United States District Court, N.D. Indiana, South Bend Division
OPINION AND ORDER
JON E. DEGUILIO, District Judge.
On November 1, 2013, Plaintiff Diane Cagle filed her Complaint in this Court seeking review of the final decision of the Defendant Commissioner of Social Security (Commissioner). [DE 1.] The Commissioner filed an Answer on January 14, 2014. [DE 9.] On March 7, 2014, Cagle filed her opening brief [DE 15], to which the Commissioner responded on June 13, 2014. [DE 21.] Cagle filed a reply on June 27, 2014. [DE 22.] Accordingly, the matter is now ripe for decision. Jurisdiction is predicated on 42 U.S.C. § 405(g).
I. Procedural History
Cagle filed an application for disability insurance benefits on October 22, 2010. (Tr. 137.) Her application was denied initially on December 27, 2010, and again upon reconsideration on March 31, 2011. (Tr. 63, 70.) On June 28, 2012, a hearing was held before Administrative Law Judge Henry Kramzyk. (Tr. 32.) On July 11, 2012, ALJ Kramzyk issued a decision denying the claim. (Tr. 14-25.) The Appeals Council denied a request for review on October 1, 2013, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-3.).
Cagle was born on March 24, 1961 and was 51 years old on the date the ALJ rendered his decision. (Tr. 24, 137.) Cagle alleges a disability onset date of October 2, 2010, mainly on account of her fibromyalgia and herniated discs in her back and neck. (Tr. 137-140.) The ALJ found that Cagle's severe impairments included degenerative disc disease, osteoarthritis of the right knee, fibromyalgia, depression, and anxiety. (Tr. 16.)
A. Medical Background
Cagle's medical evidence primarily revolves around her chronic pain. In February 2005, Cagle experienced back pain and a thoracic MRI revealed degenerative disc changes at T6-T7 and T7-T8 and disc osteophyte complex along the right parasagittal aspect of the canal at T9-T10. (Tr. 270.) In November 2006, her cervical MRI scan, taken on account of neck pain and right arm and leg numbness, showed early degenerative disc disease at C5-6 and C6-7. (Tr. 268.) The MRI of her thoracic spine showed shallow nuclear herniations causing mild mass effect on the cord at T6-T7, T7-T8, and T9-T10 without canal stenosis. (Tr. 506.)
In September 2008, treatment notes from the Interventional Spine and Pain Centers indicate that Cagle had previously sought treatment for her thoracic pain secondary to a disc herniation. (Tr. 355-376.) While those prior records were not provided, other records did indicate she sought treatment in September 2008 through mid-November 2009 with pain specialist Dr. Brian McClenic, M.D. for her right side pain, and her cervical and low back pain. Despite having a full range of motion in her spine, Dr. McClenic noted that her recent MRI showed advancement of cervical spondylosis and degenerative disc disease. Her treatment included Darvocet and epidural steroid injections with which improvement was noted in late 2008.
In June 2009, Dr. McClenic indicated that while the injections were helpful, Cagle's pain was returning and getting worse. (Tr. 355-376.) He noted that she had a full range of motion in her spine with some tenderness. He also noted that she was taking Celebrex and Darvocet, and recommended that she repeat thoracic epidural injections. With this course of treatment, Cagle showed signs of improvement, until November 2009 when the pain again returned. Dr. McClenic referred her to a spine surgeon for further evaluation and recommended another thoracic epidural steroid injection which wasn't performed until June 2010-after Cagle first tried physical therapy and consulted a spine surgeon.
In November 2009, Dr. Levin, of the Community Spine Neurosurgery Institute, reported that Cagle was a known acquaintance since she worked at the Community Hospital, and that she had been complaining for a number of years about back pain due to a work related incident in 2001. (Tr. 290-291.). Dr. Levin indicated that her pain is on the right side and she reported tingling in her hands and trouble with dropping objects. It was also documented that she had been undergoing physical therapy and injections, but that the insurance was not going to pay for further injections because they did not seem to have a significant effect. Despite her having a good range of motion, his impression was that she suffered from thoracic disc pain and he ordered another MRI. Cagle reported that she continued to work, but her pain was getting worse despite treatment. (Tr. 294-297.).
