United States District Court, W.D. Missouri, Western Division
NANETTE K. LAUGHREY United States District Judge
James Martsolf appeals the Commissioner of Social
Security's final decision denying his application
disability insurance benefits and supplemental security
income under the Social Security Act. The decision is
was born in 1956. He alleges he became disabled beginning
12/31/2011. He last worked in an IT department as a help desk
person until June 2007, when his contract expired. The
Administrative Law Judge held a hearing on 12/18/2014 and
denied his application on 1/15/2015. The Appeals Council
denied his request for review on 2/19/2016.
December 2006, James Marx, D.O., diagnosed Martsolf with
somatic dysfunction of the cervical spine. In March 2007,
Martsolf was under stress and believed he was about to lose
his job. He had high anxiety and severe neck and shoulder
pain. Dr. Martsolf diagnosed somatic dysfunction, as well as
generalized anxiety disorder. In May 2007, Martsolf reported
that his neck and shoulder pain were worse with certain
December 2008 visit, Dr. Marx recommended neck exercises.
2009, Martsolf was continuing to use narcotic pain
medications prescribed by Dr. Marx. He had high anxiety from
2010, Martsolf complained to Dr. Marx that he had cervical
pain radiating into his arm. Dr. Marx found tenderness in the
cervical muscles on the right and decreased range of motion.
Diagnoses included degenerative disc disease of the cervical
spine and generalized anxiety disorder. Dr. Marx prescribed
OxyContin and Percocet, and ordered a neurosurgical consult.
An August 2010 MRI showed cervical disc protrusion and
desiccation, and straightening of the normal lordotic curve
of the cervical spine.
visit with the neurosurgeon, John Gianano, M.D., in September
2010, Martsolf said he was not sure why he was there. He said
he had no neck pain as long as he used his narcotic
medication. He could mow his lawn and use a weed eater, and
had no numbness, tingling, or weakness. Dr. Gianano noted
Martsolf was on high doses of narcotics and recommended
conservative treatment: anti-inflammatories, NSAIDs, and
Marx noted at a September 2010 follow up appointment that the
neurosurgeon had not recommended surgery, or even steroid
injections, but that Martsolf should continue medications. He
also noted that Martsolf's anxiety levels were high at
times. Diagnoses included degenerative disc disease of the
cervical spine and generalized anxiety disorder.
started seeing another primary care provider, Elaine Joselyn,
D.O. in October 2010. He complained that he was treated like
a drug addict when he went to an outpatient, pain management
clinic at the Truman Medical Center, where he was told to use
Advil and do neck exercises. He asked for refills to avoid
running out and experiencing withdrawal. The doctor refilled
his OxyContin and Percocet for one month. In November 2010 he
requested a refill of OxyContin and hydrocodone, saying the
medicine had given him his life back. He was given
prescriptions and told to return the next month. In December
2010, he asked for Percocet to deal with break-through pain,
and suggested that he be given multiple months of refills. He
was worried that his medication would not be refilled. The
doctor gave him a new referral to a pain management clinic.
January 2011 follow up with Dr. Joselyn for prescription
refills, Martsolf had no complaints, rated his pain at 0 out
of 10, and said his pain was well controlled with OxyContin
and Percocet. At visits over the next several months, the
doctor tried adjusting Martsolf's narcotic medications to
avoid development of tolerance, but in June 2011, the doctor
prescribed OxyContin and Percocet. In early July 2011, Dr.
Joselyn and Martsolf discussed the peaks and valleys of
narcotic use. The doctor noted that Martsolf could turn his
head more freely when not aware of what he was doing. Later
the same month, Martsolf complained of sharp pain and
gabapentin was added. Martsolf later admitted to the
doctor's staff that he “over [did] it” and
felt “stupid.” Tr. 325. At a routine follow up at
the end of July 2011, Martsolf asked for refills of OxyContin
and Percocet, telling the doctor his pain was controlled with
those medications. He had no other complaints.
saw the doctor monthly from August 2011 through April 2012
for pain medication refills. His neck condition was stable.
In May 2012, Martsolf told the doctor that he was doing
better and had been more active, doing yard work and driving,
among other activities. In June 2012, he told the doctor that
his pain was controlled most days. At an August 2012 follow
up, he reported that his pain was the same, but that his
OcyContin only lasted 6 hours and he was waking up at night.
The doctor continued OxyContin and instructed Martsolf to
take Percocet in between OxyContin doses. His neck condition
was stable in September and October 2012. His medications
were refilled and he was referred to a pain management
clinic. In November 2012, he complained that his pain was
worsened by driving to the clinic, but he said his medication
made the pain manageable.
condition was stable from December 2012 through June 2013 and
the doctor continued to renew his medications. He remarked at
the March and April 2013 visits that his pain was well
controlled. June 2013 was difficult for him due to family and
financial problems. The doctor tried changing his OxyContin
to morphine. Martsolf's financial and family issues were
better by his July 2013 visit, but he said the morphine was
not entirely effective, and that OxyContin and Percocet would
control his pain well, and the doctor prescribed them. From
August to September 2013, his pain medications were refilled
and he worked to be approved for a program to cover his
prescription costs. In October 2013, he complained of
breakthrough pain and his doctor recommended adding a muscle
relaxer, but he refused it. He complained of a flare up in
November 2013. He had osteopathic manipulative therapy in
December 2013 and was give refills of his pain medication.
From January to April 2014, his condition was stable and the
doctor continued to refill his prescriptions. In May 2014, he
told Dr. Joselyn that his neck pain was exacerbated by
driving to the appointment. He had limited bilateral range of
motion in his neck. He saw the doctor in June 2014, reporting
that he had used the weed eater the previous day and had arm
pain. His medications were refilled. His condition was stable
in July 2014.
August 2014, Martsolf reported having withdrawal effects when
waiting 8 hours to take his dose of slow-release OxyContin,
and asked to be changed back to regular OxyContin, which the
doctor did. His Percocet was decreased. His medications were
refilled at monthly visits from September 2014 through
December 2014. At his December 2014 visit, Dr. Joslyn noted
Martsolf had a stiff neck and limited range of motion to the
left and right.
Mental health treatment
saw a psychiatrist, Innocent Anya, M.D., about every three or
four months from April 2011 to November 2014, and the doctor
prescribed and adjusted medications at the visits. In April
2011, Dr. Anya diagnosed depressive disorder and anxiety
disorder. In November 2011, Dr. Anya noted Martsolf was
stable. From August 2012 to May 2013, Martsolf complained of
trouble sleeping and the doctor made medication adjustments.
At his May 2013 and August 2013 visits, Martsolf complained
of financial stressors and inability to afford insurance. Dr.
Anya noted in November 2013 that Martsolf was stable. In
February 2014, Martsolf reported that he was doing fine on
his current medication, although he had run out of it because
he had lost his insurance. Martsolf's medications were
adjusted in June and July 2014, and at an August 2014 visit,
he reported that he was doing much better, and his
medications were refilled. He reported a pretty good mood and
that his anxiety was level at his November 2014 visit, and
the doctor refilled his medications.
Altomari, a state agency psychologist, reviewed
Martsolf's records and opined that Martsolf had no severe
mental impairment. The ALJ gave Dr. Altomari's opinion
significant weight, noting it was supported by Dr. Anya's
treatment records which ...