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Spomer v. Berryhill

United States District Court, D. Colorado

March 23, 2018

YVONNE SPOMER, Plaintiff,
v.
NANCY BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.

          OPINION AND ORDER REVERSING AND REMANDING DISABILITY DETERMINATION

          Marcia S. Krieger, United States District Court.

         THIS MATTER comes before the Court as an appeal from the Commissioner's Final Administrative Decision (“Decision”) determining that the Plaintiff Yvonne Spomer is not disabled under the Social Security Act. Having considered all of the documents filed, including the record (#10), the Court now finds and concludes as follows:

         JURISDICTION

         The Court has jurisdiction over an appeal from a final decision of the Commissioner under 42 U.S.C. § 405(g). Ms. Spomer sought disability insurance benefits under Title II of the Social Security Act based on mental and physical impairments that rendered her unable to work as of January 4, 2013. The state agency denied her claim. She requested a hearing before an Administrative Law Judge (“ALJ”), who issued an unfavorable decision. Ms. Spomer appealed to the Appeals Council, which denied her request for review, making the ALJ's determination the final decision of the Commissioner. Ms. Spomer timely appealed to this Court.

         STATEMENT OF FACTS

         The Court offers a brief summary of the facts here and elaborates as necessary in its analysis.

         Ms. Spomer was born July 8, 1971. She graduated from high school and took several college classes without obtaining a degree. She has worked in unskilled positions which include housecleaning, janitorial services, vending, and caregiving. She contends that mental and physical impairments prevent her from working on a full-time basis.

         Ms. Spomer suffers from multiple mental and physical impairments. Her mental health providers have diagnosed her with bipolar disorder, posttraumatic stress disorder, dependent personality disorder, mood disorder, anxiety disorder, depression, and mathematic disorder/executive functioning issues. Additionally, she is obese and suffers from temporomandibular joint disorder, osteoarthritis, insomnia, and migraine headaches.

         Treatment and Opinions by Treating Professionals

         Ms. Spomer began receiving mental health treatment as a teenager on an infrequent basis. In 2010, she was hospitalized because she was having suicidal thoughts, and she was then prescribed lithium. In approximately 2012, she began receiving regular mental health treatment through her primary care physician Chris Keenan, M.D., Rachel Shannon, a licensed clinical social worker, and Susan Mitchell, a nurse practitioner, both of whom worked for Clinica in Lafayette, Colorado. By April 2013, Ms. Spomer had not experienced significant improvement and complained that none of the medications she had received were effective. In November 2013, Dr. Keenan filled out a Colorado Department of Human Services Med-9 Form and opined that Ms. Spomer's emotional state, depression with suicidal thoughts, and manic episodes rendered her disabled for a period of six months or longer.

         In addition to providing mental health treatment, Dr. Keenan treated Ms. Spomer for a variety of chronic physical impairments, including migraine headaches, jaw pain, knee pain, insomnia, and obesity. However, he did not provide a medical source statement as to the impact Ms. Spomer's physical impairments had on her ability to work.

         Dr. Keenan referred Ms. Spomer to Mental Health Partners for specialized mental-health treatment, and in August 2013, she began receiving treatment there. Juan Contreras, a licensed professional counselor, performed an extended assessment; then she received counselling from Marilee Snyder, a licensed clinical social worker. Jule McClaughlin, a physician's assistant, managed her medications.

         After treating Ms. Spomer for about one-and-one-half years, Ms. Snyder filled out a questionnaire concerning Ms. Spomer's mental health symptoms in support of her disability claim. She noted that Ms. Spomer is morbidly obese and physically inactive, and reports that she suffers from insomnia and restless sleep. Ms. Snyder observed that Ms. Snyder had a blunt, flat, or inappropriate affect and had an inability to function outside a highly supportive living arrangement; had moderate symptoms of being depressed or having an irritable mood, had diminished interest or please in almost all activities, was fatigued or had a loss of energy, had unstable interpersonal relationships, had difficulty in maintaining social functioning, concentration, persistence, or pace, having short or long term memory loss, having problems with social interactions, and having mood or affect disturbances; and manifested extreme symptoms of having feelings of worthlessness or guilt, having difficulty thinking or concentrating, having deeply ingrained, maladaptive patterns of behavior, having pathological dependence and passivity, and being emotionally withdrawn and/or isolated.

         Patrick Bushard, M.D., a neurologist, provided Ms. Spomer with treatment to address her migraine headaches. He treated her with Botox injections and prescribed sumatriptan. However, he did not provide a medical source statement as to the impact Ms. Spomer's migraine headaches had on her ability to work.

         Opinions by Non-treating Professionals

         Mark G. Pendleton, Ph.D., a clinical psychologist and neuropsychologist, performed a neuropsychological evaluation. He performed a two-day examination in order to “(1) determine the nature and extent of any organically-based cerebral dysfunction; (2) discuss the implications of the test results for her everyday functioning; and (3) assist with treatment planning.” Dr. Pendleton found that Ms. Spomer's processing speed, nonverbal memory processing, and academic skills, except math, were all normal; her motor control, verbal memory processing, and visuospatial processing were either borderline normal or very mildly impaired; her sensory processing, language processing, and reasoning abilities were all mildly impaired; and her attentional processes and executive functions were mildly to moderately impaired. Based on her testing, Dr. Pendleton opined that Ms. Spomer was neurologically impaired with mild, bilateral cerebral dysfunction and that her cognitive functioning has been declining. He diagnosed her with Cognitive Disorder NOS and Mathematics Disorder. He then opined that these conditions rendered her only marginally able to maintain employment.

         Stuart Kutz, Jr., Ph.D. performed a psychological consultative examination. He opined that Ms. Spomer's abilities to understand and remember complex instructions, to carry out complex instructions, to make judgments on complex work-related decisions, to interact appropriately with coworkers, and to respond appropriately to usual work situations and to changes in a routine work setting were mildly impaired; and her abilities to interact appropriately with the public and with supervisors were moderately impaired.

         Linda Mitchell, M.D., performed a medical consultative examination. She found that Ms. Spomer suffered from joint effusion and mild osteoarthritis and diagnosed her with morbid obesity, right patellofemoral chondromalacia/osteoarthritis, hypothyroidism, and hypertension. She opined that Ms. Spomer could stand or walk for two hours in an eight-hour workday without limitation on the number of hours she could sit; she could pull through or carry weight in the range of twenty to fifty pounds; and she could climb stairs occasionally. She recommended that Ms. Spomer avoid ...


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