United States District Court, E.D. Missouri, Eastern Division
MEMORANDUM AND ORDER
PATRICIA L. COHEN UNITED STATES MAGISTRATE JUDGE
Kirsten Mazzanti seeks review of the decision of Defendant
Nancy Berryhill, Deputy Commissioner of Operations, Social
Security Administration (SSA), denying his application for a
period of disability and Disability Insurance Benefits under
the Social Security Act. (ECF No. 1).). Because the Court finds
that substantial evidence supports the decision to deny
benefits, the Court affirms the denial of Plaintiff's
Background and Procedural History
November 26, 2013, Plaintiff filed an application for a
period of disability and Disability Insurance Benefits
claiming that she was disabled as of January 1, 2010 due to:
disc degeneration, obsessive compulsive disorder, neck
issues/arthritis, fibromyalgia, migraines, anxiety, manic
depression, irritable bowel syndrome, and post-traumatic
stress disorder. (Tr. 182). The SSA denied Plaintiff's
claims, and she filed a timely request for a hearing before
an administrative law judge (ALJ). (Tr. 80, 87-88).
granted Plaintiff's request for review, and the ALJ
conducted a hearing in October 2014. (Tr. 100). In a decision
dated February 24, 2015, the ALJ found that Plaintiff
“ha[d] not been under a disability, as defined in the
Social Security Act, from January 1, 2010, through the date
of this decision.” (Tr. 23). Plaintiff subsequently
filed a request for review of the ALJ's decision, which
the SSA Appeal's Council denied. (Tr. 1, 6). Plaintiff
has exhausted all administrative remedies, and the ALJ's
decision stands as Defendant's final decision. Sims
v. Apfel, 530 U.S. 103, 106-07 (2000).
The Administrative Proceeding
Testimony at Hearing
appeared with counsel at the administrative hearing in
October 2014. (Tr. 33). Plaintiff was thirty-nine years of
age and testified that she was 5'10”, weighed 225
pounds, and relied on her husband as her current source of
income. (Tr. 35-37). Plaintiff stated she worked several
years after her purported January 2010 onset date in retail
and in home healthcare as a certified nursing assistant.
Plaintiff could not remember when she last worked but
explained that her back pain, fibromyalgia, migraines, and
mental impairments eventually prevented her from working.
(Tr. 38, 45).
believed her back pain began in 2010, and she received
treatment from her primary care physician (PCP), Dr. Patricia
Hinkle, and chiropractor, Dr. Ryan Moeckel. Other than
Neurontin, muscle relaxers, and a breast reduction to
“alleviate some of the weight, ” Plaintiff
received no other treatments. (Tr. 47). She alleged she was
“narcotic sensitive, ” so she “took
[herself] off all [her] narcotics.” (Tr. 48). Plaintiff
recalled Dr. Moeckel restricted her to lifting no more than
ten pounds or a gallon of milk and taking a break every
thirty minutes. (Tr. 55-56). Additionally, Plaintiff stated
that she was unable to carry laundry up and down the stairs
or wash more than a few dishes at a time. (Tr. 56).
testified that her mental impairments “became an
issue” for her when she was nine years old and, from
that point on, she was treated “off and on” her
entire life. She stressed her anxiety prevented her going
anywhere. (Tr. 58). She did not belong to any organizations
or attend family events because she could not
“deal” with “going out in public” or
being around large groups of people. (Id.).
2010, Plaintiff received counseling from a psychologist for
“maybe a year and a half.” (Tr. 50). During that
time, she also saw a psychiatrist who prescribed her
medication. (Tr. 51). At the time of the hearing, her PCP,
Dr. Hinkle, was providing Plaintiff's mental health
treatment and prescribing a small dose of Klonopin. (Tr. 53).
Plaintiff testified that Dr. Hinkle previously prescribed her
Xanax and other antidepressants, but they caused adverse
reactions because she was “very medication
sensitive[.]” (Id.). Plaintiff had scheduled a
post-trial appointment with Dr. Hinkle to “try for
another medication.” (Tr. 54).
Relevant Medical Records Before the ALJ
earliest evidence of Plaintiff's depression appears in a
report from a May 2009 visit to a family doctor.
Plaintiff's “constant and overwhelming”
symptoms included “[an] anxious mood, decreased
appetite, insomnia, crying spells, decreased ability to
concentrate, fatigue, guilt, sadness, feelings of
worthlessness, [f]rustration and tendency towards
indecisiveness.” (Tr. 354). She admitted having
suicidal thoughts but was not taking any antidepressants.
