United States District Court, M.D. Pennsylvania
RICHARD P. CONABOY, District Judge.
Here we consider Plaintiff's appeal from the Commissioner's denial of Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act"), 42 U.S.C. §§ 401-433. (Doc. 1.) Plaintiff originally alleged disability due to fibromyalgia, PTSD, depression, migraines, TBI, hypertrophic cardiomyopathy, carpal tunnel bilateral, plantar fasciitis, shortness of breath and insomnia. (R. 176.) In her application, Plaintiff said she stopped working because of her conditions on September 28, 2012. (Id. ) The Administrative Law Judge ("ALJ") who evaluated the claim concluded that Plaintiff's severe impairments of fibromyalgia, carpal tunnel syndrome, obesity, migraine headaches, post-traumatic stress disorder ("PTSD"), panic disorder, anxiety disorder, and major depressive disorder/depression did not alone or in combination meet or equal the listings. (R. 13-15.) The ALJ found that Plaintiff had the residual function capacity ("RFC") for light work with certain nonexertional limitations and that she was capable of performing jobs that existed in significant numbers in the national economy. (R. 15-27.) The ALJ therefore found Plaintiff was not disabled under the Act from September 28, 2012, through the date of the decision, October 14, 2014. (R. 27-28.)
With this action, Plaintiff asserts that the case should be remanded for further administrative proceedings based on the following errors: 1) the ALJ's discussion of Plaintiff's Veterans Administration disability rating was insufficient; 2) the ALJ did not address the work-related limitations caused by Plaintiff's migraine headaches; 3) the ALJ did not properly evaluate the medical opinion of the Agency's examining consultant, Alfred Hardaway, M.D.; 4) the ALJ erred when he failed to assess Plaintiff's credibility in light of her work history; and 5) because the RFC does not accurately set out all of Plaintiff's individual impairments and limitations, the ALJ did not meet her step five burden of showing that Plaintiff can perform other work. (Doc. 14 at 2, 15.)
After careful consideration of the administrative record and the parties' filings, we conclude Plaintiff's appeal is properly granted.
A. Procedural Background
On April 29, 2014, Plaintiff protectively filed an application for DIB. (R. 11.) As noted above, she alleges disability beginning on September 28, 2012, due to fibromyalgia, PTSD, depression, migraines, TBI, hypertrophic cardiomyopathy, carpal tunnel bilateral, plantar fasciitis, shortness of breath and insomnia. (R. 176.) The claim was initially denied on June 19, 2014. (R. 11.) Plaintiff filed a request for a review before an ALJ on June 24, 2014. (Id. ) On September 23, 2014, ALJ Michelle Wolfe held a video hearing at which Plaintiff and Vocational Expert Patricia Chilleri testified. (Id. ) At the hearing, Plaintiff was represented by Andrew Youngman, a non-attorney representative. (Id. ) The ALJ issued her unfavorable decision on October 14, 2014, finding that Plaintiff was not disabled under the Social Security Act during the relevant time period. (R. 28.)
On December 5, 2014, Plaintiff filed a Request for Review with the Appeals Council. (R. 6-7.) The Appeals Council denied Plaintiff's request for review of the ALJ's decision on January 7, 2015. (R. 1-5.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)
On March 3, 2015, Plaintiff filed her action in this Court appealing the Acting Commissioner's decision. (Doc. 1.) Defendant filed her answer and the Social Security Administration transcript on May 7, 2015. (Docs. 12, 13.) Plaintiff filed her supporting brief on June 22, 2015. (Doc. 14.) Defendant filed her opposition brief on July 14, 2015. (Doc. 15.) Plaintiff filed a reply brief on July 28, 2015. (Doc. 16.) Therefore, this matter is fully briefed and ripe for disposition.
