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Saeed v. Berryhill

United States District Court, D. Massachusetts

March 9, 2018

NANCY A. BERRYHILL, [1] Commissioner of Social Security, Defendant.



         Plaintiff Marlynn Saeed ("Ms. Saeed" or "Claimant") brings this action pursuant to section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), challenging the final decision of the Commissioner of the Social Security Administration (the "Commissioner") denying her claim for Social Security Disability Insurance ("SSDI") benefits. Currently pending are Claimant's motion to reverse the Commissioner's decision denying her disability benefits [ECF No. 23], and the Commissioner's cross-motion for an order affirming the decision. [ECF No. 27]. For the reasons described herein, the Court finds that the decision of the Administrative Law Judge ("ALJ") was not supported by substantial evidence and therefore VACATES the decision of the Commissioner and REMANDS the case for further administrative proceedings consistent with this opinion.

         I. BACKGROUND

         A. Statutory and Regulatory Framework: Five-Step Process to Evaluate Disability Claims

         "The Social Security Administration is the federal agency charged with administering both the Social Security disability benefits program, which provides disability insurance for covered workers, and the Supplemental Security Income program, which provides assistance for the indigent aged and disabled." Seavey v. Barnhart 276 F.3d 1, 5 (1st Cir. 2001) (citing 42 U.S.C. §§423, 1381a).

         The Social Security Act (the "Act") provides that an individual shall be considered to be "disabled" if he or she is:

unable 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 that has lasted or can be expected to last for a continuous period of not less than twelve months.

42 U.S.C. § 1382c(a)(3)(A); seealso42 U.S.C. § 423(d)(1)(A). The disability must be severe, such that the claimant is unable to do his or her previous work or any other substantial gainful activity that exists in the national economy. See 42 U.S.C. § 1382c(a)(3)(B); 20 C.F.R. § 416.905.

         When evaluating a disability claim under the Act, the Commissioner uses a five-step process, which the First Circuit has explained as follows:

All five steps are not applied to every applicant, as the determination may be concluded at any step along the process. The steps are: 1) if the applicant is engaged in substantial gainful work activity, the application is denied; 2) if the applicant does not have, or has not had within the relevant time period, a severe impairment or combination of impairments, the application is denied; 3) if the impairment meets the conditions for one of the "listed" impairments in the Social Security regulations, then the application is granted; 4) if the applicant's "residual functional capacity" is such that he or she can still perform past relevant work, then the application is denied; 5) if the applicant, given his or her residual functional capacity, education, work experience, and age, is unable to do any other work, the application is granted.

Seavey, 276 F.3d at 5 (citing 20 C.F.R. § 416.920).

         B. Procedural Background

         Claimant filed her application for SSDI benefits on April 19, 2013. [R. 12].[2] She alleged that she became disabled on April 19, 2013, due to carpal tunnel syndrome, obesity, and "multiple musculoskeletal disorders." [R. 12, 14, 195]. Her date last insured was June 30, 2016. [R 12].

         The Social Security Administration (the "SSA") denied Claimant's application for SSDI benefits on November 12, 2013, and again upon reconsideration on March 7, 2014. [R. 12]. Thereafter, Claimant requested an administrative hearing, and a hearing took place before ALJ Daniel J. Driscoll ("ALJ Driscoll") on May 27, 2015. [R. 12, 24]. Claimant, who was represented by counsel, appeared and testified at the hearing. [R. 12, 24]. On June 26, 2015, ALJ Driscoll issued a decision finding that Claimant was not disabled. [R. 19]. The SSA Appeals Council denied her Request for Review on August 10, 2016. [R. 1]. On September 23, 2016, she filed a timely complaint with this Court, seeking review of the Commissioner's decision pursuant to section 205(g) of the Act. [ECF No. I].[3]

         C. Factual Background

         Claimant was born in 1965 and was 50 years old when ALJ Driscoll issued his decision. [R. 18-19, 170]. She resides in Roxbury, Massachusetts with her sister and her niece. [R. 30-31]. She has a high school education and last worked in September 2014 as a cashier in the bakery department of a Stop and Shop. She previously held similar positions at Star Market, Shaw's supermarket, andDunkin' Donuts. [R. 30-36], D. Medical Evidence

         Claimant has a long history of musculoskeletal impairment, reportedly dating back to an early diagnosis of carpal tunnel syndrome in 2004, as well as an injury to her left knee when she fell from a ladder in the summer of 2008.[4] [R. 75-76]. Following her knee injury, by September 2008, she was advised that she could return to work and use a high chair to take occasional breaks while attending to her duties as a cashier. [R. 76]. In the fall of 2009, Claimant's treatment began to focus on the impairment of her right foot, as she was diagnosed with right peritoneal tendinosis. [R. 76]. In March 2010, a large object fell onto and injured Claimant's right foot while she was working at Dunkin' Donuts, after which she was advised to use a medical boot. [R. 76]. She benefited from treating her right foot with injection therapy and the use of Voltaren gel in late 2010, but declined to participate in further injection therapy in early 2011, against the advice of her treating physicians. [R. 76-77]. In July 2011, Claimant was advised that she could continue to work with the limitation that she "should refrain from any high lifting."[5] [R. 77].

         On May 22, 2012, Dr. Eric Bluman, M.D. and certified physician assistant ("PA-C") Samantha Noonan examined Claimant after a mop bucket rolled over her right foot at work. [R. 462]. Dr. Bluman determined that Claimant sprained her right foot and prescribed the use of a boot for four to six weeks. Id. On June 6, 2012, Claimant visited an urgent care clinic at Brigham & Women's Hospital for another workplace injury after a large metal cage fell onto her right foot. [R. 315]. Although X-rays following this latest accident showed no evidence of a fracture or dislocation, [R. 329], Dr. Joseph Frank, M.D. advised Claimant to wear a brace with an ACE bandage wrap. [R. 314]. On July 2, 2012, Dr. Frank examined Claimant again but was hesitant to recommend that she avoid walking and stop working. [R. 312]. He contacted PA-C Noonan for a recommendation, and, on August 2, 2012, PA-C Noonan cleared Claimant to return to work without restrictions while she wore the brace. [R. 310].

