under his care and should "avoid heavy lifting or twisting[.]" (R. 430.)

On May 31, 2012, Laureano was seen by Dr. Angela Stroe, M.D., for a pain management consultation. (R. 434.) Laureano's chief complaint was lower extremity pain. (Id.) Dr. Stroe noted some tenderness, but found that Laureano had a full range of motion. (Id.) Dr. Stroe also assessedlumbar disc displacement and lumbar radiculopathy.9 (Id.) Dr. Stroe noted that Laureano was receiving physical therapy and prescribed additional medication. (Id.)

B. May 2012 Consultative Examinations
1. Dr. Marilee Mescon, M.D. - Internal Medicine Consultative Examination

Dr. Marilee Mescon performed an internal medicine consultative examination of Laureano on May 17, 2012. (R. 422-26.) Laureano reported that she had experienced pain in her back since 2005 that began while lifting heavy objects at work and had experienced headaches, lasting for one to two hours, for two months. (R. 422.) In terms of her daily activities, Laureano reported that she could shower, bathe and dress herself, but her daughter did the cooking, cleaning, laundry and shopping. (R. 423.) She also reported spending her time watching TV, listening to the radio and reading. (Id.)

Upon examination, Dr. Mescon found that Laureano could walk on heels and toes without difficulty, but could only squat halfway down. (Id.) Dr. Mescon noted that Laureano's cervical and lumbar spine showed full flexion, extension, lateral flexion bilaterally and full rotary movement bilaterally. (R. 437.) Dr. Mescon also noted active straight leg raising in a supine position of 0 to 30 degrees on the right and 0 to 60 degrees on the left; and active straight leg raising in a seated position was 0 to 90 degrees on both the left and right. (Id.) Neurologically, Dr. Mescon found diminished sensory perception over the entire right leg, 4/5 motor strength in the right upper and lower leg and 5/5 motor strength in the left upper and lower leg. (R. 424-25.) Dr. Mesconsent Laureano for an x-ray of the lumbosacral spine, which showed degenerative spondylosis10 at L2-L3 through L4-L5, but no compression fracture. (R. 425-26.) Radiologist Dr. Lawrence Liebman, who interpreted the x-ray, concluded there were "degenerative changes[.]" (R. 426.) Dr. Mescon diagnosed Laureano with headaches and back pain with arthritis, but opined that "there are no limitations in the claimant's ability to sit, stand, climb, push, pull, or carry heavy objects at this time." (R. 425.)

2. Dr. Arlene Broska, Ph. D. - Psychiatric Consultative Examination

Also on May 17, 2012, psychologist Arlene Broska performed a psychiatric consultative examination of Laureano. (R. 418-21.) Laureano reported that she felt down every day, did not take care of her appearance and did not like to go outside. (R. 418.) She explained that she used to be very active and was distressed by the fact that she could no longer be active due to her health problems. (Id.) Laureano stated that sh...

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