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T.R. v. Berryhill

United States District Court, D. Minnesota

March 8, 2019

T. R., Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security, Defendant.

          ORDER

          ELIZABETH COWAN WRIGHT, UNITED STATES MAGISTRATE JUDGE

         This matter is before the Court on Plaintiff T. R.'s (“Plaintiff”) Motion for Summary Judgment (Dkt. No. 20) (“Motion”) and Defendant Acting Commissioner of Social Security Nancy A. Berryhill's (“Defendant”) Cross Motion for Summary Judgment (Dkt. No. 26) (“Cross Motion”). Plaintiff filed this case seeking judicial review of a final decision by Defendant denying her application for disability insurance benefits. She specifically challenges the Administrative Law Judge's (“ALJ”) evaluation of Plaintiff's treating physician's opinion and the ALJ's evaluation of Plaintiff's symptoms. For the reasons stated below, Plaintiff's Motion is granted in part and denied in part, and Defendant's Cross Motion is denied.

         I. PROCEDURAL BACKGROUND

         Plaintiff filed an application for disability insurance benefits on November 17, 2014, alleging disability beginning on June 15, 2013. (R. 165-68.)[1] She also filed an application for Supplemental Security Income on January 15, 2015, again alleging a disability beginning on June 15, 2013. (R. 169-74.) Plaintiff claimed disability due to Sjögren's syndrome, [2] fibromyalgia, lupus, arthritis, depression, anxiety with panic attacks, asthma, and allergies. (R. 202.) Her applications were denied initially and on reconsideration. (R. 112-26.) Plaintiff requested a hearing, which was held on December 20, 2016 before Administrative Law Judge Micah Pharris (“ALJ”). (R. 18-26.) At all times relevant to the ALJ's adjudication, Plaintiff was a “younger” individual (under age 50) with at least a high school education and two years of college, and past relevant work in data entry and as a customer service sales representative and receptionist. (R. 33-34.) The ALJ issued an unfavorable decision on January 23, 2017. (R. 18-35.) Following the five-step sequential evaluation process under 20 C.F.R. § 404.1520(a), [3] the ALJ first determined that Plaintiff had not engaged in substantial gainful activity since June 15, 2013, the date of the alleged onset of disability. (R. 20.)

         At step two, the ALJ found Plaintiff had the following severe impairments: chronic pain and fatigue “variously diagnosed” as Sjögren's syndrome, sicca syndrome, [4]myofascial pain syndrome, lupus, chronic pain syndrome, cervical degenerative disc disease, and mild lumbar degenerative disc disease. (Id.) At step three, the ALJ found Plaintiff's impairments did not meet or equal a listing in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 25.)

         At step four, after reviewing the entire record, the ALJ concluded that Plaintiff had the residual functional capacity (“RFC”) to perform light work as defined in 20 C.F.R. §§ 404.1567(b)[5] and 416.967(b), except only occasional bilateral reaching overhead. (R. 27.) With this RFC and the testimony of the Vocational Expert (“VE”), the ALJ determined that Plaintiff is capable of performing past relevant work as a data entry (sedentary exertional level), customer services sales representative (light exertional level), and receptionist (sedentary exertional level). (R. 33-34.) Alternatively, the ALJ determined that Plaintiff, based on her RFC and the VE testimony, is capable of performing other jobs that exist in significant numbers in the national economy, including bench assembler (DOT#706.684-022), and cashier (DOT# 211.462-010). (R. 34.) Both positions are at the light exertional level. (Id.) Accordingly, the ALJ deemed Plaintiff not disabled. (R. 34-35.)

         Plaintiff requested review of the decision. (R. 1.) The Appeals Council denied Plaintiff's request for review, which made the ALJ's decision the final decision of the Commissioner. (R. 1-3.) Plaintiff then commenced this action for judicial review. The Court has reviewed the entire administrative record, giving particular attention to the facts and records cited by the parties.

         II. MEDICAL RECORD

         In April 2013, prior to the alleged June 2013 onset of disability, Plaintiff sought a transfer of care for her claimed past diagnosis of lupus, Sjögren's syndrome and rheumatoid arthritis. (R. 302.) Plaintiff had been driving a school bus at the time. (Id.) Her main symptoms were intermittent myalgias, mouth ulcers, and photosensitivity. Dr. Ali Saijiad, M.D., found Plaintiff's examination was “reassuringly normal.” (Id.)

