United States District Court, N.D. Alabama, Northeastern Division
ANGELA L. WEBSTER, Plaintiff,
CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.
STACI G. CORNELIUS, Magistrate Judge.
Plaintiff, Angela L. Webster, appeals from the decision of the Commissioner of the Social Security Administration ("Commissioner") denying her applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). Plaintiff timely pursued and exhausted her administrative remedies, and the decision of the Commissioner is ripe for review pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). After consideration of the record and for the reasons stated below, the court is of the opinion that this action is due to be reversed and remanded to the Commissioner for further proceedings, as set forth herein.
I. Procedural History
Plaintiff initially filed applications for DIB and SSI benefits on December 29, 2010, alleging a disability onset date of March 18, 2010, due to a back injury, carpal tunnel, depression, high blood pressure, a knee injury, and chronic back pain. (R. 161-165). After the Social Security Administration ("SSA") denied her applications, she requested a hearing before an Administrative Law Judge ("ALJ"), which was held on December 14, 2011. (R. 34, 62-66, 77). Following the hearing, the ALJ found that plaintiff had the severe impairments of lumbar spondylosis with sciatica, osteoarthritis, obesity, depression, and anxiety (R. 18) but did not have an impairment or a combination or impairments listed in, or medically equivalent to, one listed in the Listings of Impairments (R. 19). The ALJ further found that plaintiff was not under a disability at any time through the date of his decision. (R. 25). Plaintiff appealed to the Appeals Council, which "found no reason under [its] rules to review the ALJ's decision" and therefore denied plaintiff's request for review. (R. 1). Thus, the ALJ's decision is the final decision of the Commissioner of Social Security. Plaintiff then filed the appeal in this court on September 13, 2013, seeking remand or reversal of the Commissioner's decision. (Doc. 1; Doc. 12 at 10). On February 6, 2015, the parties consented to magistrate judge jurisdiction pursuant to 28 U.S.C. § 636(c). (Doc. 15).
II. Factual Background
At the time of the ALJ's decision, Ms. Webster was thirty-nine years old with an educational background of a GED. (R. 35). Her prior work experience was as a cook, home attendant, and sales person. (R. 38-39, 49). Plaintiff alleges she became disabled March 18, 2010,  due to back pain which spreads to her legs. (R. 39-40, 53). She is on oxygen but does not know why her doctor prescribed it. (R. 40-41, 43, 47-48). Plaintiff asserts she also suffers from leg pain, tingling in her feet, and fibromyalgia. (R. 43-44). At one point Plaintiff attempted suicide. (R. 47).
A. Plaintiff's Medical Records
Plaintiff's medical records in the record begin in March 2008, when plaintiff was seen at an emergency room for headache, left-sided chest pain with pain radiating down her left arm, shortness of breath, and dizziness. (R. 231). She was diagnosed with Gastroesophageal Reflux Disease ("GERD") and chest pain. (R. 232).
Plaintiff was followed by Dr. Michel Farah, M.D., from November 2008 until August 2010. Upon her first visit, Dr. Farah noted plaintiff had no significant past medical history other than GERD. (R. 291). The list of diagnoses grew to include carpal tunnel syndrome, headache, low back pain, and cervicalgia. (R. 248, 250, 256, 257, 259, 261, 262-263, 264, 269). Plaintiff was seen in November 2008 for complaints of bilateral hand pain and numbness. (R. 288, 289). In December 2008 plaintiff reported dizziness, cramps in her hands and forearms, and continued mid and lower back pain radiating to her left leg. (R. 274, 283). Records from May 2009 reflect she complained of headaches and back and leg pain. (R. 262). In May and June 2009 and February 2010, plaintiff was noted to be in mild distress and tender in her neck, mid back, lumbar spine, and paraspinal area bilaterally. (R. 256, 258, 260, 263). Records from August 2010 reflect plaintiff underwent arthroscopic surgery on her right knee to repair a meniscal tear. (R. 251).
In August 2010 plaintiff was seen for pain management by Dr. S. Aggarwal, M.D., on referral from Dr. Farah. (R. 244-245). Dr. Aggarwal noted plaintiff reported benefit from medication and had "some good days and bad days." (R. 244). He diagnosed her with Chronic Pain Syndrome and noted in her records that she had a narcotics contract as part of the chronic pain management program. (R. 244).
Plaintiff was sent to Dr. Parvesh K. Goel, M.D., for a consultative physical examination in March 2011. (R. 292). Dr. Goel considered plaintiff's claims of back pain, carpal tunnel syndrome, depression, and high blood pressure and noted upon examination that plaintiff's grip was "4/5." Back tenderness over "thoracic L1, L2, L5 and S1 area, " with limited leg raise on the left, and limitations of forward flexion of the spine were also documented. (R. 293). Although plaintiff had a normal gait, she could not squat and could not walk heel to toe. (Id. ). Dr. Goel diagnosed the plaintiff with lumbar spondylosis with sciatica, carpal tunnel syndrome bilaterally, history of depression and anxiety, osteoarthritis, hypertension, and GERD. (Id. ). Limitations against walking more than one block and standing more than 30 minutes were believed appropriate. (R. 294).
After plaintiff moved from Alabama to Mississippi, she was followed by Mallory Community Health Center. Records from December 2010 reflect plaintiff's complaint of constant burning pain in her left knee (R. 379), although an MRI was normal. (R. 387). She also had lower back pain, which she described as constant and throbbing. (R. 380). Lortab and muscle relaxers helped, while motion made the pain worse. (R. 380). In February 2011 plaintiff described her hand, arm, and leg pain as a six or seven on a scale of zero to ten. (R. 377, 378). She was referred to a pain clinic. (R. 377). The March 2011 record reflects plaintiff considered her pain a five on a scale of zero to ten and that she was denied admission to the pain clinic. (R. 390). Plaintiff's treating physician ordered MRIs of her cervical and lumbar spine and referred her to a different doctor for pain management. (R. 390). In April 2011 plaintiff went to an emergency room due to shortness of breath and feeling as if her whole body was cramping. (R. 336). She described her arm and leg pain as eight on a scale of zero to ten. (R. 337). Plaintiff was diagnosed with myalgias and told to continue taking Lortab. (R. 342, 350).
Plaintiff then transferred her care to the Lexington Medical Clinic. (R. 306). Records from April and May 2011 reflect complaints of neck pain and leg cramps. (R. 304-305). Plaintiff's diagnoses included carpal tunnel syndrome, lower back pain, leg cramps, and neck pain. (R. 304, 305, 308). The records also reflect diagnoses of osteoarthritis and depressive disorder. (R. 306, 308).
Plaintiff returned to the emergency room in June 2011 due to back, shoulder, and left arm pain following a motor vehicle accident. (R. 360-361). She was diagnosed with a left shoulder sprain and myocervical strain. (R. 360-362). A CT of plaintiff's cervical spine found straightening of the lordotic curve and a minimal disk protrusion at C4-C5 with no evidence of significant central canal stenosis. (R. 365). A CT of the lumbar spine found disk desiccation changes at L5-S1, a minimal concentric disc bulge at L4-L5, and left subarticular ...