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Medeiros v. Berryhill

United States District Court, D. Massachusetts

August 12, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         This is an appeal of a final decision of the Commissioner of the Social Security Administration (“SSA”). On April 5, 2017, the Administrative Law Judge (“ALJ”) issued a decision concluding that plaintiff Leonel Medeiros is not disabled. The SSA Appeals Council declined review on April 24, 2018. Plaintiff then filed an action with this Court.

         Plaintiff seeks reversal of the Commissioner's decision on two grounds. The Commissioner has moved to affirm the decision. For the reasons stated below, the decision will be affirmed.

         I. Background

         A. Factual Background

         1. Personal History

         Leonel Medeiros is 50 years old. He was born in Portugal, where he lived until age 16. (A.R. 24). He attended school in Portugal and went to night school in New Bedford upon his arrival to the United States to learn English. (A.R. 25). He lives in Acushnet, Massachusetts, with his wife and two children. (A.R. 31). He last worked in June 2009 as a landscaper; his responsibilities included planting, spreading loam, and constructing stone, brick, and concrete walls. (A.R. 26).

         Medeiros spends time completing chores such as vacuuming and putting away clothes, but reports that he always experiences severe pain after he does so. (A.R. 32). He occasionally walks to the bus stop to meet his children after school or goes to the mall to walk for 20 to 30 minutes. (A.R. 33-34). He reports that walking hurts his back and he has to sit down for 10 to 15 minutes afterward. (A.R. 34). He occasionally uses the computer, and sometimes helps his wife with cooking tasks, such as peeling potatoes, while sitting down. (A.R. 37-38).

         2. Medical History

         a. Spinal Issues

         Medeiros suffered an injury at work in August 2008 when he attempted to pick up heavy piping. (A.R. 29, 230). He felt a pop in his lower back and was immediately in pain and unable to stand. (A.R. 230, 440).

         An MRI on November 19, 2008, revealed degenerative disc disease at ¶ 5-S1 with broad subligamentous disc protrusion. (A.R. 595-96). He initially underwent conservative treatment, such as epidural steroid injections and physical therapy. (A.R. 440). The treatment failed, however, to relieve his pain.

         On October 28, 2010, Medeiros was evaluated by nurse practitioner Julie Welch. (A.R. 288-89). She noted that his symptoms had worsened in the two years since the injury and stated that his surgeon, Dr. Pedlow, recommended a transforaminal lumbar interbody fusion at the L5-S1 level. (A.R. 289). She evaluated him again on February 10, 2011, in preparation for the surgery, and noted that the procedure had been postponed because he had an upper-respiratory infection. (A.R. 441).

         On February 23, 2011, Medeiros underwent bilateral L4-5 foraminotomies with transforaminal lumbar interbody fusion surgery. (A.R. 294).

         Medeiros testified that he continued to experience back pain after his surgery. (A.R. 29). Nurse Welch evaluated him again on March 8, 2011, after the operation, and noted that his nerve pain had improved, but he was still experiencing tingling in his leg and stiffness in his back. (A.R. 497). On April 12, 2011, she evaluated him again, and found that he had some recurrence of nerve pain but not as bad as prior to the operation. (A.R. 498).

         At various medical appointments up to December 2012, Medeiros reported that his pain had worsened since the surgery, increased while sitting or driving, prevented him from completing household chores, and did not respond to physical therapy. (See, e.g. A.R. 465, 528, 676).

         On January 30, 2013, Medeiros underwent surgery at Massachusetts General Hospital to remove the hardware that had been put in his lower back during the 2011 surgery. (A.R. 1114-17).

         Following the surgery, Medeiros was seen by various medical providers at Southcoast Physicians Network Pain Center. (A.R. 1149-1205). He began seeing Dr. Allison Gorski in June 2013 at Southcoast Health for management of his lower back pain and continued to see her through May 2014. (A.R. 1184). Dr. Gorski noted that he reported continuous, stabbing pain in his lower back. (A.R. 1172, 1178, 1181, 1184).

         On May 2, 2014, Dr. Gorski noted that his pain had improved after use of the Duragesic patch but continued to be aggravated by activity. (A.R. 1149). Medeiros reported experiencing continuous, sharp pain that was slightly improved by medications and rest and aggravated by activity and walking. (A.R. 1157). He used Tramadol, non-steroidal anti-inflammatories, and narcotics at various points to treat his pain. (Id.). He also received epidural steroid injections, which reduced his pain for one week. (Id.). He did not experience side effects from the medication. (Id.).

         b. Mental Health Issues

         Medeiros was seen at Arbour Counseling Services approximately once every other month between August 2013 and March 2016. (A.R. 1149-1244, 1252-1302, 1363-77). His medical records note that he suffered from anxiety and depression as a result of his inability to work and that he took Wellbutrin to treat his symptoms. (Id.).

         On March 27, 2015, Dr. Don Whitworth, a licensed psychologist, evaluated Medeiros. (A.R. 1245-50). Dr. Whitworth noted that he had symptoms consistent with major depressive disorder. (A.R. 1250).

         c. Disability Evaluations

         On September 23, 2009, Medeiros was evaluated by Dr. David Winnick. (A.R. 679-82). Dr. Winnick noted that he was “cautiously optimistic” that Medeiros could make a full recovery. (A.R. 682). He concluded that Medeiros was “temporarily, partially disabled, ” but could work full-time. (Id.).

         On March 24, 2010, Dr. Gilbert Shapiro examined Medeiros for an independent medical evaluation. (A.R. 688-90). He concluded that Medeiros had “light duty capacity” and full use of his arms. (A.R. 690). He noted that Medeiros would ...

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