United States District Court, D. Colorado
OPINION AND ORDER REVERSING AND REMANDING THE
COMMISSIONER'S DECISION
MARCIA
S. KRIEGER, SENIOR UNITED STATES DISTRICT JUDGE
THIS
MATTER comes before the Court on the Plaintiff's
Complaint (# 1), the Plaintiff's Opening
Brief (# 14), the Defendant's Response
(# 15), and the Plaintiff's Reply
(# 16). For the following reasons, the
Commissioner's decision is reversed, and the matter is
remanded for further proceedings.
I.
JURISDICTION
The
Court has jurisdiction over an appeal from a final decision
of the Commissioner under 42 U.S.C. § 405(g).
II.
BACKGROUND
A.
Procedural History
Plaintiff
Eleia Warson (“Ms. Warson”) seeks judicial review
of a final decision by the Defendant Commissioner
(“Commissioner”) denying both her claim for
disability insurance benefits (“DIB”) and
application for supplemental security income
(“SSI”) under the Social Security Act. In August
2014, Ms. Warson filed for DIB, claiming she became disabled
as of January 13, 2014. (# 9-9 at 483). In October 2014, Ms.
Warson filed for SSI. (# 9-9 at 485). Following two hearings
held on October 4, 2016 and March 22, 2017 before the same
Administrative Law Judge (“ALJ”), Ms. Warson
received an unfavorable decision in April 2017
(“Decision”). (# 9-2 at 48-64). Ms. Warson
appealed that Decision to the Appeals Council. However, on
May 1, 2018, the Appeals Counsel denied her Request for
Review. (# 9-2 at 1-14). Ms. Warson now appeals the final
agency action to this Court.
B.
Factual Background
The
Court offers a brief summary of the facts here and elaborates
as necessary in its discussion. Ms. Warson was born on
February 10, 1969. (# 9-2 at 62). She was 44 years old on her
initially-alleged disability onset date in January 2014 and
48 years old at the time of the ALJ's Decision. (# 9-2 at
62). She has a high school education and work history in
physically demanding jobs such as: Quality Control Inspector;
Laser Sintering Technician; Weigh Room Technician; Warehouse
Associate; Senior Production Operator; and Machinist. (# 9-10
at 547-558).
Ms.
Warson alleges she became disabled on January 14, 2014 due to
migraine headaches, confusion, fibromyalgia, irritable bowel
syndrome, post-traumatic stress disorder
(“PTSD”), restless leg syndrome, herniated lumbar
discs, cervical stenosis, cubital tunnel syndrome, and
degenerative joint disease. (# 9-10 at 532). In October 2014,
Ms. Warson had neck surgery, but she continued to have back
and leg pain and stiffness. (# 9-13 at 904). Thus, on May 13,
2015, she underwent low back surgery (bilateral L3-4, L-45
and L5 laminectomy with bilateral foraminotomies L3-L4). (#
9-17 at 1010). Due to surgical complications, Ms. Warson
developed a MRSA infection, was subsequently hospitalized
twice, and was on IV antibiotics until November 2015. (# 9-17
at 1010; # 10 at 1179-10-20 at 2270). In December 2015, while
Ms. Warson reported having nausea and stomach pain related to
the antibiotics, her back pain had subsided, and the records
indicated her “back is well healed.” (# 10-12 at
1952-62).
Additionally,
Ms. Warson's history of migraine headaches is well
documented in the record, including treatment from various
providers spanning several years. (# 9-10 at 572; # 9-11 at
631-635, 647-664, 678, 685; # 9-12 at 773; # 9-4 at 194; #
9-14 at 853-858; # 10-21 at 2328, 2331, 2338, 2340, 2352,
2356, 2360, 2376, 2406). Further, at the March 2017 hearing
before the ALJ, Ms. Warson testified to her continuing
struggles with migraine headaches. (# 9-5 at 288-292).
In
addition, the record reflects mental health impairments,
including anxiety and depression and a diagnosis of PTSD,
which is the focus of this appeal. Ms. Warson's PTSD and
related treatment is well documented in the record. (# 9-11
at 672; # 9-12 at 699, 707, 709, 712-713, 717-720, 722-724; #
9-14 at 864-868, 872, 899). In March 2014, Ms. Warson sought
treatment at Aspen Pointe for major depressive disorder and
PTSD. (# 9-12 at 700-710). An Aspen Pointe Clinical
Assessment report revealed a diagnosis of PTSD as a result of
sexual abuse Ms. Warson suffered when she was a child. (#
9-12 at 700). Aspen Pointe providers reported PTSD as an Axis
I clinical disorder. (# 9-11 at 672). The records indicate
that as a result of her PTSD, Ms. Warson experienced:
nightmares; avoidance of stimuli; feelings of detachment; a
sense of a foreshortened future; and anger outbursts. (# 9-12
at 709). Ms. Warson participated in therapy and was
prescribed various prescription medications in order to
manage her PTSD symptoms. (# 9-12 at 700-724). On January 12,
2015, Karen Rice, M.D. diagnosed Ms. Warson with PTSD and
major depressive disorder and found that her past childhood
trauma was likely the cause of her depression and PTSD. (#
9-14 at 868). Dr. Rice's treatment notes characterized
Ms. Warson's PTSD as “unstable” and
recommended “critical” treatment for her
condition. (# 9-14 at 865, 867). Dr. Rice recommended a
treatment plan that included both therapy sessions and a
prescription medication protocol. (# 9-14 at 867).
In
November 2014, state agency psychologist Irwin Matus, Ph.D.
also assessed Ms. Warson's mental impairments and
formulated his own Residual Functional Capacity
(“RFC”) assessment. Dr. Matus found Ms. Warson
had the following limitations in sustained concentration and
persistence: (1) not significantly limited in carrying out
short and simple instructions; (2) moderately limited in
carrying out detailed instructions; (3) moderately limited in
the ability to maintain attention and concentration for
extended periods; (4) moderately limited in the ability to
perform activities within a schedule, maintain regular
attendance, and be punctual within customary tolerances; (5)
not significantly limited in sustaining an ordinary routine;
(6) no limitation as to working in coordination or proximity
to others without being distracted by them; (7) not
significantly limited in making simple work-related
decisions; (8) moderately limited in the ability to complete
a normal workday or workweek without interruptions from
psychologically based symptoms and to perform at a consistent
pace without an unreasonable number and length of rest
periods; and (9) no limitations in social interactions. (#
9-6 at 314-15). Dr. Matus noted Ms. Warson's PTSD,
depression, confusion, and multiple medical conditions and
concluded that her anxiety and mood are generally stable
while she is taking her medications. He opined that Ms.
Warson could sustain lower end, moderately complex work
tasks. (# 9-6 at 315).
C.
The ...