Rodriguez v. Colvin

Decision Date31 March 2017
Docket Number15-CV-2570 (RLE)
PartiesRAFAEL RODRIGUEZ, Plaintiff, v. CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
CourtU.S. District Court — Southern District of New York
OPINION AND ORDER

RONALD L. ELLIS, United States Magistrate Judge:

I. INTRODUCTION

Plaintiff Rafael Rodriguez commenced this action under the Social Security Act (the "Act"), 42 U.S.C. § 405(g), challenging a final decision of the Commissioner of Social Security (the "Commissioner") denying his claim for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). On November 30, 2015, Rodriguez moved for judgment on the pleadings, asking the Court to reverse the Commissioner's denial, and remand for a calculation of benefits. In the alternative, Rodriguez asks for a remand for further administrative proceedings with assignment to a different ALJ and with time limits imposed on the remand proceedings. Pl.'s Mem. in Support of his Mot. for J. on the Pleadings at 1. The Commissioner filed a cross-motion for remand, asking the Court to remand the case for further administrative proceedings. Def.'s Mem. of Law in Support of the Commissioner's Cross Motion for Remand and in Opp'n to Pl.'s Mot. for J. on the Pleadings at 1. For the reasons set forth below, the case is REMANDED for further administrative proceedings. Rodriguez's request for an instruction for calculation of benefits, and his request for remand to a different ALJ with a time limit on proceedings are both DENIED.

II. BACKGROUND

A. Procedural History

Rafael Rodriguez applied for DIB on June 11, 2010, and for SSI on September 22, 2010, alleging disability that began on February 1, 2009. (Tr. at 282-89). Both claims were denied by the Social Security Administration ("SSA") on January 26, 2011. (Id. at 184). Rodriguez submitted a request for a hearing by an Administrative Law Judge ("ALJ") on February 11, 2011. (Id. at 196). ALJ Seth Grossman held hearings on December 15, 2011, April 23, 2012, and May 13, 2013. Rodriguez attended the December 2011 hearing with counsel, Karen Tobin. (Id. at 136). He attended the April 2012 hearing with a different attorney, Aaron Vega, a vocational expert, Merriam Greene, and a medical expert, Dr. Donald Goldman. (Id. at 55). Vega also represented Rodriguez at the May 2013 hearing, attended by a different vocational expert, Jakob Tikes, and a different medical expert, Dr. Malcolm Brahms. (Id. at 29). On August 8, 2013, ALJ Grossman issued a decision denying Rodriguez either benefit. (Id. at 21). Rodriguez filed a request with the Appeals Council for a review of ALJ Grossman's decision on August 8, 2013. (Id. at 7). The request was denied on March 9, 2015. (Id. at 1). Rodriguez filed this action on April 3, 2015, and both parties consented on May 7, 2015, to the jurisdiction of the undersigned pursuant to 28 U.S.C. § 636(c). (Doc. No. 1, 6).

B. Medical Evidence

Rodriguez claims his disability is caused by a number of psychological and physical impairments: anxiety, depression, schizophrenia, right leg and knee pain, left shoulder pain, and complications from past surgeries. (Id. at 188, 314). The medical evidence presented to ALJGrossman covers the period from August 8, 2006, to April 25, 2013, and individual pieces of evidence often concern multiple impairments. (See, e.g., Tr. at 070-76) (treating physician's report opining on disc herniation, lower back pain, and osteoarthritis in the right knee). ALJ Grossman was thus required to analyze a lengthy and complex record to assess the effects that a number of impairments - both independently and in combination - had on Rodriguez's ability to work. This Opinion and Order presents the medical evidence grouped by impairment.

1. Right Knee Impairment

In 2006, Rodriguez was allegedly assaulted by a co-worker and suffered a contusion to his right knee. (Id. at 149, 381). Stephen Kette, a physician's assistant at the Center for Bone and Joint Disease, diagnosed Rodriguez with a ligament sprain and meniscal tear in his right knee. (Id. at 403). Rodriguez made subsequent visits to Dr. Richard Katz at the Center, complaining of pain in his knee. Dr. Katz ordered an arthroscopy, and concluded that the meniscal tear might have aggravated some pre-existing problems. He noted that Rodriguez would have to be disciplined about physical therapy to improve his knee condition. (Id. at 398-402).

On November 19, 2010, Dr. Dipti Joshi examined Rodriguez for the SSA. Dr. Joshi found some soft tissue swelling around Rodriguez's right knee and extension out to 75 degrees. (Id. at 569). Dr. Joshi concluded that Rodriguez had "moderate limitation to walking, climbing, and standing" and "[m]arked limitation to squatting." (Id. at 570). On November 30, 2011, Dr. Daniel Sotelo-Garza, one of Rodriguez's treating physicians at All Med Clinic, diagnosed Rodriguez with severe osteoarthritis in his right knee. (Id. at 671).