         On June 18, 2013, state-agency physician Dr. Sanjay Ram, M.D. completed a physical residual functional capacity ("RFC") assessment, finding that Claimant could (a) occasionally lift and/or carry 20 pounds and frequently lift and/or carry 10 pounds; (b) stand and/or walk for at least two hours in an eight-hour workday; (c) sit for eight hours in an eight-hour workday; (d) frequently reach overhead and at the bench level; (e) frequently finger; (f) frequently feel; and (g) occasionally handle. [R 409-10].[6]

         On July 16, 2013, Dr. Lipika Samal, M.D. examined Claimant and noted that her thumb was still causing her pain, but that her "knee [was] better." [R. 289]. Claimant demonstrated a "much more normal gait" and a full range of motion in her upper and lower extremities, despite showing decreased strength when flexing her right foot. [R. 290]. One week later, on July 24, 2013, Claimant saw Dr. Kathryn Hanna, M.D. in the department of orthopedic surgery at Brigham & Women's Hospital regarding stiffness in her right thumb and middle finger. [R. 287], Dr. Hanna assessed that Claimant had early trigger finger of the right thumb and middle finger and recommended corticosteroid injections, which Claimant declined. Id. Dr. Hanna determined that surgery was unnecessary at the time and recommended stretching in the absence of an injection.[7] Id.

         In late July and early August 2013, Dr. Jonathan R. Welch, M.D. and Nicole Kostarellas, PA-C in the emergency care unit at Brigham & Women's Hospital examined Claimant after she slipped and twisted her left knee at work. [R. 280, 284-85]. Dr. Welch concluded that she likely sprained her left knee and right middle finger and advised that she stay out of work for at least two weeks. [R. 279, 284]. On August 14, 2013, Dr. Samal examined Claimant concerning the same workplace injury and noted weakness in Claimant's right foot but no abnormalities, and that an MRI of her left knee showed osteoarthritis but no tears. [R. 276-77]. Dr. Samal determined that Claimant "should be able to go back to work when the pain decreases, " and referred her to Dr. Spencer Stanbury, M.D. in the orthopedic surgery department. [R. 278]. Dr. Stanbury reviewed X-rays of Claimant's right middle finger and saw that there was "no acute fracture or dislocation" and that her bones were positioned within normal limits. [R. 460]. He also administered a corticosteroid injection in Claimant's right hand, but, on October 9, 2013, Claimant returned to Dr. Stanbury, complaining that the corticosteroid injection had not relieved her pain. [R. 274, 458, 460]. He conducted a physical examination and found that Claimant had mild swelling and stiffness of her middle finger, as well as some stiffness and locking in her thumb. [R. 458]. He ordered a nerve conduction study and prescribed the use of a wrist splint at night. Id.

         On November 7, 2013, Dr. Jane Matthews, M.D. completed a RFC assessment of Claimant. [R. 84-91]. Dr. Matthews noted that X-rays of Claimant's middle finger showed no fractures or dislocation and normal bone mineralization, and that X-rays of her knee showed osteoarthritis but no tears. [R. 87]. She also recognized that Claimant had received ibuprofen, ointment, and cortisone injections to address her pain "with moderate to good results." Id. In concluding that Claimant could perform light work, she determined that Claimant was subject to the following exertional limitations: (a) occasionally climbing (ramps, stairs, ladders, ropes, or scaffolds), balancing, stooping, kneeling, crouching, and crawling; (b) occasionally lifting and/or carrying 20 pounds and frequently lifting and/or carrying 10 pounds; (c) standing and/or walking for about six hours in an eight-hour workday; and (d) sitting for about six hours in an eight-hour workday. [R. 89]. Dr. Matthews found no manipulative limitations or limitations on her ability to push and/or pull. Id.

         On November 26, 2013, Dr. Michael Rivlin, M.D. examined Claimant after electromyography ("EMG") and nerve conduction studies showed that she had moderate-severe bilateral carpal tunnel syndrome. [R. 332-33]. Dr. Rivlin assessed that Claimant's carpal tunnel syndrome was more symptomatic in her right hand than her left hand. [R. 332]. Claimant expressed to Dr. Rivlin that she did not want a cortisone injection to treat the pain in her hand but instead wanted to undergo a procedure to release her right carpal tunnel and middle finger. [R. 332]. Dr. Alison Kitay, M.D. performed a right carpal tunnel release and trigger finger release of the thumb and middle finger on June 3, 2014. [R. 449].

         On February 19, 2014, which was prior to the carpal tunnel surgery mentioned above, state-agency reviewing physician Dr. Harold Ramsey, M.D. completed a RFC assessment of Claimant. [R. 102]. In finding that Claimant could perform light work, he assessed that she was subject to the following exertional limitations: (a) occasionally climbing ramps or stairs; (b) never climbing ladders, ropes, or scaffolds; (c) occasionally balancing, stooping, kneeling, crouching, or crawling; (d) occasionally lifting and/or carrying 20 pounds and frequently lifting and/or carrying 10 pounds; (e) standing or walking for six hours in an eight-hour workday; and (f) sitting for six hours in an eight-hour workday. [R. 99-103]. He found that she was limited in bilateral handling and fingering due to her carpal tunnel syndrome, although he did not indicate how often she could perform such activities. ...

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