United States District Court, S.D. Indiana, Indianapolis Division
ENTRY ON JUDICIAL REVIEW
WALTON PRATT, United States District Court Judge
April Lynn Woodring (“Woodring”) requests
judicial review of the final decision of the Commissioner of
the Social Security Administration (the
“Commissioner”), denying her applications for
Social Security Disability Insurance Benefits
(“DIB”) under Title II of the Social Security Act
(the “Act”), and Supplemental Security Income
(“SSI”) under Title XVI of the Act.For the following
reasons, the Court REMANDS the decision of
the Commissioner for further consideration.
December 17, 2012, Woodring filed applications for DIB and
SSI, alleging a disability onset date of January 9, 2011, due
to neck and shoulder pain, postural abnormalities,
spondylolisthesis, depression, anxiety, chronic obstructive
pulmonary disease (“COPD”), asthma, and obesity.
The claim was initially denied on April 5, 2013, and again on
reconsideration on July 23, 2013. On August 15, 2013,
Woodring filed a request for a hearing.
hearing was held before Administrative Law Judge Jason C.
Earnhart (the “ALJ”) on April 1, 2015. Woodring
was present and represented by counsel. Thomas A. Grzesik, a
vocational expert, appeared and testified at the hearing. On
May 6, 2015, the ALJ denied Woodring's applications for
DIB and SSI. Following this decision, on May 26, 2015,
Woodring requested review by the Appeals Council. On August
27, 2016, the Appeals Council denied Woodring's request
for review of the ALJ's decision, thereby making the
ALJ's decision the final decision of the Commissioner for
purposes of judicial review. On October 26, 2016, Woodring
filed this action for judicial review of the ALJ's
decision pursuant to 42 U.S.C. § 405(g).
time of her alleged disability onset date, Woodring was
thirty-six years old, and she is now forty-three years old.
Woodring attended formal schooling through the tenth grade,
but she did not complete her high school education and did
not earn a GED. Prior to the onset of her alleged disability,
Woodring had an employment history working as a taxi driver,
a cashier/checker, and a meat counter clerk.
history of anxiety and depression dates back to at least
September 2009 (Filing No. 8-8 at 29). Woodring
began experiencing severe anxiety and having panic attacks
around May 2010. At that time, Woodring had an experience
where her hands were shaky, she had chest pain and shortness
of breath, and she could not get out of her car. The anxiety
subsided, but it came back with more intensity in November
2010. She sought treatment for her anxiety from her primary
care physician. She was prescribed medication to address her
anxiety, but it made her sick, so she tried various other
medications (Filing No. 8-7 at 17).
January 10, 2011, Woodring experienced a panic attack and
went to a hospital emergency room to seek treatment
(Filing No. 8-12 at 40, 46). She was discharged from
the emergency room and immediately began experiencing panic
attacks again, so she sought additional treatment the next
day (Filing No. 8-13 at 85). She again went to the
hospital emergency room on January 14, 2011 because of
anxiety and panic attacks (Filing No. 8-7 at 20).
Throughout January 2011, Woodring went to various health care
providers to seek treatment for her anxiety and depression
(Filing No. 8-8 at 25-29; Filing No. 8-13 at
83). On January 19, 2011, Woodring began receiving
consistent, regular therapy from licensed clinical social
worker Abigail Michael (“Ms. Michael”) for
depression and anxiety (Filing No. 8-8 at 25).
February 11, 2011, Woodring had an individual therapy session
with Ms. Michael to explore her past abuse and her anxiety.
Id. at 33. She was referred to psychiatrist Alfredo
J. Tumbali, M.D. (“Dr. Tumbali”). Dr. Tumbali
conducted a psychiatric evaluation of Woodring on February
14, 2011 (Filing No. 8-7 at 17). Dr. Tumbali
diagnosed Woodring with depressive disorder and anxiety
disorder and assigned her a global assessment of functioning
(“GAF”) score of 55. He recommended continued
individual therapy with her therapist, and he prescribed new
medication. He noted that he would continue to see Woodring
for medication management. Id. at 18.
continued to receive individual therapy from Ms. Michael from
March 1, 2011 into 2013 (Filing No. 8-8 at 36-53).
She continued to exhibit depression, anxiety, and panic
attacks during that time period, however, there were periods
of progression. During her therapy session with Ms. Michael
in July 2011, Woodring completed a cost/benefit analysis of
returning to work. She decided that she would ask her
employer if she could return to work on a reduced schedule.
Id. at 42. During subsequent therapy appointments,
she was anxious, agitated, and tearful. Woodring had been
doing more driving, but during her therapy session in
November 2011, she reported experiencing another panic attack
while driving and was fearful to drive. Id. at 46.
