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Rios v. Colvin

United States District Court, D. Massachusetts

December 28, 2016

NORMA I. RIOS, Plaintiff
CAROLYN W. COLVIN, Acting Commissioner of Social Security Administration, Defendant


          KATHERINE A. ROBERTSON United States Magistrate Judge.

         I. Introduction

         Before the court is an action for judicial review of a final decision by the Acting Commissioner of the Social Security Administration ("Commissioner") regarding an individual's entitlement to Social Security Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") pursuant to 42 U.S.C. §§ 405(g) and 1381(c)(3). Plaintiff Norma I. Rios ("Plaintiff") asserts that the Commissioner's decision denying her such benefits -- memorialized in an April 25, 2014 decision of an administrative law judge ("ALJ") -- is not supported by substantial evidence and was made in error. Specifically, Plaintiff alleges that the ALJ committed three errors by failing to: (1) find that fibromyalgia was a severe impairment at step two of the five-step sequential evaluation process; (2) consider Plaintiff's obesity's impact on her musculoskeletal system at step three; and (3) support her Residual Functional Capacity ("RFC") assessment with substantial evidence. Plaintiff has filed a motion to reverse or remand (Dkt. No. 17) and the Commissioner, in turn, has moved to affirm (Dkt. No. 21).

         The parties have consented to this court's jurisdiction. See 28 U.S.C. § 636(c); Fed.R.Civ.P. 73. For the following reasons, the court will ALLOW the Commissioner's motion to affirm and DENY Plaintiff's motion to reverse and remand.

         II. Factual Background

         Plaintiff completed high school and took college courses in industrial engineering, data entry, and medical billing in Puerto Rico before coming to Massachusetts on June 16 or 18, 2012 (Administrative Record ("A.R.") at 42, 51). In Puerto Rico, she worked full-time for about seven years as a medical secretary until her health prevented her from performing the job (id. at 44, 52, 625). She stopped working on June 14, 2012, a few days before she came to the United States, when she was 48 years old (id. at 42, 250, 623). In her applications for DIB and SSI, Plaintiff alleged that she was disabled due to lumbosacral and cervical-dorsal radiculopathy, lumbosacral and cervical-dorsal "neural foraminal [stenosis]" and "central stenosis/HNP cord compression" (id. at 250).

         III. Procedural Background

         Plaintiff applied for DIB and SSI on June 21, 2012 alleging an onset of disability on June 14, 2012 (id. at 210, 215). The applications were denied initially and upon reconsideration (id. at 121-24, 128-30, 133-35). Following a hearing on January 22, 2014, the ALJ issued her decision on April 25, 2014 finding Plaintiff was not disabled (id. at 21, 30). The Appeals Council denied review (id. at 1-5). This appeal followed.[1]

         IV. Discussion

         A. Legal Standards

         1. Standard of Review

         The District Court may enter a judgment affirming, modifying, or reversing the final decision of the Commissioner, with or without remanding for a rehearing. See 42 U.S.C. §§ 405(g), 1383(c)(3). Judicial review "is limited to determining whether the ALJ used the proper legal standards and found facts upon the proper quantum of evidence." Ward v. Comm'r of Soc. Sec., 211 F.3d 652, 655 (1st Cir. 2000). The court reviews questions of law de novo, but must defer to the ALJ's findings of fact if they are supported by substantial evidence. See id. (citing Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir. 1999)). Substantial evidence exists "'if a reasonable mind, reviewing the evidence in the record as a whole, could accept it as adequate to support [the] conclusion.'" Irlanda Ortiz v. Sec'y of Health & Human Servs., 955 F.2d 765, 769 (1st Cir. 1991) (quoting Rodriguez v. Sec'y of Health & Human Servs., 647 F.2d 218, 222 (1st Cir. 1981)). "Complainants face a difficult battle in challenging the Commissioner's determination because, under the substantial evidence standard, the [c]ourt must uphold the Commissioner's determination, 'even if the record arguably could justify a different conclusion, so long as it is supported by substantial evidence.'" Amaral v. Comm'r of Soc. Sec., 797 F.Supp.2d 154, 159 (D. Mass. 2010) (quoting Rodriguez Pagan v. Sec'y of Health & Human Servs., 819 F.2d 1, 3 (1st Cir. 1987)). In applying the substantial evidence standard, the court must be mindful that it is the province of the ALJ, and not the courts, to determine issues of credibility, resolve conflicts in the evidence, and draw conclusions from such evidence. See Irlanda Ortiz, 955 F.2d at 769. That said, the Commissioner may not ignore evidence, misapply the law, or judge matters entrusted to experts. See Nguyen, 172 F.3d at 35. "If the ALJ has made a legal or factual error, the court should reverse or remand such a decision to consider new material evidence or to apply the correct legal standard." Boulia v. Colvin, Case No. 15-cv-30103-KAR, 2016 WL 3882870, at *1 (D. Mass. July 13, 2016) (citing Manso-Pizarro v. Sec'y of Health & Human Servs., 76 F.3d 15, 16 (1st Cir. 1996); 42 U.S.C. § 405(g)).

