Halbeisen v. Saul

          ORDER

          LEWIS T. BABCOCK, JUDGE

         Plaintiff, Latausha Monique Halbeisen, appeals from the final decision of the Social Security Administration (“SSA”) Commissioner^[1] 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 et. seq. 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 the Commissioner's final order and REMAND for further proceedings consistent with this opinion.

         I. STATEMENT OF THE CASE

         Plaintiff seeks judicial review of the Commissioner's decision denying her applications for disability insurance benefits and for supplemental security income. After these applications were initially denied on February 21, 2015, on the basis that the record was insufficient to find her disabled [Administrative Record at Doc #11, “AR” 84, 92], an Administrative Law Judge (“ALJ”) held an evidentiary hearing on October 14, 2016 [AR 48-75], and thereafter issued a written ruling dated December 5, 2016. [AR 27-42] The ALJ denied her applications on the basis that Plaintiff was not disabled, from April 16, 2013 through the date of the decision, because Plaintiff could perform work existing in significant numbers in the national economy considering her age, education, work experience and assessed residual functional capacity (“RFC”)(Step Five). [AR 42]

         The SSA Appeals Council subsequently reviewed additional evidence in the form of a medical source statement provided by Plaintiff dated January 19, 2017 [AR 13-16], but found that it did not “relate to the period at issue.” [AR 2] As such, it denied Plaintiff's administrative request for review of the ALJ's determination, making the SSA Commissioner's denial final. [AR 1-7] Plaintiff timely filed her complaint with this court seeking review of the Commissioner's decision.

         II. FACTS

         Plaintiff was born on April 18, 1988, and has a high school education and some college, and she is able to communicate in English. [AR 41] Her prior employment includes work as a receptionist, systems operator, systems analyst, customer service representative/supervisor, and dispatcher. [AR 40, 229] Plaintiff alleges that she became disabled on April 16, 2013 due to a “neck problem, ” “elbow problem” and “brain injury.” [AR 85, 93, 228]

         On April 16, 2013, her alleged onset date, Plaintiff was in a motor vehicle accident. Plaintiff reported to her primary care provider - Kaiser Permanente Colorado (Kaiser) - because she was experiencing neck pain and hand pain. [AR 277-92, 441] A cervical spine x-ray showed evidence of muscle spasm, but no acute bony abnormality, and was consistent with a cervical strain. [AR 441] She was diagnosed with neck pain, dorsalgia, and chest wall pain. [AR 441] A few days later, on April 19, 2013, Plaintiff went to the Emergency Room (“ER”) at Sky Ridge Medical Center reporting continuing symptoms, including neck pain, and a throbbing right-sided headache with decreased vision. [AR 445-52] A non-contrast CT scan of Plaintiff's brain at that time was normal. [AR 452]

         On April 25, 2013, Plaintiff returned to Kaiser reporting a headache with photophobia, and single short episode of horizontal diplopia. [AR 283-84] She returned again to Kaiser on April 29, 2013, reporting headache and concussion. [AR 285] On April 30, 2013, Plaintiff reported to the ER at Sky Ridge Medical Center with neck pain. [AR 454] A CT scan of her cervical spine at that time showed mild straightening, but was negative for cervical radiculopathy, spinal cord compression, fracture or weakness. [AR 455] Examination revealed moderate muscle spasms and moderate soft tissue tenderness. [AR 455]

         Plaintiff returned to Kaiser on May 6, 2013, and reported that her neck pain was intermittent, but her headache symptoms had worsened. [AR 295-96] She again went to the ER at Sky Ridge Medical Center on May 21, 2013 for a migraine headache. [AR 462-71] A follow-up MRI of her brain in June of 2013 was normal, and an MRI of her cervical spine showed a mild disc bulge at level C4-C5. [AR 583-85]

         Plaintiff then began seeing Jerry Cupps, D.O., and Wayne Miller, M.D., with Injury Rehabilitation Services. [AR 672-707] On May 10, 2013, Plaintiff reported to Dr. Cupps that as a result of the car accident, she was experiencing dizziness, memory loss, headaches, blurred vision, buzzing in the ears, ears ringing, difficulty sleeping, arm/shoulder pain, neck pain, neck stiffness, jaw pain on the right side, irritability, fatigue, stomach upset, nausea, and mid-back pain. [AR 672-76] Examination revealed pain and spasm in the cervical spine, and upper thoracic areas, dropping down into the low back. [AR 675] Dr. Cupps' range of motion assessment revealed shoulder strain of both shoulders, and mild pain with range of motion testing of the cervical spine, and minimal pain with range of motion testing of the thoracic spine. [AR 676]

         Plaintiff visited Dr. Cupps again on May 21, 2013 because she was experiencing temporomandibular joint pain at a rate of 8 out of 10; right temporal area pain at 8 out of 10; right atlanto occipital pain at 8 out of 10; headache at 10 out of 10; as well as dizziness, weakness, low back pain, blurred vision, and pain when she opened her right eye. [AR 677] She was also unable to open her mouth beyond 3 centimeters, and her grip strength was 3 out of 5. [AR 677-78] On Dr.

