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Woodring v. Berryhill

United States District Court, S.D. Indiana, Indianapolis Division

March 19, 2018

NANCY A. BERRYHILL, [1] Acting Commissioner of the Social Security Administration, Defendant.


          TANYA WALTON PRATT, United States District Court Judge

         Plaintiff 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.[2]For the following reasons, the Court REMANDS the decision of the Commissioner for further consideration.

         I. BACKGROUND

         A. Procedural History

         On 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.

         A 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).

         B. Factual Background

         At the 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.

         Woodring's 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).

         On 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).

         On 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.

         Woodring 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.

         During 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).

         On 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.

         During 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).

         Woodring 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).

         Approximately 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).

         Regarding 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. at 77-78.

         In 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.

         In June 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 85-87.

         In 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 33-43).

         On 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 ...

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