Borelli v. Berryhill

CourtDistrict Court, D. Connecticut
DecidedSeptember 6, 2019
Docket3:18-cv-00801
StatusUnknown

This text of Borelli v. Berryhill (Borelli v. Berryhill) is published on Counsel Stack Legal Research, covering District Court, D. Connecticut primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Borelli v. Berryhill, (D. Conn. 2019).

Opinion

UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT JASON BORELLI, : Plaintiff, : : No. 3:18-CV-801 (VLB) V. : NANCY A. BERRYHILL, ACTING : September 6, 2019 COMMISSIONER OF SOCIAL : SECURITY, : Defendant. : MEMORANDUM OF DECISION REMANDING THE CASE TO THE COMMISSIONER Plaintiff Jason Borelli (“Mr. Borelli” or “Plaintiff”) challenges the Commissioner of Social Security’s final decision to deny his application for disability benefits pursuant to 42 U.S.C. § 405(g). Mr. Borelli moves to reverse or remand the decision, arguing that the Administrative Law Judge (“ALJ”) failed to fully develop the record, that Mr. Borelli’s claims of pain were insufficiently evaluated, and that the residual functional capacity assessment is unsupported. Defendant Nancy A. Berryhill, Acting Commissioner of Social Security (“Defendant”), moves to affirm the Commissioner’s final decision. For the reasons stated below, the Court DENIES Defendant’s motion and GRANTS Plaintiff’s motion to remand to allow the ALJ to fully develop the record. |. Background Mr. Borelli was born in 1976 and educated up to the 8th grade.’ [R. 158, 160].2 He has a history of work in the manual trade. /d. Mr. Borelli is married with three children. /d. His disability claim is based primarily on chronic lower back pain resulting from herniated discs with impingement of the nerve root. /d. at 158, 161.

‘Mr. Borelli testified that he only went through 8th grade, though he could not remember at what age he stopped going to school, see [R. 160], and elsewhere in the record Mr. Borelli indicates he may have completed up to 10th grade, see [R. 310]. ? Citations to the record, [Dkt. 15], are identified as [R. __].

A. Medical Records* Dr. Borelli saw Dr. Xiaoming Hong for primary care treatment from March 2012 to October 2012, with continued appointments after that as well. [R. 408, 413, 417-21]. On March 23, 2012, Mr. Borelli saw Dr. Xiaoming Hong and complained of back pain stemming from a motor vehicle accident seven years prior. [R. 421]. Mr. Borelli reported tenderness and had a positive straight leg raising test, suggesting that a herniated disk may be the cause of the pain. /d. Mr. Borelli took Motrin and Percocet for the pain. [R. 418-20]. He also noted a history of mild depression and problems sleeping. /d. In April 2012, Plaintiff reported dental concerns, weight loss, difficulty sleeping, and mild depression. /d. Examinations of Plaintiff's extremities and neurological system were unremarkable. [R. 419]. During his next visit, Plaintiff reported that he was moving furniture and had pain in the middle of his back. [R. 417]. Dr. Hong prescribed Robaxin and Mobic. [R. 417]. In September 2012, Plaintiff reported low back pain; he requested Percocet, but did not want to go to pain management. [R. 413]. Dr. Hong referred Plaintiff to a cardiologist, Dr. Nathan Kruger, for dyslipidemia and complaints of chest discomfort. [R. 407]. Plaintiff saw Dr. Kruger on September 14, 2012. [R. 407]. Mr. Borelli complained of shortness of breath, jaw discomfort, severe headaches and episodic dizziness. /d. Dr. Kruger observed that Plaintiff walked comfortably and that he was neurologically intact. Id. His weight was noted at 305 pounds. Dr. Kruger recommended regular aerobic exercise to lose weight. /d.

3 The Commissioner stipulates to the facts included in Plaintiff's Brief, [Dkt. 19-1 at 2-11], and includes supplemental facts, see [Dkt. 27-1 at 2-18]. The Court’s recitation of the medical history is based on both parties’ mpgs and the record.

