THOMAS B. SMITH, Magistrate Judge.
Plaintiff Norma E. Moody brings this action pursuant to the Social Security Act (the "Act"), as amended, 42 U.S.C. § 405(g), to obtain judicial review of a final decision of the Commissioner of the Social Security Administration (the "Commissioner") denying her claim for disability insurance benefits under the Act. Upon review of the record, including the transcript of the proceedings before the administrative law judge ("ALJ"), the ALJ's decision, the exhibits, pleadings and memoranda submitted by the parties, and for the reasons that follow, I respectfully recommend that the Commissioner's final decision be reversed and remanded for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g).
Plaintiff protectively filed for a period of disability and disability insurance benefits on October 19, 2011 (Tr. 21). She alleged an onset of disability on November 12, 2010, due to diabetes, spinal column at C4-C5, lower back injury, numbness in left hand, upper and lower back pain, neck pain, and obesity (Tr. 191). Her application was denied initially and after reconsideration (Tr. 106-07; 113-14). Plaintiff requested and received an administrative hearing that was held on January 10, 2013 (Tr. 119-20; 36-83). At the time of the hearing, she was 48 years old. In a decision dated May 2, 2013, the ALJ found Plaintiff not disabled as defined in the Act through the date of his decision (Tr. 18-35). Plaintiff timely filed a request for review of the ALJ's decision, which the Appeals Council denied on June 13, 2014 (Tr. 1-3, 17). Consequently, the ALJ's unfavorable decision is the Commissioner's final decision in the case (Tr. 1). Plaintiff timely filed this action for judicial review (Doc. 1). She has exhausted all available administrative remedies and the case is properly before the Court.
[Plaintiff] was confronted with significant medical issues that surfaced in the later portion of 2010 (Tr. 21, 43). Ms. Moody began grappling with neck and shoulder pain, insomnia, vision problems, some dyspnea on exertion, and joint issues coupled with left arm numbness (Tr. 43, 362-65). Ultimately, the functional aspects of this job were too overwhelming for Ms. Moody to physically handle (Tr. 43, 82-83). As a result by the end of the work day, she was sobbing due the symptoms springing from these conditions (Tr. 43). Sadly, these impairments forced Ms. Moody to resign from a career she loved (Tr. 43, 82-83, 222); see also (Tr. 29, 78-79 — where the ALJ agreed that Plaintiff is incapable of performing any of her PRW).
Thereafter, Ms. Moody sought treatment for her health problems (especially in regard to neck and arm pain) (Tr. 362-65). For this, she established regular care at Titusville Family Practice under the direction of primary care physicians (PCP), Drs. Raguindin and Pagan (Tr. 317-98, 475-534); see also (Tr. 365 — where an overnight oximetry (oxygen) was prescribed). Dr. Pagan examined Plaintiff in April 2011, and noted Plaintiff had a smooth gait, and a normal station, with mildly restricted range of motion (ROM) in the cervical spine (Tr. 511). She displayed intact cranial nerves, 2+/4+ and symmetrical deep tendon reflexes, and normal response to light touch, pain, pin prick, stereognosis, and vibration (Tr. 511). Due to Ms. Moody's complaints, Dr. Pagan immediately ordered an X-ray for her neck (Tr. 385). This April of 2011 cervical spine (CS) x-ray showed degenerative disc disease (DDD) with dorsal osseus ridging at C4-5 (Tr. 385).
At Ms. Moody's subsequent encounter with Dr. Pagan, he recorded similar symptomology (Tr. 357-60). In consequence, he referred her to an endocrinologist for diabetic management (Tr. 361); see also (Tr. 518, 652, 658, 662 — where Ms. Moody has had elevated HB A1C levels).
Dr. Pagan probed further concerning Ms. Moody's health. He ordered further diagnostic testing.
Ms. Moody's low back and leg pain flared up in late 2011 (Tr. 318, 394, 395 — back symptoms persistent, 408 — where Ms. Moody had diminished bilateral lateral femoral cutaneous nerve distribution, 412). A November of 2011 lumbar spine MRI showed: (1) multilevel lumbar spondylosis (degenerative osteoarthritis of the spine) with inflammation noted in the left L1-2 and bilateral L2-3 to L5-S1 facet joints, (most pronounced at L4-5 and L5-S1), (2) DDD at T12-L1 and L4-5, (3) L4-5 disc displacement, and (4) spondylosis resulting in left foraminal stenosis and slight wedge deformity at T12 (Tr. 401). In December of 2011, Dr. Raguindin referred Ms. Moody to physical therapy for her unrelenting lower back symptoms (Tr. 369). But Ms. Moody was unable to tolerate the initial evaluation secondary to pain (was in tears) (Tr. 369 — where the physical therapist reported that Ms. Moody was unable to tolerate sitting longer than five minutes). Ms. Moody's back issues were then addressed by her physiatrist, Dr. Sonser (Tr. 542, 547). Dr. Sonser observed that Ms. Moody had diminished sensation to light touch throughout the bilateral lower extremities from the feet to the knees (Tr. 539, 542).