In July 2012, Woodring reported to Ms. Michael that she had
been driving her mother to appointments and had applied for
some jobs. Id. at 51. Woodring attempted to work at
a small grocery store in December 2012, but she quit after
the first day because of a panic attack. She also experienced
a panic attack in a Walmart parking lot and had to have her
boyfriend take her home. Id. at 65.
this 2011 and 2012 time period, Woodring continued to receive
treatment, including medications, from Dr. Tumbali for her
anxiety and depression. In June 2011, Woodring reported
increased anxiety. A mental status examination revealed an
anxious mood. Dr. Tumbali prescribed Xanax and Lexapro.
Woodring appeared less anxious at her next appointment, and
Dr. Tumbali continued recommending outpatient therapy, which
Woodring was receiving. In September 2011, Woodring stated
that she still felt anxious, and her mental status
examination revealed a depressed and anxious mood. A mental
status examination in November 2011 revealed a less depressed
and anxious mood. Woodring's anxiety and depression
seemed to be managed by her ongoing therapy and medication
throughout her visits with Dr. Tumbali through August 2012.
At the October 2012 appointment, Woodring stated that she
felt stressed, and the mental status examination revealed a
depressed and anxious mood. Dr. Tumbali prescribed Xanax and
Wellbutrin. In November 2012, Woodring appeared to be doing
better, but by March 2013, she had more anxiety, depression,
and panic attacks (Filing No. 8-11 at 44-57).
January 22, 2013, Woodring was admitted to a psychiatric
hospital because of increased depression. She was tearful and
had stayed in bed over the previous two weeks with little
regard for self-care. She had been having suicidal thoughts
with a plan to overdose. She was sleeping more than twelve
hours a day, and when she was going to sleep, she wished that
she would not wake up (Filing No. 8-8 at 57).
Woodring's GAF score was 30 at admission. Psychiatrist
Thomas E. Kreider, M.D., diagnosed depressive disorder and
personality disorder among other things. She was treated with
Wellbutrin and Xanax and discharged on January 25, 2013. Her
GAF score was 45 upon discharge. Id. at 66, 68-69.
After being discharged, Woodring resumed treatment and
therapy with Dr. Tumbali and Ms. Michael.
her May 28, 2013 appointment with Dr. Tumbali, Woodring
reported that she could not drive because she still was
having panic attacks. Her mental status examination revealed
an anxious mood (Filing No. 8-11 at 43). On August
6, 2013, Dr. Tumbali completed a psychiatric/psychological
impairment questionnaire regarding Woodring. He noted
diagnoses of anxiety disorder and depressive disorder. He
opined that she had a GAF score of 55. He noted the following
clinical findings to support his diagnoses: appetite
disturbance with weight change, sleep disturbance, mood
disturbance, emotional lability, recurrent panic attacks,
anhedonia or pervasive loss of interests, psychomotor
agitation or retardation, feelings of guilt/worthlessness,
difficulty thinking or concentrating, suicidal ideation or
attempts, social withdrawal or isolation, decreased energy,
intrusive recollections of a traumatic experience, persistent
irrational fears, generalized persistent anxiety, hostility
and irritability, overall sad mood, excessive worry, racing
thoughts, and fear of crowded places. Woodring's primary
symptoms were panic attacks, anxiety, avoidance of social
situations, and lack of motivation. Dr. Tumbali opined that
Woodring's prognosis was poor. He also opined that
Woodring was markedly limited in the areas of concentration
and persistence, social interactions, and adaptation
(Filing No. 8-9 at 94-101).
continued receiving treatment and therapy from Dr. Tumbali
and Ms. Michaels, and on March 23, 2014, she was admitted to
the St. Vincent stress center because she was experiencing
increased panic like symptoms and anxiety. She was fearful of
leaving her home and having panic attacks in public. She was
experiencing shaking, shortness of breath, and an extreme
sense of dread. She had increased depression, crying spells,
low energy, low confidence, and difficulty sleeping. She was
treated with various medications and discharged a few days
later (Filing No. 8-12 at 54-55). Woodring again
returned to Dr. Tumbali and Ms. Michaels after her discharge
from the stress center. In March 2015, Ms. Michael completed
a mental impairment questionnaire similar to Dr.
Tumbali's psychiatric/psychological impairment
questionnaire. Ms. Michaels reached similar conclusions
regarding Woodring's impairments as those found by Dr.
