Rosario v. Commissioner of Social Security

877 F. Supp. 2d 1254, 2012 WL 2589350, 2012 U.S. Dist. LEXIS 91838
CourtDistrict Court, M.D. Florida
DecidedJuly 3, 2012
DocketCase No. 6:11-cv-863-Orl-GJK
StatusPublished
Cited by65 cases

This text of 877 F. Supp. 2d 1254 (Rosario v. Commissioner of Social Security) is published on Counsel Stack Legal Research, covering District Court, M.D. Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Rosario v. Commissioner of Social Security, 877 F. Supp. 2d 1254, 2012 WL 2589350, 2012 U.S. Dist. LEXIS 91838 (M.D. Fla. 2012).

Opinion

MEMORANDUM OF DECISION

GREGORY J. KELLY, United States Magistrate Judge.

Loida Rosario (hereafter “Claimant”), appeals to the District Court from a final decision of the Commissioner of Social Security (hereafter “Commissioner”) denying her application for disability benefits (hereafter “Application”), which alleged a disability onset date of January 15, 2008. Doc. No. 1. Claimant argues that the final decision of the Commissioner should be reversed and remanded because the Administrative Law Judge (hereafter “ALJ”) erred by: 1) failing to state with particularity the weight given and the reasons therefor to the Residual Functional Capacity (hereafter “RFC”) opinions of Claimant’s treating physicians: Sanjay Sastry, M.D., Robert J. Martin, M.D., and Beverly M. Greenspan, M.D.; and 2) failing to provide legally sufficient reasons for finding Claimant’s testimony not credible regarding the intensity, persistence and limiting effects of her back and neck pain. Doc. No. 17 at 1. For the reasons set forth below, the final decision of the Commis[1256]*1256sioner is REVERSED and REMANDED because the ALJ did not state the weight given to, or articulate good cause for rejecting, Claimant’s treating physicians’ RFC opinions.

I. MEDICAL AND OPINION EVIDENCE

A. Early Medical History

In October 2006, Claimant presented to Angela Saenz-Acevedo, M.D., complaining of left flank pain, nocturia and frequent dysuria. R. 208.1 In December 2006, Claimant complained of low back pain and numbness in her right leg. R. 206. Dr. Saenz-Acevedo ordered an MRI which revealed “some degenerative disc of the lumbar spine with some disc bulges at L2-3 through L5-S 1.” R. 205, 207. Claimant was referred to Federico C. Vinas, M.D., a neurosurgeon, who conducted his initial evaluation on May 10, 2007. R. 221-23. Dr. Vinas indicated that Claimant was suffering from “[ljumbar spondylosis, severe back pain and clinical evidence of lower extremity radiculopathy,” as well as “[c]ervical spondylosis with upper extremity radiculopathy.” R. 223. Dr. Vinas instructed Claimant to avoid “repetitive bending or twisting of the spine, lifting of weights in excess of 15 lbs., or participating in any activity which might increase the stress over the lumbar or cervical spine.” R. 223. On May 10, 2007, Dr. Vinas provided Claimant with a “Work Status” letter indicating that Claimant was limited to light duty work with the following restrictions: no lifting over twenty pounds; no excessive/repetitive bending or twisting; no prolonged sittingfetanding or stooping; no excessive/repetitive pulling or pushing; and no excessive activity involving overhead activity or arms above the shoulders. R. 240.

On May 17, 2007, Dr. Vinas wrote another Work Status note indicating that Claimant should be excused from all work duties and that she would be reevaluated on June 25, 2007. R. 239. On June 25, 2007, Dr. Vinas indicated that Claimant was suffering from low back pain, lower extremity radiculopathy, cervical spondylosis without clinical evidence of a cervical myelopathy and diabetes related stress urinary incontinence. R. 227. Dr. Vinas instructed Claimant to avoid repetitive bending or twisting, lifting over fifteen pounds or any other activity that might increase the stress on her cervical or lumbar spine. R. 228.