Rodriguez had another orthopedic evaluation on February 2, 2012. Dr. Jose Corvalan noted mild swelling of the right knee and 40 degrees of flexion. He concluded that Rodriguezwas moderately limited in walking long distances, bending, climbing, and standing and sitting for long periods of time because of right knee and back pain. (Id. at 759-60).

Rodriguez was also examined by Dr. Henry Sardar,1a pain management specialist, on April 11, June 6, and August 8 of 2012. (Id. at 967-74). Dr. Sardar noted during each of those visits that Rodriguez had mild effusion, osteoarthritic hypertrophy, and patellar grinding in his right knee. (Id.). He ordered an x-ray on February 29, 2012, which documented degenerative change, and an MRI on August 22, 2012, which found a degenerative meniscus tear, mild effusion, and osteoarthritic changes. (Id. at 940-41). On September 14, 2012, however, Rodriguez was examined by Dr. Ashok Dubey at All Med Clinic. (Id. at 893). Dr. Dubey noted mild swelling in Rodriguez's right knee, but found no misalignment, defects, or muscle atrophy. (Id.). Rodriguez was examined again by Dr. Sardar on January 9, 2013. Dr. Sardar's findings were the same as the three prior visits. (Id. at 961).

2. Left Shoulder Impairment

During his consultative examination on November 19, 2010, Dr. Joshi noted that Rodriguez had rotator cuff surgery performed on his left shoulder and that he suffered "moderate limitation to reaching" with his left arm. (Id. at 570). Forward elevation of the left arm was limited to 100 degrees, abduction to 120 degrees, and external rotation to about 75 degrees. (Id. at 569). Dr. Corvalan also found "moderate limitation" on using the left shoulder at his February 2, 2012 consultative examination. (Id. at 759). He concluded, however, that Rodriguez should never lift or carry objects even under ten pounds because of his left shoulder pain. (Id. at 761).Similarly, Dr. Sardar noted decreased range of motion in forward flexion and abduction in the left2 shoulder during his examinations on April 11, 2012, June 6, 2012, August 8, 2012, November 7, 2012, December 12, 2012, and January 9, 2013. (Id. at 961-72).

3. Disc Herniation and Lower Back Pain

Following Rodriguez's 2006 injury, an MRI revealed he had a moderately herniated disc at L4-5. (Id. at 404). In September and October 2006, Dr. Craig Bennett recommended physical therapy to treat the pain from the herniation and an apparent lumbar sprain. (Id. at 400-05). Rodriguez later received an MRI sometime in 2010 and another on February 7, 2011, both of which showed disc herniation at L4-5. (Id. at 530, 946).

On October 22, 2010, Rodriguez visited the Clay Avenue Health Center and was examined by Lucy Palomino, a nurse practitioner, who found "no abnormalities" in his back or spine. (Id. at 559). On November 2, 2010, Anthony Mandese, a physician's assistant at All Med Clinic, ordered a disc herniation evaluation for Rodriguez. (Id. at 587). On December 29, 2010, Mandese assessed Rodriguez with "lumbar chronic pain syndrome." (Id. at 581).

On October 19, 2011, Dr. Danilo Sotelo-Garza evaluated Rodriguez at All Med and found disc herniation and tenderness at L4-5. Dr. Sotelo-Garza also performed a positive straight leg test and determined specific reductions in range of motion. He found that Rodriguez suffered a 10 degree decrease in flexion, a 5 degree decrease in extension, a 25 degree decrease in lateral bending, and a 20 degree decrease in lateral rotation, as measured against the normal range for each of those motions. (Id. at 895).

On November 30, 2011, Dr. Sotelo-Garza filled out a "Multiple Impairments Questionnaire" for the SSA and diagnosed Rodriguez with lumbar spine disc herniation, findinga decreased range of motion with pain and noting that Rodriguez had previously been prescribed a back brace. (Id. at 671). Dr. Sotelo-Garza found that the back pain affected Rodriguez's lower extremities. (Id. at 672). Rodriguez could sit and stand for only one to two hours a day, and only occasionally lift and carry objects weighing five to ten pounds. (Id. at 673-74). Dr. Sotelo-Garza opined that Rodriguez could not sit, stand, or walk continuously in a work setting. (Id.). Rodriguez also had "significant limitations in doing repetitive reaching, handling, fingering, or lifting" according to Dr. Sotelo-Garza. (Id.). Finally, Dr. Sotelo-Garza noted in the questionnaire that Rodriguez could not push, pull, kneel, bend, or stoop on a sustained basis in a work setting. (Id. at 679).

Dr. Sardar noted a decreased range of motion in the lumbar spine with pain at the end range during examinations on February 1, 2012; April 11, 2012; June 6, 2012; August 8, 2012; November 7, 2012; December 12, 2012; and January 9, 2013. (Id. at 961-74).

4. Ambulatory Impairments

There is some evidence in the record that suggests Rodriguez may suffer from significant ambulatory impairments. On November 19, 2010, Dr. Shelia Aspinal performed a psychiatric evaluation of Rodriguez for the SSA. In her report, she noted that Rodriguez "walked with a...

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