Soto v. Commissioner of Social Security

District Court, E.D. New York·Decided November 25, 2020·No. 2:19-cv-02184·Unknown

Opinion

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK

MARIA B. SOTO, Plaintiff, MEMORANDUM AND ORDER v. 19-CV-2184 (LDH) COMMISSIONER OF SOCIAL SECURITY, Defendant.

LASHANN DEARCY HALL, United States District Judge:

Plaintiff Maria B. Soto, proceeding pro se, appeals the denial by Defendant Commissioner of Social Security (the “Commissioner”) of her application for disability insurance benefits (“DIB”) under Title II of the Social Security Act (the “Act”). The Commissioner moves pursuant to Rule 12(c) of the Federal Rules of Civil Procedure for judgment on the pleadings. BACKGROUND1 I. Plaintiff’s DIB Application Plaintiff applied for DIB on June 23, 2014, alleging disability since January 1, 2011, due to imbalance, left leg spurs, benign paroxysmal positional vertigo, tropical spurs, high back spasm and pain, leg pain and cholesterol. (Tr. 23, 191-192, 222, ECF No. 7.) After her application and request for reconsideration were denied, Plaintiff requested a hearing before an administrative law judge (“ALJ”). (Tr. 114-117, 119-121, 122-23.) The hearing was held on April 17, 2017. (Tr. 63-80.) Plaintiff was represented in the hearing. (Tr. 63.) The ALJ heard testimony from Plaintiff and a vocational expert. (Tr. 63-80.) On August 9, 2017, the ALJ issued a decision finding that Plaintiff was not disabled through the date she was last insured:

1 The following facts are taken from the administrative transcript, cited in this opinion as “Tr.” (ECF No. 12.) December 31, 2016. (Tr. 23-30.) On February 13, 2019, the Appeals Council denied Plaintiff’s request for review, making the ALJ’s decision the final decision of the Commissioner. (Tr. 3–5.) II. Non-Medical Evidence Plaintiff was born on February 21, 1963. (Tr. 191.) She has a sixth or eighth grade education and previously worked as an office clerk. (Tr. 76, 223-24.) At the ALJ hearing,

Plaintiff testified that she stopped working because she felt unbalanced, causing her to miss a lot of work. (Tr. 68.) Plaintiff also testified that she has problems with her back, and had carpal tunnel. (Id.) In addition, Plaintiff suffers from leg pain due to arthritis, from which medication provided temporary relief. (Tr. 69.) Plaintiff’s daughter performs household tasks, including any driving. (Id.) Plaintiff can bathe and dress herself, except she cannot wash her own hair. (Id. 70.) Plaintiff can only walk “for a little bit” before she has to rest because of pain and she is limited in how much she can raise her arms. (Tr. 71-72.) She takes medication for reflux and vertigo. (Tr. 70-72.) The vocational expert testified that an individual who is limited to light work with additional limitations would retain the ability to perform Plaintiff’s previous job as an office

clerk. (Tr. 77.) III. Medical Evidence A. Wrist, Back, Shoulder, Extremity Pain Regarding Plaintiff’s wrist, back, and lower extremity pain, a January 21, 2014 x-ray of her wrists and left foot were normal. (Tr. 332.) On May 14, 2014, Plaintiff saw Griselle Perez Santiago, M.D., for complaints of neck and back pain. (Tr. 381-82.) Dr. Santiago ordered a cervical MRI, which was conducted on May 16 and revealed disc bulges with no evidence of stenosis. (Tr. 378.) On June 11, 2014, Plaintiff was referred to a physiatrist due to left foot complaints. (Tr. 368.) On August 6, 2014, an EMG and nerve conduction study of Plaintiff’s upper extremities demonstrated bilateral wrist entrapment neuropathy (moderate on the right and mild on the left). (Tr. 409-12.) She was advised to pursue physical therapy, take vitamins, and receive cock-up splints. (Tr. 412.) An EMG and nerve conduction study of Plaintiff’s lower extremities was normal. (Tr. 414-17.) On August 28, 2014, Plaintiff complained of back pain, (Tr. 389-90), and an August 29, 2014 lumbar CT scan revealed thoracolumbar levoscoliosis.