October 11, 2012, complaining of a variety of ailments including solid food dysphagia

(difficulty swallowing), bloating, and irregular bowel pattern. [R. 404-06]. The physical examination findings were unremarkable. Id. APRN Dunn recommended an endoscopy and a colonoscopy following cardiac clearance. Id. She also recommended a proton- pump inhibitor (PPI) and Align, but Plaintiff declined medication. Id. Mr. Borelli saw Dr. Steve Levin on November 16, 2012 for pain management evaluation for low back pain. [R. 398-403]. Mr. Borelli reported that his back pain had returned four months ago, noting that surgery was initially recommended but that he had lost weight and his back pain had improved. [R. 398]. Mr. Borelli indicated that his ability to perform activities of daily living, including household chores, shopping and driving, were intact. Id. Mr. Borelli’s gait was guarded, but he could heel and toe walk, indicating

normal muscle strength. [R. 399]. He had full strength through his upper and lower extremities and the straight leg raising tests were negative. Id. Dr. Levin noted diagnoses of degenerative disc disease with possible spondylosis, myofascial pain syndrome, sleep disturbance, and gait disturbance. [R. 402]. He referred Mr. Borelli to physical therapy / occupational therapy, and prescribed Baclofen and temporary Oxycodone. Id. On January 4, 2013, Plaintiff reported some benefit with pain medication. [R. 453-54]. Mr. Borelli reported to the emergency room at Milford Hospital on January 8, 2013 following a motor vehicle collision, reporting pain primarily in his left trapezius area. [R. 430-31]. Plaintiff reported that he did not take any medications and was prescribed

Oxycodone/acetaminophen and Flexeril. Id. On January 30 and in February 2013, Plaintiff reported continued benefit from medication to Dr. Levin. [R. 453]. Mr. Borelli had attended three physical therapy transcutaneous electrical nerve stimulation (“TENS”) unit during sessions and wanted to

use one at home as he had experienced improved symptoms after use. Id. In March 2013, Mr. Borelli returned to The Orthopaedic Group for the first time in approximately five years and saw Dr. Shirvinda Wijesekera. [R. 442-45]. On examination, Mr. Borelli’s weight was noted at 320 pounds, resulting in a Body Mass Index (“BMI”) of 41.1, within the “extreme obesity” range. Id. Mr. Borelli sat comfortably and was not in any acute distress; his mood and affect were normal. Id. Examinations of Mr. Borelli’s cervical and thoracic spine were unremarkable, but he had tenderness in his lumbar spine. Id. He had normal sensation, full strength, painless motion, and normal reflexes in his upper and lower extremities and he could toe and heel walk and rise from a seated position. Id. Dr. Wijesekera prescribed a course of steroids, Medrol Dosepak. Id. An

MRI of Mr. Borelli’s lumbar spine showed degenerative disc disease and facet arthropathy in the lumbar spine without central spinal canal stenosis; and left foraminal L3-L4 protrusion and mild facet arthropathy resulting in mild foraminal stenosis, and potential contact with the exiting L3 nerve root. [R. 447-48]. In March and April 2013, Mr. Borelli reported to Dr. Levin that he was benefitting from pain medication and use of the TENS unit. [R. 453]. Mr. Borelli had an orthopedic follow-up with physician’s assistant (“PA”) Sherri O’Connor in April 2013, reporting continued lumbar pain with radiculitis. [R. 441, 456]. On examination. Mr. Borelli showed a mildly positive straight leg raise on the left side and

a mildly antalgic gait, but was otherwise neurologically intact. [R. 441]. PA O’Connor noted that Mr. Borelli was having significant symptoms causing moderate-to-severe pain and noted her impression was that he had an L3-L4 disc bulge causing L3 radiculitis and Id.

Dr. Wijesekera administered a lumbar spine epidural injection in May 2013. [R. 432- 34, 446, 450]. Mr. Borelli reported that the injection increased his pain. [R. 423, 425, 427, 440]. Dr. Levin changed Mr. Borelli’s medication from Oxycodone to Oxycontin. [R. 452- 53]. In June 2013, Mr. Borelli asked Dr. Levin to change his medication back to Oxycodone. Dr. Levin offered him an alternative opioid, which Mr.

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Borelli v. Berryhill, Counsel Stack Legal Research, https://law.counselstack.com/opinion/borelli-v-berryhill-ctd-2019.