Traynham v. Astrue

925 F. Supp. 2d 149, 2013 WL 692800, 2013 U.S. Dist. LEXIS 25315
CourtDistrict Court, D. Massachusetts
DecidedFebruary 25, 2013
DocketC.A. No. 11-cv-30246-MAP
StatusPublished

This text of 925 F. Supp. 2d 149 (Traynham v. Astrue) 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
Traynham v. Astrue, 925 F. Supp. 2d 149, 2013 WL 692800, 2013 U.S. Dist. LEXIS 25315 (D. Mass. 2013).

Opinion

MEMORANDUM AND ORDER REGARDING PLAINTIFF’S MOTION FOR ORDER REVERSING DECISION OF COMMISSIONER AND DEFENDANT’S MOTION FOR ORDER AFFIRMING DECISION OF COMMISSIONER (Dkt. Nos. 8 & 16)

PONSOR, District Judge.

I. INTRODUCTION

This action seeks review of a final decision of the Commissioner of Social Security (“Commissioner”) denying Plaintiffs applications for Social Security disability insurance benefits. Plaintiff applied for a period of disability, disability insurance benefits, and supplemental security income on May 24, 2007, and May 4, 2009, respectively,1 alleging disability for chronic pain, back disorders, and affective disorders. (A.R. 188-97, 199-205.) After a hearing on May 3, 2011, the Administrative Law Judge (“ALJ”) found that Plaintiff was not disabled and denied Plaintiffs claim. (A.R. 45-60.) The Appeals Council denied the Plaintiffs request for review on September 13, 2011, rendering the hearing decision final and subject to judicial review. (A.R. 1-4.) Plaintiff filed this complaint on November 7, 2011.

Plaintiff now moves for an order reversing the decision of the Commissioner (Dkt. No. 8), and Defendant moves for an order affirming the decision of the Commissioner (Dkt. No. 16). For the reasons stated below, Plaintiffs motion will be allowed, and Defendant’s motion will be denied.

II. FACTS

At the time of the ALJ’s decision, Plaintiff was forty-five years old. She had completed tenth grade, obtained a general equivalency degree, and completed job training leading to a Certified Nurse’s Aide certificate. She had previously worked as a dialysis assistant, patient care technician, and certified nurse’s aide. (A.R. 13-15, 250.)

A. Physical Conditions.

Plaintiff testified that her back pain began after she was involved in a motor vehicle accident in 1999. (A.R. 30, 51.) Plaintiff underwent a left posterior C5-C6 minimally-invasive microdisectomy in March 2003 to treat cervical disc disease. (A.R. 376, 465.)

Late in the night of March 3, 2004, Plaintiff was accosted by an assailant who stole her purse and punched her in the face and head. The next morning, she went to the emergency room at Baystate Medical Center. (A.R. 376-78.) She reported severe generalized headache, double and blurry vision, severe photophobia in the right eye, diffuse facial pain, some tingling in her left hand, and diffuse neck pain with a radiation of pain into the left upper extremity, consistent with symptoms from the previous year that had required surgery. (A.R. 376.) The physicians diagnosed multiple facial contusions, neck strain, and radiculopathy of the upper left extremity. (A.R. 377.) A computed tomography (“CT”) scan of the brain revealed a moderate amount of brain atro[153]*153phy for Plaintiffs age. (A.R. 377, 380.) A CT scan of the facial bones revealed a right medial orbital wall fracture and right-sided nasal bone fracture. (A.R. 377, 381.) The consulting ophthalmologist stated that Plaintiff probably had traumatic iritis. (A.R. 377.)

Plaintiff was treated in 2005 and 2006 for complaints of chest pain, bilateral shoulder and arm pain, and recurring low back pain. (A.R. 346-47, 349-50, 356-58, 360-62.) She was diagnosed with a viral upper respiratory tract infection (A.R. 356-57), sciatica and elevated blood pressure (A.R. 347, 349), and cervical radiculopathy due to degenerative changes (A.R. 353-54).

