United States District Court, D. Delaware
GREGORY M. SLEET, Chief District Judge.
On August 11, 2008, plaintiff Sharon Kay Pringle ("Pringle") appealed from a decision of Michael J. Astrue, the Commissioner of Social Security (the "Commissioner''), denying her application for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act (the "Act"), 42 U.S.C. §§ 401-433m, 1381-1383f. This Court has jurisdiction over the matter pursuant to 42 U.S.C. § 405(g).
Presently pending are cross-motions for summary judgment filed by Pringle and the Commissioner. (D. I. 21, 26.) Pringle seeks an award of benefits in her favor or, alternatively, to reverse and remand the Commissioner's decision. (D.I. 21.) The Commissioner requests affirmance of his decision. (D. I. 26.) For the reasons set forth below, Pringle's motion is granted, and the Commissioner's motion is denied. The decision of the Administrative Law Judge is reversed, and this matter is remanded for further findings and/or proceedings consistent with this Memorandum.
On September 24, 2003, Pringle filed applications for Title II Disability Insurance Benefits ("DIB") and Title XVI Supplemental Security Income ("SSI"). (D.I. 10 at 16.) Pringle claimed she had been disabled since November 3, 2002. ( Id. ) Following the Social Security Administration's ("SSA") denial of her claim, both initially and upon reconsideration, Pringle requested a hearing before an Administrative Law Judge ("ALJ"). ( Id. at 33, 38, 43.) A hearing before ALJ, Keith A. Stanley, occurred on May 9, 2005. ( Id. at 488.) At the hearing, the ALJ heard testimony from Pringle and a vocational expert ("VE"), Lisa Keen. ( Id. at 487.) On July 19, 2005, the ALJ issued his decision denying Pringle's claim for benefits, concluding she was not disabled under sections 216(1) and 223 of the Social Security Act. ( Id. at 25-26.) Subsequently, the Appeals Council denied Pringle's request for review. ( Id. at 8.) Thereafter, she appealed the ALJ's decision to the United States District Court for the District of Kansas. ( Id. at 408.) After finding the ALJ erred in weighing the medical opinions, the court reversed and remanded the ALJ's findings for further consideration. ( Id. at 431.)
On August 25, 2005, Pringle filed a second set of applications for DIB and SSI benefits, which claimed she had been disabled since July 19, 2005. ( Id. at 442.) The SSA again denied Pringle's claims, both initially and upon reconsideration, and Pringle subsequently requested a hearing before an ALJ. ( Id. ) The ALJ, Edward Banas, conducted a hearing on July 19, 2007, hearing testimony from Pringle, a VE, Jan D. Howard-Reed, and Pringle's future daughter-in-law, Dawn Barresi ("Barresi").( Id. ) The ALJ found Pringle had been disabled within the meaning of 216(1) and 223(d) of the Act since May 17, 2007. ( Id. at 453.) However, the District Court's remand order required further consideration of all medical opinions in the record, beginning on November 3, 2002. ( Id. at 390.) Thus, ALJ Banas held another hearing on April 8, 2008, where he heard testimony from Pringle, a VE, Christina L. Beatty-Cody, and Barresi. ( Id. ) On April 18, 2008, the ALJ reaffirmed Pringle was disabled as of May 17, 2007, but found Pringle was not disabled before that date. ( Id. at 403.) After the ALJ's decision became final, Pringle filed the present appeal under consideration to challenge the ALJ's finding regarding her disability status prior to May 17, 2007. (D. I. 21.)
A. Medical Evidence
To support her claim, Pringle produced medical records regarding her conditions. The Court will summarize the relevant records.
