Roach v. Colvin, C/A No.: 2:14-2730-RMG-MGB
| Decision Date | 28 July 2015 |
| Docket Number | C/A No.: 2:14-2730-RMG-MGB |
| Court | U.S. District Court — District of South Carolina |
| Parties | Sheila Roach, Plaintiff, v. Carolyn W. Colvin, Acting Commissioner of Social Security Administration, Defendant. |
This appeal from a denial of social security benefits is before the court for a Report and Recommendation ("Report") pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for Supplemental Security Income ("SSI"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.
On March 2, 2011, Plaintiff filed an application for SSI in which she alleged her disability began on June 25, 2006. Tr. at 130, 162-68. Her application was deniedinitially and upon reconsideration. Tr. at 149-52, 153-54. On November 27, 2012, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Gregory M. Wilson. Tr. at 37-65 (Hr'g Tr.). The ALJ issued an unfavorable decision on April 11, 2013, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 11-36. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-5. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on July 3, 2014. [ECF No. 1].
Plaintiff was 45 years old at the time of the hearing. Tr. at 42. She completed the eleventh grade. Id. Although she worked briefly at a convenience store, she has no past relevant work. Tr. at 59. She alleges she has been unable to work since July 30, 2010. Tr. at 41.
Plaintiff presented to the emergency department at AnMed Health on March 21, 2010, complaining of increased back pain after sustaining a fall two days earlier. Tr. at 249. Plaintiff had limited range of motion ("ROM") in her lumbar spine with paravertebral tenderness and muscle spasm, but she had normal ROM in her extremities and negative straight-leg raise test. Tr. at 250. Her pain improved with medication. Tr. at251. She was discharged with a prescription for muscle relaxants and instructed to follow up with her family doctor or pain management physician within the week. Tr. at 252.
On April 1, 2010, Plaintiff visited Eric Loudermilk, M.D. ("Dr. Loudermilk"), for a pain management follow up visit and medication refills. Tr. at 285. Dr. Loudermilk indicated Plaintiff was "very depressed" because her daughter left her with her grandchildren and her brother-in-law recently passed away. Id. He noted he had provided medication samples to Plaintiff because she lacked prescription drug coverage and health insurance. Id. He also indicated Plaintiff had been compliant with her prescriptions and appointments. Id. Dr. Loudermilk noted Plaintiff's diagnoses to include lumbar post-laminectomy syndrome with chronic low back and left leg pain secondary to epidural fibrosis and scar tissue; chronic left-sided L4-5 lumbar disc protrusion with persistent low back and left leg pain secondary to radiculopathy; musculoskeletal low back pain; and chronic depression and anxiety disorder. Id. He refilled Plaintiff's medications, provided more samples, and instructed Plaintiff to follow up in two months. Id.
Plaintiff followed up with Dr. Loudermilk on June 1, 2010. Tr. at 284. She denied side effects from her medications and indicated her medications improved her pain and quality of life. Id. Dr. Loudermilk refilled Plaintiff's prescriptions for Lortab and Klonopin and provided samples of Cymbalta, Lyrica, and Celebrex. Id.
Plaintiff presented to Sherri L. Cheek, APRN ("Ms. Cheek"), in Dr. Loudermilk's office on July 30, 2010. Tr. at 283. She requested medication refills. Id. Plaintiff statedshe was taking Celebrex twice a week because of abdominal pain, but was taking her other medications as prescribed and had no side effects from them. Id. Plaintiff indicated she fell a few weeks earlier after a mouse ran over her foot. Id. She reported increased pain in her back and bilateral lower extremities following the fall. Id. Ms. Cheek prescribed a Medrol dosepack to address the acute flare in Plaintiff's back pain. Id. A drug screen showed Plaintiff to be compliant with her prescriptions and to be taking no illicit substances, and Ms. Cheek noted Plaintiff had been compliant with her medications in the past. Id.
Plaintiff again presented to the emergency department at AnMed Health on August 15, 2010, complaining of pain in her back and left flank as the result of a fall. Tr. at 254. A CT scan of Plaintiff's abdomen and pelvis was normal. Tr. at 269. An x-ray of her sacrum and coccyx indicated mild degenerative disc disease in the right sacroiliac joint and an x-ray of her lumbar spine showed degenerative disc disease and spondylosis to be moderate at L2-3 and L4-5 and mild at L3-4. Tr. at 270, 271. James Stumpff, M.D., indicated Plaintiff could return to work without restrictions. Tr. at 256.
