Green v. Saul
| Decision Date | 12 February 2021 |
| Docket Number | 3:20-cv-45 RP-SBJ |
| Citation | 519 F.Supp.3d 478 |
| Court | U.S. District Court — Southern District of Iowa |
| Parties | Kari E. GREEN, Plaintiff, v. Andrew SAUL, Commissioner of Social Security, Defendant. |
J. Richard Johnson, Johnson & Legislador PLC, Cedar Rapids, IA, for Plaintiff.
David L.D. Faith, William C. Purdy, United States Attorney's Office, Des Moines, IA, for Defendant.
Plaintiff, Kari E. Green, filed a Complaint in this Court on May 8, 2020, seeking review of the Commissioner's decision to deny her claim for Social Security benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq. This Court may review a final decision by the Commissioner following a hearing before an Administrative Law Judge (ALJ). 42 U.S.C. § 405(g).
Plaintiff filed an application for benefits March 13, 2017. Tr. at 178-79. Plaintiff was 48 years old at the time of the hearing on December 18, 2018, before Administrative Law Judge (ALJ) John P. Mills, III. Tr. at 38-74. The ALJ issued a Notice of Decision – Unfavorable on March 12, 2019. Tr. at 13-30. On March 11, 2020, the Appeals Council declined to review the ALJ's decision. Tr. at 1-7. Thereafter, Plaintiff commenced this action.
Before beginning the sequential evaluation ( 20 C.F.R. § 404.1520(a)(4) ), the ALJ noted that Plaintiff was insured for benefits through December 31, 2020. At the first step, the ALJ found that Plaintiff had not engaged in substantial gainful activity after December 23, 2015. At the second step, the ALJ found that Plaintiff has the following severe impairments: degenerative disc disease status post-surgery, obesity, myofascial pain syndrome, adjustment disorder with mixed anxiety and depressed mood, and major depression. Tr. at 18. The ALJ found that Plaintiff's impairments were not severe enough to qualify for benefits at the third step of the sequential evaluation. Tr. at 17. At the fourth step, the ALJ found:
After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a) except the claimant must be allowed to alternate between sitting and standing, at will, while remaining at the workstations and on-task. The claimant can occasionally climb ramps and stairs, but she can never climb ladders, ropes, or scaffolds. The claimant can occasionally balance, stoop, kneel, couch (sic), and crawl. The claimant can have frequent exposure to unprotected heights and moving mechanical parts, and she can have occasional exposure to extreme cold and vibrations. The claimant is limited to the performance of simple and routine tasks, and she is limited to making simple work-related decisions.
Tr. at 22. The ALJ found that Plaintiff is unable to perform any of her past relevant work. Tr. at 28. At the fifth step of the sequential evaluation, the ALJ found that there is work which exists in significant numbers in the national economy which can be performed by someone of Plaintiff's age, education, past relevant work and residual functional capacity. Tr. at 21. Examples of such jobs are: letter addressor; document preparer; surveillance system monitor. The three examples are unskilled and require a sedentary exertion level. Tr. at 29. The ALJ found that Plaintiff is not disabled nor entitled to the benefits for which she applied. Tr. at 29-30.
On October 1, 2002 Plaintiff saw Wayne E. Janda, M.D., at The Steindler Orthopedic Clinic. Tr. at 770-72. Diagnosis was acute left sciatica, suspect disk herniation at L4-5 or L5-S1 with radiculitis and perhaps radiculopathy in the left lower extremity, L5 root. Plaintiff complained of pain in the lower back with numbness in her left leg and arm. Plaintiff reported that the symptoms began on September 21, 2002 when she stood up from a couch. Tr. at 770. The doctor recommended an MRI and possibly an epidural steroid injection. Tr. at 771-72. The MRI showed a broad-based central disk protrusion at L4-5 that slightly flattened the ventral aspect of the thecal sac. Tr. at 773. Plaintiff received an injection on October 4, 2002, from which she received temporary relief. Dr. Janda recommended another injection. Tr. at 774.
On November 11, 2002, Plaintiff saw Edward G. Law, M.D. with a diagnosis of bulging L4-5 disk with possible annulus tear. Tr. at 776-77. The doctor advised against surgery and further epidural injections. He prescribed Bextra. Tr. at 777.
On December 2, 2002, Plaintiff saw Dr. Law. Plaintiff was working 4 hours per day. Plaintiff did not get relief from Bextra, so the doctor prescribed Celebrex. The doctor told Plaintiff to begin working six hours per day with the goal of returning to full time work. Tr. at 778.
On January 14, 2003, Plaintiff told Dr. Law she felt much better and that her back was more flexible. Plaintiff's strength was improved, and she was walking about a mile per day which the doctor encouraged. Tr. at 778.
On February 2, 2007, Plaintiff saw Dan Coons, PA-C at The Steindler Orthopedic Clinic. Plaintiff complained of left foot pain after she stubbed her toe on a wooden chest. Tr. at 780.