         2. Standard for Entitlement to Social Security Disability Insurance Benefits and Supplemental Security Income.

         In order to qualify for DIB, a claimant must demonstrate that she was disabled within the meaning of the Social Security Act (the "Act") prior to the expiration of her insured status. See 42 U.S.C. § 423(a)(1)(A), (D). SSI benefits, on the other hand, require a showing of both disability and financial need. See 42 U.S.C. § 1381a. Plaintiff's need, for purposes of SSI, and insured status, for purposes of DIB, is not challenged.

         The Act defines disability, in part, as the "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A). An individual is considered disabled under the Act

only if [her] physical or mental impairment or impairments are of such severity that [s]he is not only unable to do [her] previous work but cannot, considering [her] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which [s]he lives, or whether a specific job vacancy exists for [her], or whether [s]he would be hired if [s]he applied for work.

42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B). See generally Bowen v. Yuckert, 482 U.S. 137, 146- 49 (1987).

         The Commissioner evaluates a claimant's impairment under a five-step sequential evaluation process set forth in regulations promulgated under the Act. See 20 C.F.R. §§ 404.1520(a), 416.920(a). The hearing officer must determine: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant suffers from a severe impairment; (3) whether the impairment meets or equals a listed impairment contained in Appendix 1 to the regulations; (4) whether the impairment prevents the claimant from performing previous relevant work; and (5) whether the impairment prevents the claimant from doing any work considering the claimant's age, education, and work experience. See id; see also Goodermote v. Sec'y of Health & Human Servs., 690 F.2d 5, 6-7 (1st Cir. 1982) (describing the five-step process). If the hearing officer determines at any step of the evaluation that the claimant is or is not disabled, the analysis does not continue to the next step. See 20 C.F.R. §§ 404.1520, 416.920.

         Before proceeding to steps four and five, the Commissioner must make an assessment of the claimant's RFC, which the Commissioner uses at step four to determine whether the claimant can do past relevant work and at step five to determine if the claimant can do other work. See id. "The RFC is an administrative assessment of the extent to which an individual's medically determinable impairment(s), including any related symptoms, such as pain, may cause physical or mental limitations or restrictions that may affect his or her capacity to do work-related physical and mental activities." Social Security Ruling ("SSR") 96-8p, 1996 WL 374187, at *2 (July 2, 1996). Put another way, "[a]n individual's RFC is defined as 'the most you can still do despite your limitations.'" Dias v. Colvin, 52 F.Supp.3d 270, 278 (D. Mass. 2014) (quoting 20 C.F.R. § 416.945(a)(1)).

         The claimant has the burden of proof through step four of the analysis. At step five, the Commissioner has the burden of showing the existence of jobs in the national economy that the claimant can perform notwithstanding impairment(s). See Goodermote, 690 F.2d at 7.

         B. Medical Records

         1. Physical condition.

         Plaintiff presented the ALJ and the court with medical records that spanned the period from 2005 through 2013. Because Plaintiff alleged onset of disability mainly due to neck and back pain on June 14, 2012, the date she stopped working as a medical secretary, details of the relevant records before and after this date will be discussed.

         a. Medical Records: 2008 through June 13, 2012

         An October 29, 2008 radiology report of Plaintiff's cervical spine (neck) showed: "straightening of the cervical spine lordosis likely secondary to muscle spasm"; "degenerative disease and spondylosis at ¶ 5/C6"; and "hypertrophy of the luschka joint at ¶ 5/C6, resulting in mild bilateral foraminal stenosis" (A.R. at 452). A CT scan and nerve conduction test were performed on November 7, 2008 (id. at 338, 453). The CT scan revealed "a very small centrally herniated disc at ¶ 4/C5, C5/C6 and C6/C7" and "partial left neural foraminal stenosis at ¶ 5/C6" (id. at 453). There was "no definite evidence of canal stenosis" and "mild left neural foraminal stenosis" (id.). The nerve conduction test showed left ulnar neuropathy across the elbow and "left C6 radiculopathy with evidence of acute denervation in the biceps and brachioradialis muscle" (id. at 338).