In early 2012, Ms. Moody's treating PCP, Dr. Raguindin, noted her drop in activity level coupled with fatigue, decreased energy, shortness of breath, and lightheadedness (Tr. 396 — this physician also noted that
Plaintiff had a slow gait, 5/5 strength, tender cervical and lumbar spinous processes, and generalized moderate tenderness over the neck and shoulder girdle (Tr. 397). Plaintiff's cervical spine movement was mildly restricted, and her cranial nerves were intact (Tr. 398).
In addition, Dr. Raguindin referred Ms. Moody to Sachin R. Shenoy, at the Neurology Headache and Pain Center (Tr. 462-72, 550-76). Dr. Shenoy noted that Ms. Moody was now struggling with increased pain with prolonged sitting, standing, and lying down (Tr. 465). In addition, she was having no symptom relief from her medication regimen of Tramadol and Nucynta (Tr. 465); see also (Pl.'s Br. 12). On examination in January 2012, Plaintiff exhibited 5/5 motor strength, symmetric and normal deep tendon reflexes, and a normal gait (Tr. 466). Dr. Shenoy noted multiple areas of pain and tenderness along the large joints and areas consistent with fibromyalgia (Tr. 466). Fibromyalgia and chronic pain syndrome were noted as another explanation for her complaints and different medications were prescribed (Tr. 466). On her next return visit to Dr. Shenoy, Ms. Moody was now experiencing daily headaches (Tr. 468). Plaintiff reported her pain was not as intense as before and that the medication was working for her (Tr. 468). On examination, Plaintiff exhibited 5/5 motor strength in all four extremities, symmetric and normal deep tendon reflexes, reduced sensation on the left hand, a normal gait, normal tandem, and normal finger-nose testing, as well as pain and tenderness in areas consistent with fibromyalgia (Tr. 469). And she had elevated CRP (C-reactive protein)
Consequently, Ms. Moody began experiencing numbing, painful, coldness in her feet with a slow gait (Tr. 531, 533). By mid 2012, Ms. Moody expressed to Dr. Shenoy that her medications were no longer working for her, and she was having joint pain along with daily headaches (Tr. 557). Her medications were adjusted which helped (Tr. 553, 556).
An EMG on her lower extremities was performed in May of 2012. This test uncovered the development of neuropathy (Tr. 568-70 — performed by her treating physician, Dr. Shenoy).
Despite numerous avenues of conservative treatment, Ms. Moody's sharp pain symptoms persisted in her neck, shoulders, and forearms (Tr. 585, 588). Ms. Moody now was experiencing new pain towards the back of her head (Tr. 551). Therefore, Dr. Smith recommended an anterior cervical discectomy and fusion (Tr. 586-87, 589). On August, 15, 2012, Ms. Moody underwent major cervical spinal surgery and was provided a bone growth stimulator (Tr. 579, 581-84). A post surgical CS x-ray in October of 2012 indicated some foraminal encroachment remained bilaterally (apparently at C4-C6) along with decreased range of motion (Tr. 594); Cf; (Tr. 590 — an August 16, 2012, CS x-ray (taken right after Ms. Moody's cervical fusion) demonstrated some early DDD). The impression was "[p]ost operative change and mild degenerative change" (Tr. 594).
In May of 2012, Dr. Sonser performed bilateral facet joint injections at L4-5 and L5-S1 (Tr. 400, 536, 543, 545). This provided no significant relief for Ms. Moody (Tr. 536). Ms. Moody continued with pain in her low back pain and intermittent paresthesia in her legs (Tr. 535, 608). Due to her complaints, Dr. Sonser referred Ms. Moody to a rheumatologist (Tr. 608). Specifically, Carol Gracia, ARNP, examined Plaintiff at Space Coast Rheumatology Arthritis (Tr. 602-09).
Ms. Moody began regular treatment with Space Coast Rheumatology Arthritis in an attempt to unravel the medical mystery underlying her complaints. On her initial visit, Ms. Gracia observed restricted forward and side bending of the cervical spine; restricted forward and lateral bending of the lumbar spine; SI (sacroiliac joint) tenderness; painful range of motion in most of her joints; mild OA (osteoarthritis) changes of the hands, wrists, and shoulders (bilaterally); tender bilateral GTB (greater trochanteric bursitis) and of the knees; and 11/18 tender points for FM (fibromyalgia) (wincing at pain with signs of allodynia)
Ms. Gracia searched onward for answers to Ms. Moody's health dilemma ordering numerous diagnostic tests to uncover her medical riddle. Specifically, Ms. Gracia wanted to perform a complete laboratory work
Ms. Moody has "pain all over" (Tr. 40-41, 602). Luckily, her husband is always right where she needs him (Tr. 57-72-74). He assists her with such things as showering/washing her hair, dressing, and tying her shoes (and even with basic hygiene after using the bathroom). Id.
In determining whether an individual is disabled, the Commissioner must follow the five-step sequential evaluation process codified at 20 C.F.R. §§ 404.1520(a)(4) and 416.920(a)(4). Specifically, the Commissioner must determine whether the claimant (1) is currently employed; (2) has a severe impairment; (3) has an impairment or combination of impairments that meets or medically equals an impairment listed at 20 C.F.R. Part 404, Subpart P, Appendix 1; (4) can perform past relevant work; and (5) retains the ability to perform any work in the national economy.
