United States District Court, W.D. Arkansas, Fort Smith Division
MAGISTRATE JUDGE'S REPORT AND
RECOMMENDATION
HON.
ERIN L. WIEDEMANN UNITED STATES MAGISTRATE JUDGE
Plaintiff,
Jennifer Martin-Harris, brings this action pursuant to 42
U.S.C. § 405(g), seeking judicial review of a decision
of the Commissioner of the Social Security Administration
(Commissioner) denying her claims for a period of disability
and disability insurance benefits (DIB) and supplemental
security income (SSI) under the provisions of Titles II and
XVI of the Social Security Act (Act). In this judicial
review, the Court must determine whether there is substantial
evidence in the administrative record to support the
Commissioner's decision. See 42 U.S.C. §
405(g).
I.
Procedural Background:
Plaintiff
protectively filed applications for DIB and SSI on November
16, 2015, alleging an inability to work since August 3, 2012,
[2] due
to degenerative disc disease, generalized anxiety disorder,
depression, chronic panic disorder, agoraphobia,
Asperger's Syndrome, Posttraumatic Stress Disorder, and
battered wife syndrome.[3] (Tr. 88, 105, 124, 143). For DIB
purposes, Plaintiff maintained insured status through
September 30, 2018. (Tr. 87, 104, 123, 142). An
administrative hearing was held on May 3, 2017. (Tr. 42-84).
Plaintiff was present and testified. (Tr. 55-75). Julie A.
Harvey, Vocational Expert (VE), was also present and
testified. (Tr. 75-84).
In a
written opinion dated September 8, 2017, the ALJ found that
Plaintiff had the following severe impairments: degenerative
disc disease, cervical degenerative disc disease, cervical
spondylosis without myelopathy, lumbar spondylosis without
myelopathy, chronic pain syndrome, depression, opioid
dependence, generalized anxiety disorder with panic attacks
and agoraphobia, and post-traumatic stress disorder. (Tr.
13). However, after reviewing the evidence in its entirety,
the ALJ determined that the Plaintiff's impairments did
not meet or equal the level of severity of any listed
impairments described in Appendix 1 of the Regulations (20
CFR, Subpart P, Appendix 1). (Tr. 13-16). The ALJ found
Plaintiff retained the residual functional capacity (RFC) to
perform light work as defined in 20 CFR 404.1567(b) and 416.
967(b), except for the following:
[C]laimant can perform frequent overhead reaching
bilaterally; the claimant can perform unlimited reaching
(except overhead) in all other directions bilaterally; the
claimant can perform “simple” tasks;
“simple” tasks are unskilled entry-level tasks
with a SVP of one, which can be learned by simple
demonstration, and a SVP of two, which can be learned in
thirty days or less; the claimant can relate to others,
including supervisors and co-workers (except the general
public) on a “superficial” work basis;
“superficial” means brief, succinct, cursory,
concise communication relevant to the tasks being performed;
the claimant cannot relate to the general public; and can
adapt to a work situation. The claimant has no other physical
or mental limitations or restrictions.
(Tr. 16-23). With the help of a VE, the ALJ determined that
there were jobs that existed in significant numbers in the
national economy that Plaintiff could perform, such as a
merchandise marker, housekeeping cleaner, and routing clerk.
(Tr. 24). Ultimately, the ALJ concluded that Plaintiff had
not been under a disability within the meaning of the Social
Security Act from August 3, 2012, through the date of the
ALJ's opinion. (Tr. 24).
Subsequently,
Plaintiff requested a review of the hearing decision by the
Appeals Council, which denied that request on April 10, 2018.
(Tr. 1-6). Plaintiff filed a Petition for Judicial Review of
the matter on June 12, 2018. (Doc. 1). Both parties have
submitted briefs, and this case is before the undersigned for
report and recommendation. (Docs. 15, 16).
The
Court has reviewed the transcript in its entirety. The
complete set of facts and arguments are presented in the
parties' briefs and are repeated here only to the extent
necessary.
II.
Evidence Submitted:
At the
hearing before the ALJ on May 3, 2017, Plaintiff testified
that she was born in 1966 and received a college degree. (Tr.
55). Testimony showed that after Plaintiff's alleged
onset of disability, she worked for the Arkansas Department
of Human Services and for Arkansas Therapy Outreach. (Tr.
69-74).