         On August 20, 2013, Plaintiff saw Dr. Jennifer Lake, M.D., [6] for fatigue and pain. (R. 345.) Plaintiff reported daily pain in all of her joints, specifically the spine. (Id.) She reported missing many days of work due to pain and fatigue, eventually forcing her to quit. (Id.) Plaintiff's general examination revealed that she was not in any distress, her head was atraumatic, her eyes were clear, her neck was supple, her back showed no vertebral angle tenderness, she showed normal range of motion of all joints, she demonstrated normal strength and sensation as part of her neurological examination, and she had a normal gait. (R. 345.) Dr. Lake assessed Plaintiff as having lupus erthematosus, sicca syndrome, and chronic fatigue syndrome. (Id.) She added Vicodin and Celebrex for pain to Plaintiff's prescriptions and advised Plaintiff to take daily walks. (R. 348.)

         On October 1, 2013, Plaintiff saw Dr. Lake related to Sicca syndrome and pain. (R. 342.) Plaintiff claimed to have pain every day and was using Vicodin daily. (Id.) Plaintiff's general examination revealed that she was not in any distress, her head was atraumatic, her neck was supple, she demonstrated normal strength and sensation as part of her neurological examination, and she had a normal gait. (Id.)

         On January 13, 2014, Plaintiff saw rheumatologist Dr. Thomas Harkcom, M.D., for an evaluation of her pain, fatigue, and sicca complaints. (R. 360.) Plaintiff asserted that her severe fatigue started in 2005 during her third pregnancy. (Id.) Dr. Harkcom noted that Plaintiff could move about comfortably. (R. 361.) The examination of Plaintiff showed that her eyes were normal and that she had normal mouth moisture. (Id.) According to Dr. Harkcom, Plaintiff's shoulders, hips, knees, hands, wrists, and ankles showed full range of motion with no swelling. (Id.) Plaintiff also had normal cervical, thoracic, and lumbar spine motion. (Id.) In addition, her strength and gait were normal. (Id.) While there were past documented complaints of dry eyes and mouth, Dr. Harkcom saw nothing to suggest lupus. (Id.) Although there could have been some component of fibromyalgia, Dr. Harkcom believed it was probably due to depression. (Id.) Plaintiff noted during the examination that she planned to buy an elliptical trainer and Dr. Harkcom encouraged her in this and to start exercising for five minutes at a time and increase to 30 minutes. (Id.)

         On February 4, 2014, Plaintiff saw Dr. Lake for a follow-up. (R. 339.) Plaintiff's general examination revealed that she was not in any distress, her neck was supple, she demonstrated normal strength and sensation as part of her neurological examination, and she demonstrated a normal gait. (R. 339.) Dr. Lake prescribed daily exercise. (Id.) On March 12, 2014, Plaintiff had a follow-up appointment with Dr. Lake related to medication, including a refill for acetaminophen-codeine. (R. 337.) Plaintiff reported less pain and that she was trying to exercise. (Id.) On April 30, 2014, Plaintiff saw Dr. Lake related to her anxiety and pain. (R. 334.) Plaintiff's general examination revealed that she was not in any distress, her neck was supple, she demonstrated normal strength and sensation as part of her neurological examination and had a normal gait. (Id.)

         Plaintiff also saw Dr. Saijiad for a follow-up in April 2014 related to arthritis like pain, cervical disc degeneration, and Sicca symptoms. (R. 304.) Plaintiff reported feeling as though her hands were being hit by a sledge hammer and that her body felt like it had been hit by a semi-truck. (Id.) Plaintiff was referred to an ophthalmologist for eye issues secondary to sicca syndrome given her severe sicca symptoms. (R. 307.) Dr. Saijiad found no evidence of any inflammation of Plaintiff's tissues. (Id.)

