United States District Court, N.D. Alabama, Southern Division
DAVID PROCTOR UNITED STATES DISTRICT JUDGE.
Shandi Olivares (“Plaintiff”) brings this action
pursuant to Section 205(g) of the Social Security Act (the
“Act”), seeking review of the decision of the
Commissioner of Social Security (the
“Commissioner”) denying her claims for a period
of disability insurance benefits (“DIB”) and
supplemental security income (“SSI”) under Titles
II and XVI of the Act. See 42 U.S.C. §§
405(g) and 1383(a). Based on 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
filed applications for a period of disability, disability
insurance benefits, and supplemental security income on
August 21, 2013. (R. 9, 78). In the applications Plaintiff
alleges disability beginning on January 10, 2013. (R. 157).
Both Plaintiff's SSD and SSI applications were initially
denied by the Social Security Administration
(“SSA”). (R. 78-93). Plaintiff then requested and
received a hearing before Administrative Law Judge
(“ALJ”) Jerome L. Munford on April 29, 2015 in
Gadsden, Alabama. (R. 31-77, 109-11). In his decision dated
August 21, 2015, ALJ Munford determined that Plaintiff had
not been under disability as defined by the Social Security
Act from January 10, 2013 through the date of the decision.
(R. 26). After the Appeals Council denied Plaintiff's
request for review of the ALJ's decision (R. 1-4), the
ALJ's decision became the final decision of the
Commissioner, and therefore a proper subject of this
court's appellate review.
was thirty (30) years old at the time the ALJ issued his
decision, and attended school through the tenth grade. (R.
26, 38, 164, 189). Her previous work experience includes
employment as a fast food worker, a cashier-checker, a
poultry laborer, and most recently a housekeeper. (R. 70,
197-203). Plaintiff claims disability due to a back injury
and severe migraines. (R. 188).
back injury occurred on January 10, 2013. According to
medical records from the Gadsden Regional Medical Center, she
“slipped on wet steps and went bouncing down several of
them, now has severe pain to lower and mid back, left hip and
left leg pain, worse in upper leg, denies toe, no neck pain.
Symptoms came on suddenly. Symptoms are present now.”
(R. 41, 309). She was diagnosed with acute lumbar strain and
contusion to the proximal left lower extremity, left hip,
left knee, and left foot and was prescribed medication for
pain and muscle spasms. (R. 309-15). Before she was
discharged, X-rays of Plaintiff's lumbosacral and
thoracic spine were taken. (R. 326, 328, 531). Those X-rays
revealed “moderate degenerative thinning of the L5-S1
disc” and “scoliosis of the thoracic spine”
with no evidence of fracture. (R. 326, 328, 535). An X-ray
was also taken of Plaintiff's left femur, which revealed
“chronic degenerative joint disease, mild at the knee
and less at the hip” but “no acute bony
finding.” (R. 330, 533).
followed-up with general practitioner Dr. Ochuko Odjegba on
March 29, 2013 at the Canterberry Family Practice Center,
complaining of worsening low back pain with “shooting
pains in mid lumbar spine with leg weakness when walking
[and] numbness and tingling of right calf and great
toe.” (R. 333). She was prescribed additional
medications for pain and was referred to radiology for
diagnostic testing of her lumbar spine. (R. 335, 382). She
returned to the Center on April 11, 2013 with no improvement
of the back pain. (R. 337, 384). She was diagnosed with an
upper respiratory infection and medications for the back pain
were increased. (R. 339, 386).
Plaintiff had been referred to radiology for an MRI of her
lumbar spine, when she visited Dr. Odjegba on May 29, 2013
she reported that she had not had the MRI because she did not
have the money. (R. 335, 382, 388). She rated her back pain a
9/10 and stated that she was not able to leave bed on some
days, the pain was worse with activity and radiated to both
feet, and she experienced numbness and tingling in her toes.
(R. 388). On physical exam, it was noted that Plaintiff
experienced tenderness at the lumbar spine area. (R. 390).
