United States District Court, N.D. Alabama, Southern Division
MEMORANDUM OF DECISION
R. DAVID PROCTOR, District Judge.
Plaintiff Jennifer Starks Braggs brings this action pursuant to Sections 205(g) and 1631(c)(3) of the Social Security Act (the "Act"), seeking review of the decision by the Commissioner of the Social Security Administration ("Commissioner") denying her applications for a period of disability and disability insurance benefits ("DIB") under Title II of the Act, and Supplemental Security Income ("SSI") benefits under Title XVI of the Act. Based upon the court's review of the record and the briefs submitted by the parties, the court finds that the decision of the Commissioner is due to be reversed and remanded. See 42 U.S.C. §§ 405(g), 1383(c)(3).
I. Proceedings Below
A. Procedural History
Plaintiff filed applications for a period of disability, DIB, and SSI on June 27, 2008, alleging that she became disabled as of June 4, 2008. (Tr. 53). After Plaintiff's applications were initially denied, she then requested a hearing. (Tr. 54-59, 63-64). The hearing took place on February 24, 2010, before Administrative Law Judge Jill Lolley Vincent. (Tr. 23-50). In her decision dated May 3, 2010, the ALJ determined that Plaintiff had not been under a disability, as defined in the Act, at any time from June 4, 2008, through the date of the decision. (Tr. 17-18). After the Appeals Council denied Plaintiff's request for review of the ALJ's decision, that decision was appealed to the United States District Court for the Northern District of Alabama. Braggs v. Astrue, Case No.: 2:11-cv-759-CLS (N.D. Ala. Jan. 6, 2012). The Honorable Lynwood Smith, in an opinion dated January 6, 2012, reversed the decision of the Commissioner and remanded the case for further proceedings, finding that the decision of the ALJ was not based on substantial evidence. ( See id. at 7).
After gathering additional medical records, the ALJ held another hearing on June 13, 2012. (Tr. 462-93). In a decision dated June 29, 2012, the ALJ again found Plaintiff not to be under a disability at any time from June 4, 2008, through the date of the decision. (Tr. 455). When the Appeals Council denied Plaintiff's request for review, the ALJ's decision became the final decision of the Commissioner. This appeal followed. (Doc. 1).
At the time of her June 2012 hearing, Plaintiff was 42 years old. (Tr. 466-67). She completed the eleventh grade and never received a GED. (Tr. 467). She last worked in 2006 at DSW. ( Id. ). Plaintiff stated she left that job because of health problems, including carpal tunnel in both wrists, arthritis in both knees, plantar fasciitis, Type II diabetes, degenerative joint disease in her right shoulder, and acid reflux. ( Id. ). She also reports suffering from migraine headaches and sleep apnea. (Tr. 480, 482-83). She has reported that at times her hands become weak and numb, her right arm hurts if she tries to vacuum, she cannot walk very far, has trouble with her memory, and gets sleepy and feels weak when her diabetes is not under control. (Tr. 468-76). Her feet sometimes swell, burn, and are generally tender. (Tr. 480). She also suffers from depression and anxiety. (Tr. 477). She has had auditory and visual hallucinations. ( Id. ). In her own estimation, Plaintiff can stand and walk no more than ten minutes at a time, lift no more than five pounds and sit no more than ten minutes at a time. (Tr. 478).
In 2006 Plaintiff was using splints for relief of symptoms from bilateral carpal tunnel syndrome. (Tr. 279-80). November 2006 and June 2008 nerve conduction studies confirmed moderate bilateral carpal tunnel syndrome. (Tr. 300-01). The splints helped more in her left hand than her right, and her shoulder was noted to be tender with degenerative joint disease and positive impingement. (Tr. 328-29, 338). She underwent a shoulder arthroscopy, debridement, and decompression. (Tr. 336).
Plaintiff's treating physician for most of the relevant time period was Dr. Jeremy Allen. (Tr. 485). Plaintiff was seen by Dr. Allen throughout 2007 for uncontrolled diabetes, knee pain, and migraine headaches. (Tr. 207, 209, 212, 213, 267). His records reflect that Plaintiff has complained of right shoulder pain since at least April 2008. (Tr. 202, 262, 307). Neurology Clinic records reflect that nortiptyline helped with Plaintiff's chronic migraine headaches, as did taking Pamelor at the onset of a headache. (Tr. 264). Plaintiff is also followed for obstructive sleep apnea. (Tr. 302-04, 402). She had been using a C-PAP machine since October 2007 which improved her sleep and increased her energy level. (Tr. 263).
