United States District Court, N.D. Indiana, Fort Wayne Division
DAVID SPRAGUE, on behalf of GEORGIA SPRAGUE, deceased, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
OPINION AND ORDER
P. Rodovich United States Magistrate Judge
matter is before the court on petition for judicial review of
the decision of the Commissioner filed by the plaintiff,
David Sprague, on behalf of Georgia Sprague, deceased, on
August 14, 2015. For the following reasons, the decision of
the Commissioner is REMANDED.
plaintiff, David Sprague, on behalf of Georgia Sprague,
deceased, filed an application for Disability Insurance
Benefits on February 23, 2012, alleging a disability onset
date of June 15, 2010. (Tr. 21). The Disability Determination
Bureau denied Sprague's application on May 22, 2012, and
again upon reconsideration on August 7, 2012. (Tr. 21).
Sprague subsequently filed a timely request for a hearing on
August 31, 2012. (Tr. 21). A hearing was held on October 17,
2013, before Administrative Law Judge (ALJ) Patricia Melvin,
and the ALJ issued an unfavorable decision on March 17, 2014.
(Tr. 21-31). Vocational Expert (VE) Robert S. Barkhaus,
Sprague, and Sprague's husband, David Sprague, testified
at the hearing. (Tr. 21, 29). The Appeals Council denied
review, making the ALJ's decision the final decision of
the Commissioner. (Tr. 1-6).
found that Sprague met the insured status requirements of the
Social Security Act through December 31, 2015. (Tr. 23). At
step one of the five step sequential analysis for determining
whether an individual is disabled, the ALJ found that Sprague
had not engaged in substantial gainful activity since June
15, 2010, the alleged onset date. (Tr. 23). At step two, the
ALJ determined that Sprague had the following severe
impairments: fibromyalgia and degenerative disc disease of
the lumbar spine. (Tr. 23). The record contains evidence of
other impairments present during the relevant period, but
they did not result in functional limitations. (Tr. 23). An
examination was completed by Michele Thurston, M.D. in May
2010. (Tr. 24). She assessed Sprague with uncontrolled
diabetes. (Tr. 24). After visits to Dr. Thurston and
hospitalization, Sprague developed better monitoring
techniques by her May 2012 consultative examination with H.
M. Bacchus Jr., M.D. (Tr. 24). Dr. Bacchus' normal
sensory results were countered by the diagnosis of Jeremy
Grogg, M.D. of neuropathy and paresthesia. (Tr. 24). He found
neuropathy in the fourth and fifth digits of both hands,
however, her hemoglobin A1c had declined to 9. (Tr. 24). Dr.
Grogg described Sprague's prognosis as “excellent,
” and no limitations existed with respect to diabetes.
indicated that Sprague's chronic obstructive physical
pulmonary disease and abnormal liver tests were non-severe
physical impairments. (Tr. 24). Also, the ALJ concluded that
Sprague's mental impairments of depression and anxiety
caused a minimal limitation on her ability to perform basic
mental work activities and were nonsevere. (Tr. 24). Henry
Martin, Ph.D. conducted memory recall and serial 7s tests and
diagnosed Sprague with adjustment disorder with mixed
emotional features. (Tr. 24). Dr. Martin provided a global
assessment of functioning (GAF) score of 45, indicating
serious symptoms, which the ALJ afforded little weight
because the score was not standardized and only provided a
brief glimpse into functioning. (Tr. 25). The ALJ also
indicated that Sprague's minimal treatment for the mental
health impairments supported the state agency opinion that
the impairments were not severe. (Tr. 25).
three, the ALJ concluded that Sprague did not have an
impairment or combination of impairments that met or
medically equaled the severity of one of the listed
impairments. (Tr. 26). Specifically, she found that Sprague
did not meet Listing 1.04, severe lumbar degenerative disc
disease. (Tr. 26).
then assessed Sprague's residual functional capacity as
The claimant has the residual functional capacity to perform
light work as defined in 20 CFR 404.1567(b) except she can
never climb ladders, ropes, or scaffolds; she can
occasionally climb ramps and stairs; and she can occasionally
balance, stoop, kneel, crouch, and crawl.
