Mitchell v. Comm'r of Soc. Sec.
| Decision Date | 12 March 2020 |
| Docket Number | Case No. 1:19-cv-1401 |
| Court | U.S. District Court — Northern District of Ohio |
| Parties | SUSAN ROSE MITCHELL, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant. |
Plaintiff, Susan Rose Mitchell, seeks judicial review of the final decision of the Commissioner of Social Security, denying her applications for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act. This matter is before me pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3), and Local Rule 72.2(b). Because the Administrative Law Judge ("ALJ") failed to apply proper legal standards and build an adequate and logical bridge between the evidence and the result when he failed to consider - or even indicate whether he considered - Mitchell's bipolar disorder in assessing her residual functional capacity ("RFC"), I recommend that the Commissioner's final decision denying Mitchell's applications for SSI and DIB be VACATED and that Mitchell's case be REMANDED for further consideration.
On October 14, 2016, Mitchell applied for DIB and SSI. (Tr. 214-39).1 Mitchell alleged that she became disabled on January 1, 2012, due to low back pain, PTSD, and depression. (Tr. 64, 80). She later amended her alleged onset date to October 14, 2016. (Tr. 249). The Social Security Administration denied Mitchell's applications initially and upon reconsideration. (Tr. 63-125). Mitchell requested an administrative hearing. (Tr. 157-60). ALJ William Leland heard Mitchell's case on November 14, 2018, and denied the claims in a July 25, 2018, decision. (Tr. 12-62). On April 22, 2019, the Appeals Council denied further review, rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-6). On June 18, 2019, Mitchell filed a complaint to seek judicial review of the Commissioner's decision. ECF Doc. 1.
From March 14, 2012, through June 7, 2016, Javier Alvarez-Tostado, MD, treated Mitchell for chronic back and leg pain. (Tr. 343-44-53, 358, 366-82, 387, 390-91, 397-98, 926-28). Dr. Alvarez-Tostado noted that x-rays showed well-maintained vertebral bodies and disc heights and treated Mitchell's leg pain and varicose veins with a combination of compression therapy and sclerotherapy. (Tr. 343-44-53, 358, 366-82, 387, 390-91, 397-98, 926-28). In July 2015, Mitchell indicated that her legs felt better, although she continued to have some back and leg pain. (Tr. 368).
From May 14, 2012, through December 19, 2013, Mitchell saw Edwin Capulong, MD, for her back pain. (Tr. 406-07, 418-30, 438-40). During his examinations, Dr. Capulong found that Mitchell had no scoliosis, no kyphosis, no focal atrophy, no gait problems, full strength in her extremities, mild tenderness in her spine, pain on thoracolumbar rotation. (Tr. 406-07, 421, 439-40). He diagnosed Mitchell with lumbar spondylosis and myofascial pain, and treated her with Lyrica, Neurontin, tramadol, medial branch block injections. (Tr. 407, 418, 428). Dr. Capulong also referred Mitchell to physical therapy, which she "failed" after attending three sessions without improvement. (Tr. 430, 440); see also (Tr. 430-36) (physical therapy notes indicating, inter alia, that Mitchell had fair posture and recommending that she engage in a home exercise program).
On July 3, 2014, Mitchell told her primary care physician, Kevin Bogar, MD, for treatment of chronic headaches and back pain, and she noted that she took lorazepam, Buspar, and Prozac for anxiety . (Tr. 398-400). Dr. Bogar gave Mitchell medications and recommended moist heat treatment, home exercise, weight loss, and improved posture to help her back pain. (Tr. 400).
On October 21, 2014, Mitchell saw Harpreet Singh, MD, for a pain management evaluation after a September 11, 2014, referral from Lisa Echeverry, CNP. (Tr. 392); see also (Tr. 395-97) (Nurse Echeverry's notes showing that Mitchell reported "almost complete relief" of her back pain with Neurontin and finding that Mitchell had a bulging lumbar disc). Mitchell reported that sitting and medication helped, but her pain interfered with her physical activities and sleep. (Tr. 392). Based on a 2012 MRI, Dr. Singh determined that Mitchell had only "minimal" bulging discs and some facet atrophy in her lumbar spine, but she was otherwise normal and there were no acute findings. (Tr. 392-93. On examination, Mitchell had a full range of motion without pain in her extremities, full strength, normal gait, and no problems withcoordination, reflexes, or sensation. (Tr. 394). Dr. Singh referred Mitchell for an aqua therapy consultation and an MRI, continued her tramadol prescription, and increased her Neurontin prescription. (Tr. 394). Dr. Singh also prescribed Vitamin D and recommended she ask her psychiatrist to add Effexor, noting that she had reported panic attacks and depression and appeared depressed at the appointment. (Tr. 394).
