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Medina v. Berryhill

United States District Court, D. Colorado

January 24, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Jessica L. Medina 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 48 year-old woman with a GED and some specialized schooling. [Administrative Record (“AR”) 248, 285] She seeks judicial review of SSA's decision denying her applications for disability insurance benefits and supplemental security income. Pl.'s Br., ECF No. 13 at 1-2. Plaintiff filed her application for disability insurance benefits in June 2014 alleging that her disability began in September 2009 and her application for supplemental security income in September 2014 alleging that her disability began in February 2013. [AR 221, 225]

         The applications were initially denied on October 30, 2014. [AR 156, 160] After Plaintiff's request for review, the Administrative Law Judge (“ALJ”) conducted an evidentiary hearing and issued a written ruling on October 18, 2016. [AR 32-45, 51-98] In that ruling, the ALJ denied Plaintiff's application on the basis that she was not disabled because, considering her age, education, work experience, and residual functional capacity, Plaintiff could perform jobs existed in significant numbers in the national economy. [AR 44]

         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 1-4]; 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. Relevant Medical History

         Plaintiff's claims on appeal relate to her mental health and her neck, back, and arm. Her injuries mainly stem from an assault that occurred in 2009 where she was severely injured in her home. [AR 828-30]

         A month after the assault, Plaintiff visited the Summit Medical Clinic where she was examined by Todd Knauf, PA. [AR 659-61] Plaintiff noted numerous maladies including: memory loss; severe, infrequent headaches; severe neck pains; numbness and tingling in her right arm; and trouble sleeping. [AR 659] Mr. Knauf noted that Plaintiff had a decreased range of motion in her neck and appeared mildly distressed. [AR 660] He assessed Plaintiff with severe neck pain, severe headaches, numbness and tingling in her right arm, and right arm pain. [AR 660- 61] A neurologist diagnosed her with a concussion. [AR 673]

         In March and June 2010, Mr. Knauf added diagnoses of anxiety and depressive disorder and advised her to seek counseling. [AR 683, 690] In December, Plaintiff presented symptoms of chronic nausea and headaches and acute vomiting and Mr. Knauf ordered an MRI of her brain. [AR 701-02] Plaintiff returned a few weeks later, reporting another assault and was diagnosed with cervicalgia and lumbago-neck and lower back pain. [AR 707] A radiology report from that month read that Plaintiff had mild degenerative changes in her cervical and lumbar spine. [AR 888-89]

         In January 2011, Plaintiff complained of continued fatigue and depression, but was afraid to take depression medication prescribed to her. [AR 718] An MRI showed minimal changes when compared to a 2009 MRI. [AR 354] In May, Mr. Kanuf diagnosed Plaintiff with vertigo. [AR 730] In July, Plaintiff began therapy at Aspen Pointe with Lyndsay Ross, PsyD writing that Plaintiff felt as though she was having a nervous breakdown and social anxiety. [AR 360]

         In January 2012, Dr. Ross noted that Plaintiff had been feeling more emotionally stable, but reported continued issues with family. [AR 464] That same month, Plaintiff reported to Mr. Knauf moderate right arm pain that did not limit daily activities and chronic depression. [AR 742] In March, Pratheep Arora, MD of Summit Medical Clinic prescribed Plaintiff Xanax for anxiety and noted acute anxiety due to familial issues. [AR 404] In August, Dr. Ross wrote that Plaintiff reported that

she has been avoiding problems in her life by isolating inside her house and avoiding social contact as well as several of her responsibilities. She reports her depression has decreased somewhat in intensity over the past 6 months, but that her anxiety and irritability are still very high. She states that she feels the way she did two years ago when she first initiated mental health treatment.

