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Jamison v. Saul

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

September 16, 2019

IRMA J. JAMISON, Plaintiff,
ANDREW M. SAUL,[1] Commissioner of Social Security, Defendant.



         Plaintiff Irma J. Jamison seeks review of the decision of the Social Security Administration (SSA) denying her application for Disability Insurance Benefits under the Social Security Act. For the reasons set forth below, the case is reversed and remanded.

         I. Background and Procedural History

         Plaintiff, who was born in February 1959, applied for Disability Insurance Benefits on December 8, 2014. (Tr. 10). In her application, Plaintiff claimed she was disabled as of January 25, 2014 as a result of: cervical fusion, herniated disc lumbar spine, arthritis in knees, lumbar radiculopathy, diverticulitis, migraines, and acid reflux. (Tr. 162-68, 182) The SSA denied Plaintiff's claim, and she filed a timely request for a hearing before an administrative law judge (ALJ). (Tr. 64-75, 155-57)

         The SSA granted Plaintiff's request, and an ALJ conducted a hearing in December 2016. (Tr. 12, 36-63) In a decision dated March 7, 2017, the ALJ determined that Plaintiff “has not been under a disability within the meaning of the Social Security Act from January 25, 2014, through the date of this decision.” (Tr. 19-20)

         In her decision, the ALJ applied the five-step evaluation set forth in 20 C.F.R. § 404.1520, and found that Plaintiff had the following severe impairments: “degenerative disc disease (DDD), degenerative joint disease, obesity, tarsal tunnel syndrome, and peroneal tendinitis.” (Tr. 36-63) The ALJ determined that Plaintiff had the residual functioning capacity (RFC) to:

[P]erform a range of light work as defined in 20 CFR 404.1567(b) in that she can lift, carry, push, or pull 20 pounds occasionally and 10 pounds frequently; sit for 6 hours in an 8-hour workday; stand or walk for 3 hours in an 8-hour workday; never climb ropes, ladders, or scaffolds; occasionally climb ramps and stairs, balance, stoop, kneel, crouch and crawl; no exposure to extreme cold, unprotected heights, or hazardous machinery.

(Tr. 14) At step four of the sequential evaluation, the ALJ found that Plaintiff could return to her past work as a customer service representative. (Tr. 19-20)

         Plaintiff filed a request for review of the ALJ's decision with the SSA Appeals Council, which denied review on January 12, 2018. (Tr. 1-6) Plaintiff has exhausted all administrative remedies, and the ALJ's decision stands as the SSA's final decision. Sims v. Apfel, 530 U.S. 103, 106-07 (2000).

         II. Evidence Before the ALJ

         A. Testimony

         Plaintiff testified that she was fifty-seven years old and had a high school education and some technical school. (Tr. 48) Plaintiff lived with her daughter and grandchildren, who did “all the chores around the house.” (Id.)

         Plaintiff worked for AT&T for fifteen years, most recently as a supply attendant. (Tr. 40, 45, 49) In that position, she operated a forklift to load the truck or van she was driving and then transported the products to “technicians in the field.” (Id.) Prior to becoming a supply attendant, Plaintiff worked as a senior consultant, or customer service representative, for AT&T. (Tr. 42) Plaintiff left that position because she was suffering vertigo. (Tr. 44)

         Plaintiff testified that she could not work because

Due to the neck surgery, I have problem...turning my head some days, swallowing. My arms give out, my hands tingle....I have pains that go down in my knees. If I don't take my medication, I burn from my waist down and it goes all between my legs, down in my feet...I have canes and stuff, but I can't use my canes because...some days I don't have the strength.

(Tr. 49) Plaintiff explained that she was unable to turn her head “side to side” because “I have the clicking like the hardware get hung up.” (Tr. 49) Her doctors were discussing the possibility of a “removal surgery” and “bone shaving” at the C7 level. (Tr. 50)

         Plaintiff described intermittent, daily numbness and tingling in her arms. (Tr. 50) Plaintiff stated that she could lift “maybe a gallon of milk at the most...[j]ust once or twice.” (Tr. 50-51) Some days she was unable to comb her hair. (Tr. 50) If she attempted to push or pull, her arms “g[a]ve out, ” and she was unable to “grip stuff due to numbness and lack of strength. (Tr. 51)

         Plaintiff testified that her pain was currently “coming down the back of my head going into my shoulders, into my biceps and my fingers are tingling. I have it in my knees and my right foot is like it's short circuiting my toes.” (Tr. 53) Plaintiffs lower back pain was “just burning and it's on the top of my hip...[i]t goes down the right side, down into the hip, down into the knee, into the...leg, into the foot....” (Tr. 53) Plaintiff stated that the pain in her low back, knees, and feet was constant. (Id.) Pain medications reduced the pain to “a numbness, ” but they made her “foggy” and forgetful. (Id.) She was currently taking Percocet, gabapentin, and Mobic. (Id.)

