United States District Court, D. Colorado
OPINION AND ORDER REVERSING AND REMANDING DISABILITY
S. Krieger, United States District Court.
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:
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.
Court offers a brief summary of the facts here and elaborates
as necessary in its analysis.
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.
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.
and Opinions by Treating Professionals
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.
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.
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.
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
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
by Non-treating Professionals
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.
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
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 ...