Martin-Harris v. Saul

          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 ...