United States District Court, D. Massachusetts
MEMORANDUM & ORDER
Talwani United States District Judge
before this court are Plaintiff Dawn Ares' Motion for
Order Reversing the Decision of the Commissioner of
the Social Security [#16], seeking judicial review of a
final decision denying her application for social security
disability insurance benefits (“SSDI”) and
supplemental security income benefits (“SSI”),
and Defendant, Acting Commissioner of the Social Security
Administration Nancy Berryhill's Motion to Affirm the
Decision of the Commissioner [#18]. For the
following reasons, Plaintiffs motion is ALLOWED in part and
DENIED in part, Defendant's motion is DENIED, and the
matter is REMANDED for further proceedings consistent with
Procedural and Medical History Through the ALJ's Denial
of Plaintiff's First Set of Claims
documented history of back pain began in at least the early
1990s, when she underwent two surgeries for a ruptured disc
in her back. A.R. 504 [#13-7]. In September 2005, Plaintiff
was seen by Ronald Birkenfeld, M.D., of Associates in
Neurosurgery, “complaining of recurrent right leg pain
and low back pain.” Id. In November 2005,
Plaintiff underwent nerve root decompression surgery.
Id. at 501-05. Records indicate that Plaintiff had
worked during this period but stopped working sometime in
2008. A.R. 384 [#13-5]; A.R. 412-13 [#13-6].
2009, Plaintiff filed applications for SSDI and SSI, alleging
a disability onset date of February 28, 2008. A.R. 132
[#13-3]. Her application was denied both initially and upon
reconsideration. Id. After a hearing on April 8,
2011, the ALJ issued a written opinion on April 26, 2011,
finding that Plaintiff was not disabled, and affirming the
denials of both SSDI and SSI. Id. at 132-42.
Procedural and Medical History From April 2011 to the
ALJ's Initial Denial of Plaintiffs Second Set of
18, 2011, Plaintiff was seen by Rizwan Mufti, M.D., a
psychiatrist at Boston Health Care, regarding her mental
health. A.R. 537 [#13-7]. Dr. Mufti noted that Plaintiff was
glum, downcast, and stated that Plaintiff conveyed to Dr.
Mufti her unchanged anxiety, worsening depression, and
increased sadness. Id. Based on those observations,
Dr. Mufti diagnosed Plaintiff with “Bipolar 2”
and an anxiety disorder. Id. Plaintiff was seen four
more times by Dr. Mufti in 2011, who noted bipolar, anxiety,
and depression symptoms at all of those visits. Id.
at 529, 531, 533, 535. Plaintiff returned to Dr. Mufti on six
occasions in 2012, and each time Dr. Mufti noted continued
depression and anxiety with varying levels of intensity and
frequency. Id. at 527, 589, 591, 593, 595, 597.
2011 and 2012, Plaintiff visited a therapist, Debra Sirota,
MSW, LICSW, for examinations related to her depression and
anxiety conditions. A.R. 617-18 [#13-7]. Plaintiff met with
Ms. Sirota five times in 2011, see id, and twenty
times in 2012, Id. at 619-23. Ms. Sirota noted
depression, irritability, anxiety, racing thoughts, mood
swings and disorders, social isolation, decreased
concentration, and weight gain due to limited activity.
Id. at 617-23.
addition to appointments with Dr. Mufti and Ms. Sirota,
Plaintiff began to see Rania Husseini, M.D., at Brigham and
Women's Hospital in 2012, regarding Plaintiffs physical
health. Dr. Husseini, Plaintiffs primary care physician,
examined Plaintiff three times in 2012. A.R. 578-79, 584, 606
[#13-7]. Dr. Husseini's notes from those examinations
detail lower back pain and trouble sitting and standing,
while also mentioning anxiety and bipolar symptoms, as well
as a severe headache. Id.
returned to Dr. Mufti twice in early 2013 for mental
examinations, first on January 3, 2013, at which time Dr.