B. Factual Background
Plaintiff was born on September 9, 1971, and was forty-one years old on the alleged disability onset date. (R. 26.) Plaintiff testified that she has an associates degree in criminal justice. (R. 60.) Plaintiff has past relevant work as a claims processor, security guard, front desk clerk, housekeeper, correctional officer at a state hospital, and a chemical operations specialist. (Id. ) Plaintiff served in the United States Army from 1989 to 2004 and is an Iraq War veteran. (R. 550; Doc. 14 at 3.)
1. Impairment Evidence
Because Plaintiff's claimed errors relate to certain physical impairments and specific opinions, our review will focus on evidence related to the alleged errors.
a. Migraine Headaches
The following evidence charts the history of Plaintiff's migraine headache impairment. We include related evidence to provide context.
A November 4, 2009, Neurology Resident Note from the Hunter Holme McGuire VA Medical Center states that Plaintiff was seen for follow up because of headache for which she was seen in the emergency department on October 21, 2009. (R. 656.) Plaintiff was prescribed Topamax and Imitrex and she reported the Imitrex had a mild effect on her headache. (Id. ) Because Plaintiff also complained of eye redness at the emergency department, she was sent to the eye clinic where some problems were noted and a lumbar puncture was offered which Plaintiff refused. (Id. ) Plaintiff continued to report blurry vision at the November 4th visit. (Id. ) It was noted that a lumbar puncture was necessary for a proper diagnosis. (R. 658-59.) The pain assessment conducted at the time indicates that the headaches were accompanied by nausea and an inability to concentrate but did not affect Plaintiff's sleep, mood, or activities of daily living. (R. 559-60.) Plaintiff reported that the pain was sharp and unbearable, and she had the headache constantly for days. (Id. ) Her pain was eight out of ten at the time. (R. 660.)
Plaintiff was scheduled to have a lumbar puncture on November 5, 2009, but did not show up for her appointment. (R. 648.) The procedure was rescheduled for November 9, 2009, but Plaintiff, who arrived at the appointment with her husband, was anxious and refused to continue with the procedure. (Id. ) The procedure was rescheduled for November 12, 2009. (Id. )
A Primary Care Walk-in Patient Note of November 9, 2009, authored by Cynthia Kosuda, a licensed practical nurse, indicates that Plaintiff came in requesting a letter from her primary care provider "stating why she can't work." (R. 651.) The note also provides the following information: "She states that he has difficulty falling and staying asleep and is drowsy during the day, feels as though she has difficulty breathing at night, snores and suffers with headaches daily. She voices no complaint of pain at this time." (Id. ) Ms. Kosuda discussed Plaintiff's request with Wayne Ham, M.D., and Dr. Ham did not write the note but ordered a sleep study. (R. 652.) Because Plaintiff was being seen by the ENT and neurology clinics, Ms. Kosuda advised her to speak with the clinics about the requested note. (Id. )
On November 17, 2009, VA CWT/SE Treatment Plan Note addresses Plaintiff's unemployed status and notes her strengths, abilities, job needs and preferences, vocational goals, and barriers to employment. (R. 638-39.) Medical difficulties were not noted to be barriers. (R. 639.)
On November 24, 2009, Plaintiff again presented to the neurology clinic requesting medication for headache and stating the neurologist had told her there was other medication she could take but he did not order it. (R. 621.) Plaintiff rated her discomfort at three out of ten and reported daily headaches with blurred vision but denied nausea, vomiting, photophobia or phonophobia. (Id. ) Plaintiff was informed that the neurologist's previous note stated that a different medication would be considered depending on the results of the lumbar puncture. (R. 622.) A November 29, 2009, Addendum to the note by the attending neurologist stated that it was imperative to perform a lumbar puncture to properly diagnose Plaintiff and she would be given Lorazapam to help reduce her anxiety for the procedure. (R. 622-23.)
