United States District Court, D. Delaware
Sommer L. Ross, Esq., Duane Morris LLP, Wilmington, DE; Eddy Pierre Pierre, Esq., Law Offices of Harry J. Binder and Charles E. Binder, P.C.s, New York, NY, Attorneys for Plaintiff.
Nora Koch, Acting Regional Chief Counsel Social Security Administration, Office of the General Counsel, Philadelphia, PA; Charles M. Oberly, III, United States Attorney, Wilmington, DE; Heather Benderson, Special Assistant United States Attorney, Office of the General Counsel, Philadelphia, PA, Attorneys for Defendant.
RICHARD G. ANDREWS, District Judge.
Plaintiff, Rosely Altagracia Stokes, appeals the decision of Defendant Carolyn W. Colvin, Acting Commissioner of Social Security (the "Commissioner"), denying her application for disability insurance benefits ("DIB") and supplemental security income ("SSI'') under Title XVI of the Social Security Act (the "Act"). 42 U.S.C. §§ 401-433, 1381-1383f. This Court has jurisdiction pursuant to 42 U.S.C. §§ 405(g) & 1383(c)(3).
Presently pending before the Court are cross-motions for summary judgment filed by Stokes and the Commissioner. (D.I. 13, 16). The case was referred to the United States Magistrate Judge, who issued a Report and Recommendation (D.I. 19) recommending that Stokes' motion be denied and the Commissioner's motion be granted. Stokes filed objections (D.I. 20) to which the Commissioner has responded. (D.I. 21). I review the objections de nova. For the reasons set forth below, the Court grants Plaintiff's motion for summary judgment, denies the Commissioner's motion, and remands for further proceedings.
A. Procedural History
Stokes filed her applications for DIB on November 9, 2009 and SSI on November 27, 2009, alleging disability beginning on January 9, 2009, due to a heart condition, back problems, and numbness in her arm and back. (D.I. 10 & 11 (hereafter "Tr.") at 440, 460-61, 470, 478-79). Stokes' applications were initially denied on May 19, 2010 and again were denied upon reconsideration on September 28, 2010. Id. Thereafter, a hearing was held before an Administrative Law Judge (the "ALJ") on August 30, 2011. (Tr. at 398-439). The ALJ issued an unfavorable decision on October 9, 2011. (Tr. at 18-29). The Appeals Council denied Stokes' request for review on June 26, 2013. (Tr. at 1-4). Stokes filed this lawsuit on August 26, 2013. (D.I. 1).
B. Plaintiff's Medical History, Condition, and Treatment
1. Medical Evidence
At the time of the ALJ's decision, Stokes was 48 years old and defined as a "younger person" under 20 CFR § 404.1563(c). (Tr. at 29, 536, 602). Stokes has a ninth grade education and has relevant work experience as a hand packager, machine operator, assembler, warehouse worker, and housekeeper. (Tr. at 423-23, 428).
Stokes' detailed medical history is contained in the record, but the Court will provide a brief summary of the pertinent evidence. Stokes suffers from degenerative disc disease, chronic obstructive pulmonary disease, coronary artery disease, as well as depression and post-traumatic stress disorder. (Tr. at 21, 602).
In 2006, prior to the onset of her alleged disabilities, Stokes underwent open heart surgery for a thoracic aortic aneurysm, followed by a month of intensive care. (Tr. at 622). Stokes suffers from emphysema, which has been stable since 2006. (Tr. at 683). On January 21, 2008, and again on March 31, 2008, Dr. Madhavi Y. Yemeni, M.D. treated Stokes. (Tr. at 620-23). Dr. Yemeni diagnosed Stokes with hyperlipidemia/dyslipidemia, hypertension, asthma, spondylosis/osteoarthritis of the spine, chest pain, and depression. Id.
On April 9, 2008, during a follow-up visit, Stokes complained to Derreck Robinson MS PA-C of"needle-like" thoracic back pain. (Tr. at 624). Dr. Yemeni prescribed Tramadol and referred Stokes to physical therapy. (Tr. at 626). On September 19, 2008, Stokes returned to Dr. Yemeni, because progressive thoracic pain prevented her from working. (Tr. at 632). Dr. Yemeni diagnosed thoracic spine tenderness with paresthesias and suspected a herniated disk. (Tr. at 633). On September 25, 2008, Stokes went to the Rhode Island Hospital emergency room complaining of shortness of breath and chest pain radiating to her back. (Tr. at 608-09). An MRI of the thoracic spine showed mild degenerative changes. (Tr. at 637). On February 4, 2009, Stokes reported to Dr. Yemeni that her back pain improved because she was no longer working. (Tr. at 640). On August 11, 2009, Stokes informed Dr. Yemeni she was doing well without shortness of breath or chest pain, but had experienced episodes of vertigo. (Tr. at 655).
On November 4, 2009, Stokes saw Dr. Irene Szeto, M.D. for recurrent leg pain and dizziness. (Tr. at 724). Dr. Szeto diagnosed hyperlipidemia and hypertension, prescribed Benazepril, and referred Stokes to a vascular surgeon. (Tr. at 725). On November 25, 2009, Stokes saw Dr. Bhaskar Rao, M.D., complaining of lower leg pain that increased when walking long distances. (Tr. at 837-38). Dr. Rao ordered a CT angiography. (Tr. at 838). The CT angiography revealed a chronic type A aortic dissection. (Tr. at 835). On December 16, 2009, Stokes was referred to the emergency department and evaluation by a cardiac surgeon, John Kelly III, M.D., who found Stokes was stable and that her condition did not require surgery. Id. Dr. Kelly noted that Stokes' chest pain worsened with emotional stress. (Tr. at 705). Dr. Kelly recommended close follow-up regarding Stokes' chronic thoracoabdominal aortic dissection and treatment with beta blockers. Id. A treadmill test, administered on December 23, 2009, suggested that Stokes' lower leg pain was not arterial, but neuromuscular in nature. Id. On February 23, 2010, Dr. Szeto diagnosed Stokes with aortic dissection, restless leg syndrome, carpal tunnel syndrome, hyperlipidemia, and hypertension. (Tr. at 714-15). On April 6, 2010, Dr. Szeto noted that during the appointment, Stokes was cooperative, had an appropriate mood and affect, evidenced normal judgment, and was non-suicidal. (Tr. at 741). On a July 2, 2010, Stokes complained to Dr. Szeto of shortness of breath, coughing, apnea, abnormal balance, and memory loss. (Tr. at 742). Dr. Szeto diagnosed Stokes with depression, but noted that Stokes' general health status was good and that Stokes reported she was engaged in aerobic activity four to five times per week. Id.
On October 6, 2011, Dr. Heip Nguyen performed open heart surgery on Stokes for an aortic arch replacement. (Tr. at 338). Stokes underwent another open heart surgery on September 10, 2012 to repair the proximal aortic thoracic dissection. (Tr. at 53).
On February 1, 2012, Dr. Szeto ordered a CT scan of Stokes' lumbar spine. (Tr. at 380). The CT scan revealed severe degenerative disk disease at L4-L5 with a moderate size disk protrusion causing extradural impression on the spinal cord, a narrowing of the lateral nerve root bilaterally, and mild disk protrusion at L3-L4. Id. Dr. Rao concluded that Stokes' lower extremity pain was caused by the ...