(Id.). The doctor diagnosed her with depression and
first record of back pain was from a visit to her
chiropractor, Dr. Moeckel, in January 2010. Dr. Moeckel
diagnosed her with lumbar subluxation. (Tr. 496). In addition
to seeing Dr. Moeckel, Plaintiff saw Dr. Hinkle several times
later in the same year. Plaintiff did not mention back pain
at an appointment in August but complained of back pain in
September and October. (Tr. 376-79, 382, 384). Plaintiff
stated she was seeing Dr. Moeckel and reported “some
pain relief” as his treatment was “helping a
little.” (Tr. 385). Dr. Hinkle ordered x-rays of
Plaintiff's lower back, which showed a “[m]oderate
decrease in diskal height at the L1-2, L2-3 and L3-4
disks.” (Tr. 392). In November, Dr. Hinkle prescribed
Percocet because Plaintiff's “pain [worsened] with
pretty much anything.” (Tr. 394).
notes from a January 2011 visit to Dr. Hinkle's office
revealed that Plaintiff was “positive for back
pain” but “had been doing great
[emotionally].” (Tr. 400). Plaintiff denied having
suicidal thoughts. (Id.). She attributed this
improvement to being able to work, which “[got] her out
of the house.” (Id.). Dr. Hinkle did not
prescribe additional medication for depression or refill
Plaintiff's past prescriptions.
did not return to Dr. Moeckel until February 2011, at which
point he diagnosed her with lumbar and thoracic radiculitis,
sacral/coccyx subluxation, and thoracic subluxation in
addition to the lumbar subluxation. (Tr. 496). In April 2011,
Dr. Hinkle noted Plaintiff experienced “some pain
relief with rest and [P]ercocet.” (Tr. 394, 408). Later
that year, Plaintiff returned to Dr. Hinkle with complaints
of back pain and disclosed that she did “a lot of
lifting at work.” (Tr. 411). Dr. Hinkle refilled
Plaintiff's Percocet prescription in April 2011. (Tr.
Shajitha Nawaz, a psychiatrist, treated Plaintiff throughout
2011. In April, Dr. Nawaz performed a psychiatric evaluation.
She noted Plaintiff was hospitalized twice as a teenager for
psychiatric reasons. She also discussed Plaintiff's
history of drug abuse. In May, June, and August reports, Dr.
Nawaz noted Plaintiff exhibited borderline personality
November 2011, Plaintiff presented to Dr. Hinkle with anxiety
and “classic migraine.” (Tr. 429). Dr. Hinkle
noted that Plaintiff's anxiety disorder “was
originally diagnosed 1/2011” and her symptoms included
constant “chest pain, dry mouth, light-headedness,
palpitations, and shortness of breath.” (Tr. 429). She
claimed “[m]arital discord, crowds or public places,
and- everything” triggered her anxiety. (Id.).
Plaintiff did “not feel like she has been getting any
benefit from current counselor and psychiatrist.” (Tr.
432). Dr. Hinkle prescribed Xanax. (Id.).
follow-up appointment in January 2012, Plaintiff reported she
“[was] doing really, really well with [C]elexa.”
(Tr. 438). Dr. Hinkle continued Plaintiff's prescription
of Celexa and noted that Plaintiff also took Xanax “if
she is going into a social situation that will usually cause
a panic attack or occasionally to sleep.”
April 2012, Plaintiff visited Dr. Hinkle because she
“[had] been lifting and bending over a lot for the past
couple of weeks, ” which caused back pain. Plaintiff
was working full-time at a new job. Dr. Hinkle recommended
heat and ice therapy along with rest. (Tr. 443). Dr. Hinkle
noted no changes in Plaintiff's depression and anxiety
medication or mood.
returned to Dr. Hinkle's office in April, September, and
November 2012. In December 2012, Plaintiff reported
“she is still having pains, ” including
“pains showing down her legs L>R. She feels like the
L leg will go out on her at times.” (Tr. 449). In
regard to her mental health, Plaintiff was “doing
February 2013, Plaintiff presented to Dr. Moeckel after she
injured her lower spine lifting a 250-pound patient at work.
(Tr. 497). Plaintiff described “severe constant sharp
low back pain and remarkably severe constant shooting
anterior pain in the left leg.” (Id.). Dr.
Moeckel administered manipulation to T2, T3, L4, and RSI and
electrical muscle stimulation to the lumbar region. (Tr.
498). Dr. Moeckel advised Plaintiff to use cold packs, visit
him three times per week, and “not work, ” noting
that she “has been placed on temporary total
saw an orthopedic surgeon in March 2013. He ordered x-rays
and an MRI of her spine. The x-rays revealed Plaintiff
suffered from “mild degenerative disc disease at ¶
3 -L4, ” and the MRI showed “mild desiccation and
disc space height loss seen at the L3-L4
level…remaining intervertebral discs are normal in
appearance.” (Tr. 303, 305).
returned to Dr. Moeckel in June 2013, complaining of pain in
her right hip, buttock, and thigh. (Tr. 498). After Dr.
Moeckel administered manipulation and electrical muscle
stimulation, Plaintiff's “pain decreased.”
(Tr. 499). Dr. Moeckel noted “patient [was] expected to
reach maximum medical improvement.” (Id.). The
same month, Plaintiff presented to the emergency room at
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