Baines v. Astrue

781 F. Supp. 2d 228, 2011 U.S. Dist. LEXIS 17189, 2011 WL 722959
CourtDistrict Court, D. Delaware
DecidedFebruary 22, 2011
DocketCivil Action 10-006-LPS
StatusPublished
Cited by3 cases

This text of 781 F. Supp. 2d 228 (Baines v. Astrue) is published on Counsel Stack Legal Research, covering District Court, D. Delaware primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Baines v. Astrue, 781 F. Supp. 2d 228, 2011 U.S. Dist. LEXIS 17189, 2011 WL 722959 (D. Del. 2011).

Opinion

MEMORANDUM OPINION

STARK, District Judge:

I. INTRODUCTION

Plaintiff Brenda Baines (“Baines”) appeals from a decision of Defendant Michael J. Astrue, the Commissioner of Social Security (the “Commissioner”), denying her application for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Title II and Title XVI of the Social Security Act (the “Act”), 42 U.S.C. §§ 401-433, 1381 — 1383f. This Court has jurisdiction over the matter pursuant to 42 U.S.C. § 405(g).

Presently pending before the Court are cross-motions for summary judgment filed by Baines and the Commissioner. (D.I. 8, 10) Baines asks this Court to direct an award of benefits in her favor or, alternatively, to reverse and remand the Commissioner’s decision. (D.I. 8) The Commissioner requests that this Court affirm his decision. (D.I. 10) For the reasons set forth below, Baines’ motion will be granted, and the Commissioner’s motion will be denied. The decision of the Commissioner dated March 3, 2009 will be reversed, and this matter will be remanded to the Commissioner for further findings and/or proceedings consistent with this Memorandum Opinion.

II. BACKGROUND

A. Procedural History

Baines filed her claim for DIB and SSI on January 26, 2007, alleging disability since June 15, 2006, due to high blood pressure, migraine headaches, blackouts, dizzy spells, tumors, tendinitis, a separated *230 rotator cuff, anemia, vertigo, and irregular heart activity. (D.I. 5 (“Transcript” and hereinafter “Tr.”) at 8, 122-33, 164) Baines’ application was denied initially and on reconsideration at the pre-hearing administrative levels. (Tr. 88-92, 96-101) Thereafter, Baines requested a hearing before an administrative law judge (hereinafter “ALJ”). A hearing was held on August 5, 2008. (Tr. 24-57) The ALJ issued a decision dated February 26, 2009, concluding that Baines was not disabled and denying benefits. (Tr. 6-19) Baines timely requested review of the ALJ’s decision by the Appeals Council, and the Appeals Council denied the request for review without substantive explanation. (Tr. 1-5) Thus, the March 3, 2009 decision of the ALJ became the final decision of the Commissioner. 20 C.F.R. §§ 404.955, 404.981; Sims v. Apfel, 530 U.S. 103, 107, 120 S.Ct. 2080, 147 L.Ed.2d 80 (2000).

On January 5, 2010, Baines filed a complaint seeking judicial review of the ALJ’s March 3, 2009 decision. (D.I. 1) On June 28, 2010, Baines moved for summary judgment. (D.I. 8) In response, the Commissioner filed a cross-motion for summary judgment, and a combined opening brief in support of his cross-motion and opposition to Baines’ motion requesting the Court to affirm the A.L.J.’s decision. (D.I. 10, 11) Baines has filed a reply brief. (D.I. 12) Accordingly, the Court will proceed to address the merits of Baines’ claims.

B. Factual Background

1. Baines’ Medical History, Treatment, And Condition

At the time the ALJ issued his decision, Baines was forty-six years old and defined as a younger individual under 20 C.F.R. §§ 404.1563(c), 416.963. (Tr. 122) Baines has a high school education and past work experience as a mail room clerk, secretary, stenographer, customer service representative for Ticketmaster, and possibly as a telemarketer. (Tr. 32-35, 136, 147-149)

Baines treated with Sung Ho Bae, M.D., a neurologist, for complaints of vertigo, dizziness, frequent tripping, and occasional migraine headaches. (Tr. 232) Baines’ examination was essentially normal, and an MRI of Baines’ brain was also normal. (Tr. 234, 221) During follow-up examinations, Dr. Bae reported no obvious or genuine organic weakness in Baines’ motor examination, and no evidence of focal neurological lesion. (Tr. 287) Dr. Bae advised Baines to exercise regularly and lose weight. (Tr. 298) Because Dr. Bae believed some of Baines’ symptomology may be related to her medications, he also suggested eliminating or reducing certain prescriptions. (Tr. 298)

At Dr. Bae’s suggestion, Baines also underwent two sleep studies. Both showed no significant sleep disorder, but suggested that the possibility of narcolepsy be considered. (Tr. 234, 298)

Baines’ family physician, Pasquale Fucci, M.D., referred Baines to two orthopedic surgeons, Mohammad Kamali, M.D. and J. Douglas Patterson, M.D., for treatment of left shoulder pain and left arm pain. In February 2007, Dr. Kamali diagnosed Baines with left shoulder impingement syndrome, gave her a steroid injection, and recommended exercise. In April 2007, Baines returned to Dr. Kamali for difficulties with her left arm and leg due to a stroke she suffered on March 10, 2007. Dr. Kamali suggested that Baines see a neurologist, (Tr. 345)

In June 2007, Baines treated with Dr. Patterson. He diagnosed adhesive capsulitis of the right shoulder and recommended physical therapy and an MRI to rule out a rotator cuff tear. (Tr. 343) A July 2007 MRI of Baines’ right shoulder confirmed Dr. Patterson’s impression of adhesive capsulitis and showed no signifi *231 cant rotator cuff pathology. (Tr. 342, 347) An August 2007 MRI showed a small (10-20%) partial thickness undersurface tear of the supraspinatus with some adjacent tendinopathy and mild degenerative changes. Dr. Patterson advised Baines that most surgeons would not repair a 10-20% partial thickness tear, but that surgery for either a shoulder release or closed manipulation could be considered. (Tr. 611)

At the referral of Dr. Patterson, Baines saw Joseph J. Mesa, M.D., another orthopedic surgeon. Dr. Mesa performed a manipulation of Baines’ right shoulder in October 2007, in order to achieve full range of motion. (Tr. 403, 447) Dr. Mesa referred Baines to physical therapy with Daniel A. Elkins, who noted that Baines “met most goals.” Baines was discharged with a home exercise program.

In April 2008, Dr. Mesa referred Baines for an MRI of the cervical spine. Baines’ MRI findings were limited due to motion. However, the MRI indicated multi-level significant spondylotic degenerative change, disc bulge resulting in a variable amount of spinal stenosis and multi-level foramina narrowing. (Tr. 372, 459)

Shortly thereafter, Baines treated with Philip S. Kim, M.D., for neck and shoulder complaints. (Tr. 462) Dr. Kim noted that Baines was not employed, but that she did a lot of housework, which exacerbated her condition. Dr. Kim recommended physical therapy and cervical epidural steroid injections. (Tr. 463) An MRI of Baines’ lumbar spine was normal. (Tr. 370) Dr. Kim treated Baines with two cervical epidural injections and referred her back to Dr. Mesa for re-evaluation of the possibility of shoulder impingement or rotator cuff tear.

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Bluebook (online)
781 F. Supp. 2d 228, 2011 U.S. Dist. LEXIS 17189, 2011 WL 722959, Counsel Stack Legal Research, https://law.counselstack.com/opinion/baines-v-astrue-ded-2011.