In June 2010, Cagle described her pain as being located in her neck and radiating to her right shoulder, arm and hand with associated numbness, tingling, and weakness. (Tr. 355-376.) At this point she started seeing pain specialist Dr. Shariq Ibrahim and she underwent another epidural injection in July, which helped, but she continued to experience right shoulder pain and hand weakness. Despite her persistent neck and radicular pain, in August 2010, Dr. Ibrahim indicated that Cagle received about 60% improvement, and therefore recommended no further interventions, except strength exercises and the addition of Savella.
In October 2010, it was noted that she could not tolerate the side effects of Savella and Cymbalta, and her pain had become more severe and her depression worse. It was also noted that her cervical range of motion was diminished. As a result, Dr. Ibrahim started her on Lexapro and recommended that she see a psychologist for nonpharmacological methods to help her cope with her pain.
Also in October 2010, Dr. McIntire, Cagle's treating physician since at least early 2005 (Tr. 270), noted that Cagle's neck and back pain were constant, chronic, and severe, and that she could not sleep at night due to the pain and she was becoming more and more depressed by having to call off of work more frequently. He noted that she recently dropped a bottle of laundry detergent because of her pain, and she had to stand up and shift positions to get comfortable. He also noted her normal range of motion in her neck and back. Dr. McIntire opined that she suffered from fibromyalgia and chronic pain.
On November 30, 2010, consultative examiner J. Smejkal, M.D. noted that despite spinous and paraspinal tenderness throughout the spine, Cagle had a full range of motion and no restrictions. (Tr. 403-406.) She reportedly had normal grip strength with fine finger manipulative abilities. It was his impression that Cagle suffered from a history of depression and herniated discs in the lumbar and cervical spine, with pain but no restrictions, but there was a need to rule out fibromyalgia.
On December 22, 2010, state agent J. Sands, M.D., reviewed Cagle's file and found that while Cagle appeared credible, the evidence indicated that her impairments were not severe. (Tr. 410.) State agent D. Neal, M.D., affirmed this opinion in March 2011. (Tr. 435.)
Also in December 2010, state agent Kari Kennedy, Psy.D., performed a psychiatric review technique and concluded that Cagle suffered from major depressive disorder and bereavement (Tr. 411-428.) He opined that Cagle had mild restrictions in her activities of daily living, moderate limitations in maintaining social functioning and in maintaining concentration, persistence, and pace, and no episodes of decompensation. Psychologist Kennedy also performed a mental RFC assessment which indicated that the only limitations Cagle faced was moderate limitations with maintaining attention and concentration for extended periods, interacting with the general public, and responding appropriately to changes in the work setting. Despite these findings, he indicated that Cagle was "able to deal with changes in a routine work setting" and was capable of unskilled work. On March 25, 2011, reviewing state agent Joelle Larsen, Ph.D., affirmed the opinion. (Tr. 434.)
In June 2011, Dr. McIntire ordered MRI imaging of Cagle's spine. (Tr. 468.) MRI imaging of the cervical spine revealed spondylotic changes at C5-C6 and C6-C7, and minimal central stenosis at C5-C6. (Tr. 468.) MRI imaging of the thoracic spine revealed small disc bulges and protrusions. (Tr. 469.) MRI imaging of the lumbar spine revealed mild degenerative disc and facet disease, mild left lateral recess compromise, and mild left lateral recess compromise. (Tr. 471.)
Dr. McIntire also examined Cagle and observed tender points in the elbows, upper back, and legs, along with tightness from the neck to the lumbar area. (Tr. 467.) Dr. McIntire opined that Cagle suffered from early arthritis, a bulging disc in the upper back, and slippage of the cervical spine. (Tr. 467.)
