United States District Court, Southern District of Indiana, Indianapolis Division
REPORT AND RECOMMENDATION
Mark J. Dinsmore United States Magistrate Judge
Plaintiff Melissa Riley requests judicial review of the final decision of the Commissioner of the Social Security Administration (“Commissioner”) denying her application for Social Security Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“the Act”). See 42 U.S.C. §§ 416(i), 423(d). For the reasons set forth below, the Magistrate Judge recommends that the decision of the Commissioner be REVERSED AND REMANDED.
I. Procedural History
Riley filed an application for DIB on August 13, 2009, alleging an onset of disability of December 19, 2007. Riley’s application was denied initially and on reconsideration. Riley requested a hearing which was held on November 1, 2011 before Administrative Law Judge Ronald Jordan (“ALJ”). Riley previously filed an application for DIB in September 2008. Because the present application was filed within 12 months of the initial determination of the 2008 application, the ALJ reopened the prior application. The ALJ issued a decision on December 2, 2011 finding that Riley was disabled from December 19, 2007 through June 11, 2009, but that she was no longer disabled beginning June 12, 2009 due to medical improvement.
The Appeals Counsel denied Riley’s request for review on January 30, 2013, making the ALJ’s decision the final decision for purposes of judicial review. Riley filed her Complaint on March 29, 2013.
II. Factual Background
On December 19, 2007, Riley suffered a fall resulting in an ankle injury. She had multiple surgeries on her ankle, wore a cast, and required the use of a walker and later a quad cane. Riley was discharged from physical therapy on April 21, 2009. On June 12, 2009, an MRI revealed moderate enlargement and bulbous configuration of the distal Achilles tendon, minor amounts of intrasubstance signal, diffuse soft tissue edema, and mild reactive tenosynovitis. By 2010, Riley no longer used a quad cane or other hand-held walking assistant, however, she did wear an ankle-foot brace.
Riley has been treated for back pain since at least January 2008. She received injections for the pain. MRI results revealed mild spondylitic changes at L4-L5 and L5-S1 as well as mild facet hypertrophy of the lower lumbar spine. The record does not indicate any complaints of back pain after December 2009.
Riley has been treated for headaches since at least June 2007 by neurologist Dr. Huffman. In August 2008, Riley reported that she experienced headaches twice per week. She asserted that she avoided sunlight so as not to trigger the headaches. The record shows infrequent treatment of headaches between 2007 and 2010. By 2010, Riley reported more frequent headaches. Dr. Huffman completed a Headaches Residual Functional Capacity Questionnaire in January 2011. He opined that Riley suffered from complicated migraines that are severe in nature. He indicated that she suffers from nausea, vomiting, photosensitivity, and stammering and jerking movements as a result. Dr. Huffman stated that her headaches occur two to three times per week and last from four to eight hours and are triggered by bright lights. It was Dr. Huffman’s opinion that Riley would need to be absent from work more than four days per month.
Riley underwent a consultative examination in October 2009 at the request of the Disability Determination Bureau (“state agency”). Based on the examination, Dr. Sands completed a Physical Residual Functional Capacity Assessment opining that Riley could occasionally lift twenty pounds and frequently lift ten pounds, and that she could stand/walk/sit for six hours in an eight-hour workday.
Riley also received a psychological evaluation from the state agency in December 2009. Based on the exam, state agency psychologist Dr. Shipley opined that Riley did not have a severe impairment. He further found that Riley only had mild limitations in activities of daily living. There is only one other treatment record for a mental impairment which was in October 2009 for anxiety and panic.
III. Applicable Standard
To be eligible for DIB, a claimant must have a disability under 42 U.S.C. § 423. Disability is defined as “the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). In order to be found disabled, a claimant must demonstrate that her physical or mental limitations prevent her from doing not only her previous work, but any other kind of gainful employment which exists in the national economy, considering her age, education, and work experience. 42 U.S.C. § 423(d)(2)(A).
In determining whether a claimant is disabled, the Commissioner employs a five-step sequential analysis. At step one, if the claimant is engaged in substantial gainful activity she is not disabled, despite her medical condition and other factors. 20 C.F.R. § 404.1520(b). At step two, if the claimant does not have a “severe” impairment (i.e., one that significantly limits her ability to perform basic work activities), she is not disabled. 20 C.F.R. § 404.1520(c). At step three, the Commissioner determines whether the claimant’s impairment or combination of impairments meets or medically equals any impairment that appears in the Listing of Impairments, 20 C.F.R. pt. 404, subpt. P, App. 1, and whether the impairment meets the twelvemonth duration requirement; if so, the claimant is disabled. 20 C.F.R. § 404.1520(d). At step four, if the claimant ...