On June 10, 2009, Plaintiff was seen at North Liberty Family Health Center for sinusitis, cough and a yeast infection. Tr. at 347. On September 16, 2009, Plaintiff was seen for abdominal pain. Tr. at 346. Plaintiff was seen again on September 23, 2009 for the abdominal pain. the doctor ordered an ultrasound of the right upper quadrant. Neither blood work nor the ultrasound showed anything which explained the symptoms. Tr. at 345.
On February 21, 2012, Plaintiff saw Scott A. Frisbie, PA-C at The Steindler Orthopedic Clinic. Tr. at 782-83. Plaintiff complained of back pain. Tr. at 782. Mr. Frisbie ordered an MRI. Tr. at 783. On February 28, Mr. Frisbie diagnosed L4-5 disk herniation. Mr. Frisbie adjusted Plaintiff's medications and advised her to remain off work for ten days after which an epidural injection would be considered. Tr. at 784.
On March 9, 2012, Plaintiff saw Mr. Frisbie status post lumbar translaminar epidural steroid injection of February 24, 2012. Plaintiff reported no change in her symptoms. Mr. Frisbie had spoken to Dr. Overton who recommended trying a left L4 and L5 nerve root transforaminal injection. Tr. at 786. Plaintiff received the injection on March 12, 2021 from Fred J. Dery, M.D. Tr. at 787.
On March 20, 2012, Plaintiff saw Dr. Overton. Tr. at 788-89. Dr. Dery's injection was not successful, providing no relief at all. It was noted that Plaintiff was an administrative assistant for an oral surgeon. Plaintiff was noted to be 5 foot nine inches tall with a weight of 202 pounds. The doctor noted that the MRI of February 22, 2012 showed some congenital canal stenosis at multiple levels. The doctor diagnosed left L4 radiculopathy, possibly from L4-5 subarticular stenosis, possibly from other causes. The doctor ordered an EMG nerve conduction study. Tr. at 788.
On March 29, 2012, Plaintiff underwent left L4-5 laminotomy performed by Dr. Overton. Tr. at 791-03.
On May 9, 2012, six weeks post-surgery, Plaintiff reported that her pain increased when she increased her work hours from 4 per day. The doctor wrote he was not surprised given the degree of her pain the nature of her condition. He recommended she return to working 4 hours per day. Tr. at 795.
On June 1, 2012, Plaintiff saw Dr. Overton and reported that she had been worse for about a week. Plaintiff was taking Gabapentin and the doctor increase the dosage and advised her to work only six hours per day. He also refilled her prescription of hydrocodone. Tr. at 794.
On June 29, 2012, Plaintiff saw Dr. Overton. Plaintiff reported that she did not feel she was getting any better. Plaintiff reported recently developing some pain in the right back, right buttock, right posterior thigh, calf and sometimes to the foot as well as occasional shooting pain on the left side. The doctor diagnosed continued radiculopathy pain after left L4-5 laminectomy and recent increase in right leg pain. Tr. at 796.
On July 2, 2012, Plaintiff saw Dr. Dery. Tr. at 797-98. Plaintiff reported that she had not received any relief from the surgery performed by Dr. Overton. The doctor opined that the pain was likely due to scar tissue adhering to or irritating the surrounding nerve roots. The doctor discontinued gabapentin and prescribed Lyrica. The doctor ordered a series of epidural injections. The doctor also asked Plaintiff to consider nerve stimulation therapy. Tr. at 797. Plaintiff was to discontinue using hydrocodone. Tr. at 798. Dr. Drey gave Plaintiff an injection on July 3, 2012. Tr. at 799. Another injection was given July 17, 2012. Tr. at 800.
Plaintiff saw Dr. Dery on August 3, 2012. Plaintiff reported being limited by her pain. The epidurals did not help. Plaintiff's medication was adjusted, and Plaintiff asked for more information about the neurostimulator. Tr. at 801.
On August 31, 2012, Todd Ajax, M.D., wrote that an MRI indicated that EMG nerve conduction studies would be helpful to determine if epidural fibrosis was causing ongoing nerve injury. Tr. at 846.
On September 13, 2012, Plaintiff saw Dr. Dery to discuss a spinal cord stimulator device for chronic pain. Tr. at 803-04. Plaintiff said she was "pretty sure" she would proceed with the trial, so the doctor ordered an MRI of the thoracic spine. The doctor also ordered a "psych prescreen eval." Tr. at 804.
On September 14, 2012, Dr. Ajax wrote that he concurred that repeat surgery was not a good option for Plaintiff. Tr. at 847. The doctor also wrote that inflammatory studies were normal. Tr. at 848.
On November 1, 2012, Plaintiff saw Dr. Dery. Tr. at 805-06. Plaintiff reported that she had fallen down some stairs and hurt her back and right hip. X-rays of the pelvis did not show any abnormality. On examination the doctor did not observe any bruising. The doctor told Plaintiff she could...
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