United States District Court, D. Massachusetts
MEMORANDUM AND ORDER REGARDING PLAINTIFF'S MOTION
FOR JUDGMENT ON THE PLEADINGS AND DEFENDANT'S MOTION FOR
ORDER AFFIRMING DECISION OF COMMISSIONER (DKT. NOS. 17 AND
22)
MICHAEL A. PONSOR U.S. DISTRICT JUDGE
I.
INTRODUCTION
Plaintiff
Cynara Ciraulo has applied for Social Security Disability
Insurance benefits (DIB) and Supplemental Security Income
benefits, alleging disability due to various physical
impairments dating from August 6, 2012. Her initial
application and petition for reconsideration were denied. A
hearing before Administrative Law Judge (ALJ) Kim Griswold
took place on January 6, 2015. After considering all the
evidence, a second ALJ, Addison Massengill, issued a decision
dated June 26, 2015, concluding that Plaintiff was not
disabled.[1]Plaintiff seeks to have the unfavorable
finding reversed and moves for judgment on the pleadings. In
response, Defendant has moved to affirm the final decision of
the Commissioner. For the reasons laid out below,
Plaintiff's motion will be allowed and Defendant's
denied.
II.
FACTUAL BACKGROUND
At the
time of her initial application, Plaintiff was a 27-year old
female claiming disability due to chronic pain,
hydronephrosis of the left kidney, an undiagnosed muscle
condition, muscle spasm, and severe muscle tension. She has a
high school education and a Bachelor of Science degree.
Plaintiff
has worked as a parking lot attendant, medical records clerk,
and a camp counselor. Plaintiff lives mainly with her
parents, but visits her husband in Kentucky every several
months, where she stays for a month. All citations are to the
Social Security Administration's Administrative Record of
Social Security Proceedings (“A.R.”) (Dkt. No.
16).
A.
Medical Background
Plaintiff
has a complex medical history, including asthma, chronic
pain, chronic laryngitis, bilateral kidney issues, and
frequent visits to emergency rooms for primary care. (A.R.
418-525, 606-07.)
In
August 2011, Plaintiff underwent ureteropelvic junction
surgery with pyeloplasty to remove a blockage in her left
kidney. (A.R. 555, 584.) She subsequently had a right
pyeloplasty in February 2012 and cystoscopy and bilateral
retrograde pyelogram with stent placement in August 2012.
(A.R. 555-56, 916-17.) In October and November 2012,
Plaintiff underwent a thoracic epidural steroid injection in
her left flank. (A.R. 557-59, 562-63.)
In
December 2012, Plaintiff presented to the Albany Medical
Center Hospital emergency room complaining of flank pain for
which she had had multiple interventions, including ureteral
stent placement and nephrostomy tubes placed on the left
side, without any significant reduction in pain. (A.R. 584.)
An ultrasound revealed left mild-to-moderate hydronephrosis.
(A.R. 584, 603.)
In
January 2013, Plaintiff visited Brian Banker, M.D.,
complaining of a sinus infection, difficulty breathing, and
nausea. (A.R. 608.) Dr. Banker treated Plaintiff for acute
bacterial sinusitis and refilled her Albuterol. (A.R. 609.)
That same month, Plaintiff visited Spencer L. Haller, M.D.,
reporting urological concerns and back pain; Dr. Haller
renewed her prescription for oxydocone. (A.R. 682-84.)
In
February 2013, Plaintiff continued to report back pain to Dr.
Haller as well ongoing flank pain, swelling and pain in her
fingers and neck, trouble sleeping, heartburn, and mild ankle
swelling. (A.R. 680.) Dr. Haller ordered MRI testing of the
spine and a bilateral renal ultrasound. (A.R. 682.) The MRI
of the thoracic spine showed minimal discogenic degenerative
changes with no focal signal abnormalities in the spinal cord
or focal disc herniation or spinal cord compression at any
level. (A.R. 611.) The MRI of the lumbar spine showed minimal
bulging of the L5-S1 disc. (A.R. 612.) The renal ultrasound
revealed “bilateral pelvocaliectasis left greater than
right.” (A.R. 613.)
In
March 2013, Plaintiff visited the Mercy Medical Center
emergency room complaining of flank pain occurring every few
months. (A.R. 615.) Her physical examination was normal
except for paraspinal muscle tenderness. (A.R. 616-17.) An
x-ray was unremarkable. (A.R. 618.) The physician recommended
Plaintiff take Dilaudid if her pain worsened. (Id.)
The same month, Plaintiff presented to Jeffrey G. Mulhern,
M.D. for further evaluation of her left flank pain and
urological concerns. (A.R. 606-07.) Dr. Mulhern noted that
Plaintiff reported constant pain, mainly on her left flank.
(A.R. 607.) He noted that the physical examination was
remarkable for blood pressure, which he reported as 128/75.
He told Plaintiff he did not believe there was an active
issue regarding kidney function and recommended Plaintiff
speak to her urologist. (Id.)
In May
2013, Plaintiff presented to the emergency room with
complaints of left leg pain, numbness, hoarseness, muscle
pain, and sleep problems. (A.R. 626.) On examination,
Plaintiff had normal range of motion in her back and
“sock like numbness and delayed hyperesthesia of [the]
left lower leg and foot in a sock-like distribution.”
(A.R. 628.) The differential diagnosis included chronic pain,
conversion, fibromyalgia, and multiple sclerosis; she was
discharged in stable condition. (Id.)
