Archer v. Commissioner of Social Security

CourtDistrict Court, E.D. New York
DecidedMarch 19, 2024
Docket2:21-cv-05648
StatusUnknown

This text of Archer v. Commissioner of Social Security (Archer v. Commissioner of Social Security) is published on Counsel Stack Legal Research, covering District Court, E.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Archer v. Commissioner of Social Security, (E.D.N.Y. 2024).

Opinion

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK ------------------------------------------------------------------X BERNARDO ARCHER,

Plaintiff, AMENDED MEMORANDUM AND ORDER -against- CV 21-5648 (ARL)

COMMISSIONER OF SOCIAL SECURITY,

Defendant. ------------------------------------------------------------------X LINDSAY, Magistrate Judge:

The plaintiff, Bernardo Archer (“Archer”), brought this appeal pursuant to the Social Security Act, 42 U.S.C. § 405 et seq. (the “Act”), challenging a final determination by the Commissioner of the Social Security Administration that he was ineligible to receive Social Security disability insurance benefits. Before the Court are the parties’ cross motions for judgment on the pleadings pursuant to Fed. R. Civ. P. 12(c). For the reasons set forth below, the plaintiff’s motion is granted, the defendant’s motion is denied, and the matter is remanded for further administrative proceedings, including a de novo hearing and new decision. BACKGROUND The following facts are drawn from the parties’ Joint Stipulation of Facts. 1. Factual Background Archer is currently 50 years old, has a high school education and previously worked for a sanitation company as a garbage collector. Tr. 48-9, 5-2.1 He has not engaged in substantial gainful activity since July 8, 2018. Tr. 23, 49. Archer injured his back in a work-related accident in early 2017, which resulted in radiating pain into his left leg. Tr. 279. A CT scan revealed degenerative changes and a nonspecific sclerotic focus in the right lilac bone possibly

1 Tr. are citations to the Administration Transcript found at ECF No. 14. representing an incidental bone island. Tr. 283. But the films showed no acute fracture or subluxation and no high-grade spinal canal or foraminal stenosis. Tr. 283. During the examination following the accident, Archer exhibited no tenderness to palpation of the cervical, thoracic, or lumbar spine. Tr. 281. He did have decreased range of motion of the lumbar spine

secondary to pain in the lower back and his straight leg raising test was positive. Tr. 281. He also walked with a “mild” limp secondary to pain in the back. Tr. 281. He was able to move all extremities and had normal strength. Tr. 281. Archer was not hospitalized and was advised to take Tylenol and Motrin. Tr. 281. Following his February 2017 injury, and prior to the date he claims to have become disabled,2 Archer went to physical therapy, saw a chiropractor and received injections for pain relief. Tr. 305, 308, 317, 322, 326, 334. Archer claims that he has been disabled since July 8, 2018. At an examination on September 25, 2018, he presented with painful swallowing, dark urine and difficulty with walking. Tr. 502. Dr. Fanaee, his treating physician, noted that an MRI of his lumbar spine showed degenerative disc disease at L4-5 and L5-S1, facet arthropathy and lumbar spondylosis

at L4-5 and L5-S1, in addition to disc bulge at L4-5 and L5-S1 moderately narrowing the neural foramina bilaterally. Tr. 503. During the examination, Archer exhibited normal range of motion over his major joints and full motor strength. Tr. 503. His straight leg raising test was negative, but he had a decreased area of sensation consistent with an L5 dermatome in the left leg. Tr. 503. Archer agreed to try epidural steroid injections to treat his back pain. Tr. 503. Archer saw Dr. Fanaee again in January and February 2019, complaining of low back and right leg pain and numbness. Tr. 733-34. Dr. Fanaee noted in the chart that Archer had received medial branch blocks in October 2017 and January 2019 with 60 percent pain relief for two

