United States District Court, D. Colorado
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
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