United States District Court, N.D. Indiana, South Bend Division
ANGELIA R. NEWTON Plaintiff,
CAROLYN W. COLVIN, COMMISSIONER OF SOCIAL SECURITY,  Defendant.
OPINION AND ORDER
JON E. DeGUILIO, District Judge.
On November 28, 2012, Plaintiff Angelia R. Newton ("Newton"), by counsel, filed her Complaint seeking review of the final decision of the Defendant Commissioner of Social Security ("Commissioner") [DE 1]. The Commissioner filed an Answer to Newton's Complaint on March 28, 2013 [DE 11]. This matter has now been fully briefed and is ripe for ruling. [DE 21, 26, 29]. For the following reasons, the Commissioner's decision is vacated and remanded for further proceedings consistent with the conclusions in this order.
I. PROCEDURAL HISTORY
On November 13, 2009, Newton filed an application for disability insurance benefits ("DIB") and supplemental security income ("SSI"). (Tr. 16, 157-68). Newton alleged a disability beginning October 15, 2009 resulting primarily from her rheumatoid arthritis and fibromyalgia. (Tr. 157, 164, 217). Newton's applications were initially denied on March 2, 2010, and again upon reconsideration on May 14, 2010. (Tr. 89, 105). Consequently, on May 25, 2010, Newton requested a hearing before an Administrative Law Judge ("ALJ"). (Tr. 115-16).
On June 15, 2011, Newton, represented by counsel, appeared and testified at a hearing held before ALJ John H. Metz in Indianapolis, Indiana. (Tr. 36). Two medical experts and a vocational expert also testified. (Tr. 37-83). On August 17, 2011, the ALJ issued his decision, denying benefits to Newton based on his finding that she was capable of performing jobs that exist in significant numbers in the national economy. (Tr. 16-30). Newton requested a review of the ALJ's decision; however, the Appeals Council denied Newton's request for review on September 28, 2012, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-3, 12). Newton thereafter filed a complaint with this court on November 28, 2012, requesting a review of the Commissioner's final decision. [DE 1]. Jurisdiction is established pursuant to 42 U.S.C. § 405(g).
II. STATEMENT OF FACTS
Newton was born on July 5, 1967, and was 44 years old at the time of the ALJ's opinion. (Tr. 40). She suffers from a number of ailments, including rheumatoid arthritis, fibromyalgia, asthma, chronic obstructive pulmonary disease, and depression. (Tr. 47). She has a 12th grade education, and previously worked as a certified nurse assistant. (Tr. 28, 45-46). She was laid off from her position as a certified nurse assistant on October 15, 2009, which is considered the last date she engaged in substantial gainful activity ("SGA"). (Tr. 18, 45-46). She worked in an office setting for about a month in April 2011, but was unable to maintain her employment due to her health. (Tr. 43-44).
A. Medical History
The medical history in the record begins in 2008, though Newton had previously been diagnosed with fibromyalgia in 2000. (Tr. 350, 356). On July 24, 2008, Newton visited Chantel Willmann, a nurse practitioner, for the first time. (Tr. 350). At that appointment, Ms. Willmann observed that Newton had "point tenderness pretty much throughout all the fibromyalgia points, at the base of the neck, on her lower back, just below the elbows, just above the knees, along the upper aspect of the sternum as well." (Tr. 350). Ms. Willmann reiterated Newton's diagnosis of fibromyalgia, and gave Newton a prescription for amitriptyline for that condition. (Tr. 350). Newton visited Ms. Willmann again on August 5, 2008, at which time she reported neck pain between her shoulder blades, and on September 3, 2009 Newton reported muscle and joint pain, including at the back of her neck and her lower back. (Tr. 346-47). Newton reported similar symptoms at her appointment with Ms. Willmann on October 5, 2009, with the addition of pain and swelling in her shoulders, elbows, hands, and fingers. (Tr. 345).
Newton therefore met with Dr. Nighat Tahir, a rheumatologist, for a consultation on October 28, 2009. (Tr. 321). Newton reported that she had noticed pain in her fingers the previous winter, and that she currently had pain in her fingers, wrists, elbows, shoulders, hips, and knees. (Tr. 321). She also reported swelling in her fingers and wrists and stiffness in the morning for about one to two hours, mostly in her hands. (Tr. 321). Dr. Tahir noted that Newton's "recent workup showed rheumatoid factor positive at 109, range 0-14. Anti-CCP antibody positive at greater than 250, range 0-19." (Tr. 321). Dr. Tahir also observed synovial proliferation in both of Newton's wrists and rheumatoid nodules close to Newton's right elbow, left wrist, and left fifth metatarsophalangeal ("MTP") joint, as well as trace synovitis in her elbows. (Tr. 323). Dr. Tahir diagnosed Newton with "Rheumatoid arthritis, seropositive, anti-CCP antibody positive, nodular." (Tr. 323). She further noted, "[Newton] has had symmetric inflammatory polyarthropathy with positive serologies for rheumatoid arthritis. She seems to have an aggressive disease as her serologies are high titer and she also has rheumatoid nodules." (Tr. 323). Dr. Tahir prescribed low-dose prednisone and methotrexate, and ordered further tests and x-rays. (Tr. 323). The x-rays of Newton's right hand showed a narrowing of the third metacarpophalangeal ("MCP") joint, mild narrowing of the first MCP joint, a 4.3 mm cyst in the proximal metaphysis of the third proximal phalanx, and possible narrowing of the carpalmetacarpal joints. (Tr. 333). The x-rays of Newton's left hand also showed "slight narrowing of the 1st and 3rd MCP joints." (Tr. 333).
