Dunbar v. Commissioner of Social Security

CourtDistrict Court, W.D. New York
DecidedFebruary 3, 2021
Docket1:19-cv-00994
StatusUnknown

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

Bluebook
Dunbar v. Commissioner of Social Security, (W.D.N.Y. 2021).

Opinion

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK ______________________________________

TIFFANY D.,1 DECISION AND ORDER

Plaintiff, 1:19-CV-0994(JJM) v.

COMMISSIONER OF SOCIAL SECURITY,

Defendant. ______________________________________

This is an action brought pursuant to 42 U.S.C. §1383(c)(3) to review the Commissioner of Social Security’s final determination that plaintiff was not entitled to Supplemental Security Income (“SSI”) benefits. Before the court are the parties’ cross-motions for judgment on the pleadings [10, 15]. 2 The parties have consented to my jurisdiction [16]. Having reviewed the parties’ submissions [10, 15], the action is remanded. BACKGROUND The parties’ familiarity with the 534-page administrative record [6] is presumed. Plaintiff filed for SSI in June 2016,3 when she was 45 years old, due to depression, history of cervical cancer, seizures, blackouts, fibromyalgia, a cracked pelvic bone in 2004, and nerve damage. Id., pp. 65, 163.

1 In accordance with the guidance from the Committee on Court Administration and Case Management of the Judicial Conference of the United States, which was adopted by the Western District of New York on November 18, 2020 in order to better protect personal and medical information of non- governmental parties, this Decision and Order will identify the plaintiff using only her first name and last initial. 2 Bracketed references are to the CM/ECF docket entries. Unless otherwise indicated, page references are to numbers reflected on the documents themselves rather than to the CM/ECF pagination.

3 Earlier applications for benefits had been filed by plaintiff in 2008 and 2011. [6], p. 65. Preceding the filing of this SSI application, plaintiff was seen at the Community Health Center of Buffalo on October 31, 2014 for “chronic pain all over the body”. Id., p. 201. At that time, she reported that she could not sit or stand for long periods of time. Id. It was noted that she had “positive tender points for [fibromyalgia]” and was referred to “neurology for

evaluation of possible fibromyalgia”. Id., p. 202. Although that evaluation does not appear to be in the record, when she returned on September 14, 2015 for a routine visit, her “assessments” included fibromyalgia and depressive disorder. Id., p. 204. On April 27, 2016, plaintiff returned to the Community Health Center of Buffalo for treatment of her continued depression and body pain. Id., p. 206. For her fibromyalgia, plaintiff was placed on an increased dosage of Lyrica. Id., p. 207. Following her application for SSI, plaintiff was involved in a November 29, 2016 motor vehicle accident. Prior to this, she had no previous neck injury, and underwent no physical therapy or chiropractic treatment. Id., p. 211. Thereafter, she treated regularly with chiropractor Scott Croce, DCPC, through May 29, 2018 for her back and shoulder pain. Id., pp.

241-417. During his treatment, he regularly noted that the Jackson’s lateral compression test, maximum cervical compression test, straight leg test, 4 and Kemp test5 were all positive on the right side. Id., pp. 253, 403, 410, 370, 375, 382, 393. On January 16, 2017 plaintiff began treating with the Dent Neurologic Institute (“Dent”) for headaches that increased with frequency and intensity since her motor vehicle

4 “A straight-leg-raise test involves mechanical manipulation of the legs, stressing the neurological tissues in the spine; specific symptoms reported at different degrees of flexion can indicate nerve compression.” Leticia T. v. Saul, 2020 WL 5044130, *3 n. 7 (C.D. Cal. 2020).