On August 27, 2008, Plaintiff was seen at the Caring Health Center for complaints of neck pain radiating into her left arm. Examination revealed limited neck movement with tingling of her left arm and numbness in her fingers. (A.R. 399.) Magnetic resonance imaging (“MRP’) of the cervical spine on September 5, 2008, revealed multilevel degenerative disc changes as well as a reversal of the cervical lordosis.2

In February 2009, she was evaluated by Dr. Christopher Comey at New England Neurosurgical Associates, LLC, due to increasing left-sided neck and arm pain as well as diffuse weakness in the left arm. (A.R. 465-66.) Imaging revealed an acute left C5-C6 disc herniation. The physical examination by Dr. Comey revealed mild diffuse weakness in the left upper extremity. Her examination was limited due to pain. (A.R. 52, 465.)

On April 22, 2009, Plaintiff returned for another evaluation by Dr. Comey. Dr. Comey reviewed the CT scan of the cervical spine that was done in March 2009. He noted severe degenerative changes with reversal of her cervical lordosis at C4-C5, C5-C6, and C6-C7. Again, this examination was limited due to Plaintiffs pain. Dr. Comey recommended that, if the pain was severe and incapacitating, Plaintiff should undergo an anterior diskectomy and fusion. (A.R. 464.) Plaintiff did not want to consider surgery for fear that she would not be able to move her neck again. (A.R. 464, 467, 470, 523.) For that reason, Dr. Comey recommended that Plaintiff be evaluated for a trial of injection therapy. (A.R. 464.)

Plaintiff was treated by two primary care physicians in 2009 and 2010 for her chronic pain. At Baystate Health, Dr. Abdulrahman Alkabbani, M.D., treated Plaintiff for chronic pain three times in 2009 and 2010. Plaintiff also went to the emergency room at Baystate Health in November 2009 complaining of low back pain.

In October 2010, Dr. Martin Bern became Plaintiffs primary care physician. Dr. Bern referred Plaintiff to two specialists: Dr. Raghu Bajwa, M.D. and Dr. Douglas Molin, M.D. at Pioneer Spine and Sports Physicians PC. (A.R. 554-55.) Dr. Bajwa evaluated Plaintiff for neck pain that radiated into her left arm and lower back pain. Dr. Bajwa noted that Plaintiff was in “mild distress,” her left shoulder motion was limited, and her shoulder was positive for tenderness. Dr. Bajwa recommended physical therapy. Dr. Molin evaluated claimant based on her complaints of pain in her neck, lower back, left arm, and left leg. (A.R. 558.) Dr. Molin noted that Plaintiffs left arm was “so painful I could not move it.” Dr. Molin diagnosed Plain[154]*154tiff with postlaminectomy syndrome cervical region, chronic pain syndrome, tobacco disorder, and pain in limb. (A.R. 559-60.)

Dr. Bern also treated Plaintiff three times between October 2010 and January 2011 for her neck and back pain. (A.R. 567-76.) Dr. Bern noted that Plaintiff had multiple medical problems: anxiety, depression, insomnia, chronic low back pain, chronic neck pain syndrome, high blood pressure, hypertension, chronic pain syndrome, smoker, and sciatica. (A.R. 575.)

In December 2010, Plaintiff presented to the emergency room at Mercy Medical Center with complaints of back pain, rated ten out of ten on a pain scale. (A.R. 542.) Her exam was positive for back pain and the physician noted that she was tearful and in pain. (A.R. 548-49.) Plaintiff was diagnosed with acute lumbar spasm. (A.R. 550.)

B. Mental Conditions.

Plaintiff also suffered from well-documented depression. On August 18, 2008, she presented at Liberty Street Counseling Services and underwent an initial psychological evaluation. (A.R. 382-96.) Plaintiff reported that she was self-medicating with alcohol and had panic attacks when she tried to sleep. (A.R. 382-83.) The interviewing clinician, David Hamilton, reported that, while Plaintiff was cooperative, she was also disheveled, tense, depressed, sad, and restless.

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Bluebook (online)
925 F. Supp. 2d 149, 2013 WL 692800, 2013 U.S. Dist. LEXIS 25315, Counsel Stack Legal Research, https://law.counselstack.com/opinion/traynham-v-astrue-mad-2013.