A. Sanjay Sastry, M.D., Pain Management

On January 17, 2008, Dr. Sastry, Claimant’s pain management physician, completed a form indicating that Claimant is limited to “Light/Limited Duty.” R. 353. Dr. Sastry indicated that Claimant cannot lift over five pounds, perform overhead work, bend or stoop. R. 353. On January 18, 2008, Dr. Sastry gave Claimant a lumbar epidural steroid injection. R. 372-73. On January 21, 2008, Claimant reported pain in the “right sacroiliac joint region” and Dr. Sastry administered a right sacroiliac joint injection. R. 367, 370. On January 22, 2008, Dr. Sastry administered, at Claimant’s request, bilateral suboccipital blocks based on Claimant reporting “severe bilateral headaches.” R. 366, 368. On January 28, 2008, Dr. Sastry gave Claimant a cervical epidural steroid injection. R. 363-64. Dr. Sastry indicated that Claimant reported “60% pain relief’ after receiving her first lumbar epidural steroid injection. R. 363. On January 31, 2008, Dr. Sastry injected Claimant with a second lumbar epidural steroid injection. R. 360-61. Dr. Sastry noted that Claimant re[1257]*1257ported “75% pain relief’ following her second cervical epidural steroid injection and was hoping for similar results with the lumbar epidural steroid injection. R. 360.

On February 7, 2008, Dr. Sastry, at Claimant’s request, injected Claimant with a third lumbar epidural steroid injection. R. 357-58. Dr. Sastry noted that Claimant was aware that if the epidural steroid injections did not work she was to proceed with a neurosurgical consultation. R. 357. Dr. Sastry indicated that Claimant is “limited to light duty with no bending or stooping, no overhead work no lifting over 3-5 pounds, and no pushing, pulling, or grasping in her occupation.” R. 357. On February 11, 2008, Dr. Sastry indicated it was urgent for Claimant to have a “neurosurgical consultation for evaluation and possible ... surgical decompression of [her] lumbar disc herniations” based on Claimant’s statement that she was losing bowel and bladder function. R. 355.

On June 26, 2008, Dr. Sastry noted that Claimant was complaining of left-sided headache that made her head feel heavy. R. 459. Dr. Sastry noted that Claimant complained of left neck and upper back pain that was aggravated when she bent her neck, worked or exercised, but was relieved by medication, rest and sleep. R. 459. Dr. Sastry administered a left subocciptal block and trigger point injections to Claimant’s left neck and upper back. R. 457-58.

On July 1, 2008, Claimant reported having a headache that made her head feel heavy, as well as left neck pain, upper back pain and muscle spasms. R. 452. Dr. Sastry, at Claimant’s request, gave Claimant a left suboccipital block and trigger point injections. R. 452-54. On July 17, 2008, Dr. Sastry noted that Claimant stated the post trigger point injections and occipital nerve block helped her considerably, but that she was still experiencing pain in her neck and upper back. R. 451. Claimant requested a spinal cord stimulator and Dr. Sastry directed Claimant to return for a “trial placement of percutaneous spinal cord stimulator.” R. 451. On July 22, 2008, Dr. Sastry performed a “fluoroscopically-assisted trial placement of percutaneous spinal cord stimulator.” R. 446-48. On July 25, 2008, Dr. Sastry noted that Claimant reported excellent results with the trial placement of the spinal cord stimulator. R. 444. Dr. Sastry recommended placement of a permanent spinal cord stimulator. R. 444.

In summary, Dr. Sastry treated Claimant for her back pain and headaches, ultimately recommending that Claimant have a permanent spinal cord stimulator be implanted. Based on his treatment relationship, Dr. Sastry opined that Claimant was limited to light duty work that did not involve bending, stooping, pushing, pulling, grasping, overhead work or lifting more than 3-5 pounds. R. 357.

B. Robert J. Martin, M.D., Claimant’s Treating Neurosurgeon

On March 5, 2008, Robert J.

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

Related

Cite This Page — Counsel Stack

Bluebook (online)
877 F. Supp. 2d 1254, 2012 WL 2589350, 2012 U.S. Dist. LEXIS 91838, Counsel Stack Legal Research, https://law.counselstack.com/opinion/rosario-v-commissioner-of-social-security-flmd-2012.