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Oliveras v. Social Security Administration

United States District Court, D. Massachusetts

January 2, 2019




         This is an action for judicial review of a final decision by the Commissioner of the Social Security Administration (“Commissioner”) denying the application of Colleen Oliveras (“Plaintiff”) for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”). Plaintiff has filed a Motion for Order Reversing the Decision of the Commissioner (Docket No. 15), and the Commissioner has filed a cross Motion to Affirm the Commissioner's Decision. (Docket No. 15). For the reasons set forth below, Plaintiff's motion (Docket No. 15) is granted and Defendant's motion (Docket No. 19) is denied.


         1. Procedural History

         On July 21, 2015, Plaintiff filed for disability benefits under Title II and Title XVI, alleging disability beginning July 2, 2014. (AR 206-19). Her claim was denied at the initial and reconsideration levels. (AR 103-30). Subsequently, Plaintiff requested and received an administrative hearing. (AR 146-47). On April 3, 2017, Administrative Law Judge Kim K. Griswold (“ALJ”) concluded that Plaintiff was not disabled (AR 11-23).

         The Appeals Council denied Plaintiff's request to review the decision, and the ALJ's decision therefore became the final decision of the Commissioner. (AR 1-4). Plaintiff has exhausted her administrative remedies, and this case is therefore now ripe for review under 42 U.S.C. 405(g).

         2. Medical History

         On March 7, 2014, Plaintiff saw Dr. Shubhada Javlekar, her primary care physician. Dr. Javlekar noted that Plaintiff's past medical history was significant for psoriasis, scoliosis, and that she had a history of chronic low back pain. Dr. Javlekar also reported that Plaintiff had Crohn's disease and could not tolerate nonsteroidal anti-inflammatories. Plaintiff was taking Percocet 5/325 mg four times per day for her back pain. On examination, Plaintiff had no edema, no point tenderness in her spine, and minimal sensitivity on the bilateral paraspinal muscle and lumbosacral area. In addition, her deep tendon reflexes were intact. (AR 381-82).

         On July 2, 2014, Plaintiff again saw Dr. Javlekar for a follow-up to monitor her blood pressure. She had “[n]o abdominal pain, nausea, vomiting . . . diarrhea [or] constipation.” (AR 368). The examination showed no abnormalities, and her Crohn's was “stable.” (AR 369-70).

         On February 7, 2015, Plaintiff again treated with Dr. Javlekar for low back pain. Plaintiff claimed that her back pain flared up because her work involved standing for long periods. Dr. Javlekar noted that her Crohn's “has been OK.” Further, Plaintiff denied abdominal pain, nausea, vomiting, heart burn, diarrhea, or constipation. Dr. Javlekar's revealed no edema and she reported that Plaintiff's chronic low back pain and Crohn's were well controlled on her current medications. She described Plaintiff as “medically stable.” (AR 352-54).

         On June 24, 2015, Plaintiff again treated with Dr. Javlekar. Dr. Javlekar noted: “The patient has a history of Crohn's disease. She is on Humira. She follows up with Dr. Papper periodically. She has been experiencing some trouble related to fistulas and she is going to set up the appointment. As far as her low back pain she takes Percocet up to four times a day as needed. She tries to space them out. Usually, the pain is under control enough for her to carryout day-today activity; otherwise, she has difficulty doing so.” On examination, Dr. Javlekar found Plaintiff was not in any acute distress. Plaintiff's abdomen was soft and nontender and her bowel sounds were normal. Further, her extremities showed no edema. Dr. Javlekar additionally reported that Plaintiff's blood pressure was adequately controlled, and that Plaintiff stated that she periodically has some discomfort in the rectal area secondary to her Crohn's disease. (AR 329-30).

         On August 27, 2015, Plaintiff filled out a Function Report in connection with her application. She reported that she cares for her five children, with help from her mother. Plaintiff indicated that she must dress and bathe slowly due to her back pain and uses the bathroom frequently due to her Crohn's. Plaintiff further reported that she prepares meals for herself and her children daily, goes shopping, drives, and attends to her children's schools. She said she has difficulty with physical activities due to her back pain but reported no problems paying attention, following instructions, or getting along with others. (AR 262-69).