         On June 2, 2014, Plaintiff saw Dr. Lake related to her depression and pain. (R. 331.) Plaintiff reported that her pain was “all over” and had not improved. (R. 331.) Plaintiff did not appear to be in distress, her neck was supple, and exhibited no clubbing or edema in her extremities. (Id.) Tramadol did not work for her pain. (Id.) Dr. Lake recommended that Plaintiff attend a pain clinic and that she engage in daily exercise. (R. 332.)

         On July 14, 2014, Plaintiff saw Dr. Harkcom with complaints of joint pain. (R. 363.) She was only able to use her elliptical for 6 minutes at a time. (Id.) Upon examination, Plaintiff's shoulders, elbows, knees, hands, wrists, and ankles showed full range of motion with no inflammation, and she exhibited no tender points. (Id.) It was unclear to Dr. Harkcom whether her condition was inflammatory in nature. (R. 364.) Dr. Harkcom started Plaintiff on prednisone and asked her to continue with her exercise and Prozac. (Id.)

         On August 10, 2014, Plaintiff saw Dr. Anthony Genia, M.D. for facial pain. (R. 324.) While she had some tenderness in her jaw, she was not in any distress, she had a normal range of motion in her neck, and her coordination was normal. (R. 324.) Plaintiff was prescribed a muscle relaxant. (R. 326.)

         On September 19, 2014, Plaintiff saw Dr. Lake related to her anxiety and medications. (R. 328.) Plaintiff also reported being very weak and in pain. (Id.) The immune-suppressant methotrexate prescribed by the rheumatologist did not offer Plaintiff any relief. (Id.) Plaintiff requested Vicodin because it worked better for her pain. (Id.) During the examination, Dr. Lake found Plaintiff's eyes to be clear, she was not in any distress, and she exhibited no clubbing or edema in her extremities. (Id.) Along with pain medications, including Tramadol and Vicodin, Dr. Lake encouraged Plaintiff to take daily walks. (R. 329.)

         On August 12, 2014, Plaintiff saw Dr. Harkcom regarding a mixture of Sjögren's syndrome and fibromyalgia. (R. 365.) Plaintiff reported feeling 75% better as the result of taking prednisone. (Id.) She noted that she still had some discomfort in her upper back, neck, and hips. (Id.) Dr. Harkcom noted that Plaintiff's labs were unremarkable. (Id.)

         Plaintiff again had a follow-up with Dr. Harkcom on November 13, 2014 complaining of “a lot” of discomfort despite using prednisone and describing her improvement with prednisone as “slight.” (R. 367.) She reported that after several months on prednisone, she had not really noticed any difference. (Id.) Plaintiff's eyes were unremarkable, she displayed no tender points or inflammation related to arthritis. (Id.) Dr. Harkcom wanted to get Plaintiff into pool therapy and tai chi. (R. 368.)

         On February 4, 2015, Plaintiff saw Dr. Lake for depression and chronic fatigue. (R. 394.) Dr. Lake noted that Plaintiff had been unable to work as the result of her pain and fatigue. (Id.) Dr. Lake noted that Plaintiff “needs disability paperwork filled out today.” (Id.) Plaintiff's general examination revealed that she was not in any distress, her neck was supple, she demonstrated normal strength and sensation as part of her neurological examination, and she had a normal gait. (Id.)

         On May 6, 2015, Plaintiff saw Dr. Lake for her yearly examination. (R. 498.) Plaintiff reported having “no concerns” and that “[h]er pain is stable.” (Id.) Plaintiff was not in any acute distress, the range of motion in her neck was normal, and her neurological examination was normal. (R. 498-99.) Dr. Lake recommended that Plaintiff exercise 30 minutes 4-5 days per week. (R. 499.)

         On June 2, 2015, Plaintiff saw Dr. Harkcom for a follow-up of her Sjögren's syndrome and fibromyalgia. (R. 559.) Dr. Harkcom found Plaintiff's Sjögren's syndrome to be stable on her medications, but that she continued to have fibromyalgia-like symptoms. (Id.) She did receive relief from pool therapy, but she lived too far away from a pool. (Id.) She was also able to do yoga. (Id.) There were no tender points during her examination and her joints were unremarkable. (R. 560.) Dr. Harkcom's notes stated that Plaintiff had initially thought she got some benefit from her prednisone prescription, but it seemed to decrease, and noted that she had then been prescribed methotrexate “with no benefit.” (R. 559.) He prescribed prednisone again and directed her to report back in three weeks with a detailed description of her response. (R. 560.)