For purposes of benefits, Dr. McIntire submitted an assessment of Cagle's functional capacity in June 2011, stating that she suffered from fibromyalgia and neck and back pain that caused abnormal motion with joint pain and stiffness. (Tr. 453-454.) He indicated that Cagle's pain could be as severe as a 9 on a 10 point scale, and that it was aggravated by bending, lying down, twisting, and sitting. He also opined that the pain moderately interfered with Cagle's concentration, preventing her from performing complicated/detailed tasks. He concluded that she was unable to perform simple gripping, pushing or pulling, and fine manipulation with the right hand, nor could she perform repetitive motions with her right hand. She could lift and carry up to 10 pounds frequently, up to 19 pounds occasionally, and between 20 and 49 pounds rarely. Furthermore, he concluded that she could sit for less than 4 hours in an 8 hour day, provided that she was allowed to change positions at will from sitting and standing, that she could stand or walk for less than 1 hour in an 8 hour day, and that she could never bend, squat, crawl, climb, or reach above shoulder level.
Four months later, on October 14, 2011, Cagle was examined by Dr. Kevin Joyce, a rheumatologist, who observed "irritability for range of motion of the cervical spine" and found 18 of 18 positive soft tissue tender points, consistent with her diagnosis of fibromyalgia. (Tr. 566). Dr. Joyce opined that she obviously suffered from active depression, and that she may have a sleep disorder for which he recommended further work-up. Days later, he saw Cagle again, and his assessment listed the following problems: fibromyalgia, arthralgias in multiple sites, fatigue, obstructive sleep apnea, osteoarthritis, and emphysema. (Tr. 558.)
Dr. Joyce noted in November 2011 that her current "active" problems included in relevant part, arthralgias in multiple sites, arthritis, depression, emphysema, fatigue, fibromyalgia, herniated cervical disc, myalgia and myositis, and neck pain. (Tr. 553-554.) He noted that she had some irritability for range of motion of the cervical spine, but no major limitations. His treatment plan for Cagle indicated that she continued to have widespread pain and he would need to address her fibromyalgia syndrome more completely. Subsequently, Cagle's sleep evaluation indicated that she suffered from mild sleep apnea syndrome. (Tr. 590-594.)
In late November 2011, Dr. McIntire documented that Cagle suffered from depression and fibromyalgia. (Tr. 587.) In January 2012, Dr. McIntire noted that Cagle attempted to stop smoking and started using a treadmill because she was gaining weight, but then her pain returned. (Tr. 610.) He also noted that she did not want any muscle relaxants or other pills, and that she was trying to wean herself off of the Vicodin. (Tr. 611.)
Cagle's medical records further include frequent notations of her depression. At one point, Dr. McIntire noted that her prior psychiatric treatment records were not kept by St. Catherines. (Tr. 455.) However, the record does show that in October 2010, Drs. Ibrahim and McIntire both noted that Cagle appeared depressed. (Tr. 355, 379.) Also, on July 15, 2011, Dr. McIntire noted that Cagle tearfully told him that she had not been sleeping well because of pain and stress, and that she felt lonely since her husband's sudden death in September 2007. Sometimes Cagle did not want to wake up from sleep. (Tr. 463.) This prompted Dr. McIntire to diagnose Cagle with acute depression and contacted Cagle's son to take her to the emergency room for mental health treatment. (Tr. 463.) Cagle's son took her to the hospital, where she was admitted for the day and diagnosed with major depressive disorder. (Tr. 444-45.) In August 2011, clinical nurse specialist Patricia Lennon diagnosed Cagle with major depressive disorder and general anxiety disorder. (Tr. 530.) Ms. Lennon indicated Cagle should continue Alprazolam and start Citalopram.
Consultative psychologists Drs. J. Singh and Harry Gunn conducted a mental status examination of Cagle on November 30, 2010, for the purpose of disability benefits. (Tr. 399-402.) They found that Cagle's mood was depressed and she suffered from drowsiness due to her medications. They noted that while Cagle was generally able to take care of her personal needs, she has had chronic back pain since 2002 and bouts of depression since her husband's death in 2007. Drs. Singh and Gunn diagnosed Cagle with ...