Botelho v. Colvin

153 F. Supp. 3d 451, 2015 U.S. Dist. LEXIS 169504, 2015 WL 9272854
CourtDistrict Court, D. Massachusetts
DecidedDecember 18, 2015
DocketCIVIL ACTION NO. 15-11778-MPK
StatusPublished
Cited by2 cases

This text of 153 F. Supp. 3d 451 (Botelho v. Colvin) is published on Counsel Stack Legal Research, covering District Court, D. Massachusetts primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Botelho v. Colvin, 153 F. Supp. 3d 451, 2015 U.S. Dist. LEXIS 169504, 2015 WL 9272854 (D. Mass. 2015).

Opinion

MEMORANDUM AND ORDER ON PLAINTIFF’S MOTION FOR JUDGMENT ON THE PLEADINGS ' (#10) AND DEFENDANT’S MOTION TO AFFIRM COMMISSIONER’S DECISION (#13).

KELLEY, UNITED STATES MAGISTRATE JUDGE

I. Introduction

Plaintiff Lucia F; Botelho seeks reversal of the decision of Defendant Carolyn Col-vin, Acting Commissioner of the Social Security Administration (“SSA”), denying her Disability Insurance Benefits (“DIB”). (#10.) Defendant moves for an Order affirmin the Commissioner’s decision. (#13.) With the administrative record having been filed and the issues fully briefed (##7, 11, 12), the cross motions stand ready for decision.

II. Background

A. , Procedural History

Plaintiff applied for DIB on February 29,2012. (TR at 315-316.)2 She alleged that she became disabled on December 16, 2010, due to lupus; chronic pain in muscles, joints, and nerves; fatigue; depression; and anxiety. (TR at 210.) Her applications were denied initially (TR at 236-238) and upon reconsideration. (TR at 240-242.)

[454]*454Botelho filed a written request for a hearing on December 3, 2012. On October 31,2013, a hearing was held before Administrative Law Judge (“ALJ”) Stephen C. Fulton. (TR at 39-75.) At the hearing, ALJ Fulton heard testimony from Plaintiff and James F. Scorzelli, Ph.D,, a vocational expert. (TR at 23.) On December 23, 2013, the ALJ found Plaintiff not disabled. (TR at 20-38.) Plaintiff requested review by the Appeals Council on January 21, 2014 (TR at 18), but was denied on March 6, 2015. (TR at 1-7.) As a consequence of the denial, the ALJ’s decision de facto became the final decision of the Acting Commissioner, subject to judicial review under 42 U.S.C. § 405(g). Plaintiff filed the instant case in federal court on May 5, 2015. (#1.) She has not challenged the ALJ’s findings on her mental limitations, only his determination of her physical impairments. (#11 at 2 n.4.)

B. Factual History

1. Medical Records .

'Plaintiffs relevant medical history begins on August 1, 2008, when she was hospitalized following one month of symptoms including daily fevers of up to 103 degrees, chills, drenching sweats, weakness, vomiting, headaches, decreasing apr petite, a rash, and weight loss. (TR at 385, 392.) She was tentatively diagnosed with systemic lupus erythematosus (“SLE”) before being discharged on August 5, 2008. (TR at 373-388.)

On December 4, 2008, Plaintiff was seen by Bonnie Lee Bermas, M.D. “in consultation for possible diagnosis of systemic lupus erythematosus.” (TR at 493.)' On this date Dr. Bermas noted that Plaintiff had “diffuse alopecia;” she had no ’skin rashes or lymphadenopathy; her lungs were clear; her hands appeared normal and had good grip strength; her fingers, elbows, shoulders, and wrists had a good range of motion; her ankles were “fine;” and her muscle strength was “5/5.” (Id.) Plaintiff was taking CellCept, prednisone, hydroxychlo-roquine, and hydrochlorothiazide; (Id.) Lab testing showed her kidney function was “slightly better” than it had been in the hospital. (TR at 480.)