         Plaintiff estimated she could walk “about ten minutes” before needing to take a break, stand ten to fifteen minutes, and sit ten to fifteen minutes. (Tr. 55) Plaintiff explained that her doctors prescribed her a cane, which she used once or twice a day. (Tr. 56-57) Plaintiff elaborated: “I would use it more, but my hands give out, so it's either take the chance of falling without or with it and I just take the chance without because I got a metal cane and I fall on it, that's not good either.” (Tr. 57)

         A vocational expert also testified at the hearing. (Tr. 60) The ALJ asked the vocational expert to consider a hypothetical individual with Plaintiffs age, education, and work history who was “limited to work at the light exertion level in that they can lift, carry, push, or pull 20 pounds occasionally, 10 pounds frequently; sit for six hours in an eight-hour workday; but can only stand or walk for three hours total in an eight-hour workday.” (Id.) The vocational expert stated that such person could perform Plaintiffs past work as a customer service representative. (Tr. 61) When the ALJ added to the hypothetical that “the individual would be unable to keep the neck in a stable position for more than 30 minutes and thus would need to take an additional 10-minute break after that period, ” the vocational expert stated that such person would not be able to perform any jobs in the national economy. (Id.) In response to Plaintiffs counsel's question, the vocational expert testified that, if the first hypothetical individual could “only occasionally use their hands for fine manipulation or gross manipulation, ” she would not be able to perform the customer service position. (Id.)

         B. Relevant medical records

         In early January 2014, Dr. Thomas Forget, a neurosurgeon, ordered an MRI of Plaintiff s lumbar and cervical spine. (Tr. 492). The MRI revealed: “(1) multilevel degenerative changes of the lumbar spine, unchanged since the prior study; (2) annular tear identified at the posterior aspect of the L4-L5 disc; [and] (3) multilevel foraminal and lateral recess stenosis....” (Tr. 494)

         Later that month, at an appointment with her primary care physician, Dr. Marketa Kasalova, Plaintiff complained of fatigue and stated that “she is worried that she will lose her job due to her chronic neck and low back pain.” (Tr. 351) Dr. Kasalova diagnosed Plaintiff with cervical radiculopathy, generalized anxiety disorder, depressive disorder, and hyperlipidemia. (Tr. 352)

         Two days later, Plaintiff had a follow-up appointment with Dr. Nabil Ahmad, a pain management specialist.[2] (Tr. 495) Plaintiff complained of neck, back, leg, and right arm pain. (Tr. 495) Plaintiff reported she “was still having pain in her lower back and bil[ateral] legs worse than before injections.” (Id.) Plaintiff's pain was “constant” and she rated it at a four to six on a ten-point scale. (Id.) A physical examination revealed: tenderness and reduced range of motion in her neck; tenderness to palpation and mildly reduced range of motion on bilateral rotation in her cervical spine; tenderness to palpation and mildly reduced range of motion of the lumbar spine; positive straight-leg raise, FABER, and Gaenslen tests on the right; and bilateral knee crepitus. (Tr. 498) Dr. Ahmad diagnosed the following: “cervical radiculopathy, cervical spondylosis, HNP (cervical), lumbar spondylosis, lumbar degenerative disc disease, lumbar radiculopathy, sacroiliitis, low back pain, and osteoarthritis knee.” (Tr. 499-500).

