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Davidson v. Colvin

United States District Court, N.D. Indiana, Hammond Division

March 17, 2014

CAROLYN W. COLVIN, Acting Commissioner of the Social Security Administration, Defendant.


PAUL R. CHERRY, Magistrate Judge.

This matter is before the Court on a Complaint [DE 1], filed by Plaintiff Marilyn K. Davidson on July 26, 2012, and a Plaintiff's Memorandum in Support of Summary Judgment or Remand [DE 14], filed on November 14, 2012. Plaintiff requests that the decision of the Administrative Law Judge denying her claims for disability insurance benefits and supplemental security income be reversed or remanded for further proceedings. On February 22, 2013, the Commissioner filed a response, and Plaintiff filed a reply on March 8, 2013. For the following reasons, the Court grants Plaintiff's request for remand.


On November 19, 2010, Plaintiff filed applications for disability insurance benefits and supplemental security income, alleging an onset date of October 1, 2009. The applications were denied initially on February 7, 2011, and upon reconsideration on April 4, 2011. Plaintiff timely requested a hearing, which was held on September 28, 2011, before Administrative Law Judge ("ALJ") Bryan J. Bernstein. In appearance were Plaintiff, her attorney Kenneth McVey, and vocational expert Sharon D. Ringenberg. The ALJ issued a written decision denying benefits on January 12, 2012, making the following findings:

1. The claimant meets the insured status requirements of the Social Security Act through March 31, 2014.
2. The claimant has not performed substantial gainful activity since the alleged onset date (20 CFR 404.1571 et seq., and 416.971 et seq. ).
3. The claimant has severe impairments.
4. The claimant failed to establish with reliable evidence that she has an impairment or combination of impairments that meets or medically equals any one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926).
5. The claimant failed to establish with reliable evidence that she experiences limitations that would be more restrictive than the limitations accommodated in the residual functional capacity considered here and presented to the vocational expert.
This individual is not able to perform work that imposes close regimentation of production.... This person cannot lift and carry more than 10 pounds occasionally and 5 pounds frequently. She predominantly uses her nondominant hand for lifting. This person cannot successfully engage in work demanding constant manipulation involving fine work, gripping, grasping, twisting, turning, picking, pushing, or pulling with hands or fingers. This person cannot undertake work in hazardous conditions. Such work would include work requiring balance in the context of unprotected heights. This individual cannot work around dangerous machinery or around vehicles moving in close quarters. The claimant's lifting would involve predominant use of the non-dominant hand.
6. The claimant is unable to perform any past relevant work (20 CFR 404.1565 and 416.965).
7. The claimant was born on [ ], 1962, and was 47 years old, which is defined as a younger individual age 45-49, on the alleged disability onset date (20 CFR 404.1563 and 416.963).
8. The claimant has at least a high school education and is able to communicate in English (20 CFR 404.1564 and 416.964).
9. Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant is "not disabled, " whether or not the claimant has transferable job skills (See SSR 82-41 and 20 CFR Part 404, Subpart P, Appendix 2).
10. Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform (20 CFR 404.1569, 404.1569(a), 416.969, and 416.969(a)).
11. The claimant has not been under a disability, as defined in the Social Security Act, from October 1, 2009, through the date of this decision (20 CFR 404.1520(g) and 416.920(g)).

(AR 17-25).

On April 23, 2012, the Appeals Council denied Plaintiff's request for review, leaving the ALJ's decision the final decision of the Commissioner. See 20 C.F.R. §§ 404.981, 416.1481. On July 26, 2012, Plaintiff filed this civil action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) for review of the Commissioner's decision.

The parties filed forms of consent to have this case assigned to a United States Magistrate Judge to conduct all further proceedings and to order the entry of a final judgment in this case. Therefore, this Court has jurisdiction to decide this case pursuant to 28 U.S.C. § 636(c) and 42 U.S.C. § 405(g).