26). The ALJ explained that in considering Sprague's
symptoms, she followed a two-step process. (Tr. 26). First,
she determined whether there was an underlying medically
determinable physical or mental impairment that was shown by
medically acceptable clinical and laboratory diagnostic
techniques that reasonably could be expected to produce
Sprague's pain or other symptoms. (Tr. 26). Then, she
evaluated the intensity, persistence, or functionality
limiting effects of pain or other symptoms to determine the
extent to which they limited Sprague's functioning. (Tr.
alleged that she has diabetic-related neuropathy and could
not work due to back pain that radiated into her legs. (Tr.
26). As a result, she could not sit more than 30 minutes,
stand more than 20 minutes, walk more than 2 blocks, or lift
more than 10 pounds. (Tr. 26). Sprague indicated she was
unstable when she walked causing her to fall once a month,
therefore, she used a cane that was not prescribed for her by
a doctor. (Tr. 26-27). Sprague testified that her diabetes
interfered with her ability to talk, walk, and grip items.
(Tr. 27). She had been prescribed Levemir, Novolog, and
Metformin for diabetes; Nabumetone, Oxycodone, Zanaflex,
Vicodin, and Soma for pain; and Cymbalta for mental
impairments. (Tr. 27). The medications only eased, but did
not eliminate, the impairments and caused her to sleep
approximately half of each day. (Tr. 27).
February of 2010, prior to the alleged onset of disability
date, Sprague presented to pain specialist William Hedrick,
M.D. diagnoses of knee osteoarthritis, right rotator cuff
tendinitis, lumbar facet arthropathy, sacroiliitis,
fibromyalgia, cervicalgia, and lumbar radiculopathy. (Tr.
27). Dr. Hedrick focused on the lumbar discomfort and
provided an epidural steroid injection at ¶ 4-L5 and
L5-S1. (Tr. 27). He repeated this procedure in April,
however, the pain continued through her June 2010 alleged
onset date. (Tr. 27). Three months after the April injection,
Sprague overdosed by taking 88 Percocets and 30 Robaxins in a
single week. (Tr. 27). Sprague revisited Dr. Hedrick when she
was short on Percocets. (Tr. 27). Dr. Hedrick entrusted the
medications to her husband and recommended substance abuse
treatment. (Tr. 27). Sprague's lack of insurance
interfered with her ability to receive injections, but Dr.
Hedrick's follow-up reports indicated the prescriptions
were working well. (Tr. 27).
received another epidural injection at ¶ 4-L5 and L5-S1
from Dr. Hedrick in September of 2011. (Tr. 27). It provided
a 60 percent improvement in her pain, however, the pain
returned by November. (Tr. 27). Dr. Hedrick found that
Sprague had cervical facet tenderness, myofascial tenderness,
decreased range of motion, and lumbar and knee joint
tenderness. (Tr. 27). Dr. Hedrick provided samples of Flector
patches and Voltaren gel, yet the pain persisted. (Tr. 27).
April 2012, Sprague went to the emergency room with low back
pain. (Tr. 27). Emergency physician Pablo Perez, M.D. found
tenderness to palpation in the lumbar area, so he
administered Toradol and Norflex. (Tr. 27). At discharge, he
prescribed Vicodin, Dolobid, and Soma. (Tr. 27). At a May
2012 consultative examination, Dr. Bacchus described Sprague
as having difficulty getting on and off the exam table,
reduced range of motion throughout all testing areas, and
reduced 4 out of 5 muscle strength in all extremities. (Tr.
27-28). However, Sprague's gait was stable, and she did
not need an assistive device. (Tr. 28). He confirmed the
prior diagnoses of fibromyalgia, osteoarthritis, and a
history of chronic back pain. (Tr. 28). Also in May, Sprague
saw emergency room physician David Reed, M.D. for lumbar
pain. (Tr. 28). An image of the spine showed mild lumbar
degenerative changes and L1-L2 disc narrowing. (Tr. 28).
physician Monica Reddy, M.D., in October of 2012 found that
Sprague's range of motion had improved since the May 2012
consultative examination with Dr. Bacchus, yet she still had
restricted lumbar flexion. (Tr. 28). Dr. Reddy took x-rays of
Sprague's feet that showed degenerative changes of the
first metatarsophalangeal joints, hallux valgus deformities,
and heel spurs. (Tr. 28). Sprague attended physical therapy