On January 29, 2009, Dr. Bermas saw Plaintiff for headache, sinus infection, and bloating. (TR at 492.) Dr. Bermas wrote: “Skin is without rashes. No lymphadenopa-thy. Lungs are clear. Cardiac exam is normal. Abdomen is benign. Examination of her joints reveals normal-appearing hands, good grip strength, normal DIPs, PIPs, MCPs, wrists, elbows, shoulders, hips, knees and ankles within normal limits.”3 Dr. Bermas also noted that Plaintiffs “Lupus is stable.” (Id.) Dr. Bermas increased the dose of CellCept and decreased the prednisone. (Id.) Lab testing showed “some mild proteinuria.” (/d)

On March 12, 2Ó09, Dr. Bermas saw Plaintiff for “followup of her lupus.” (TR at 482.) Plaintiff was “noticing more and more joint pain,” had continuing headaches, swollen and painful hands, and wore an ankle brace. (Id.) Plaintiff was taking CellCept, clobetasol, fioricet, hydrochlo-rothiazide, hydroxychloroquine, and pred-nisone. (Id.) Despite these increased symptoms, Dr. Bermas again noted “Lupus is stable,” and wrote that “Examination of her joints reveals normal-appearing hands, good grip strength, normal DIPs, PIPs, MCPs... and ankles within normal limits.” (Id.) She deferred adjusting Plaintiffs medication until after 'her appointment with a renal specialist. (Id.)

[455]*455On the same date, Plaintiff was seen by Johannes Schlondorff, M.D., Ph.D., a renal specialist, for “lupus with proteinuria” (TR at 486.) He noted- that Plaintiff had “SLE with possible renal involvement,” but was unable to determine if her kidneys were affected by lupus or by another cause. (TR at-487.) On April 2, 2009, Dr. Schlondorff reviewed' Plaintiffs medical records, and recommended “close monitoring and renal biopsy” only if her condition worsened. (TR at 483.)

On May 21,2009, Dr. Bermas saw Plaintiff for “followup of her lupus.” (TR at 482.) Dr. Bermas again noted “Lupus is stable,” and mentioned that Plaintiffs right ankle had "some decreased” range of motion.4 (Id.) Despite this, she again wrote that her “ankles [were] within normal limits.” (Id.) Dr. Bermas prescribed lisinopril and discontinued prednisone. (Id.) Labs showed Plaintiffs kidney function was “slightly better” than the previous test. (TR at 480.)

On August 24, 2009, Dr. Bermas saw Plaintiff for mouth sores, headaches, and slurred speech. (TR at 479.) Dr. Bermas again noted “Lupus is stable.” (Id.) Labs showed “the kidney function tests are better.” (TR at 477.)

On November 19, 2009, Dr. Bermas saw Plaintiff for swollen hands, arm stiffness, diarrhea, occasional mouth sores and chest pain, headaches, and tiredness. (TR at 476.) Dr. Bermas again noted “Lupus is stable.” (Id.) Labs showed increased protein in Plaintiffs urine. (TR at 474.)

On .February 4, 2010, Plaintiff had breast reduction surgery due to back and neck pain. (TR at 440-441, 472, 495.) She “tolerated the procedure without difficulty” and had an “uneventful” postoperative period. (TR at 441.) On February 10, March 17, and July 7, 2010, Plaintiff was seen for- follow-up by Bohdan Pomahac, M.D., who noted that she had “nicely healed” from the procedure. (TR at 469-471.)

On March 21, 2011, Dr. Bermas saw Plaintiff for weight loss and feeling “worse” after having been unable to afford her medication for four months. (TR at 464.) Dr. Bermas again noted “Lupus is stable.” (Id.) Labs showed protein in.her urine, and Dr. Bermas prescribed Cell-Cept, hydroxychloroquine, and lisinopril. (TR at 463-64.)

On November 10, 2011, Dr. Bermas saw Plaintiff for lupus symptoms including hair loss, “rare mouth sores,” and joint pain. (TR at 461.) Dr. Bermas again noted “Lupus is stable.” (Id.) Labs showed protein in Plaintiffs urine, and Dr. Bermas prescribed lisinopril. (TR at 458.)

On March 1, 2012, Dr. Bermas saw Plaintiff for lupus symptoms including “a lot of pain... stiffness, she feels as if her nerve [endings] are bothering her. Right thumb is stiff. No fluid retention. Some headaches, minimal skin lesions, no chest pain.” (TR at 455.) Dr.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
153 F. Supp. 3d 451, 2015 U.S. Dist. LEXIS 169504, 2015 WL 9272854, Counsel Stack Legal Research, https://law.counselstack.com/opinion/botelho-v-colvin-mad-2015.