         On November 11, 2008, Plaintiff went to the hospital complaining of pain in her neck that began two to three weeks earlier and pain radiating into her left arm (A.R. at 319). Her neck was tender to palpation at ¶ 4-C6 and her range of motion was limited (id. at 320). An MRI that was conducted the next day showed intervertebral disc desiccation with intervertebral disc bulges at ¶ 4-C5 and C5-C6, and left lateral intervertebral disc herniation at ¶ 5-C6 level "producing compression of exiting nerve roots" (id. at 345). No myelomalacic changes were evident (id.).

         In January 2010, radiology studies were conducted of Plaintiff's neck, lumbar spine (back), right wrist, and right hand (id. at 354-57). A minimal rotoscoliotic deviation was present on her neck, thoracic spine, and lumbosacral spine (id. at 354-56). Straightening of the lordosis, which suggested muscle spasm, and anterolateral osteophytic formations were present at the C5 and C6 levels of her cervical spine with "slight relative narrowing" at the C5-C6 level (id. at 356). The radiographs of her lumbosacral spine showed "some relative straightening of the lordosis, which could represent postural effect versus muscle spasm" (id. at 354). "Small anterolateral osteophytic formations" were observed at multiple levels of her lumbosacral spine along with grade 1 retrolisthesis at ¶ 4-L5 and "very slight spondylolisthesis" at ¶ 3-L4 levels (id. at 354). "AP, lateral and carpal tunnel projections of the right wrist show[ed] no gross bony or joint abnormalities" (id. at 357). There was "[n]o acute bony or joint pathology" observed in her right hand (id. at 504). A December 2010 nerve conduction study of Plaintiff's upper extremities revealed a right median focal entrapment neuropathy at the wrist, and a left ulnar focal entrapment neuropathy at the elbow "(Cubital Tunnel Syndrome)" (id. at 349). The electromyographic study was "compatible" with a right C6 radiculitis and a left C6 radiculopathy (id.).

         In January 2011, Dr. Luis J. Deliz Varela assessed Plaintiff with pain in the low back, thoracic spine, and neck, along with neuralgia neuritis, unspecified radiculitis, generalized osteoarthrosis, and "[m]orbid obesity" (id. at 351). Electroacupuncture and diet and exercise to promote weight loss were included in Dr. Deliz Varela's recommendations for treatment (id.).

         Additional radiology studies were conducted on Plaintiff's neck and back in March 2011 (id. at 362-63). The MRI of her neck showed "evidence of generalized osteophyte formations, disc desiccation and narrowing of the intervertebral discs spaces" and "congenital narrowing of the canal with short pedicles and scanty epidural fat" (id. at 362). The neck studies also showed mild central canal stenosis secondary to a mild posterior disc bulge at the C2-C3 level and moderate central canal stenosis secondary to a posterior disc bulge at the C3-C4 level (id.). "The C3-C4, C4-C5 and C5-C6 levels show large posterior disc bulges, cord compression, canal stenoses and bilateral neural foramina stenoses" (id.). The MRI of Plaintiff's lumbosacral spine showed grade 1 anterolisthesis of L4 on L5 and disc desiccation at this level, generalized osteophyte formations, and "generalized hypertrophy of the apophyseal joints" (id. at 363). The central and lateral canal stenosis at the L4-L5 level was severe (id.). At the L3-L4 level, the MRI showed mild central and moderate lateral canal stenosis secondary to a posterior disc bulge and hypertrophic apophyseal joints (id.).

         In April 2011, Roberto Leon Perez, M.D. examined Plaintiff due to complaints of bilateral hand swelling (id. at 469). Dr. Perez reported that: Plaintiff's gait and station were normal; her upper extremities' ranges of motion were intact; and she had fairly good range of motion in her back without spasm, but she experienced pain on flexion and hyperextension (id.). There was no evidence of "focal weakness, loss of sensation or incoordination" (id.). Dr. Perez diagnosed Plaintiff with bilateral and ulnar nerve entrapment at the elbow and recommended a neurosurgical evaluation (id.). In August 2011, Hector Cortes Santos, M.D. evaluated the electromyography of Plaintiff's back as demonstrating evidence of a chronic left L5 radiculopathy (id. at 370).

         In May 2012, approximately one month before Plaintiff left Puerto Rico, she reported to the Caribbean Medical and Rehabilitation Corp. that her symptoms had not changed (id. at 365). According to Plaintiff, her pain ranged from two to nine on a scale of ten and limited her range of motion in her neck and back (id.).

         b. Medical Records: June 14, 2012 to January 22, 2014

         Plaintiff first visited Northgate Medical P.C. in Springfield ("Northgate") on July 12, 2012 (id. at 543). She returned on August 2, 2012 to follow up for the pain in her neck and lumbar spine (id. at 542). She weighed 178 with a ...

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