5 “The Kemp test assesses the lumbar-spine facet joints to detect pain.” Leticia T., 2020 WL 5044130, *3 n. 8. accident. Id., pp. 234-37. At that time, plaintiff was examined by Nicolas Saikali, M.D., who assessed her with full range of motion in her extremities, as well as “5/5” strength. Id., p. 236. Her gait was “steady and symmetric”. Id. “[S]ome trigger points” were felt in the trapezius muscles bilaterally”, which were “tender to light touch”. Id. Plaintiff was assessed with

“myofascial muscle pain and “migraine[s] without aura and with status migrainosus, not intractable”. Id., p. 237. On January 24, 2017, plaintiff began receiving trigger point injections for her headaches. Id., pp. 232-34. At that time, the range of motion in her neck was noted to be “slightly limited in all directions”, and she had “trapezius tenderness . . . present bilaterally around associated trigger points”. Id., p. 233. Plaintiff was assessed with myalgia and myofascial muscle pain. Id. A subsequent MRI of her brain revealed a “large vellum interpositum cyst”, but without any ventricular obstruction. Id., p. 239. On February 6, 2017, plaintiff was seen by Zair Fishkin, M.D. of Pinnacle Orthopedic and Spine Specialists, who saw plaintiff for her neck and low back pain. Lumbar and cervical MRIs taken on January 20, 2017 revealed a “central subligamentous L5-S1 disc

herniation indenting the anterior aspect of the thecal sac”; a “left paracentral subligamentous C4- 5 disc herniation indenting the anterior aspect of the thecal sac”; and a “central subligamentous C5-6 disc herniation indenting the anterior aspect of the thecal sac”. Id., p. 212. On examination, Dr. Fishkin noted that plaintiff had normal gait and full strength in her upper and lower extremities, but had decreased range of motion in her cervical and lumbar spines. Id., p. 213. A straight leg test was negative bilaterally. Id. Dr. Fishkin opined that plaintiff “suffered significant injuries to [her] spine as a result of the motor vehicle accident”, and recommended continued chiropractic treatment. Id., p. 214. At an October 30, 2017 reevaluation with Dent, plaintiff reported that the earlier trigger point injections had “worked extremely well for her”. Id., p. 229. At a subsequent November 7, 2017 appointment for trigger point injections, it was noted that the range of motion in her cervical spine was “moderately limited in all directions”. Id., p. 228. Many of the Dent

records reflect that plaintiff was “counseled on the importance of moderate physical activity daily”. See, e.g., id., pp. 228, 231, 234, 237, 494, 500. On February 8, 2018, plaintiff was seen by Marc Frost, M.D. for an evaluation of her seizures. Id., p. 506. Dr. Frost found that she was alert, followed all “1 and 2 step” commands, and had “appropriate mood”. Id., p. 508. Physically, she continued to have full strength in her all extremities and normal gait. Id. All tests conducted, including finger to nose, heel to shin, Romberg, pinprick sensation, and vibratory sensation, were all normal, negative, or intact. Id. Dr. Frost assessed plaintiff with “epilepsy, not refractory”. Id., p. 509. On March 14, 2017, plaintiff was seen by A. Marc Tetro, M.D. for her right shoulder pain, which she reported was aggravated by reaching and lifting. Id., pp. 221-25. Dr.

Tetro assessed plaintiff with “right shoulder rotator cuff tendonitis/impingement syndrome, possible rotator cuff tear, post-traumatic AC joint sprain and cervical origin pain” arising from the November 2016 motor vehicle accident. Id., p. 223. Plaintiff received a subacromial corticosteroid injection, which resulted in “overall improvement in shoulder symptoms”. Id., p. 224. On January 5, 2018 plaintiff was seen at Dent for migraines and neck pain. Id., p. 497. At that time, plaintiff had a “slight decrease in cervical range of motion 25% left and right lateral rotation”. Id., p. 499. However, it was noted that because of “significant cervical spasming”, a “discogenic condition” could not be ruled out. Id.

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Dunbar v. Commissioner of Social Security, Counsel Stack Legal Research, https://law.counselstack.com/opinion/dunbar-v-commissioner-of-social-security-nywd-2021.