United States District Court, D. South Carolina, Aiken Division
Melinda J. Gibeau, Plaintiff,
Carolyn W. Colvin, Acting Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
SHIVA V. HODGES, Magistrate Judge.
This appeal from a denial of social security benefits is before the court for a Report and Recommendation ("Report") pursuant to Local Civil Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.
I. Relevant Background
A. Procedural History
On May 5, 2006, Plaintiff filed applications for DIB and SSI in which she alleged her disability began on April 5, 2006. Tr. at 100-07. Her applications were denied initially and upon reconsideration. Tr. at 62-67. On March 2, 2009, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Edward T. Morriss. Tr. at 14-41 (Hr'g Tr.). The ALJ issued an unfavorable decision on April 14, 2009, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 8-13. Subsequently, the Appeals Council denied Plaintiff's request for review, and Plaintiff commenced an action in this court seeking review of the Commissioner's decision. On February 3, 2012, the court reversed and remanded the matter for further proceedings. Tr. at 499-505.
During the pendency of the appeal of this matter, Plaintiff filed a new application for benefits. In a decision dated March 30, 2012, ALJ Regina L. Warren found the Plaintiff became disabled on April 14, 2009. Tr. at 532-38. Therefore, the only time period relevant to the present appeal is April 5, 2006, through April 13, 2009.
Following remand of this matter, ALJ Morriss held a second hearing on July 11, 2012. Tr. at 461-85. He issued a second unfavorable decision on August 8, 2012. Tr. at 448-60. Thereafter, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 432-34. On July 8, 2013, Plaintiff filed this action seeking judicial review of the Commissioner's decision. [Entry #1].
B. Plaintiff's Background and Medical History
Plaintiff was 39 years old at the time of the second hearing. Tr. at 466-67. She obtained her graduate equivalency diploma. Tr. at 467. Her past relevant work ("PRW") was in the food service industry and answering telephones. Tr. at 34, 467-68. She alleges she has been unable to work since April 5, 2006. Tr. at 103.
2. Medical History
Plaintiff was examined at the Grand Strand Regional Medical Center ("GSRMC") on September 25, 2005, for back pain and left leg pain. Tr. at 214. The treating physician diagnosed her with a mild case of sciatica, prescribed Vicodin, and instructed her to apply ice to the affected areas. Id.
On December 20, 2005, Plaintiff visited GSRMC and complained of nagging, aching right knee pain that was worse when she walked and had been present for about a month. Tr. at 212. She was diagnosed with probable arthritic pain and instructed to follow up with her primary care physician. Id.
Dr. Jerry A. Schexnayder of Strand Regional Specialty Associates examined Plaintiff on February 1, 2006. Tr. at 226-27. Plaintiff reported a three-month history of right knee pain during stair climbing and prolonged walking. Id. Examination revealed effusion in her knee and aspiration yielded 9 cc of fluid. Id. Dr. Schexnayder's initial impression was possible anti-inflammatory arthritis of Plaintiff's right knee. Id. The aspirated fluid tested positive for rheumatoid factor, and it was noted that Plaintiff's sedimentation rate was elevated. Tr. at 228, 231. Dr. Schexnayder referred Plaintiff to Dr. Stephen G. Gelfand with Intracoastal Arthritis & Rheumatology. Tr. at 246.
On February 16, 2006, Plaintiff reported to Dr. Gelfand that she had an eight-month history of polyarthralgias, which first started in her elbows and involved her shoulders, right knee, and hands, as well as pain and swelling in her right knee and hands over the prior three months. Tr. at 246. Examination revealed puffiness and tenderness in the joints in both of her hands; tenderness and synovial thickening of both wrists; slightly diminished range of motion in both wrists; decreased flexion in her left knee; synovitis, effusion, and limited flexion in her right knee; and tenderness and slightly limited range of motion in her right ankle. Tr. at 247. Dr. Gelfand's impression was that Plaintiff had probable rheumatoid arthritis. Id. He recommended additional laboratory testing, use of Prednisone and Methotrexate therapy, and physical therapy. Tr. at 247-48.
On May 5, 2006, Dr. Gelfand noted that Plaintiff's rheumatoid arthritis was responding to treatment although her prescription of Methotrexate had gradually been increased. Tr. at 242. Even with the favorable response, Plaintiff noted continued pain and swelling in both hands and pain in her cervical spine region. Id. Testing from the prior visit revealed that Plaintiff's rheumatoid factor was markedly elevated. Id. Dr. Gelfand increased Plaintiff's Methotrexate dosage, added Skelactin, and suggested that Plaintiff might be a candidate for the addition of a biological agent to supplement the Methotrexate. Id.
Treatment notes from Dr. Gelfand on June 23 and July 31, 2006, reveal that Plaintiff's rheumatoid arthritis was stable on her regimen of Methotrexate. Tr. at 261-62. Plaintiff continued to complain of some pain and swelling in her knees and ankles, as well as some limited range of motion in her neck with some spasms in her right trapezius. Id.