Tumbali (Filing No. 8-13 at 71-75).
one year before she was admitted to the stress center but
soon after filing her applications for DIB and SSI, Woodring
underwent a consultative psychological evaluation with
Michele Koselke, Psy.D. (“Dr. Koselke”), at the
request of the Social Security Administration. Woodring
reported she had been unable to work because of depression
and anxiety with panic attacks. She discussed her bi-weekly
counseling, explaining that it had been helpful but had not
eliminated her anxiety and depression. She also discussed her
inpatient hospital treatment from January 2013, explaining
that it was not helpful and actually made her anxiety and
depression worse. Woodring noted that she had difficulty
sleeping and had lost forty pounds in the previous three
months. Woodring's mental status examination revealed
clinical impressions of anxiety disorder, alcohol dependence
in remission, and poly-substance dependence in remission,
with a GAF score of 69. Dr. Koselke opined that Woodring was
in the average range for functioning, and she was able to
focus for one hour, get along with others, and follow
directions (Filing No. 8-9 at 3-7).
her physical impairments, Woodring went to the hospital
emergency room on January 16, 2011 because of neck and back
pain (Filing No. 8-7 at 30). On November 8, 2012,
Woodring was examined by Melissa M. Roche, M.D. (“Dr.
Roche”), for chronic neck and shoulder pain that had
been going on for many years (Filing No. 8-8 at 8).
Dr. Roche recommended physical therapy, so Woodring was
evaluated by Christie DeCraene, P.T., for physical therapy to
address her neck, shoulder, and upper back pain. Id.
at 75. Following the evaluation, it was noted that Woodring
had T1 through T3 flexion dysfunction, pectoralis minor
restriction, and postural dysfunction. A physical therapy
plan was established to correct these issues. Id. at
75-76. Woodring participated in physical therapy about two
times a week through November and December 2012. Id.
November 2012, Woodring underwent pulmonary function testing,
which revealed moderate obstructive airway disease. The
objective results of the test were above listing level
severity. It was noted that Woodring had a significant
response to and improvement with bronchodilators (Filing
No. 8-8 at 15-16). On December 11, 2012, Woodring went
to Dr. Roche for chest pain, a cough, and a sore throat. Dr.
Roche noted that Woodring's ongoing COPD was exacerbated.
Id. at 6. Progress notes from late 2012 and into
early 2013 indicate that Woodring continued to seek ongoing
treatment and care for her chronic back and neck pain, as
well as her COPD and asthma. It was noted that physical
therapy had been unsuccessful at resolving her back and neck
pain. Id. at 2-8. Chest x-rays in January 2013
revealed streaky perihilar densities with associated
peribronchial cuffing. Id. at 87. During her January
2013 visit with Dr. Roche, it was noted that Woodring's
lungs were clear and respiration normal. It appeared that her
medications were helping her to improve her asthma and COPD.
Id. at 4.
2013, Woodring underwent a second pulmonary function test,
which revealed a moderate obstruction and mild upper
respiratory restriction, with one measure below listing level
severity, but the test results had a variance (Filing No.
8-9 at 79-81). One month later in July 2013, Woodring
underwent a third pulmonary function test, which revealed
results back above listing level severity. Id. at
October 2013, Woodring saw Carleigh Wilson, D.O. (“Dr.
Wilson”) because she was experiencing shortness of
breath, a cough, and shoulder and neck pain. Dr. Wilson noted
that Woodring's COPD was stable but still an ongoing
impairment, so she prescribed medications to address the
cough and any potential bronchitis (Filing No. 8-10 at
24-25). Dr. Wilson recommended that Woodring receive
physical therapy to help with her back and neck pain, so she
started physical therapy again. Id. at 4-12. Dr.
Wilson continued to treat Woodring through at least June 2014
for her back and neck pain and COPD (Filing No. 8-13 at
December 6, 2013, Dr. Wilson completed a pulmonary impairment
questionnaire for Woodring. She noted Woodring's
diagnosis of COPD, and a good prognosis with the need to quit
smoking. Dr. Wilson noted clinical findings of shortness of
breath, chest tightness, wheezing, rhonchi, episodic acute
bronchitis, fatigue, and coughing. Woodring's primary
symptoms were back, shoulder, and neck pain as well as
frequent respiratory infections. She also suffered from acute
asthma attacks precipitated by upper respiratory infections
and cold air/change in weather. Dr. Wilson opined that,
during asthma attacks, Woodring was incapacitated for minutes
to hours at a time. Dr. Wilson further opined that in an
eight-hour workday Woodring could sit for two hours and
stand/walk for one hour, and she could lift/carry up to ten
pounds frequently. Dr. Wilson opined that Woodring would need
to take unscheduled breaks to rest every one to two hours for
about fifteen to twenty minutes. She was likely to have good
days and bad days, and she was likely to be ...