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Dennis v. Berryhill

United States District Court, E.D. Missouri, Southeastern Division

January 31, 2017

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



         This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the applications of plaintiff Sandra Kay Dennis for disability insurance benefits (DIB) and supplemental security income benefits (SSI) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401- 434, 1381-1385. The parties have consented to the exercise of plenary authority by the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the final decision of the Commissioner is affirmed.

         I. BACKGROUND

         Plaintiff was born in 1961 and was 53 years old at the time of her second hearing. (Tr. 71.) She filed applications for DIB and for SSI on February 26, 2013 and March 12, 2013, respectively. (Tr. 4, 205-06.) She alleged an August 20, 2009 onset date. (Tr. 4, 99.)[2] In her Disability Report, she alleged disability due to post-traumatic stress disorder (PTSD), acid reflux, bulging discs, depression, and irritable bowel syndrome (IBS). (Tr. 219.) Her applications were denied, and she requested a hearing before an ALJ. (Tr. 4, 128-36.)

         On November 20, 2014, following a hearing, an ALJ found that plaintiff was not “under a disability” as defined in the Act. (Tr. 14-26.) The Appeals Council denied her request for review. (Tr. 5-8.) Thus, the decision of the ALJ stands as the final decision of the Commissioner.


         On June 10, 2009, plaintiff saw Carl F. Patty, D.O., gynecologist, for pelvic and low back pain and was prescribed an antibiotic for a possible bladder infection. On June 22, 2009, plaintiff saw Dr. Patty, noting her pelvic pain had improved but that she had both low back and right leg pain. (Tr. 510-11.)

         On July 14, 2010, she saw Sonjay Joseph Fonn, D.O., a neurosurgeon, reporting that she had been experiencing back pain for about a year, which was worsening and radiating down her right leg. Dr. Fonn noted degenerative changes at ¶ 4/5 and L5/S1 with L4/5 being worse. Dr. Fonn recommended conservative treatment of physical therapy with epidural injections to be considered in the future. (Tr. 492-93.)

         On August 19, 2010, plaintiff reported to Dr. Patty that prescribed exercises were increasing the soreness in her lower back and that she was also experiencing pelvic pain. (Tr. 512-13.)

         On September 15, 2010, plaintiff saw Dr. Fonn, reporting that physical therapy helped somewhat, but that she wanted to try epidural injections. (Tr. 490.)

         On September 23, 2010, plaintiff underwent an abdominal hysterectomy for pelvic pain and had no post-operative problems. She reported that she was having increased moodiness and that she did not feel Prozac, the antidepressant she was taking, was helpful. (Tr. 360-366, 514.)

         In November 2010 plaintiff had additional epidural injections for her back pain. (Tr. 484-89.)

         During a November 23, 2010 visit, plaintiff told Dr. Patty that she had stopped taking Celexa, an antidepressant, due to gastrointestinal problems, that she had no improvement in her mood, and that she was experiencing irritability without the Celexa. (Tr. 515.)

         On December 28, 2010, plaintiff saw Christopher Montgomery, M.D., family practitioner, for ongoing mood issues. She had been unsuccessful on several antidepressants and Dr. Montgomery prescribed another antidepressant for her to try. (Tr. 400-02.)

         On January 13, 2011, plaintiff underwent radiofrequency ablation (RFA), a procedure used to reduce pain whereby an electrical current produced by a radio wave is used to heat up a small area of nerve tissue, thereby decreasing pain signals from that specific area, for her back pain. (Tr. 481-82.)

         On January 20, 2011, plaintiff saw Dr. Montgomery for follow-up on her psychiatric medications. She was having difficulty sleeping, which had worsened since receiving the nerve ablation. She also reported excessive heartburn and was concerned the Ranitidine, used to treat gastroesophageal reflux disease (GERD), was not working well. She also reported that Cymbalta, an antidepressant, was causing nausea. Dr. Montgomery's assessment included low back pain, GERD, hypertension, and depression intolerant to Cymbalta and other medications. Dr. Montgomery discontinued Cymbalta and prescribed Klonopin. He increased the Ranitidine. (Tr. 398-99.)

         On January 27, 2011, plaintiff reported to Dr. Fonn that the ablation procedure had provided good relief on her left side, but that she was still experiencing symptoms on her right side. (Tr. 480.)

         On March 22, 2011, plaintiff saw Dr. Montgomery for her hypertension which was under control. Her sleep and anxiety had improved with Klonopin. Her acid reflux symptoms had improved but she still had nausea in the mornings. Despite being on hormone replacement therapy, she was also experiencing hot flashes, mood swings, and sweatiness. Dr. Montgomery changed her acid reflux medication and continued Klonopin. (Tr. 397.)

         On April 21, 2011, plaintiff saw Dr. Fonn with renewed complaints of back pain. He recommended another course of facet blocks or epidural injections before receiving more ablation therapy. (Tr. 478.)

         On May 3, 2011, plaintiff reported her stomach pain had improved but that she still had diarrhea two to four times per week and was constipated with Loperimide, an antidiarrheal. She was encouraged to use another antidiarrheal medication. (Tr. 304-05; 394-95.)

         On May 6, 2011, plaintiff received a facet block at ¶ 4/5 and L5/S1 for her back pain. (Tr. 351.) She was still experiencing back and leg pain, and on May 12, 2011, Dr. Fonn recommended facet blocks over another RFA treatment. (Tr. 334-35.) She received a facet block treatment that day and again on June 2, 2011. (Tr. 350, 352, 477.)

         On June 8, 2011, plaintiff reported to Dr. Fonn that the epidural injections had provided her good relief and that she wanted to hold off on another ablation procedure. (Tr. 333, 475.)

         On June 13, 2011, Dr. Fonn discontinued hydrocodone and started plaintiff on Tylenol #3 with codeine. She reported muscle spasms in her back after moving a mattress. (Tr. 331-33, 473-74.)

         On August 4, 2011, plaintiff saw Dr. Montgomery for follow-up. Her heartburn and diarrhea had improved. Dr. Montgomery's assessment included hypothyroidism, hyperlipidemia, GERD, hormone deficiency, and hypertension. Dr. Montgomery prescribed Synthroid, used to treat the thyroid, and fish oil. (Tr. 301-03, 391-93.)

         On September 6, 2011, plaintiff reported to Dr. Montgomery that she still felt fatigued even after starting Synthroid. (Tr. 299.) On October 8, 2011, Dr. Fonn prescribed Norco (hydrocodone) and Valium. Dr. Fonn recommended an MRI of plaintiff's lumbar spine. (Tr. 329-30, 472.)

         On October 18, 2011, plaintiff saw Dr. Montgomery for anxiety and difficulty sleeping. Dr. Montgomery believed that she was moving toward normal thyroid function and was experiencing withdrawal symptoms from Valium and pain medication. (Tr. 293-94.) Dr. Fonn refilled her Norco and Valium. (Tr. 471.)

         On October 26, 2011, Dr. Fonn recommended a course of three epidural injections following an MRI. (Tr. 328, 337, 470.) On January 25, 2012, she underwent an ...

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