         On October 2, 2015, Plaintiff saw Dr. Raul Endriga for a consultative physical examination. On examination, Dr. Endriga noted that Plaintiff had no tenderness on pressure over the spinal rea and no muscle spasms. Movements of the back were normal and there was no tenderness on twisting movements. Examination of the abdomen showed that it was soft and non-tender with normal bowel sounds, there was no evidence of ascites, and the liver and spleen were not palpable. The rest of the examination was unremarkable. (AR 394-96).

         On December 11, 2015, Plaintiff treated with Michael Richards, PA-C, for her Crohn's disease. PA-C Richards noted that Plaintiff's symptoms had primarily been abdominal pain and diarrhea. That day, Plaintiff reported that abdominal pain had not been an issue, it was only occasional and short-lived when it did occur. Plaintiff reported experiencing nausea in the evening about one a week, which was relieved by a bowel movement. She further reported that diarrhea occurred perhaps twice a month and could last all day. She was taking Tylenol No. 3 for her back pain and believed that might cause the diarrhea. According to Plaintiff, her biggest concern over the past couple of months was diffuse joint pain with stiffness in the morning in her elbows, wrists, and knees. On examination, Plaintiff was sitting comfortably in no accuse distress. Abdominal exam showed positive bowel sounds, soft, non-tender, non-distended, with no masses and no hepatosplenomegaly. Ultimately, PA-C Richards concluded that Plaintiff's Crohn's appeared to be well-controlled on Humira, which she tolerated well. (AR 412).

         The same day, PA-C Richards filled out a Medical Source Statement. He indicated that Plaintiff has a history of small bowel Crohn's, with symptoms under “fair-good control.” In addition, PA-C Richards reported that Plaintiff randomly has “breakthrough” symptoms causing pain and diarrhea which last all day and that she cannot work during these episodes. (AR 400).

         On December 15, 2015, PA-C Richards filled out a Crohn's and Colitis Residual Functional Capacity questionnaire. He reported that Plaintiff had chronic diarrhea, but no pain. In addition, Plaintiff's symptoms were seldom severe enough to interfere with attention and concentration, and emotional factors did not contribute to her symptoms. In PA-C Richards's opinion, Plaintiff would “possibly” need to take restroom breaks hourly, with minutes of advanced notice needed for a restroom break. Finally, PA-C Richards opined that Plaintiff would likely be absent from work about three days per month due to her Crohn's. (AR 401-405).

         On December 18, 2015, Dr. Javlekar filled out a Medial Source Statement. She indicated that Plaintiff could frequently lift/carry less than 10 pounds, that Plaintiff could stand/walk less than 2 hours per day, and that Plaintiff must periodically alternate between sitting and standing to relieve pain or discomfort. Dr. Javlekar additionally noted that Plaintiff could only occasionally climb and balance and never kneel crouch, crawl, or stoop. Finally, Dr. Javlekar noted that Plaintiff had limited ability to perform fine manipulation and that cold temperatures exacerbate her symptoms. (AR 406-409).

         In both the initial and reconsideration determinations, the State Agency consulting physicians concluded Plaintiff had no severe impairments. (AR 103-14; 117-28).

         Standard of Review

          This Court may not disturb the Commissioner's decision if it is grounded in substantial evidence. 42 U.S.C. 405(g); 1383(c)(3). Substantial evidence exists when there is sufficient evidence that a reasonable person could agree with the conclusion. Rodriguez v. Sec'y of Health & Human Servs., 647 F.2d 218, 222 (1st Cir. 1981). Thus, this Court must uphold the Commissioner's findings “if a reasonable mind, reviewing the evidence in the record as a whole, could accept it as adequate to support his conclusion, even if the administrative record could support multiple conclusions.” Ortiz v. Sec'y of Health & Human Servs., 955 F.2d 765, 769 (1st Cir. 1991) (quotation marks and citation omitted).

         Standard of ...

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