A December 1, 2009, VA Progress Note indicates that Plaintiff presented with a chief complaint of migraine headaches. (R. 600.) The following history was recorded:
38 u/o WF with pmh of exposure to two bomb blasts in 2003 and new onset headache 10/2009. She was seen in the ER 10/28/09 and found to have a swollen optic nerve, referred to opthamologist where she was dx with pseudotumor cerebi and referred to Neurology. Upon her visit to the Neurology clinic 11/4/09 a lumbar puncture procedure was attempted but the patient could not tolerate it. The plan was to administer Diamox depending on the opening pressure. She has been taking Topamax and Imitrex, Naproxen with very minimal relief it decreases from 7/10 ->3/10.
Today she presents to the Neurology clinic complaining of new onset dizziness, blackouts and blurry vision. She reports that she blacked out while sitting watching television lasting only a few minutes which was witness [sic] by her husband. Prior to the blackout, patient experienced dizziness and lightheadedness. She describes her headaches as being frontal and occipital with worse pain in the latter. She also has photophobia and phonophobia. She also c/o decreased sensation in her right hand and leg since 11/04/09.
(R. 600.) The Assessment was "pseudotumor cerebri and migraine headaches with little relief from meds." (R. 603.) Plaintiff was scheduled for another lumbar puncture and was to follow up in the Neurology clinic one week thereafter. (Id. )
Plaintiff had the lumbar puncture on December 3, 2009. (R. 589-94.)
On December 7, 2009, Plaintiff presented to the Emergency Department complaining of headache, nausea and dizziness since the December 3rd lumbar puncture. (R. 586.) Plaintiff was given morphine for pain and a neurology consult was ordered. (Id. ) Assessment included the observation that "[h]eadaches could be secondary to tension headaches vs migrane [sic] headaches vs tumor vs sinus venous thrombosis vs aneurysm (non leaking aneurysm). Post LP pressure headache may be contributing to pts headaches." (Id. ) The plan included further diagnostic studies and changes to her medical regimen. (Id. )
Plaintiff was seen in the neurology resident clinic on December 15, 2009, for follow up. (R. 566.) Plaintiff reported that the neurologist she saw on December 7th "discontinued the topiramate and started her on amitriptyline to titrate to 100 mg at bedtime." (Id. ) Plaintiff reported that she was taking 75 mg. and was doing well and she got significant relief from Imitrex (R. 564, 566.) She also reported that she continued to have daily headaches but they were not as intense and did not last as long. (R. 566.) The plan was to titrate Elavil to 100 mg. and if the headaches were not sufficiently controlled with Elavil, to restart Topamax at a low dose. (R. 565.)
A VA psychology note from December 30, 2009, indicates that Plaintiff reported that she did not feel her physical and mental health allowed her to work at the time. (R. 549.) The note provides the following background information:
Upon returning from Iraq, Ms. Reeves returned to her home in Pennsylvania, but changed jobs - she had previously worked for 9 years doing insurance claims for Tri-Care while in the reserves but changed to work as a police officer at a school.... She worked for 2.5 years, but decided to leave and move to Virginia to help care for her mother when she became ill. She said she has since regretted moving as she has not found work she enjoyed and has been "very stressed." She added that she remains in pain every day, has been very depressed, and some symptoms of PTSD. She reported she has attempted to work three jobs, most recently leaving her job working as a housekeeping manager for a hotel after being treated in a negative way by her manager at the hotel. She currently is remaining at home and caring for her three children ages 10, 9, and 2. She has a fourth child from a prior marriage who has recently joined the Marines.
At a January 14, 2010, kinesiotherapy initial assessment, Plaintiff's problem list included migraine headaches for which she was on medication. (R. 544.) It was noted that Plaintiff was unemployed and was going to school for her associates degree in criminal justice but was thinking of changing her major to respiratory therapy. (R. 545.)
A January 14, 2010, psychology note indicates Plaintiff reported feeling better since she got more medication for her headaches and her mood had improved. (R. 546.) Plaintiff also reported that she wanted to return to work and was hoping to return to school to develop skills as a respiration therapist or x-ray technician-she ...