In September 2008, a consultative mental examiner found Plaintiff to have no psychological limitations other than she "simply does not exert herself." (Tr. 350-51). A physical consultative examination, also conducted in September 2008, noted Plaintiff suffered from a host of physical ailments, that she was depressed, and that she needed help with bathing, dressing, grooming, and preparing food. (Tr. 355). The consultative physician observed Plaintiff guarding her right arm, but making good effort throughout the exam. ( Id. ). The examiner also noted limitations in her range of motion in a variety of joints (Tr. 356-57) and diagnosed Plaintiff with bilateral carpal tunnel syndrome, osteoarthritis, and sleep apnea. (Tr. 357). Plaintiff was also found to be limited to standing or walking for less than two hours in an eight-hour workday due to osteoarthritis in the knees, unlimited in sitting, and requiring an assistive device for uneven terrain and long distances. ( Id. ). Further, she was limited to lifting and carrying no more than ten pounds frequently and ten pounds occasionally due to carpal tunnel syndrome. (Tr. 358).
A March 2009 examination noted Plaintiff complained of bilateral knee pain, shoulder pain, and wrist pain. (Tr. 385). In May 2009, Dr. Allen completed a Clinical Assessment of Pain form in which he opined that Plaintiff suffered from pain to such an extent as to be distracting to performance of work, that physical activity would greatly increase this pain, and that she had some limitations from her medications. (Tr. 390). At the same time, Dr. Allen completed a Physical Capacities Evaluation in which he shared his belief that Plaintiff could lift no more than ten pounds occasionally to five pounds frequently, could not stand and walk for any length of time, could sit for six hours in an eight-hour workday, had limitations on pushing and pulling movements, climbing, fine and gross manipulation, bending, stooping, reaching, operating motor vehicles and working around hazardous machinery, and would miss approximately four days of work per month due to her impairments. (Tr. 391).
Follow up visits in 2009 noted that Plaintiff still had plantar fasciitis, bilateral knee pain, and uncontrolled diabetes, as well as anxiety and continued shoulder pain. (Tr. 408). An MRI of her right shoulder found mild degenerative changes in the AC joint and a partial rotator cuff tear. (Tr. 421). A June 2010 emergency room record reflects Plaintiff was seen for a migraine headache which had began seven days previously. (Tr. 715).
A second psychological consultative examination was conducted in September 2010. (Tr. 593). William B. Beidleman, Ph.D., determined Plaintiff suffered from dythemic disorder and generalized anxiety disorder, and assigned a Global Assessment of Functioning ("GAF") Score of 58. (Tr. 594). He also believed Plaintiff had difficulties coping with ordinary work pressures. (Tr. 594). The same month, a second physical consultative examination was performed. (Tr. 596). Again, it was determined Plaintiff had a limited range of motion in her right shoulder and both hips (Tr. 598), although she retained bilateral hand dexterity. (Tr. 599). Plaintiff was diagnosed with carpal tunnel syndrome, chronic low back pain, shoulder pain, and knee pain. ( Id. ). The examining physician opined Plaintiff could stand or walk for two to four hours in an eight-hour workday with frequent breaks; sit for six to eight hours without frequent breaks; and did not believe manipulative or environmental limitations were warranted. ( Id. ).
In 2010 and 2011, Plaintiff was followed by Dr. Ramy Toma for uncontrolled diabetes, GERD, depression, carpal tunnel syndrome, migraine headaches and osteoarthritis. (Tr. 670-72). An August 2010 emergency room visit for leg pain diagnosed Plaintiff with peripheral neuropathy. (Tr. 705-06). In September 2010, Plaintiff complained of bilateral foot pain she described as a sharp burning pain made worse by walking. (Tr. 650). A nerve conduction study of her lower legs was basically normal. (Tr. 647-48). A November 2010 visit record reflects Plaintiff had pain in her knee, uncontrolled diabetes, and anxiety. (Tr. 641-42). Dr. Toma also concluded Plaintiff suffered from depression, sleep apnea, carpal tunnel syndrome, migraine headaches, and osteoarthritis in her lumbar spine and shoulders. (Tr. 627, 679). Plaintiff complained of constant parasthesias in her right wrist, from which she obtained little relief from medications. (Tr. 631).
Plaintiff was seen by Theodis Bugg, Jr., M.D., for carpal tunnel syndrome and knee pain. (Tr. 633, 675). He found only minimal degenerative changes in both knees, formed a diagnosis of patellofemoral syndrome, and prescribed knee ...