[AR 470]

         In October, Plaintiff visited Summit Medical Center, where her medicine for depression and anxiety was increased and she was prescribed medicine for muscle spasms in her shoulder. [AR 410] One month later, Plaintiff continued to experience neck and shoulder pain and was ordered to have an X-ray of her neck. [AR 411-12]

         In January 2013, Plaintiff presented to Maninder Bali, MD that she had stress dealing with people, poor memory when anxious, and excessive worrying. [AR 475] Dr. Bali noted a restricted affect, better mood, and an otherwise unremarkable psychiatric exam, but increased Plaintiff's prescription for Zoloft, continued her on Xanax, and started her on Prasozin. [AR 476-77] In March, Plaintiff reported to Dr. Bali that she was fired from her job and that she had severe pain in her neck. [AR 481] Dr. Bali increased her Zoloft prescription. [AR 483]

         In April, Plaintiff reported continued pain in her neck and Dr. Arora ordered an MRI of her cervical spine. [AR 415] That MRI showed mild to moderate disc degeneration in parts of her spine and severe disc degeneration in other parts “with mild cord flattening by disc osteophyte.” [AR 352-53]

         In May, shortly after the MRI, Dr. Bali noted that Plaintiff still had depression and low energy with severe pain in her neck and back that made “her daily work impossible to be done.” [AR 488] Dr. Bali added a prescription for Wellbutrin. [AR 490] Through June and July, Plaintiff continued her pain management with Dr. Arora. [AR 420-23]

         In August, Dr. Bali wrote that Plaintiff had nightmares related to the anniversary of her assault and that post-traumatic stress disorder made her unable to work. [AR 495] In September and December 2013 and March 2014, Plaintiff reported to Dr. Bali that she had no concerns and her mood was stable and Dr. Bali renewed her medication. [AR 502, 504, 509, 515]

         In June, Plaintiff saw Jay Balestrieri, NP, who noted neck and arm pain. [AR 379] In July, Dr. Bali noted that Plaintiff was “[q]uite depressed” and increased her medication. [AR 523] In August, Plaintiff had an X-ray of her right shoulder with no remarkable findings, but that pain continued into September. [AR 584, 765] Dr. Bali wrote that Plaintiff was still doing well on her medication regime, but added an adjunct to assist with obsessive compulsive disorder and depression. [AR 608] After Plaintiff had an MRI on her shoulder, Mr. Knauf assessed her with cervicalgia and cervical radiculopathy. [AR 768]

         Shortly thereafter, Victor Nwanguma, MD performed a consultative exam on Plaintiff. [AR 589] Dr. Nwanguma wrote that Plaintiff was awake, alert and in no acute distress. [AR 590] He diagnosed Plaintiff with “[c]ervical spinal stenosis, chronic with right upper extremity radiculopathy.” [AR 592] He provided a functional assessment where he wrote that Plaintiff “may have frequent limitation performing activities requiring use of the right upper extremity due to radiculopathy from cervical spinal stenosis;” limited her to carrying 50 pounds occasionally and 25 pounds frequently; and suggested occasional limitation with reaching, handling, fingering, and feeling. [AR 592-93]

         In November, Plaintiff reported continued shoulder and neck pain alongside dizziness. [AR 772] Dr. Arora added medicine for the dizziness. [AR 773] A lumbosacral spine X-ray lead to an impression of mild spondylosis and facet joint arthropathy. [AR 776] Dr. Arora assessed Plaintiff with cervical radiculopathy. [AR 777]

         In December, Plaintiff saw Dr. Bali and cried throughout the interview, where she noted stress regarding her family and asked for medicine to control her insomnia. [AR 612-14] Mr. Knauf assessed Plaintiff was spinal stenosis in her cervical region and restarted her on hydrocodone. [AR 786]

         In January and May 2015, Plaintiff reported no concerns to Dr. Bali and she planned on continuing her regimen. [AR 619-21, 626] Plaintiff again reported to Mr. Knauf neck and shoulder pain and Mr. Knauf assessed her with cervical degenerative disc disease. [AR 790] In March she was assessed with spinal stenosis in her cervical region and in April, she was assessed with cervicalgia. [AR 795]

         In June 2015, Plaintiff established care with Value Care Health Clinic, where it was noted that her depressive disorder was chronic but well controlled and that her cervical spine stenosis was chronic and unchanged. [AR 897] Plaintiff reported it to be stable, but it was noted that she had slight right arm and hand weakness. [AR 899-900] Through July and August, Plaintiff's pain continued, but was controlled, and additional MRIs were ordered. [AR 901-09] In September, Plaintiff began therapy after being retraumatized when she witnessed an assault. [AR 114] Tracy Kinsley, LPC noted an unremarkable mental status exam. [AR 114-15] Ms. Kinsley saw Plaintiff over ...

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