Moronta v. Comm'r of Soc. Sec.
| Decision Date | 30 September 2019 |
| Docket Number | 18-CV-2964 (BCM) |
| Parties | MARIA LUISA BERNABE MORONTA, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant. |
| Court | U.S. District Court — Southern District of New York |
Plaintiff Maria Luisa Bernabe Moronta filed this action pursuant to § 205(g) of the Social Security Act (the Act), 42 U.S.C. § 405(g), seeking judicial review of a final determination of the Commissioner of Social Security (the Commissioner) denying her application for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI). The parties consented to the disposition of this case by a United States Magistrate Judge pursuant to 28 U.S.C. § 636(c) (Dkt. No. 12) and cross-moved for judgment on the pleadings pursuant to Fed. R. Civ. P. 12(c). For the reasons set forth below, plaintiff's motion (Dkt. No. 20) will be denied, defendant's motion (Dkt. No. 26) will be granted, and the case will be dismissed.
On May 27, 2014, plaintiff submitted her applications for DIB and SSI. See Administrative Record (Dkt. No. 18) ___") at 253-68. In both applications, plaintiff asserted disability as of April 11, 2014, due to lumbar radiculopathy and cervical hernia. (R. 79-81, 89.) Both claims were denied on September 15, 2014. (R. 21, 97.) Plaintiff timely requested a hearing before an Administrative Law Judge (ALJ) (R. 105), after which ALJ Sheila Walters held hearings on July 6, 2016 and May 25, 2017. (R. 38, 52.)
In a written decision dated June 22, 2017 (the Decision), the ALJ determined that plaintiff was not disabled, within the meaning of the Act, from April 11, 2014 to the date of the Decision. (R. 21-32.) On June 29, 2017, plaintiff requested Appeals Council review. (R. 250.) The Appeals Council denied that request on November 7, 2017 (R. 1), making the ALJ's determination final.
Plaintiff was born on October 11, 1961 and was 52 years old on the alleged onset date of April 11, 2014. (R. 81, 89.) She attended school the through ninth grade. (R. 59.) Her primary language is Spanish (R. 289, 529), and though she reads and writes "some" English (R. 60), she testified before the ALJ through a translator. (R. 21, 54, 57.)
Plaintiff worked as a cashier from 1996 to 2000; a home attendant from 2000 to 2002; a nanny from 2002 to 2006; and again as a home attendant beginning in 2008. (R. 304-08.) In May 2013, plaintiff was injured while tending to a patient in a wheelchair, and began to experience back pain (R. 337, 1108, 1431), but continued working as a home attendant until April 2014. (R. 269, 304.) She has been unemployed since, except for a six-month period in 2015 - after the alleged onset date - during which she cared for a one-year old child. (R. 66.)
According to a Function Report completed on June 11, 2014, plaintiff spent her days making coffee, cooking meals, watching television, and attending appointments. (R. 330.) She was able to take care of her grandchild, "feeding her and mak[ing] sure she's good," and her pet birds. (Id.) She wrote that due to pain in her back, legs, and arms, it took her "about 30 minutes to get dressed," and she took a chair into the tub when she showered. (Id.) She cooked her own foods, though her daughter helped her do so on the days she was not feeling well. (R. 331-32.) Plaintiff wrote that the only household chore she could do was "dust," and that her daughter assisted her with dusting on occasion. (R. 332.) Plaintiff used public transportation and shopped once a week, but generally did not go out alone. (R. 332-33.)
Plaintiff wrote that since her "condition began" she was "no longer able to sit or lay in one position for too long." (R. 333.) She reported that she could "no longer lift more than 5 pounds" or carry a gallon of milk, could "no longer stand for more than 5 minutes," and could not "sit in one position for more than 20 minutes." (R. 334-35.) She reported that she could not kneel or reach "too high or far." (R. 335.)
Plaintiff did not list any walking limitations in her Function Report. Instead, she wrote that she could walk seven blocks before needing to stop to rest, and that her daily activities included "walking to run errands." (R. 336, 339.) She also wrote that she was able to climb stairs (albeit with breaks), including the stairs to her fourth-floor apartment. (Id.)
At the time she completed her Function Report, plaintiff was taking Mapap (acetaminophen) for her pain. (R. 338.)
Plaintiff and the Commissioner have each provided a summary of the medical records and opinion evidence in the administrative record. See Pl. Mem. (Dkt. No. 21) at 2-8; Def. Mem. (Dkt. No. 27) at 2-13. The Court adopts the parties' summaries for purposes of this action, and highlights only those facts relevant to the Court's decision.
On February 27, 2014, before the alleged onset date, an MRI of plaintiff's lumbar spine revealed disc herniation at the L2-L3, L4-L5, and L5-S1 levels, as well as "[n]eural foraminal narrowing seen at the L4-5 and L5-S1 levels," with the "[m]ost significant disease at the left L5-S1 level appearing overall moderate in amount." (R. 1108-09.)