A. Background

Plaintiff was born in 1962 and was 47 years old on the alleged onset date. She completed the 12th grade as well as six weeks of certified nursing assistant ("CNA") training. Her prior relevant work includes employment as a machine operator (heavy as performed), driver (medium per the DOT), assembly work (light work as performed), and CNA (heavy as performed, medium per DOT).

B. Medical Background

1. Treatment History

Plaintiff presented at the emergency room on September 27, 2009, after passing out briefly and reported a history of seizures since age nine, migraine headaches, insomnia, and dizziness. Plaintiff declined hospitalization. The diagnosis was acute orthostatic syncope, etiology uncertain; multiple system complaints and weight loss; and possible depression. A head CT that same date was normal. A chest x-ray revealed mild pulmonary hyperinflation with no acute disease. A brain MRI showed a moderate number of small bilateral white matter lesions in the cerebral hemispheres ranging in size up to 8 to 10 mm with possibilities including chronic small vessel disease, demyelinating process such as multiple sclerosis, prior inflammation, or vasculitis. Also that date, a Holter monitor confirmed isolated atrial premature complexes, intermittent sinus arythmia, and intermittent sinus tachycardia.

On October 2, 2009, Plaintiff sought treatment at the Matthew 25 Clinic for headaches and follow up of her emergency room visit, reporting depression, nausea, and migraines noted to be frontal with photophobia and lasting about once per week for a period of 5-10 years. Plaintiff's medications were Amitriptyline, Imitrex, and Effexor XR.

On October 13, 2009, a Holter monitor again showed intermittent sinus arrhythmia and intermittent sinus tachycardia, simple ventricular arrythmia, and isolated premature ventricular complexes. A Doppler confirmed left ICA at less than 50% stenosis. The same day, a brain MRI revealed a moderate number of small bilateral white matter lesions ranging from 8-10 mm. An ECG was technically adequate with ejection fraction at 60% and trace insufficiency in the mitral valve.

On November 30, 2009, Plaintiff was treated at the Matthew 25 Clinic for persistent migraine headaches and GI complaints. Effexor was discontinued, and Protonix was prescribed. She was to continue taking Amitriptyline each night.

In December 2009, Plaintiff was administered an adrenocorticotropic hormone ("ACTH") stimulation test for adrenal insufficiency at Parkview Hospital.

A January 20, 2010 brain MRI again revealed extensive white matter hyper intensities either from old inflammation, demyelinating process, migraines, or vasculitis.

On February 26, 2010, Plaintiff returned to the Matthew 25 Clinic for a scheduled follow up on depression. She reported depression, migraine headaches, and carpal tunnel syndrome. She reported that her gastrointestinal complaints were resolved. However, she reported that the Amitriptyline helped her sleep but did not help the headaches. For her carpal tunnel syndrome, the treatment note says that the plan is the "ortho clinic." (AR 367).

On June 8, 2010, Plaintiff was treated at the Matthew 25 Clinic for migraine headaches (frequency of twice a week) and gastroesophageal reflux disease. Imitrex was discontinued and Plaintiff was prescribed Ultram for her headaches. She was continued on Protonix. A note indicates that an EEG was not ordered due to financial reasons. Plaintiff also declined a GI referral for financial reasons.

On June 29, 2010, Plaintiff returned to the Matthew 25 Clinic. She reported falling at work in September 2009, a history of seizures since age 11, and migraine headaches for 10-12 years. She reported that the headaches, left frontal or bilateral, had become especially bad in the previous two years, with four to five headaches a day, throbbing, photophobia, and nausea. Imitrex had in the past provided some benefit but it no longer worked. The doctor determined that preventative medication was needed and prescribed Topamax. Plaintiff also reported insomnia.

On August 4, 2010, Plaintiff was seen at the Matthew 25 Clinic, reporting chronic issues of gastroesophageal reflux disease, headaches, insomnia, migraines, and seizures. She reported that her headaches had decreased from daily to three times a week and were less severe. She was tolerating the Topamax well, and the doctor ...

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