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Morealli v. Astrue

February 23, 2010


The opinion of the court was delivered by: McLAUGHLIN, Sean J., J.


Plaintiff, Christina Morealli (hereinafter "Plaintiff"), commenced the instant action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of the final decision of the Commissioner of Social Security denying her claims for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. § 401 et seq, and § 1381 et seq. Plaintiff filed applications for DIB and SSI on October 20, 2006, alleging that she was disabled since March 3, 2006 due to a back injury (Administrative Record, hereinafter "AR", 16; 66-68; 73). Her applications were denied and she requested a hearing before an administrative law judge ("ALJ") (AR 51; 53-57). Following a hearing held April 23, 2008, the ALJ rendered a decision dated June 16, 2008 finding that the Plaintiff was not entitled to a period of disability or disability insurance, and was not eligible for SSI benefits (AR 16-24). Plaintiff's request for review by the Appeals Council was denied (AR 4-6), rendering the Commissioner's decision final under 42 U.S.C. § 405(g). The instant action challenges the ALJ's decision. Presently pending before the Court are cross-motions for summary judgment. For the reasons set forth below, the Defendant's motion will be denied and the Plaintiff's motion will be granted only to the extent she seeks a remand for further consideration.


Plaintiff was 49 years old on the date of the ALJ's decision (AR 23). She is a high school graduate with past work experience as a part-time fast food manager and a light-duty housekeeper (AR 74; 78).

Plaintiff has been treated by Anthony Ruffa, D.O., since January 12, 2005 for routine medical care (AR 136-158). On December 14, 2005, Plaintiff complained of lower back pain (AR 152). Physical examination was essentially unremarkable, and Dr. Ruffa recommended chiropractic therapy (AR 152).

An MRI of the Plaintiff's lumbar spine dated February 23, 2006 showed spondylosis with disc space narrowing primarily at the lumbosacral junction (AR 144). A repeat MRI on March 9, 2006 revealed right subarticular and medial foraminal disk protrusion at L4-5 and L5-S1, as well as a right foraminal annular tear at L3-4, and shallow scoliosis (AR 142).

Plaintiff returned to Dr. Ruffa on March 28, 2006 and continued to complain of lower back pain with occasional radiculopathy (AR 140). Dr. Ruffa reviewed the Plaintiff's MRI's and noted that she had two protruded discs with "bulging discs throughout her lumbar spine" with the "potential for radiculopathy as well" (AR 140). She was diagnosed with low back pain, referred to physical therapy and prescribed Lodine and Flexeril (AR 140).

At her initial physical therapy evaluation on March 30, 2006, Plaintiff complained of low back pain radiating down into her buttock and hip areas, ranging from a two to an eight out of ten at times (AR 134). She reported increased pain with bending, twisting, maintaining positions, lifting and housework (AR 134). Plaintiff reported a history of falling down the stairs at work in December 2004 but that chiropractic therapy had relieved her pain after several visits (AR 134). Her symptoms progressively worsened and she returned to the chiropractor in January 2006 (AR 134). On physical examination, Jamie L. Wolfe, PT, found Plaintiff had a decreased range of motion of her lumbar spine, but that her rehabilitation potential was "good" (AR 134-135).

Plaintiff continued a course of physical therapy treatment for approximately twenty-one visits (AR 119-133). On April 25, 2006, the Plaintiff reported improvement in her mobility and decreased pain (AR 128). She reported that her pain at its worst was a four or five out of ten and at times she was pain free (AR 128).

On May 1, 2006, the Plaintiff reported to Dr. Ruffa that her back pain had improved forty to fifty percent with physical therapy (AR 139). She was diagnosed with low back pain and was to continue physical therapy (AR 139). On May 5, 2006, Plaintiff reported to Ms. Wolfe that she had been able to increase her activity level and had walked for thirty minutes around her neighborhood the previous day, and was able to walk twice a day at home (AR 127). She reported being more "pain free" and Ms. Wolfe found that her range of motion had increased (AR 127). By May 15, 2006, Plaintiff reported that she was returning to karate class and on May 25, 2006, Plaintiff reported that it had "[gone] well" (AR 124; 126). She indicated she had no problem working out and was pain free during class (AR 124). Plaintiff did state, however, that her pain seemed to be "stuck" at about a three out of ten (AR 124).

Plaintiff was discharged from physical therapy on June 6, 2006 after having "met all goals" (AR 119). Ms. Wolfe reported that she had normal range of lumbar spine motion and full lower extremity strength (AR 119). Her reported pain level had decreased to a range of zero to three out of ten (AR 119).

Plaintiff returned to Dr. Ruffa on June 12, 2006 for follow-up and reported that her back pain had improved, but not one hundred percent (AR 138). Although Dr. Ruffa found she was able to function appropriately, Plaintiff stated that she did not want to return to work because lifting laundry aggravated her back (AR 138). She declined steroid injection therapy at that time (AR 138). On physical examination, Plaintiff had a stable gait and full muscle strength in all extremities, there were no gross motor or sensory deficits and no atrophy, clubbing, inflammation or cyanosis in her extremities (AR 138). She was diagnosed with stable low back pain and was to continue to stay off work (AR 138).

On October 10, 2006, Plaintiff continued to complain of low back pain, claiming that she could not do much work or lifting (AR 137). Her physical examination was unremarkable and she was assessed with, inter alia, low back pain with herniated disk (AR 137).

Plaintiff completed a Daily Activities Questionnaire on November 8, 2006 and reported that she had to rely on others to lift and carry items such as laundry and groceries, and sometimes needed help getting dressed, getting out of the bathtub, getting out of the car and arising from a chair or sofa (AR 97). She was able to prepare meals, but unable to perform household chores (AR 98). Plaintiff claimed she suffered from pain "[a]ll the time" and was incapable of lifting, bending, twisting, stretching, standing or walking for longer than fifteen to twenty minutes on a hard surface or sitting longer than twenty to thirty minutes (AR 101; 103).

Plaintiff was treated by Paul Carnes, M.D., a pain management specialist, from January 2007 to January 2008 (AR 167-244). Dr. Carnes administered a lumbar epidural steroid injection on January 16, 2007 (AR 244).

On February 2, 2007, Alfred M. Mancini, M.D., a state agency reviewing physician, reviewed the medical evidence of record and concluded that the Plaintiff could occasionally lift ten pounds and frequently lift and/or carry "slightly less than" ten pounds; stand and/or walk for at least two hours in an 8-hour workday; sit for about six hours in an 8-hour workday; and had no limitations in her pushing and/or pulling abilities (AR 160). Dr. Mancini further concluded that posturally, the Plaintiff was limited to occasionally balancing, stooping, kneeling, crouching and crawling, and could occasionally use ramps and climb stairs, but was precluded from climbing ladders, ropes or scaffolds (AR 161).

Plaintiff received another lumbar epidural steroid injection from Dr. Carnes on April 3, 2007 and on August 16, 2007, he administered a lumbar facet block (AR 243-244). On September 26, 2007 Dr. Carnes conducted a radiofrequency ablation of the Plaintiff's right-sided lower lumbar area (AR 193).*fn1

Plaintiff returned to Dr. Carnes on January 28, 2008, and he conducted a radiofrequency ablation of the Plaintiff's left lumbar medial branch nerves (AR 178). Dr. Carnes noted that the Plaintiff stated that following the September procedure, she had "good" pain relief and had been able to walk better (AR 178). Following the ...

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