On April 22, 2014, shortly after plaintiff's alleged onset date, she saw internist Ofelia R. Flores, M.D. at the Segundo Ruiz Belvis Diagnostic & Treatment Center of Lincoln Medical andMental Health Center (Lincoln Medical). (R. 574.) On examination, plaintiff's back flexion and extension were limited, but she had a "normal motor and sensory exam." (R. 575.) Dr. Flores noted that plaintiff had a "[b]ack pain/disc problem," and wrote that she went to "therapy" and saw an unnamed "orthopedic MD" for that problem. (Id.)
On January 16, 2015, Dr. Flores saw plaintiff again for a follow-up. (R. 751-52.) Her examination revealed "normal joint range of motion, no effusion, tenderness or deformities" (R. 752), and plaintiff again had a "normal motor and sensory exam." (Id.) Dr. Flores noted that plaintiff should come back for a return visit in three months with internist Winifred Egbuna, M.D. (Id.)
Dr. Egbuna examined plaintiff on March 26, 2015. (R. 922.) The record contains only the third page of a three-page treatment record on that date. (Id.) On examination, plaintiff's extremities had a "normal joint range of motion, no effusion, tenderness or deformities," and her motor and sensory exam was normal. (Id.) Plaintiff complained about a "left thumb cyst." (Id.)
On July 29, 2015, pain management specialist Robert Kramberg, M.D. of Rehabilitation Medicine Practice of N.Y. (Rehabilitation Medicine) examined plaintiff. (R 863-64.) Plaintiff reported symptoms of "sharp shooting low back pain radiating down to both lower extremities," "difficulty standing for long periods of time," and a need for frequent changes of position "when sitting due to discomfort and pain." (R. 863.) On examination, plaintiff was "was unable to get on and off the exam table without assistance." (Id.) Dr. Kramberg observed a "loss of lordosis"; "muscle spasms palpated bilaterally"; "paraspinal tenderness present bilaterally from L1-S1"; and tightness in plaintiff's left and right lumbar areas. (Id.) A supine straight leg raise test was positive bilaterally at "20 degrees on the right and 40 degrees on the left." (Id.) A neuromuscular examination revealed no evidence of any specific loss of tone or strength, and no evidence of lossof sensory function "other than those findings listed in the low back exam." (R. 864.) Dr. Kramberg assessed left S1 radiculopathy. (R. 863.) On September 16, 2015, Dr. Kramberg examined plaintiff again, with similar results. (R. 858.)
On September 23, 2015, Jose F. Colon, M.D., also of Rehabilitation Medicine, performed an epidurogram of plaintiff's lumbar spine and a transforaminal epidural steroid injection. (R. 929-31.)1 The epidurogram revealed "[d]isc herniation at L4-5 with an annular tear contacting the traversing right L5 nerve root, disc herniation at L5-S1 displacing the traversing left S1 nerve root, and left S1 radiculopathy." (R. 930.)
On December 15, 2015, plaintiff returned to Lincoln Medical for a follow up visit with Dr. Egbuna, during which she complained about pain in her knees, particularly the left knee. (R. 874-76.) On examination, plaintiff had crepitus in both knees. (R. 874.)2 Dr. Egbuna noted that plaintiff had "complete independence in all ADL's self care" (R. 875), and prescribed Tylenol and "rice" (rest, ice, compression, and elevation) for plaintiff's knee pain. She also referred plaintiff to "orthopedic." (Id.)
a. Lincoln Medical
On January 13, 2016, plaintiff presented at Lincoln Medical's Orthopedic Department with left knee pain at a level of 8/10, with "giving way, clicking, and instability." (R. 869.) However, an x-ray of plaintiff's knees showed no evidence of fracture or dislocation. (R. 870, 1246.) The attending physician assessed a "likely meniscal tear" and recommended six weeks of physical therapy to "help strengthen and stabilize the knee." (R. 870.)
On March 10, 2016, plaintiff saw physiatrist Peter Kaganowicz, M.D. at Lincoln Medical's Rehabilitation Department. (R. 1064.) Plaintiff reported that her pain was down to 4/10, and Dr. Kaganowicz noted that she ambulated without a cane, that she had a full range of motion, and that her left knee had no swelling. (Id.)
On April 28, 2016, plaintiff saw physical therapist Yomaira E. Vanegas. (R. 1261.) Ms. Vanegas noted that plaintiff's pain remained 4/10, that she ambulated without a cane, and that she was "Independent in all Activities of Daily Living [ADL], self-care, & instrumental No gait aid needed." (Id.) However, Ms. Vanegas noted that plaintiff "came to PT OPD ambulatory with no device slow and mild limping gait pattern," and gave plaintiff a straight cane. (R. 1263-64.) Plaintiff reported to physical therapy with the cane on May 12 and...
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