On July 26, 2006, Dr. George T. Keller, a state-agency physician, reviewed Plaintiff's file. Tr. at 251-58. In light of her current treatment plan, Dr. Keller opined that within twelve months of the alleged onset of disability date, Plaintiff would have the residual functional capacity ("RFC") to lift 20 pounds occasionally and 10 pounds frequently; stand/walk and sit for about six hours each in an eight-hour workday; occasionally climb ramps or stairs; never climb ladders, ropes, or scaffolds; frequently balance; and occasionally stoop, kneel, crouch, and crawl. Id.
Plaintiff began seeing Dr. April Blue at Carolina Health Specialists as a primary care physician on August 4, 2006. Tr. at 292. Plaintiff complained of neck and upper back pain for the previous three months. Id. She also stated that she did not sleep well at night and reported fatigue, decreased appetite, and weight gain. Id. She experienced pain on flexion of the neck, but had no joint swelling, erythema, or deformity. Tr. at 292. Dr. Blue noted that Plaintiff was suffering from depression that might be related to her untreated hypothyroidism. Id. Images of Plaintiff's spine revealed no acute findings in the thoracic or cervical spines, normal height and alignment of the thoracic vertebrae, no significant disc space narrowing, and no lesions. Tr. at 286-87.
On August 18, 2006, Plaintiff again visited Dr. Blue, complaining of chronic neck pain, radiating to the arm. Tr. at 291. After viewing the images of Plaintiff's spine, Dr. Blue noted that there had been no changes since 2003. Id. Dr. Blue ordered an MRI and noted that Plaintiff could consider physical therapy, pending the results. Id. On September 21, 2006, Dr. Blue examined Plaintiff, noted that her obesity was improving, and counseled her on continued weight loss. Tr. at 290.
On December 1, 2006, Dr. Katrina B. Doig, a state-agency physician, reviewed Plaintiff's file and reached the same conclusions as Dr. Keller. Tr. at 293-300. Dr. Jeffrey Vidic, Ph.D., a state-agency psychologist, reviewed Plaintiff's records and completed a Psychiatric Review Technique form on December 5, 2006. Tr. at 301-14. He opined that Plaintiff had depression, but did not have a severe mental impairment. Tr. 301, 304. He further opined that Plaintiff had mild restriction of activities of daily living ("ADLs"); moderate difficulty in maintaining social functioning; moderate difficulty in maintaining concentration, persistence, or pace; and no episodes of decompensation. Tr. at 311.
Plaintiff transferred her primary care to South Strand Internists and was initially seen by Dr. Brian Adler and Candyce McLeod, MSN, ARNP on July 21, 2008. Tr. at 357-58. Plaintiff stated that she continued to have chronic joint and muscular pain all over her body; pain in her neck, shoulders, back, and hips; depression; and chronic fatigue. Tr. at 357. Physical findings included morbid obesity, swelling in her wrists and hands, crepitus in her right knee, and multiple trigger points. Tr. at 358. Plaintiff was diagnosed with polyarthralgia, chronic insomnia and fatigue, morbid obesity, and depression. Id. She was referred for a sleep study. Id.
On August 20, 2008, Plaintiff presented to South Strand Internists, complained of pain all over her body, and received a prescription for Lyrica. Tr. 356.
On September 10, 2008, treatment notes from South Strand Internists indicate that Plaintiff complained of headache, back pain when walking, and depression. Tr. at 355. Images of Plaintiff's spine and sacroiliac joints taken on this day revealed no abnormalities. Tr. at 328-29. Plaintiff stated that she had tried to slice her wrists twice, but was not sure if she wanted to hurt or kill herself. Tr. at 355. She stated that she had no current plans to hurt herself. Tr. at 355. Plaintiff explained that she was stressed about bills and her 15-year-old daughter being pregnant. Id. Treatment notes indicate that Plaintiff would be sent to a psychiatrist. Id.
On September 12, 2008, Plaintiff complained that Seroquel made her groggy, but said she was sleeping better. Tr. at 354. On September 17, 2008, Plaintiff complained of edema in her hands and feet, as well as low back pain. Tr. at 353. She was diagnosed with depression and her Seroquel prescription was increased. Id. A lumbar spine MRI on October 1, 2008, revealed early degenerative changes at L5-S1. Tr. at 331.
On October 9, 2008, Plaintiff informed her providers at South Strand Internists that she experienced headaches and face flushing. Tr. at 352. She reported blurry vision and occasional vomiting. Id. Her rheumatoid arthritis was noted to be "OK." Id.
On November 11, 2008, Plaintiff saw Dr. R.R. Tupton, III, and complained of increasing blurriness in her eyes over the prior two months. Tr. at 371. Examination revealed decreased tearing in her eyes. Id. Dr. Tupton's assessment was questionable early Sjorgrens Syndrome, unspecified adverse effect of drugs, and Hydroxycholoroquine toxicity. Tr. at 372. He prescribed eye drops with a plan to consider eye plugs or prescribing Restasis upon her return if no improvement was noted. Id.
On November 11, 2008, Plaintiff returned to South Strand Internists complaining of low back pain and it was noted that she could not afford physical therapy for her back. Tr. at 351. She later attended physical therapy from January 9 through February 6, 2009. Tr. at 361-70. On January 22, 2009, she reported to providers at South Strand Internists that she had increased swelling over the ...