(Tr. 392.) A CT scan of the left foot from August 29 revealed a bone exostosis (or bone spur). (Id.) An MRI of Plaintiff’s lumbosacral spine, performed on October 20, 2014, revealed the presence of exaggerated lumbar lordosis, a small central disc bulge at L4-5 and L5-S1, and an absence of stenosis with normal intervertebral foramina. (Tr. 427.) On January 29, 2015, x-rays of Plaintiff’s right knee revealed minimal degenerative changes. (Tr. 523.) An August 11, 2015, right knee MRI revealed mild chondromalacia and a small joint effusion, with no evidence of a tear or rupture and normal cruciate ligaments. (Tr. 539.) On July 9, 2016, Plaintiff complained of right shoulder pain, (Tr. 598), and a right shoulder x-ray revealed no evidence of acute fracture or subluxation. (Tr. 605.) An October 18,

2016, MRI of Plaintiff’s right shoulder revealed minimal rotator cuff tendinopathy with no evidence of a tear, mild subacromial subdeltoid bursitis, and minimal early acromioclavicular joint degenerative joint disease. (Tr. 552.) On January 25, 2017, Plaintiff received a Toradol injection for shoulder pain. (Tr. 584- 85.) Her shoulder pain was improved with over-the-counter medication, and she was sent to physical therapy. (Tr. 581, 577.) She had full range of motion in all extremities and 2+ deep tendon reflexes in both upper extremities. (Tr. 581.) A March 27, 2017, left knee MRI revealed no evidence of internal joint derangement or acute osseous injury, mild tibiofemoral joint degenerative joint disease with slightly extruded menisci and mild degenerative free edge blunting, and a small suprapatellar effusion (small water in the knee). (Tr. 677.) B. Vertigo Plaintiff’s medical history reflects a diagnosis of benign positional paroxysmal vertigo. For example, in 2010, Plaintiff saw Dr. Gustavo Gigante twice. (Tr. 284-289.) Plaintiff

complained of, and was diagnosed with, vertigo, and was prescribed vitamins as treatment. (Id.) Likewise, she presented to San Francisco Hospital on several occasions with benign positional vertigo. (See, e.g., Tr. 294, 304.) On August 5, 2014, Dr. Jorge Lugo Rodriguez confirmed Plaintiff’s vertigo diagnosis. (Tr. 376.) She sought medical treatment for her vertigo in 2016. (Tr 541.) In one appointment, for example, Dr. Mario Corona Ruiz found a normal physical examination, diagnosed Plaintiff with paroxysmal vertigo and noted that she responded well to Antivert medication. (Tr. 541-543.) C. Medical Opinions There are several consultative medical opinions in the record. On August 29, 2014, Plaintiff saw Martin Martino Berio, M.D., for a consultative orthopedic examination. (Tr. 394- 95.) Dr. Berio observed that Plaintiff was able to get onto the examination table without

assistance. (Id.) Plaintiff complained of vertigo and cervical back muscular spasms. (Id.) On examination, Plaintiff had no atrophy of the upper extremities; demonstrated normal range of upper extremity motion; and had 5/5 strength bilaterally. (Tr. 395.) Plaintiff walked normally; was able to perform 50% of a squat; and had full range of back movement without limitation. (Id.) Dr. Berio’s assessment was that Plaintiff’s neck and back pain was compatible with muscle spasms, but otherwise found that Plaintiff was able to “perform daily basic things.” (Id.) Dr. Berio’s assessment was not accompanied by any other more-detailed functional assessment. Two state agency medical consultants reviewed Plaintiff’s file and completed Disability Determination Explanations—Rafael Queipo, M.D. on September 11, 2014, and Pedro Nieves, M.D. on December 2, 2014. (Tr. 81-93, 95-109.) Both opined that Plaintiff could: stand and/or walk about six hours in an eight-hour work day; sit about six hours in an eight-hour work day; push and/or pull to an unlimited degree except as indicated for lifting and carrying; frequently

climb ramps/stairs, balance, stoop, and kneel; and occasionally climb ladders/ropes/scaffolds, crouch, and crawl. (Tr.

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