Caynor v. Berryhill

          ORDER

          LEWIS T. BABCOCK, JUDGE.

         Plaintiff Kathy M. Caynor appeals from the Social Security Administration (“SSA”) Commissioner's final decision denying her application for disability insurance benefits, filed pursuant to Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq., and her application for supplemental security income, filed pursuant to Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383c. Jurisdiction is proper under 42 U.S.C. § 405(g). Oral argument would not materially assist me in the determination of this appeal.

         After consideration of the parties' briefs, as well as the administrative record, I REVERSE and REMAND the Commissioner's final order for further proceedings.

         I. Statement of the Case

         Plaintiff is a 66 year-old woman who has performed work as an administrative and personal assistant. [Administrative Record (“AR”) 166, 171, 204] She seeks judicial review of SSA's decision denying her application for disability insurance benefits and supplemental security income. Pl.'s Br., ECF No. 17 at 2. Plaintiff filed her applications in June 2014 alleging that her disability began in January 2014. [AR 140, 147]

         The applications were initially denied in September 2014. [AR 55-65, 83-85] The Administrative Law Judge (“ALJ”) conducted an evidentiary hearing and issued a written ruling on June 29, 2016. [AR 17-42, 66-81] In that ruling, the ALJ denied Plaintiff's applications on the basis that she was not disabled because she had the ability to perform her past relevant work. [AR 76-77] The SSA Appeals Council subsequently denied Plaintiff's administrative request for review of the ALJ's determination, making SSA's denial final for the purpose of judicial review. [AR 1-5]; see 20 C.F.R. §§ 404.981, 416.1481. Plaintiff timely filed her Complaint with this court seeking review of SSA's final decision. ECF No. 1.

         II. Background

         A. Relevant Medical History

         The relevant medical history relates to Plaintiff's mental ailments. In February 2014, Plaintiff saw Randal Villalovas, M.D. at Heart of the Rockies Regional Medical Center. [AR 285] Dr. Villalovas explained that Plaintiff's chief complaint and history of present illness related to a “significant history of bipolar disorder, treated with lithium for the past 20 to 30 years.” [Id.] She complained of increasing symptoms of “weakness, difficulty walking, and general body pain” and described shakiness and unsteadiness of gait. [Id.] Dr. Villanovas noted that Plaintiff reported that “she has not had her lithium level checked in the past, and their current symptoms are consistent with lithium toxicity.” [AR 286] He referred her to a psychiatrist. [Id.]

         Shortly thereafter, Plaintiff saw Amy Ellis, M.D. for an initial psychiatric evaluation. [AR 357] Dr. Ellis noted that Plaintiff said her functioning was increasingly poor over the prior few months. [Id.] Plaintiff arrived in a wheelchair and said she could not sleep, had nearly all-day episodes of nausea and vomiting, severe tremors, low energy, poor concentration, and no appetite. [Id.] Plaintiff denied suicidal ideation or psychotic symptoms of hallucinations or paranoia. [Id.] Dr. Ellis noted that Plaintiff showed symptoms of lithium toxicity and Plaintiff had to leave the evaluation midway-through because of a hot flash consistent with a panic attack. [AR 358] In part, Dr. Ellis diagnosed Plaintiff with “Bipolar I Disorder; most recent episode depressed, severe without psychotic features; panic disorder with agoraphobia”, lithium toxicity, and problems related to limited social interaction. [AR 359] Dr. Ellis directed Plaintiff to wean off lithium and prescribed Ativan to ameliorate panic attacks. [Id.]

         Dr. Ellis saw Plaintiff on a follow-up two weeks later. [AR 354] Plaintiff noted issues with urination which interfered with her ability to sleep. [Id.] She stated that her strength was returning, potentially because of her weaning off lithium. [Id.] Dr. Ellis noted that Plaintiff's anxiety and panic attacks were occurring less, but she was experiencing visual hallucinations in the form of red and purple color ribbons. [Id.] Dr. Ellis wrote that Plaintiff was calm initially, but became easily anxious and began to experience a panic attack. [Id.] Dr. Ellis suggested discontinuing lithium completely and trying Seroquel in a low dose to help with sleep, psychotic symptoms, and mood stabilization. [AR 355] These general sentiments were echoed by Dr. Villanovas. [AR 284-89]

         At a follow up in April 2014, Dr. Ellis noted Plaintiff was improving and responding to treatment regarding her bipolar disorder. [AR 352] Dr. Ellis found Plaintiff to be anxious, but otherwise noted an unremarkable psychiatric exam. [AR 352-53] This included normal thought processes, normal thought content, fair insight and judgment, normal concentration, normal memory, and normal higher cognitive functioning. [Id.] Dr. Ellis noted similar findings in additional follow-up appointments in May, June, July, August, and September. [AR 335-37, 340-50]

         In August 2014, Plaintiff had a consultative exam performed by Matthew Simpson, M.D. [AR 300-06] Plaintiff stated to Dr. Simpson that since ceasing lithium, her symptoms had been improving, though she did not feel completely back to normal. [AR 300] Dr. Simpson wrote that Plaintiff's switch to other medications left her feeling in better control of her bipolar disorder. [Id.] Dr. Simpson noted that Plaintiff “was pleasant, cooperative, and appeared in no acute distress, ” and “did not appear particularly anxious, agitated, or drowsy and responded appropriately with adequate effort throughout.” [AR 302]

         In November and January of 2015, Dr. Ellis noted similar findings as in her prior records, except that Plaintiff's mood was anxious and depressed in relation to her husband's temperament. [AR 330, 334] In March 2015, Dr. Ellis again noted Plaintiff's mood as depressed and anxious because of her home environment and wrote that her status was worsening. [AR 321-22] The next appointment, Dr. Ellis noted Plaintiff's mood as euthymic and content, but that she was mildly anxious due to her husband's back pain. [AR 318] Similar findings followed in June, July, and August. [AR 407-423] This irritation from her home life and her anxious thoughts continued in ...