She was diagnosed with chronic lumbago with radiculopathy
from nerve compression. (R. 390). She was referred to a
neurosurgeon at the UAB Kirklin Clinic and was prescribed
additional pain medications. (R. 390).
saw Dr. Odjegba again on June 26, 2013 presenting with
improved back pain, rating it a 4/10. (R. 345, 347, 392).
Plaintiff asked for pain medication refills and asked for
diet pills. (R. 345). She was advised to use the pain
medications for the chronic lumbago only as needed. (R. 394).
She returned to Dr. Odjegba on August 1, 2013, having lost
some weight and complaining of persistent lower back pain
rated 5/10. (R. 349, 396). She described that the “pain
has radiated to the right foot, right thigh, and right
buttock. The patient describes the pain as numbness and
shooting.” (R. 349). All of her prescriptions were
refilled. (R. 352).
August 30, 2013 Plaintiff returned to the Family Practice
Center and indicated that she “continues to have severe
shooting pains in lower back, with bilateral leg weakness.
Makes it difficult to work.” (R. 353, 400). She rated
her back pain a 7/10 yet had appropriate mood and affect and
was advised to continue with her current medications without
change. (R. 355, 402). On October 15, 2013 she visited again
with a chief complaint of weight gain and a secondary issue
of having trouble sending the correct paperwork to UAB for
the MRI and neurosurgical evaluation. (R. 404). Although she
rated her pain as an 8/10, she again demonstrated appropriate
mood and affect. (R. 406). She was advised to stop taking the
weight loss drug since it was not helping her lose weight and
to follow up in one month. (R. 407).
was back at the Family Practice Center on November 19, 2013.
(R. 410). She rated her back pain 9/10 and stated that the
pain “worsens spontaneously and shoots into legs
causing her legs to give out. Has been unable to provide all
UAB charity care paper work. Wants to pay for MRI. Continues
on meds.” (R. 410). An MRI of the lumbar spine was
taken on November 25, 2013. (R. 364). The MRI revealed
“prominent subcutaneous similar diffuse adipose changes
with moderate multilevel facet DJD; disc signal changes at
4/5 and 5/1 with minor 4/5 bulging and slightly greater
central bulging or very shallow HNP at 5/1; no visible canal,
lateral recess, or foraminal stenosis at 5/1 or any other
level is identified in no intrinsic CNS or significant
paraspinal or retroperitoneal abnormalities otherwise are
evidence.” (R. 364). On December 10, 2013 an MRI of
Plaintiff's thoracic spine was taken revealing “no
significant abnormalities” and the “vertebral
elements and bony structures” within normal limits. (R.
sought treatment with Dr. James White at Northeast Alabama
Neurological Services on March 10, 2014. (R. 520). At that
time, Plaintiff reported constant low back pain radiating to
her left leg and numbness with bilateral
“burning” hip pain. (R. 520). Dr. White's
plan was to “treat conservatively with at least one set
of epidurals.” (R. 514). Plaintiff testified that Dr.
White told her that she needed surgery but was “too
young” and that surgery might result in further
problems with her back. (R. 42-43). Various other visits to
medical professionals in 2014 resulted in diagnoses of low
back pain, chronic backache, hypertension, depressive
disorder, migraines,  and anxiety. (R. 548, 557, 573).
Sathyan Iyer evaluated Plaintiff (as requested by the SSA) on
October 11, 2014. (R. 375). Plaintiff reported to Dr. Iyer
that “some days she cannot get out of the bed and
barely walk. Sitting, standing, bending, and climbing bother
her. She saw neurosurgeon who apparently told her that she
has a ruptured disc. She has not been able to take epidural
shots because of lack of insurance. The neurosurgeon
apparently did not recommend any surgery. She has problems
with her hips. She cannot bend the left hip and the right hip
bothers her some. She has a burning kind of pain over the
left thigh and legs. Ankles bother her. She has problems with
the neck and shoulder area.” (R. 375). Dr. Iyer's
conclusion was that Plaintiff “will have impairment of
functions involving standing, walking, bending, lifting,
pushing, pulling, overhead activities, squatting, climbing,
working at heights, working around moving ...