Prior
to the relevant time period, medical records showed that
Plaintiff was treated for chronic neck pain and pain in her
lumbar spine region, right shoulder, right arm, pelvic
region, and right hip. She was also seen for a conversion
reaction that was psychiatric in nature and was referred for
a psychiatric evaluation. She was treated for anxiety, chest
pain, right arm numbness, panic disorder, hot flashes,
cervical radiculitis, cervicalgia, and headaches.
Medical
evidence during the relevant time period reflects that on
April 29, 2014, Plaintiff presented at Baptist Family Clinic
for a follow up visit with Dr. Jerry Cavaneau for her
anxiety, which was poorly controlled. (Tr. 805).
Plaintiff's physical examination was normal. (Tr. 806).
Her anxiety medication was adjusted. (Tr. 807).
On May
16, 2014, Plaintiff saw Dr. Butchaiah Garlapati at Arkansas
Pain Center for a follow up examination for her neck and
right shoulder pain. (Tr. 509). Plaintiff stated that her
medications were working well and that she had not
experienced any side effects. Her pain level remained at a
seven out of ten. (Tr. 509). Plaintiff's physical
examination showed tenderness and restricted range of motion
in areas of her spine. (Tr. 510). Her neurologic and psych
examinations were normal. Plaintiff was diagnosed with
cervicalgia, cervical radiculitis, and headache. Plaintiff
was instructed to continue with her current medication
regimen of fentanyl and oxycodone-acetaminophen. (Tr. 511).
On May
29, 2014, Plaintiff went to Baptist Family Clinic for a
follow up visit. Plaintiff's anxiety-related symptoms
were well controlled; however, she still reported difficulty
in functioning. Her hyperlipidemia was stable. (Tr. 801). Dr.
Cavaneau instructed Plaintiff to continue her medications.
(Tr. 803).
On July
14, 2014, Plaintiff was seen at Arkansas Pain Center, Ltd. by
Rebecca Foster, Physician Assistant, and supervising
physician, Dr. Butchaiah Garlapati for a follow up
examination for her neck pain and right shoulder pain. (Tr.
505). Plaintiff reported that her medications were working
well. (Tr. 505). Examination notes indicated that Plaintiff
had a non-antalgic gait and did not use any assistive
devices; she was able to sit comfortably on the examination
table without difficulty or evidence of pain; and she showed
signs of tenderness and restricted range of motion in areas
of her spine. (Tr. 506). She was diagnosed with cervicalgia,
cervical radiculitis, and headache. Her medications were
refilled as she was stable and had seen improvement of
function and activities of daily living on her current
regimen. (Tr. 507).
On July
15, 2014, Plaintiff was seen at the Baptist Family Clinic.
She reported that her headaches were mild and improving; her
hot flashes were improving; her hyperlipidemia was stable;
and her anxiety symptoms were well controlled. (Tr. 784).
Plaintiff was assessed with hyperlipidemia, headaches, hot
flashes, and anxiety. Dr. Cavaneau continued her medication.
(Tr. 786).
On
August 1, 2014, Plaintiff visited Dr. Cavaneau at Baptist
Family Clinic for a follow up of her anxiety and
hyperlipidemia. Clinic notes indicated that Plaintiff's
related symptoms were well controlled, and her hyperlipidemia
was stable. (Tr. 797). Plaintiff's medications were
refilled. (Tr. 799).
On
September 8, 2014, Plaintiff was seen at Baptist Family
Clinic by Dr. Cavaneau, where she reported some associated
symptoms of hyperlipidemia, some symptoms of anxiety, and
some mild memory loss. (Tr. 792). Plaintiff was instructed to
continue her medication for her anxiety, and a MRI of the
brain/head was ordered. (Tr. 794).
On
September 12, 2014, Plaintiff was seen at Arkansas Pain
Center by Rebecca Foster (PA) for a follow up examination of
her right neck and shoulder pain. (Tr. 500). With the
exception of some constipation, Plaintiff was doing well on
her medications. (Tr. 500). Plaintiff was able to sit
comfortably on the examination table without difficulty or
evidence of pain; had a non-antalgic gait; and did not use
any assistive devices. (Tr. 501). Her physical examination
showed tenderness and restricted range of motion in areas of
her spine. (Tr. 501-502). Her neurologic and psychiatric
examinations were normal. For her diagnoses of cervicalgia,
cervical radiculitis, and headaches, Plaintiff's current
medications were refilled. Clinic notes indicated that
function and activities of daily living improved optimally on
current doses of medications. (Tr. 503).
