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Moller v. Colvin

United States District Court, W.D. Missouri, Western Division

February 10, 2015

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


NANETTE K. LAUGHREY, District Judge.

Plaintiff Rachelle Moller seeks review of the Administrative Law Judge's (ALJ) decision denying her application for disability insurance and supplemental security income benefits under Titles II and XVI of the Social Security Act. [Doc. 14]. For the reasons set forth below, the ALJ's decision is reversed in part, and the case is remanded for further consideration.

I. Background

A. Medical Records

Moller alleges a disability onset date of July 13, 2011, from the combined effects of degenerative disc disease, chronic neck and back pain, headaches, diabetes mellitus, neuropathy and numbness in her left hand, legs and feet, carpal tunnel syndrome, anxiety, depression, bipolar disorder, poor concentration secondary to pain, and poor ability to interact with the public, coworkers and supervisors on a sustained basis. [Tr. 40-41].

Moller suffers from chronic back pain. The record shows consistent complaints of middle and lower back pain from April 2010 until August 2012. A May 2010 x-ray revealed hypertrophic spurring with near bridging spurs on the lower half of the thoracic spine and small hypertrophic spurs, mild degenerative joint disease and atherosclerotic vascular disease in the lumbar spine. [Tr. 278-79]. An MRI in May 2010 showed desiccation of the disc material at L2-3 and no evidence of disc herniation or central spinal canal stenosis. [Tr. 361]. Moller received two epidural steroid injections in April and June 2011, but reported no improvement. [Tr. 366-69].

A September 2011 CT scan of Moller's spine revealed "[p]rominent extradural defects on the left side at C4-C5 and C5-C6 due to endplate spurring and associated disc bulging." [Tr. 444]. In October 2011, Moller complained that the bulging disc in the back of her neck caused her left arm to go numb. [Tr. 425]. Four days after this complaint, Moller underwent surgery for a cervical microdiscectomy of C4-C5 and C5-C6, a corpectomy of the C5 vertebral body, fibular strut grafting of C4 through C6, and cervical plating of C4 through C6. [Tr. 446-452]. In November 2011, at a follow-up appointment, the nurse practitioner stated that Moller was "recovering well" and that her incision was giving her minimal discomfort. [Tr. 426]. Moller complained of muscle spasms in the back of her neck, continued numbness in her left arm, weakness in her hand grip, and weakness in her arm muscles. Id. In December 2011, at another follow-up appointment, Moller complained of numbness in both arms. [Tr. 428]. Moller complained that using pain medication was difficult because it inhibited her from caring for her grandson. Id. In January 2012, Moller complained of persistent numbness in some fingers on her right hand and all fingers on her left hand. [Tr. 430]. She stated her fingers "lock up" and that she could not pick things up. Id. Moller's specialist, Dr. Wilkinson, remarked that Moller "certainly could not return to work" as a CNA "at this point." Id. Dr. Wilkinson observed weakness in her left arm and the muscles of her thumb and little finger. In February 2012, a CT revealed an intact anterior metallic plate stabilized by screws at C4 and C6 and a bone graft at C5. [Tr. 453-55]. In March 2012, after reviewing a CT, Dr. Wilkinson determined that a posterior foraminotomy was necessary to decompress a particular nerve affecting Moller's left fingers. Dr. Wilkinson noted that Moller had a foraminal stenosis at C5-C6 on the left from osteophytic change. In addition to decompressing the nerve at Moller's C5-C6, Dr. Wilkinson recommended that surgery be done on the median nerve of Moller's wrist. [Tr. 432]. This surgery was performed in May 2012. [Tr. 459-63]. In June 2012, Dr. Wilkinson noted that Moller still had numbness in the index finger and thumb of her left hand, but that her sensation seemed to be improving. [Tr. 469]. In August 2012, Dr. Wilkinson noted that Moller's pain was better and that she was doing "fairly well, " but that she still had persistent numbness in her thumb and little finger. [Tr. 472].

Moller also has a history of documented complaints and diagnoses of anxiety and depression. Moller complained of anxiety and depression from January to July 2010 and again in August 2011. [Tr. 288-299, 487]. Her primary care physician, Dr. Amber Campbell, prescribed various medications for anxiety and depression.

The medical records also reveal a history of insulin-dependent diabetes mellitus, which was often described as uncontrolled. See e.g. [Tr. 293, 485, 489-90]. Moller also complained of frequent headaches. The record also reveals diagnoses of hypertension. See e.g., [Tr. 493, 503].

B. Medical Opinions

Both Moller's treating physician, Dr. Amber Campbell, and her treating surgeon, Dr. Wilkinson, submitted medical opinions regarding Moller's physical ability to work. [Tr. 381-82, 398-99]. There is also an opinion from a non-examining state agency consultant, Dr. Karen Sarpolis. [Tr. 401-5]. These opinions will be compared in detail to the ALJ's residual functional capacity (RFC) determination below.

Dr. Campbell also submitted an opinion on Moller's mental limitations. [Tr. 384-85]. In August 2011, Dr. Campbell opined that Moller had marked limitations in the ability to interact appropriately with the public, supervisors, and coworkers and the ability to respond appropriately to usual work situations and to changes in a routine work setting. [Tr. 385]. Moller was extremely limited in her ability to complete a normal work-day and week without interruptions from psychologically-based symptoms and to perform at a consistent pace without an unreasonable number and length of rest. Id.

C. ALJ's Opinion

After a hearing, the ALJ issued an unfavorable decision, finding at Step 5 of his determination that Moller could perform work that existed in significant numbers in the national economy, including as an address clerk, laminator, and patcher. [Tr. 21]. Moller had the following severe impairments: degenerative disc disease of the cervical spine with a history of two surgeries, degenerative disc disease of the thoracic and lumbar spine, carpal tunnel syndrome, diabetes mellitus, depression, and anxiety. [Tr. 13]. Moller had the RFC to perform sedentary work, including lifting and carrying ten pounds occasionally and less than ten pounds frequently, and standing and walking two hours and sitting six hours in an eight-hour workday. Moller cannot perform repetitive pushing or pulling with her upper extremities. She can occasionally climb, balance, stoop, kneel, crouch, crawl, and bilaterally reach in all directions. She can frequently handle, finger, and feel with her left dominant hand. She must avoid ...

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