On December 3, 2014, Mitchell told Samuel Samuel, MD, that she had aches and pains, especially in her lower back. (Tr. 388-89). Dr. Samuel found that Mitchell's MRI results were mild, but she had tenderness in fibromyalgia tender points on examination. (Tr. 389). Dr. Samuel diagnosed Mitchell with myalgia/myositis, fibromyalgia, and possible lumbar degenerative disc disease; indicated that he would consider a bursa injection; ordered a follow-up MRI; and prescribed Lyrica. (Tr. 389). On January 28, 2015, Mitchell reported some improvement with Lyrica, and Dr. Samuel noted that her MRI was normal with some mild stenosis and facet arthritis. (Tr. 385-86). Dr. Samuel treated Mitchell with a medial branch block on February 9, 2015, and an epidural steroid injection on March 9, 2015; however, Mitchell said she only had temporary relief from the medial branch block. (Tr. 376, 379-80, 383). Dr. Samuel performed medial branch radiofrequency ablations on Mitchell's lumbar spine on May 18 and June 15, 2015. (Tr. 369, 372).
On September 17, 2015, Mitchell told Dalbir Singh, PA, that she continued to have back pain (8 out of 10 in severity), and that radiofrequency ablation did not help. (Tr. 363-64). Examination showed that Mitchell had normal strength in her extremities, no atrophy, and an antalgic gait. (Tr. 364). Sing diagnosed Mitchell with vertebral disc degeneration and prescribed vitamin D and Topamax. (Tr. 364).
On November 24, 2015, Marina Tudico, PA, and Dr. Teresa Ruch, MD, evaluated Mitchell for neurosurgery after a September 18, 2015, referral from Nurse Echeverry. (Tr. 355-57); see also (Tr. 361-62) (Nurse Echeverry's examination and referral). Tudico noted that conservative treatment - physical therapy, medication, and epidural steroid injections - had not helped Mitchell's pain. (Tr. 355). Examination and an MRI showed mild degenerative changes in the spine, normal spine health, no paraspinal pain, normal muscle bulk, full strength, normal sensation, and a normal gait. (Tr. 356). On March 28, 2016, Dr. Ruch found that a follow-up MRI showed only "some slight degenerative disease" in Mitchell's spine and that there was "no [neurological] reason for [Mitchell's] back pain and her posture." (Tr. 346).
On February 29, 2016, Mitchell told Dr. Bogar that pain management had not helped her. (Tr. 348). Dr. Bogar refilled Mitchell's pain medications, ordered a knee x-ray, and recommended a follow-up with a spine surgeon. (Tr. 349). On July 14, 2016, Mitchell reported continued pain, fatigue, and headaches, and Dr. Bogar referred her to pain management. (Tr. 339-41). On December 1, 2016, Dr. Bogar noted that Mitchell had not gone to pain management, failed physical therapy, and used tramadol, Motrin, other NSAIDs, and heat for her pain. (Tr. 814). Dr. Bogar diagnosed Mitchell with chronic headaches, spondylosis of the lumbar spine without myelopathy or radiculopathy, chronic bilateral back pain without sciatica, knee pain, hypothyroidism, and B12 deficiency. (Tr. 816). He continued Mitchell's Topamax, refilled her tramadol, and referred her to pain management. (Tr. 816).
On July 28, 2016, Mitchell saw Alla Model, MD, for a rheumatology consultation. (Tr. 336). Examination revealed no deformities in her extremities, mild fullness of pip joints with decreased grip, normal gait, normal reflexes, and intact sensation. (Tr. 338). Dr. Model diagnosed Mitchell with low back pain at multiple sites and ordered testing for inflammatory markers. (Tr. 338). The inflammatory testing was negative. (Tr. 814).
On March 28, 2017, Mitchell told Abdallah Kabbara, MD, that she had no pain relief from medications and physical therapy. (Tr. 1216). Steroid injections gave her short-term relief.(Tr. 1216). Examination revealed a normal range of motion in Mithcell's neck, back and extremities. (Tr. 1217-18). Dr. Kabbara also noted that Mitchell had a normal mood and affect. (Tr. 1218). Dr. Kabbara referred Mitchell to physical therapy and prescribed Cymbalta and Mobic. (Tr. 1218). On April 25, 2017, Dr. Kabbara gave Mitchell a medial nerve branch block to assist with her pain. (Tr. 1215).
On April 22, 2016, Mitchell saw Susan Shefner, Psy.D., for a counseling intake evaluation. (Tr. 797-801; see also Tr. 1205-09). Mitchell told Dr. Shefner that she "sometimes feels like [she] could be bipolar" because she had different moods and was never happy when she was a child. (Tr. 797). Mitchell said that she lived off her boyfriend's income and had one friend from high school, but she mostly kept to herself. (Tr. 797). She said she had back pain and arthritis that interfered with her ability to do things around the house. (Tr. 799). Mitchell always felt sad and she had inconsistent self-esteem, history of suicidal ideation, anxiety with panic attacks, traumatic stress from a history of physical and sexual abuse, anger, difficulty with concentration and memory,...
To continue reading
Request your trial