A MRI
of Plaintiff's brain also performed on September 12,
2014, showed unremarkable pre- and post-contrast MRI of the
brain for age, and no findings explained the patient's
headaches. (Tr. 950).
On
September 15, 2014, Plaintiff was seen by Dr. Cavaneau for a
follow up appointment. (Tr. 788). Plaintiff stated that her
hot flashes were improving; that she was adhering to her
medication for her hyperlipidemia; and that her headaches
were improving. (Tr. 788). She was assessed with
hyperlipidemia, headaches, and hot flashes. (Tr. 790).
On
November 11, 2014, Plaintiff was seen at Arkansas Pain Center
by Rebecca Foster (PA), and Dr. Garlapati for a follow up
examination. (Tr.496). Plaintiff reported that she was doing
well on her medication. (Tr. 496). Plaintiff's physical
examination showed that she was doing well except that she
appeared to be in mild pain and tearful. Plaintiff had a
non-antalgic gait and did not use any assistive devices. (Tr.
497). She had tenderness and limited range of motion in areas
of her spine; her neurological examination was normal; and
her psych examination was normal. She was diagnosed with
cervicalgia, cervical radiculitis, and headache. (Tr. 498).
Her medications were refilled. (Tr. 498).
On
December 19, 2014, Plaintiff presented at Baptist Family
Clinic. Plaintiff reported that her anxiety had improved, her
hot flashes had improved, and her hyperlipidemia was stable.
(Tr. 780). Her medications were continued. (Tr. 782).
On
January 9, 2015, Plaintiff returned to Arkansas Pain Center
for a follow up examination. (Tr.492). Plaintiff described
her quality of sleep as good; stated that her medications
were working well; and that her activity level remained the
same. (Tr. 492). Clinic notes stated that Plaintiff was in no
distress, was alert and oriented, and was able to sit
comfortably on the table without difficulty or evidence of
pain. Plaintiff had a non-antalgic gait and did not use any
assistive devices. (Tr. 493). Plaintiff's physical
examination showed tenderness and restricted range of motion
in some areas of the spine; her neurologic examination was
normal; and her psych examination was normal. Plaintiff's
diagnoses were cervicalgia, cervical radiculitis, and
headache. (Tr. 494). Plaintiff's medications were
refilled. (Tr. 495).
On
March 10, 2015, Plaintiff was seen at Arkansas Pain Center by
Rebecca Foster (PA) and Dr. Garlapati for her a follow up
examination for her low back pain, headache, right shoulder
pain, and right leg pain. (Tr. 487). Plaintiff stated that
her medications were working well; that she had no side
effects to report; and that her quality of sleep was fair.
(Tr. 487). Clinic notes stated that Plaintiff was in no
distress, was alert and oriented, and was able to sit
comfortably on the table without difficulty or evidence of
pain. Plaintiff had a non-antalgic gait and did not use any
assistive devices. (Tr. 488). Plaintiff showed no signs of
depression or anxiety. (Tr. 489). A physical examination of
her spine showed tenderness and restricted range of motion in
some areas, and Plaintiff's diagnoses were cervicalgia,
cervical radiculitis, and headache. (Tr. 489).
Plaintiff's medications were continued at the current
dosage. (Tr. 489).
On
March 13, 2015, Plaintiff saw Dr. Cavaneau for a follow up
visit. Plaintiff complained of difficulty functioning,
anxiousness and fearful thoughts. (Tr. 775). She was assessed
with hyperlipidemia, a ganglion cyst, hot flashes, and
anxiety. (Tr. 777).
On May
8, 2015, Plaintiff Rebecca Foster (PA) and Dr. Garlapati for
low back pain, headache, right shoulder pain and right leg
pain. (Tr. 483). Plaintiff was complaining that her pain had
worsened since her last visit; however, Plaintiff also
reported that her medication was working well. (Tr. 483).
Clinic notes indicated that Plaintiff appeared to be
fatigued, but that she was well groomed, well nourished, and
had a non-antalgic gait. (Tr. 484). Plaintiff's physical
examination showed tenderness and restricted range of motion
in some areas of her spine; a normal neurologic examination;
and a normal psych examination. Her diagnosis was
cervicalgia, cervical radiculitis, and headache. (Tr. 485).
Plaintiff's fentanyl patch and ...