2 Archer does not claim to have become disabled as of the date of the accident. weeks before returning to baseline. Tr. 733. Upon examination, Archer had normal strength. Tr. 734. His spine was not tender and a straight leg raising test was negative bilaterally. Tr. 734. Archer did have a decreased area of sensation along the L5 dermatome of the left leg. Tr. 734. Dr. Fanaee diagnosed him with lumbar herniated disc, lumbar spondylosis, lumbar degenerative

disc disease and lumbosacral radiculitis, and recommended radiofrequency ablation of L3, L4 and L5. Tr. 733-34. Archer returned to Dr. Fanaee in March 2019, complaining of occasional severe back and leg pain despite recently undergoing radiofrequency ablation. Tr. 722-23. A physical examination revealed a decreased area of sensation consistent with an L5 dermatome in the left leg. Tr. 723. By that point, Archer had undergone physical therapy, epidural steroid injections, and medial branch blocks, with varying degrees of success. Tr. 722. His examination was unchanged. Tr. 723. According to Dr. Fanaee’s records from March 26, 2019, Archer had “failed conservative therapy.” Tr. 723. On April 2, 2019, Archer then had an MRI of his lumbar spine that revealed significant degenerative disc disease from L4 to S1, facet arthropathy

and lumbar spondylosis L4-S5 and L5-S1, and a disc bulge at L4-L5 and L5-S1 moderately narrowing the neural foramina bilaterally. Tr. 731, 734. Archer returned to Dr. Fanaee’s office on April 9, 2019, complaining of low back pain that radiated into both of his legs. Tr. 718. He reported that he had been undergoing chiropractic treatments, which he found “somewhat helpful.” Tr. 718. Archer also reported 100% improvement of leg symptoms following an epidural steroid injection in October 2018, but only mild improvement in back pain. Tr. 718. He further stated that his left leg pain had subsequently returned. Tr. 718. Archer denied arm or leg weakness but reported difficulty with walking. Tr. 718. On examination, Archer appeared in “minimal distress,” had normal joint stability, normal range of motion over major joints, full motor strength, and a decreased area of sensation consistent with the L5 dermatome bilaterally. Tr. 719. However, his straight leg raising test was positive. Tr. 719. Dr. Fanaee recommended another injection, as well as a surgical consultation. Tr. 719.

Archer presented to Dr. Salvatore Palumbo in April 2019 with continued complaints of back pain. Tr. 692-93. A lumbar MRI demonstrated advancing significant degenerative disc disease at L4 – 5 and L5 – S1 and central disc herniation at L5 – S1 with some contact of the traversing nerve roots and non-significant compression. Tr. 693, 713. Archer indicated that he had pain across the lumbosacral junction as well as some intermittent pain in the anterior of his right thigh. Tr. 693. He also noted that he had received several injections that did provide some temporary relief but that the pain eventually returned. Tr. 693. During the examination, Archer had mild tenderness to palpation of the low back. Tr. 693. His motor examination was intact and reflexes were 2+ and symmetric. Tr. 693. Dr. Palumbo recommended continued conservative measures and Archer agreed not to pursue surgery. Tr. 693.

In June 2019, Archer returned to Dr. Fanaee complaining of low back pain radiating into his right leg. Tr. 659. At the time, Archer’s chief complaint was “low back pain radiating into the right leg for several years.” Tr. 659. Archer noted that he was recovering from epidural steroid injections in his lumbar spine with no apparent complications. Tr. 659. He further reported almost near improvement since the injection and stated that he had resumed chiropractic treatments and had no new issues to report. Tr. 659. After examining him, Dr. Fanaee noted that Archer had a positive straight leg raise test and decreased area of sensation consistent with L5 dermatome in both the right and left side. Tr. 660. He had normal joint stability with normal range of motion over his major joints. Tr.

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Archer v. Commissioner of Social Security, Counsel Stack Legal Research, https://law.counselstack.com/opinion/archer-v-commissioner-of-social-security-nyed-2024.