That
same month, Plaintiff reported to Dr. Haller that she was
having “ascending pain that went up to her shoulder and
now into her neck, and also started to go down her
legs.” (A.R. 672.) Plaintiff's physical examination
was normal except for diffuse tenderness to palpation in her
back and extremities. (A.R. 673.) Dr. Haller said that
Plaintiff's diffuse pain was of unclear etiology and
recommended a neurological evaluation and brain and cervical
spine MRIs. (A.R. 674.)
At the
end of August 2013, Plaintiff met with Dr. Haller. She was
assessed with chronic back pain, dysuria, and central pain
syndrome. (A.R. 666.)
The
next month, Plaintiff presented to Dr. Haller with complaints
of chronic pain in her back, calves, thighs, head, neck,
shoulders, and legs. She reported tingling, numbness, and
muscle spasms in her legs, and tics in her legs and hands as
well as elbow pain and pain in her left knee, hip, and ankle.
(A.R. 660.) Her physical examination was normal except for
mild back pain to palpation on the left straight-leg raise.
Plaintiff's diagnoses included mild, intermittent asthma;
chronic back pain; and ureteropelvic junction obstruction.
Dr. Haller noted that “fibromyalgia has been questioned
but I'm not certain given some of her neurologic
symptoms.” (A.R. 663.)
In
October 2013, Plaintiff presented to Lahey Clinic Medical
Center for a preoperative visit ahead of vocal cord surgery.
She reported suffering from urological concerns, chronic
pain, asthma, hay fever, gastroesophageal reflux, muscle pain
and weakness, and swelling in her legs, more on the left than
right. (A.R. 689.) Treatment notes stated that Plaintiff was
being treated by “neurology who continue to follow her,
considering fibromyalgia at this time.” (A.R. 689.)
Plaintiff denied musculoskeletal concerns and said her
asthma, hay fever, and gastrointestinal reflux were
controlled with medication. (A.R. 691.) Plaintiff said she
was able to climb two flights of stairs without symptoms.
(A.R. 692.)
That
same month, Plaintiff was examined by neurologist Kinan
Hreib, M.D. The exam was normal as to motor and sensory
function. (A.R. 745.) He assessed “[p]ain without a
neurological explanation . . . with a possible diagnosis of
fibromyalgia.” (A.R. 730).
In
December 2013, Plaintiff told Dr. Haller that she had
continued back pain and toe problems. (A.R. 1046.)
Plaintiff's examination was essentially normal except for
mild erythema (reddening of the skin) and swelling in her
right toe. (A.R. 1048.)
The
same month, Plaintiff visited rheumatologist Matthew Axelrod,
M.D. of the Lahey Clinic with complaints of a hoarse voice,
sore throat, and radiating left flank pain. Dr. Axelrod noted
that Plaintiff's “initial flank pain improved but
she has been left with long standing flank and muscle pain on
the left side.” He also noted that Plaintiff had been
told she had fibromyalgia. (A.R. 1128.) On physical
examination, Plaintiff had tenderness at the left greater
trochanter (hip joint) with palpation as well as diffusely
tender muscles but no weakness and full range of motion and
motor strength. (A.R. 1129.) Dr. Axelrod assessed chronic
pain and administered a Depo-Medrol and lidocaine injection
in her left hip. (A.R. 1130.)
Later
that month, Plaintiff visited Dr. Hreib with reports of
chronic pain and involuntary movements in her hands.
Plaintiff said Gabapentin had “reduced the pain by
75%.” (A.R. 1122.) On examination, Dr. Hreib noted that
Plaintiff had no tremors, myoclonus (muscle contractions), or
focal weakness; her gait was normal. The doctor did not
observe any involuntary movements. (A.R. 1124.)
In
February 2014, Plaintiff visited Priya Shastri, M.D., a Lahey
Clinic neurologist, with complaints of involuntary motor
movements for the past eight to nine months. Plaintiff said
although Gabapentin helped with the pain, it did not with the
movements. (A.R. 1102.) Plaintiff's musculoskeletal and
neurological examinations were normal. (A.R. 1103.) Dr.
Shastri made similar findings in May 2014 and July 2014.
(A.R. 1079, 1088-89.)
A
physical examination conducted by Dr. Axelrod on March 7,
2014, showed muscle tenderness but no weakness or limitations
in range of motion. (A.R. 1100.) Dr. Axelrod assessed
swelling in the larynx, diffuse pain, and “symptoms
that sound like inflammatory back pain.” (A.R. 1101.)
Dr. Axelrod administered an injection of Depo-Medrol and
lidocaine. (Id.)
Plaintiff
underwent an x-ray and an MRI of the pelvic joints in March
2014. The x-ray revealed no acute bone or joint abnormality,
while the MRI demonstrated mild bilateral sacroiliitis. (A.R.
1097, 1098.) That same month, Plaintiff reported continued
problems with hoarse voice and back pain. (A.R. 1099.) On
April 15, 2014, Dr. Axelrod noted that the MRI had shown
bilateral sacroiliitis and spondyloarthropathy, and stated
that he felt this was “likely anky[l]osing
spondylitis.”[2] (A.R. 1094.) Follow-up visits on July 8,
and October 15, 2014, showed the same symptoms. (A.R. 1076,
1082, 1093.) During an April 2014 visit, Dr. Haller also
assessed ankylosing spondylitis. (A.R. 1043, 1094.)
In May
2014, Plaintiff underwent a routine gynecological
examination. (A.R. 1032.) Plaintiff reported no gynecological
concerns and denied chest pain, leg swelling, palpitations,
back pain, joint pain or swelling, muscle pain, headaches,
...