         Plaintiff also saw Dr. Harkcom on June 25, 2015. (R. 561.) Plaintiff did not obtain any relief from her pain from the prednisone prescription, which led to Dr. Harkcom believe she was suffering from fibromyalgia. (R. 561-62.) Dr. Harkcom noted that Plaintiff “has been aggressively treated in the past for this without much success. I gave her a three-week trial of 10 mg of prednisone and she is not one shred better as far as pain. It is also disturbing her sleep.” (R. 561.)

         On July 28, 2015, Plaintiff continued to see Dr. Lake related to various complaints of pain, fatigue, and depression. (R. 495-96.) All of the general examinations for Plaintiff revealed that she was not in any distress, her head was atraumatic, her neck was supple, she demonstrated normal strength and sensation as part of her neurological examination, and she had a normal gait. (Id.) Dr. Lake started Plaintiff on Ritalin for her chronic fatigue. (R. 496.)

         On September 25, 2015, Plaintiff again saw Dr. Lake for a recheck. (R. 492.) Plaintiff reported that Ritalin did not help with her fatigue. (Id.) Plaintiff was using Percocet 1-2 times per week for pain. (Id.) Plaintiff was advised to only use Vicodin for severe pain, to continue seeing her chiropractor, to take daily walks, and to see Dr. Lake again as needed. (R. 493.)

         On October 18, 2015, Plaintiff was examined by nurse practitioner Nancy Nyongesa (“Nyongesa”) at the United Pain Center regarding an evaluation related to complaints of headaches and low back pain. (R. 419.) Plaintiff reported that she was taking ibuprofen daily for headaches and back pain, but that it did not help all of the time. (R. 420.) Plaintiff's back pain would improve when she laid down and worsened with increased activity and standing. (Id.) Plaintiff was also taking Vicodin on a rare occasion for headaches. (Id.) Pool therapy did not help Plaintiff. (Id.) Plaintiff had taken a number of other pain medications she claimed did not help with her pain, including Tylenol, Lycria, Gabapentin, Tramadol, Tylenol No. 3, and Cymbalta. (Id.) Plaintiff also complained about general joint pain. (Id.) Her physical examination showed that Plaintiff was not in any acute distress, she reported a little headache, she had full range of motion of cervical spine with no tenderness, no tenderness on her thoracic spine, and exhibited flexion and extension of the lumbar spine without any difficulty. (R. 421.) The FABER[7] test was negative bilaterally, Plaintiff's lower strength was “5/5, ” and she was able to walk without difficulty. (Id.) Nyongesa assessed Plaintiff with chronic lower back pain, chronic neck pain, and chronic headaches (frontal and occipital). (Id.)

         On November 6, 2015, Plaintiff saw Dr. Chad Evans, M.D., for reports of a worsening headache. (R. 519.) Plaintiff was not in any acute distress, had normal sensory capability, normal reflexes, her fine motor movements were intact, her gait and balance were completely normal, and she demonstrated tenderness across the cervical and upper-thoracic spine, with particular tenderness over the occipital nerve branches. (R. 520.) Dr. Evan was concerned about possible migraines or that Plaintiff's use of ibuprofen was contributing to her headaches. (Id.)

         On November 12, 2015, Plaintiff had an MRI performed on her cervical spine. (R. 528.) There was a small left paracentral disc herniation causing a moderate effacement to the left ventral aspect of the cervical spinal cord. (Id.) A mild posterior marginal spurring and disc bulge was also present at the C6-7 level. (Id.)

         On November 16, 2015, Plaintiff was seen at the Noran Neurological Clinic and examined by a physician assistant (“PA”). (R. 515.) Plaintiff's pain had not changed since her previous visit with Dr. Evans. (Id.) Plaintiff reported that she had stopped physical therapy because it was unhelpful. (Id.) She also reported daily headaches. (Id.) The examination of Plaintiff showed that she was not in any acute distress, her neurological examination was normal, her motor examination showed normal bulk and tone with no focal asymmetries of strength. (R. 516.) Plaintiff's MRI of her ...


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