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Caterino v. Berryhill

United States District Court, D. Massachusetts

February 7, 2019




         Janet Caterino (“Caterino” or “plaintiff”) seeks judicial review of the denial of her application for disability insurance benefits by Nancy A. Berryhill (“the Commissioner” or “defendant”), the Commissioner of the Social Security Administration (“the SSA”). Pending before the Court are plaintiff's motion to reverse or remand the Commissioner's decision (Docket No. 14) and defendant's motion to affirm that decision (Docket No. 18). For the reasons that follow, plaintiff's motion will be denied and the Commissioner's motion will be allowed.

         I. Background

         A. Employment History and Alleged Disability

         Caterino was born in 1965. She completed 12 years of school. Her late husband owned a company that installed bathtubs and glazed tiles. She was the bookkeeper for that company and also helped her husband move materials to and from vans. At some point before 2014, plaintiff's husband died.

         On July 14, 2014, the alleged onset date for purposes of her application for disability insurance benefits, Caterino went to New England Neurological Associates and was seen by Dr. Arya Farahmand. Caterino had been treated by Dr. Farahmand for migraine headaches two years before. She again complained of migraines, severe neck pain that radiated down her right shoulder and occasional numbness in her right hand and fingers. Upon examination, Dr. Farahmand determined that she had normal strength and sensation in her arms. Dr. Farahmand, nevertheless, ordered an MRI which was done in August, 2014. It revealed several disc herniations. At about the same time, Caterino also began complaining of numbness in her left arm and hand. Dr. Farahmand referred her to an orthopedic surgeon for a second opinion.

         In late August, 2014, plaintiff met with Dr. Joseph Weistroffer and complained of right-sided neck pain and numbness that radiated down her left arm into her fingers. She also reported that her migraine headaches and neck pain had worsened over the previous two months. Dr. Weistroffer noted that plaintiff had significant bilateral stenosis at two of her discs which could have caused her pain. Upon examination, Caterino demonstrated a normal range of motion of her neck and shoulders and full strength and intact sensation in her arms. The doctor offered her injections to manage the pain and surgery if the injections were ineffective.

         In November, 2014, plaintiff saw Dr. Farahmand again, reporting significant improvement in her headaches but noting pain when she moved her head and neck. She displayed no abnormalities in her extremities or focal neurological deficits. Dr. Farahmand administered an injection to further alleviate her pain.

         Caterino next saw Dr. Farahmand in February, 2015. She reported that the earlier injection had relieved her pain for several months but that it had gradually recurred over the right side of her neck and head. She also reported that her migraine headaches were generally under control.

         In April, 2015, Caterino met with Dr. Farahmand again. She reported that her headaches and her pain had improved after beginning a new medication, Topomax. Upon examination, she displayed no abnormalities in her extremities or focal neurological deficits. Dr. Farahmand prescribed a low dose of propanol to alleviate her migraines. That was Caterino's last medical appointment before her eligibility for disability insurance benefits expired on April 30, 2015.

         B. State Physician Medical Opinions

         Two doctors rendered opinions as to plaintiff's residual functional capacity (“RFC”), meaning her ability to perform physical and mental work activities on a sustained basis despite the limitations from her impairments. Both doctors were state agency physicians.

         Dr. Robin Tapper performed a review of Caterino's then-existing medical record in June, 2015, and Dr. John Benanti did the same in September, 2015. Both doctors indicated that Caterino has exertional limitations of 1) lifting and/or carrying no more than 20 pounds occasionally and no more than 10 pounds frequently and 2) standing, sitting or walking no more than six hours out of an eight-hour workday. Both doctors agreed that Caterino has additional postural limitations with respect to 1) climbing ramps, stairs, ladders, ropes and scaffolds, 2) balancing, 3) stooping, 4) crouching and 5) crawling.

         Neither doctor found that Caterino had manipulative limitations. Dr. Benanti specifically found that, based on her medical records, Caterino had no neurological deficits and her hand movements were normal despite her neck and shoulder pain. Based on their assessments of plaintiff's physical RFC, the doctors both concluded that she is able to perform light work.

         C. Subsequent Medical History

         Since Caterino's last date of eligibility, she has continued to receive treatment from various doctors for her neck pain and related issues. In July, 2015, images from a thoracic MRI indicated moderate changes of cervical spondylosis in several of the discs in her neck and mild degeneration of the lower thoracic disc spaces. At about that time, she reported increased neck and right arm pain and several new problems, including 1) a burning sensation in her abdomen that radiated to her right leg and 2) low back, hip and leg pain. In August and September, 2015, Caterino underwent physical therapy for pain in her back and hip with little to no improvement in her pain levels. She continued to see Dr. Farahmand periodically for her chronic migraines, neck and back pain and also received numerous injections, including several to her lumbar spine.

         In March, 2016, plaintiff had neck surgery to repair her herniated disc and spinal stenosis. She reported improvement with respect to her arm pain in the three and a half months that followed that surgery and she engaged in physical therapy to deal with general weakness in her arms. In August, 2016, however, Caterino reported to Dr. Farahmand a new complaint of abnormal sensation, swelling and numbness in her legs and Dr. Farahmand noted, for the first time, the possibility that Caterino had some degree of fibromyalgia.

         By October, 2016, plaintiff's neck surgeon reported that she had experienced minimal reduction of the pain in her neck and right arm, even after surgery and physical therapy. She also told her surgeon that she had been diagnosed with fibromyalgia. Her surgeon noted, however, that it was unclear how much the recently diagnosed fibromyalgia contributed to her pain. In November and December, 2016, plaintiff met with a rheumatologist who determined that there was no evidence of a rheumatological autoimmune disease, such as lupus, but also suggested myalgia as a possible diagnosis. In January, 2017, Dr. Farahmand reiterated his suspicion that Caterino was suffering from fibromyalgia due to her history of migraines and chronic pain.

         In February, 2017, plaintiff met with Dr. Salony Mujmudar, a rheumatologist in Dr. Farahmand's office, who indicated that plaintiff had demonstrated loss of motion and constant throbbing pain ...

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