Newton visited Dr. Tahir for a follow-up appointment on November 30, 2009. (Tr. 335). At that time, Newton had begun taking the low-dose prednisone and methotrexate. Newton reported that her pain was worst in her hands, left knee, and low back, and that she had morning stiffness lasting three to four hours. (Tr. 335). Dr. Tahir noted that Newton "has aggressive rheumatoid arthritis, she has not responded to methotrexate, and is also experiencing some side effects." (Tr. 336). Dr. Tahir began the authorization process for Newton to begin taking etanercept, a biologic medication. (Tr. 336). At a further appointment on December 30, 2009, Dr. Tahir noted that Newton had received one injection of etanercept, but had not been able to continue her treatment since she lost her insurance. (Tr. 338). Newton reported at that time that she was stiff in the morning for 2 hours, mostly in her hands and back. (Tr. 338). She also noted occasional pain in her shoulders, knees, and ankles. (Tr. 338). Dr. Tahir observed rheumatoid nodules close to Newton's right elbow, left wrist, and left fifth MTP joint, but noted that they were decreasing in size. (Tr. 339). Dr. Tahir's assessment at that time was that Newton "continues to have active rheumatoid arthritis." (Tr. 340).
On January 6, 2010, Ms. Willmann completed a disability questionnaire for Newton. (Tr. 358-63). She stated that Newton's diagnoses were rheumatoid arthritis, myalgias, and rheumatism. She noted that Newton had "joint pain [in her] fingers, wrist, elbows, shoulders, low back, [and] neck" as well as "rheumatoid nodules." (Tr. 360). She further noted that Newton experienced "multiple joint pain [and] swelling." (Tr. 360). In assessing Newton's physical limitations, Ms. Willmann checked that Newton had "Significant" limitations as to lifting, pushing, pulling, bending, squatting, crawling, climbing, reaching above the shoulder, and being around machinery. (Tr. 363). She wrote that Newton "cannot do these [due to] risk of further damage to joints." (Tr. 363). She also opined that Newton "is not able to physically work [due to] the RA [rheumatoid arthritis] & multiple joint pain & swelling, " and that Newton "can't do heavy labor" but "could do [a] sit down job." (Tr. 362).
On February 3, 2010, Newton met with Dr. Maya Hosein for a consultative physical examination regarding her disability claim. (Tr. 367-71). Dr. Hosein found that Newton's range of motion was largely normal, with some minor limitations in the lumbar region. (Tr. 368). She also noted that Newton had "tenderness of her second and third MCP joints in the right hand and second through fifth MCP joints on her left hand. Her third MCP joints in the right hand had some fullness on palpitation." (Tr. 371). Dr. Hosein found that Newton "had an extremely small rheumatoid nodule below the right nodule, which have significantly decreased in size, " and further noted that Newton "has the ability to pick up a coin and button a shirt." (Tr. 371). Dr. Hosein recorded her clinical impressions as follows: "Rheumatoid arthritis which was significantly well controlled with addition of etanercept given that she had side effect for high dose methotrexate." (Tr. 371).
On February 17, 2010, Dr. J. Sands conducted a residual functional capacity ("RFC") assessment of Newton. (Tr. 376-83). Dr. Sands checked that Newton could lift or carry items of up to 20 pounds occasionally, and up to 10 pounds frequently. (Tr. 377). He stated that she could stand, sit, or walk for a total of 6 hours in an 8-hour workday. (Tr. 377). He also found that Newton had no limitations relative to pushing or pulling. (Tr. 377). In addition, Dr. Sands observed that Newton's "grip strength was normal and fine finger skills are normal, " and that she "has the ability to pick up a coin and button a shirt." (Tr. 377). Dr. Sands additionally found that Newton could "Occasionally" climb stairs, ladders, ropes, and scaffolds, balance, stoop, kneel, crouch, and crawl. (Tr. 378). He found no manipulative limitations, and expressed that Newton should "avoid concentrated exposure to noxious fumes and unprotected heights." (Tr. 380). Finally, Dr. Sands stated, "[Newton] is partially credible. She reported that she can walk for 10 minutes, stand for 10 minutes, climb about 5 steps and her activity is limited by shortness of breath. She lifts about 15 lbs in each arm. These restrictions are not supported with the ME [Medical Evidence]." (Tr. 381).
On March 1, 2010, Newton again visited Dr. Tahir. (Tr. 559). She noted having morning stiffness lasting for 2 hours, and she reported that she had pain at her left elbow, shoulder, hip and knee, with her worst pain in her hands and back. (Tr. 559). During the physical examination, Dr. Tahir noted "multiple tender points" and several rheumatoid nodules. (Tr. 560-61). In a subsequent follow-up on April 13, 2010, Newton reported some improvement, as she had been able to begin taking etanercept again. (Tr. 550, 552). She was still experiencing morning stiffness for about two hours, though, and noted that "her worst symptoms are at her low back, neck and her left elbow." (Tr. 550). For her assessment, Dr. Tahir stated, "Her rheumatoid arthritis has improved on current regimen which she will continue.... Patient does have rheumatism and chronic low back pain.... She might be a candidate for left elbow corticosteroid injection. We might consider imaging her spine if her back pain persists." (Tr. 552).
On May 5, 2010, Ms. Willmann wrote a letter regarding Newton's disability claim. She stated:
[Newton] has been diagnosed with chronic rheumatoid arthritis. She does have chronic pain secondary due to that diagnosis. [Newton] cannot stand, push, pull or lift objects of much weight at all due to the chronic pain and the rheumatoid arthritis that she has. I cannot give you specific weight limits but certainly I do not believe that she would be able to tolerate any sustained activity for any length of time. I do not think it is reasonable to expect her to do any sort of physical work ...