On September 29, 2010, Plaintiff followed up with Dr. Loudermilk for medication refills. Tr. at 282. Dr. Loudermilk described Plaintiff as "an unfortunate 42-year old female with failed back syndrome and chronic pain in her lower back and left leg." Id. He indicated Plaintiff battled a lot of depression and anxiety and had a lot of social and family issues. Id. He noted Plaintiff had always been compliant with her prescriptionsand appointments and tolerated her medications without side effects. Id. Dr. Loudermilk refilled Plaintiff's medications and referred her to Kashfia Hossain, M.D. ("Dr. Hossain") for psychiatric management and treatment. Id.
On November 17, 2010, Plaintiff visited Dr. Loudermilk for follow up and medication refills. Tr. at 281. She complained of pain and spasms over the left side of her neck and in her suprascapular region. Id. She indicated she had been unable to see Dr. Hossain because she could not afford to pay $200 for an initial evaluation. Id. Dr. Loudermilk observed Plaintiff to have two localized areas of tenderness and administered trigger point injections. Id. He indicated Plaintiff was compliant with her medications and appointments, refilled her medications, and encouraged her to see a psychiatrist for depression and anxiety. Id.
Plaintiff followed up with Dr. Loudermilk on January 14, 2011, to obtain medication refills. Tr. at 280. Dr. Loudermilk indicated Plaintiff responded well to the trigger point injections administered during her last appointment. Id. He stated Plaintiff had been unable to see a psychiatrist due to the cost. Id. He indicated Plaintiff was compliant with her medications and appointments. Id. Dr. Loudermilk refilled Plaintiff's medications, gave her samples of Cymbalta and Lyrica, encouraged her to see a psychiatrist, and instructed her to follow up in two months. Id.
Plaintiff visited Gerald Welch, D. Min., for family therapy on February 9, 2011, February 21, 2011, and March 2, 2011. Tr. at 272-75. On February 9, she reported beingmore upset and depressed and described abuse she endured as a child. Tr. at 274. On February 21, she reported sleep problems and described problems with her incarcerated daughter and a history of childhood sexual abuse. Tr. at 275. She stated she had taken Cymbalta and Klonopin for three years and indicated they helped because she would not leave her house before she started taking them. Id.
Plaintiff presented to Ms. Cheek on March 16, 2011, for follow up and medication refills. Tr. at 277. Ms. Cheek indicated Plaintiff was taking Lortab, Klonopin, Celebrex, Cymbalta, and Lyrica, and was doing well without side effects. Id. She stated Plaintiff shared joint custody of her grandchildren with the children's other grandparents, which created a lot of stress and worsened her pain. Id. Plaintiff complained of increased muscle spasms. Id. Ms. Cheek refilled Plaintiff's medications, and prescribed a muscle relaxant. Id.
On March 31, 2011, Dr. Loudermilk completed a questionnaire regarding Plaintiff's mental condition. Tr. at 289. He indicated Plaintiff's diagnoses included depression and anxiety and that he prescribed Klonopin and Cymbalta. Id. Dr. Loudermilk noted medication had helped Plaintiff's condition, but stated psychiatric care had been recommended. Id. He indicated Plaintiff was oriented to time, person, place, and situation; had an intact thought process; had appropriate thought content; and had adequate attention/concentration and memory. Id. However, he noted Plaintiff had a worried/anxious mood/affect and exhibited slight work-related limitation in function dueto her mental condition. Id. Dr. Loudermilk suggested Plaintiff was capable of managing her funds. Id.
Plaintiff presented to Anderson-Oconee-Pickens Mental Health Center for initial clinical assessment on April 20, 2011. Tr. at 291. She reported mood disturbance, panic, tearfulness, and recent changes/stressors. Id. Cheryl Rogers, MA, LPC/I ("Ms. Rogers"), observed Plaintiff to demonstrate confusion and tearfulness, but to be oriented to person, place, time, and situation. Id. She indicated Plaintiff was not a threat to herself or others and diagnosed adjustment disorder without depressed mood and indicated a need to rule out anxiety disorder, not otherwise specified ("NOS") and personality disorder. Tr. at 291-92. Ms. Rogers recommended Plaintiff's needs be met in the community through pastoral counseling and pain management. Tr. at...
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