         In February 2014, Dr. Ahmad administered a “L5 transforaminial epidural steroid injection” and a “sacroiliac joint injection.” (Tr. 500) Dr. Ahmad noted: “The injections don't last long.” (Id.) Dr. Ahmad placed Plaintiff on light duty, stating “[h]er restrictions are permanent, ” scheduled knee Synvisc injections, ordered physical therapy, and recommended at-home exercises. (Tr. 500) Five days later, Dr. Ahmad administered knee joint injections. (Tr. 501)

         When Plaintiff presented to Dr. Kasalova in late-February 2014, she reported that the weekly knee Synvisc injections helped “some.” (Tr. 353) Plaintiff complained that Tramadol was not controlling her cervical pain and made her sleepy. (Tr. 353) Dr. Kasalova provided Plaintiff a sample of Lyrica and instructed her to follow up with her orthopedic surgeon. (Tr. 353-54)

         Plaintiff returned to Dr. Forget's office in early April 2014. (Tr. 248) Plaintiff complained of “extreme” neck pain “localized at the posterior cervical region that has been present for 2 weeks. It is extreme (9-10/10) and radiates into the right and left arm in a non-specific distribution.” (Id.) Additionally, Plaintiff reported an acute onset of weakness in her right tricep. (Tr. 252) Plaintiff informed Dr. Forget that she recently began taking Lyrica, “which has improved the global pain.” (Id.) Upon examination, Dr. Forget noted limited range of motion in Plaintiff's cervical spine, normal range of motion in her right and left upper and lower extremities, and weakness in her right upper extremity. (Tr. 250). Dr. Forget wrote a letter to Dr. Ahmad recommending another MRI. (Tr. 252)

         Plaintiff underwent an MRI in April 2014, which revealed: “[d]egenerative changes at ¶ 4-C5, C5-C6 and C6-C7” and “[c]entral spinal canal stenosis…, most pronounced at ¶ 6-C7 with flattening of the spinal cord.” (Tr. 254). At Plaintiff's next appointment with Dr. Kasalova in May 2014, she complained of ankle swelling on the right side and neck pain. (Tr. 355) Dr. Kasalova recommended weight loss and continued Plaintiff's medications. (Id.)

         Dr. Donald deGrange, an orthopedic surgeon, examined Plaintiff in late-May 2014.[3] (Tr. 379) Dr. deGrange noted that Plaintiff's chief complaint was “mechanical neck pain at the base of the neck extending into both shoulders, usually worse on the right than the left as well as the pain, tingling, numbness, and weakness that has appeared in the last several weeks.” (Id.) Plaintiff informed Dr. deGrange that she had “dropped several items…because of unexpected weakness of grip and has actually gotten stuck in the bathtub on a couple of occasions unable to pull herself out because of the weakness in her arm.” (Id.) Dr. deGrange noted that Plaintiff experienced “no significant improvement” from physical therapy and “no significant or sustained benefit” from a series of epidural injections administered by Dr. Ahmad. (Id.)

         Plaintiff returned to Dr. deGrange's office in mid-July 2014 “[h]aving failed prolonged and appropriate conservative care[.]” (Tr. 387) Dr. deGrange noted that Plaintiff's recent MRI showed “2 large disc herniations with severe stenosis of C4-5 and C5-6 corresponding to the patient's symptoms.” (Id.) Dr. deGrange performed an elective decompression and fusion at ¶ 4-5 and C5-6. (Tr. 431) Following the procedure, Dr. deGrange applied a cervical collar and prescribed Percocet. (Tr. 433, 435). When Plaintiff followed up with Dr. deGrange eleven days later, she complained of “the normal surgical pain in the cervicothoracic junction, ” but reported that her “arms and hands feel better noticeably.” (Tr. 392)

         In August 2014, Plaintiff followed up from her cervical spine fusion with Nurse Practitioner (NP) Eileen McKeon at Dr. Kasalova's office. (Tr. 338) Plaintiff reported that her “neck pain is much better.” (Tr. 340) NP McKeon noted that Plaintiff was “moving all extremities equally strong” and advised Plaintiff to discuss all pain management and medication with Dr. deGrange. (Tr. 339).

         At Plaintiff's follow-up appointment in September 2014, Dr. deGrange wrote that Plaintiff's “neck continues to improve, ” “[h]er arms and hands feel much better, ” and “[s]he has no residual numbness or tingling, ”but she “still is having some difficulty swallowing. (Tr. 394) Plaintiff only required her pain medicine “a couple of days a week.” (Id.) Dr. deGrange observed “excellent strength in both upper extremities, ...

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