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Sprague v. Colvin

United States District Court, N.D. Indiana, Fort Wayne Division

January 5, 2017

DAVID SPRAGUE, on behalf of GEORGIA SPRAGUE, deceased, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          OPINION AND ORDER

          Andrew P. Rodovich United States Magistrate Judge

         This 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.[1] For the following reasons, the decision of the Commissioner is REMANDED.

         Background

         The 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).

         The ALJ 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. (Tr. 24).

         The ALJ 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).

         At step 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).

         The ALJ then assessed Sprague's residual functional capacity as follows:

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.

         (Tr. 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. 26).

         Sprague 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).

         In 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).

         Sprague 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).

         In 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).

         Treating 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 with ...


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