         Cupps' recommendation, Plaintiff reported to the ER later that day with a migraine headache reporting pain of 10 out of 10, and blurred vision, photophobia, and severe nausea. [AR 473]

         On May 23, 2013, Plaintiff requested that Dr. Cupps fill out a form for her employer. [AR 679] In his report, Dr. Cupps indicated that “[t]his patient has significant problems with her head/headache, blurred vision, neck pain, muscle spasms and in general, a lack of ability to work” and then excused her from work through June 30, 2013. [AR 679] He also noted that “[a]s per the patient's employer (Linda B.); if patient should make a dramatic recovery before June 1, with my approval, she can go back to work.” [AR 679-80]

         On May 28, 2013, Plaintiff reported to Dr. Cupps that she was unable to work with computers because of her eyes. [AR 681] On examination, Dr. Cupps noted some restriction in Plaintiff's cervical spine range of motion, significant pain and spasms in her trapezius muscles and neck, tingling in both hands, and shoulder pain on range of motion testing. Plaintiff reported nausea, some dizziness, and a great deal of difficulty sleeping. Dr. Cupps opined that all of Plaintiff's symptoms were the “direct result” of the motor vehicle accident on April 16, 2013. [AR 681-82] An MRI of Plaintiff's head on June 13, 2013 was normal. [AR 585] An MRI of the brain without contrast on June 26, 2013, revealed no brain abnormalities, and a cervical spine MRI revealed a mild disc bulge at ¶ 4-5. [AR 583-84]

         On June 14 and July 3, 2013, Plaintiff followed-up with Dr. Miller at Injury Rehabilitation Services, reporting headache and migraine pain, as well as pain and discomfort in her shoulders, neck, arms, and back. [AR 683-87] At an appointment on July 10, 2013, Plaintiff discussed her anxiety and fears concerning the auto accident, and Dr. Cupps referred her to a psychologist. [AR 688] Dr. Cupps also reported the conclusions of Bennett Machanic, M.D., a neurologist, by re-stating his assessment as follows:

         A rather violent motor-vehicle accident of April 16, 2013, currently did result in a closed head injury/trauma and a cerebral concussion. She now has posttraumatic mixed headache syndrome with a chronic daily headache basis pattern. Many of these events are clearly migraine events. Clinically, she has significant cervical strain, upper thoracic strain, bilateral scalenus anticus dysfunction and signs to implicate bilateral upper extremity thoracic outlet syndrome and right carpal tunnel syndrome. [AR 688]

         Plaintiff again saw Dr. Miller on August 1, 2013, who referred her for physical therapy for thoracic outlet syndrome, neck pain and back spasms, and continued chiropractic care. [AR 690-91] Dr. Miller also noted at this visit that Plaintiff was still off work, per her neurologist, and was scheduled to be off work for another three or four weeks. [AR 691] On August 16, 2013, Plaintiff reported to Dr. Cupps that she was very stressed out over her financial situation, she was “very tearful and concerned, ” and she reported that she continues to have pain in her head, neck, trapezius muscles, as well as intermittent neuropathy of the arms and hands. [AR 692] Dr. Cupps referred Plaintiff to a pain management specialist. [AR 693] He also wrote her a doctor's note stating that “[h]er medical conditions do involve no excessive computer work, critical thinking or physical activities (such as lifting, pushing or pulling).” [AR 692]

         On September 4, 2013, Plaintiff reported to Dr. Cupps that her problems had continued or worsened, and she was directed to follow up with Dr. Fuller, a pain management specialist. [AR 694-95] On October 2, 2013, Plaintiff reported to Dr. Miller neck pain radiating down her back, and headaches, but fewer migraines. [AR 696] She indicated that she planned to receive pain injections from Dr. Fuller. [AR 697] On October 23, 2013, Plaintiff reported to Dr. Cupps that she was having a fair amount of pain in her neck and back, and her headaches had worsened. [AR 698] She also reported anxiety that made her back pain worse and gave her bilateral hand and arm pain and muscle spasms. [AR 698-99] On November 15, 2013, Dr. Miller reported that Dr. Machanic had performed an EMG study on July 11, 2013, and that Plaintiff was diagnosed with possible brachial plexus stretch injury and possible thoracic outlet syndrome at that time. [AR 700] Dr. Miller also stated that Dr. Fuller, the pain specialist, wanted to obtain a new EMG of Plaintiff's upper right extremity. [AR 700-01] On January 8, 2014, Plaintiff reported she was still experiencing back pain, neck pain, headaches, and numbness and tingling in her arms and hands. [AR 702] On May 8, 2014, Plaintiff was discharged from care with Injury Rehabilitation Services, as Dr. Miller indicated that she “has reached a point where additional care here is unlikely to provide any additional significant relief of her accident-related complaints. She is felt to be at [maximum medical improvement] at this time.” [AR 704-706]

         On June 4, 2014, Plaintiff saw Jeffrey Kleiner, M.D., at the Spine Center of the Medical Center of Aurora for evaluation of her neck pain and bilateral upper extremity dyesthesias and weakness. [AR 474] Plaintiff reported to Dr. Kleiner that since the accident she had migraine headaches about once a week, and tension-type headaches about three times a week. Dr. Kleiner noted that imaging showed a loss of disc space at ¶ 5-6, but no instability and a loss of normal cervical lordosis. [AR 474-75] His examination revealed bilateral weakness in her upper extremities and breakaway weakness in both hands. She also had a positive straight arm test and ...