At step one the ALJ found that Plaintiff has not engaged in substantial gainful activity since her alleged onset date (Tr. 23). At step two, the ALJ determined that Plaintiff had the following severe impairments: diabetes mellitus, degenerative disc disease of the cervical spine status post fusion, degenerative joint disease of the right shoulder, degenerative disc disease of the lumbar spine, fibromyalgia/polyarthiritis, and morbid obesity (Tr. 23-24). At step three, the ALJ concluded that Plaintiff does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (Tr. 24-25). Before proceeding to step four, the ALJ found that Plaintiff retained the residual functional capacity ("RFC") to:
(Tr. 25).
At step four, the ALJ determined that Plaintiff is unable to perform her past relevant work, but the ALJ concluded, based on the testimony of a vocational expert, that there are jobs in the national economy including dispatcher, receptionist, and ID clerk that Plaintiff can perform (Tr. 29-30). Based upon this evidence and his other findings, the ALJ held that Plaintiff has not been under a disability, as defined in the Act, from November 12, 2010, through the date of the decision (Tr. 30).
The scope of the Court's review is limited to determining whether the Commissioner applied the correct legal standards and whether the Commissioner's findings are supported by substantial evidence.
My discussion begins with Plaintiff's third contention because I find it to be dispositive of the case. Plaintiff argues that the ALJ did not adequately consider all of her impairments when determining her RFC (Doc. 19 at 15-24). A person's RFC is:
SSR 83-10, 1983 WL 31251 (S.S.A. 1983).
Plaintiff's RFC assessment does not include limitations for headaches. Plaintiff began having headaches in 2011 and that at times they have been so intense that she has sobbed and retreated to the dark (Tr. 441, 555). Plaintiff's headaches are well documented in her medical records (Tr. 63-65, 330, 335, 340, 441, 443, 465, 468, 531, 541, 551-554, 556-557, 559, 604, 626, 631, 635). At step two of the sequential evaluation process the ALJ recognized Plaintiff's long history of migraine headaches (Tr. 24). The ALJ wrote that by June, 2012, the frequency and severity of Plaintiff's headaches had been reduced by medication (
(
The Commissioner argues that any error is harmless because Plaintiff failed to demonstrate what functional limitations result from her headaches.
This is not the only problem with the ALJ's analysis. The ALJ found that Plaintiff is severely impaired by fibromyalgia (Tr. 23). "[Fibromyalgia] is a complex medical condition characterized primarily by widespread pain in the joints, muscles, tendons, or nearby soft tissues that has persisted for at least 3 months." SSR 12-2p, 2012 SSR LEXIS 1, at *1. A diagnosis of fibromyalgia — literally meaning "pain in the muscles and the fibrous connective joints (the ligaments and tendons)" — depends mostly on a person's own subjective reports of symptoms, namely pain.
The Commissioner issued SSR 12-2p to assist factfinders in the evaluation of fibromyalgia. SSR 12-2p, 2012 SSR LEXIS 1, at *1. Social Security Ruling 12-2p "provides that once a claimant is determined to have fibromyalgia her statements about symptoms and functional limitations are to be evaluated according to the two-step process set forth in SSR 96-7p, 1996 SSR LEXIS 4."
The ALJ discredited Plaintiff's reports of pain because of her "relatively minor examination findings." (Tr. 28). In relying exclusively on the objective medical findings the ALJ committed error. "It is a misunderstanding of the nature of fibromyalgia to require "objective' evidence for a disease that eludes such measurement.'"
The ALJ discredited Plaintiff's testimony in part because "[t]he claimant has declined her doctors' request that she pursue cognitive behavior therapy to address her disproportionate pain reports and weight loss . . .)." (Tr. 28). "The Secretary may deny . . . disability benefits if the Secretary determines that 1) the claimant failed to follow a prescribed course of treatment, and 2) her ability to work would be restored if she had followed the treatment."
An inability to pay excuses noncompliance with recommended treatment.
Additionally, an ALJ may not draw an adverse inference from a claimant's failure to pursue recommended treatment without inquiring about the claimant's reasons for not doing so, and addressing those reasons in the decision.
Remand is warranted for these reasons which is why I do not address Plaintiff's remaining assignments of error.
Upon consideration,
1. The Commissioner's final decision be
2. The Clerk be directed to enter judgment accordingly and CLOSE the file.
3. Plaintiff be advised that the deadline to file a motion for attorney's fees pursuant to 42 U.S.C. § 406(b) shall be thirty (30) days after Plaintiff receives notice from the Social Security Administration of the amount of past due benefits awarded.
4. Plaintiff be directed that upon receipt of such notice, he shall promptly email Mr. Rudy and the OGC attorney who prepared the Commissioner's brief to advise that the notice has been received.
A party waives the right to challenge on appeal a finding of fact or conclusion of law adopted by the district judge if the party fails to object to that finding or conclusion within fourteen days after issuance of the Report and Recommendation containing the finding or conclusion.