Mufti noted no change in symptoms. A.R. 599 [#13-7]. At the
second visit on February 14, 2013, Dr. Mufti noted that
Plaintiff appeared to be in remission and was not displaying
any symptoms, though Dr. Mufti maintained Plaintiffs
diagnosis. Id. at 601. Plaintiff also continued to
visit Ms. Sirota in 2013, and was seen by her six times
between January 2013 and July 2013. Id. at 623-25,
632-33. Ms. Sirota noted continuing anxiety, depression,
irritability, frustration, poor concentration, a racing mind,
distractions, bipolar disorder, chronic pain, and sleep
on November 30, 2011, and November 17, 2011, respectively,
Plaintiff filed applications for SSDI and SSI, alleging an
onset date of February 28, 2008. A.R. 155-56 [#13- 3].
Plaintiff's applications were initially denied in March
2012, A.R. 242-47 [#13-4], and upon reconsideration in July
2012, id. at 250-55. On August 23, 2012, Plaintiff
requested a hearing before an ALJ. Id. at 256-68.
11, 2013, Plaintiff received a hearing regarding her SSDI and
SSI applications. A.R. 214 [#13-3]. The ALJ considered, among
other things, Plaintiff's medical records dating from
2005 through June 28, 2013. Id. at 236-37. The ALJ
found that Plaintiff was not disabled. Id. at
Procedural and Medical History From July 2013 through
Plaintiff's Appeal of the Final Denial of Her Second Set
August 19, 2013, after not working since 2008, Plaintiff
began working part time in the laundry room of a retirement
home. A.R. 390-91 [#13-5].
2013, Plaintiff made her first three visits to psychiatrist
Alice Freeman, M.D. A.R. 645-47, 660-63 [#13-8]. During all
three visits, Dr. Freeman noted bipolar symptoms, anxiety,
depression, angry outbursts, irritability, and decreased
concentration of varying severity. Id. On one
occasion in late 2013, Plaintiff also saw Dr. Husseini, who
noted back issues that prevented Plaintiff from shoveling.
Id. at 691.
met with Ms. Sirota eleven times in 2014 for examination.
A.R. 634-39 [#13-7]. After each session, Ms. Sirota noted
continued anxiety, racing thoughts, irritability, chronic
pain, decreased concentration, problems with personal
relationships and leaving the house, and a prominent mood
also continued to visit Brigham and Women's Hospital
throughout 2014. Id. at 641-44; A.R. 686, 717-18
[#13-8]. During that time, both Dr. Husseini and a
physician's assistant excused Plaintiff from a collective
five weeks of work due to a diminished range of motion in
Plaintiff's back; reduced strength; and discomfort while
sitting, standing, or walking. A.R. 641-44 [#13-7]; A.R. 686,
717-18 [#13-8]. Plaintiff also visited Dr. Freeman multiple
times in 2014. Dr. Freeman noted bipolar symptoms, anxiety,
lack of concentration, mood swings, a racing mind,
depression, and irritability. A.R. 652-59 [#13-8].
August 20, 2014, the Appeals Council reviewed the ALJ's
2013 disability determination, vacated the ALJ's
decision, and remanded the case to the ALJ for a new hearing.
A.R. 238-41 [#13-3]. The Appeals Council instructed the ALJ
to: (1) address the impact of res judicata in light of
Plaintiff's prior applications for disability benefits,
(2) consider the treating source opinions and explain the
weight given those opinions, (3) further evaluate subjective
complaints of pain, and (4) further consider Plaintiff's
maximum Residual Functioning Capacity. Id.
September 3, 2014, Plaintiff stopped working, again citing
her back pain as the reason she could no longer work. A.R.
Weisheipl, M.D., of Brigham & Women's Hospital
performed an MRI on September 18, 2014, to examine
Plaintiff's lower back. A.R. 702 [#13-8]. Dr.
Weisheipl's findings detailed mild, moderate, and marked
changes in Plaintiff's back, and noted degenerative
changes in the impression section of that report.
Id. Following the MRI, Plaintiff had two follow-up
visits, one with Dr. Weisheipl and one with Dr. Husseini.
Id. at 711-14, 717-18. Both Dr. Weisheipl and Dr.
Husseini noted continued chronic pain, that injection
treatments were not working, and mentioned ...