1. Dr. David E. Brown, D.O. (2/18/02-3/25/02) & Miami County Medical (12/28/02-3/6/03)
Dr. Brown diagnosed Pringle with epigastric abdominal pain and chronic dyspepsia on January 2, 2002 after she complained of severe abdominal pain that required a visit to the emergency room one week prior. (D.I. 10 at 190.) Dr. Brown found a large incarcerated ventral hernia, and diagnosed gastroesophageal reflux disease and hemorrhagic gastritis, and recommended Prilosec therapy. ( Id. at 188.) He performed a ventral incarcerated herniorrhaphy to repair the ventral hernia on February 12, 2002. ( Id. at 164.) Pringle had "significant incisional pain" for six days following the surgery. ( Id. ) Five weeks after the surgery, Dr. Brown reported she was "progressing extremely well, " and Pringle did not return for additional post-operative check-ups. ( Id. at 162.)
2. Dr. Mark Holscher (1/28/02-10/15/03)
Dr. Holscher was Pringle's treating physician from January 28, 2002 through October 15, 2003 ( Id. at 252.) His annotations during office visits show GERD, hypothyroidism, abdominal pain, diarrhea, and fibromyalgia. ( Id. at 258, 261.) Pringle's correspondence with Dr. Holscher's office detail ongoing complaints about stomach pain and swelling. ( Id. at 259, 263-64.) During a telephone conversation on September 24, 2003, Pringle requested temporary disability, and on forms later submitted to the SSA, she listed Lactinex, Cholestyramine, Claritin, Singulair, and an albuterol inhaler as the medications Dr. Holscher prescribed. ( Id. at 259, 131.) In an undated memo, Dr. Holscher stated Pringle was "unable to search for employment effectively at this time." ( Id. at 267.)
3. Dr. Christopher Nichols, M.D. (4/14/03-6/4/03)
Dr. Holscher referred Pringle to Dr. Nichols, a gastrointestinal specialist, who examined her on April 14, 2003, and noted diffuse upper abdominal bloating, distention, and acid reflux. ( Id. at 235.) His report states Pringle has suffered from bloating and distention since fall of 2002. ( Id. ) His examination revealed clear lungs, a regular heart rate and rhythm, and mild depression. ( Id. at 236.) In subsequent office visits, Pringle complained of unchanged continual abdominal pain since beginning the Prilosec regimen. Dr. Nichols diagnosed diverticulitis. ( Id. at 233.) Diverticulitis had been previously diagnosed during an emergency room visit on July 21, 2002 for severe stomach pain, which resulted in four day hospital admission. ( Id. )
4. Dr. Cedric B. Fortune, M.D. (Kansas Consultative Examination) (12/11/03)
On December 11, 2003, Dr. Fortune conducted a state consultative physical examination of Pringle. ( Id. at 268.) Dr. Fortune noted asthma, ongoing heartburn, all-over body pain, gastrointestinal issues, postural problems bending or stooping, and lower back discomfort in his summary of her medical history. ( Id. ) He noted normal heart and lung functions and an unremarkable liver, spleen, and kidney were reported. ( Id. ) Dr. Fortune's orthopaedic exam revealed Pringle had no difficulty getting on or off the exam table, exhibited normal range of motion, and mild difficulty walking on her heels and toes. ( Id. at 269.) He noted her efforts during the orthopaedic exam were poor. ( Id. ) He reported Pringle was "alert and oriented to time, place, and situation." ( Id. at 269.) He did, however, conclude she embellished her symptoms. ( Id. ) His diagnoses included shortness of breath with asthma, low back pain, reflux esophagitis, generalized arthralgia, and obesity. ( Id. ) Despite these diagnoses, Dr. Fortune found Pringle could "perform reasonable activities, including sitting, standing, walking and lifting, " but noted difficulty standing for more than ten minutes. ( Id. )
5. RFC Assessment (12/17/03)
A state medical examiner subsequently relied on Dr. Fortune's findings to determine Pringle's Residual Functional Capacity ("RFC"). ( Id. at 270.) Regarding exertional limitations, the examiner found she could occasionally lift and/or carry fifty pounds, frequently lift and/or carry twenty-five pounds, stand, walk or sit for about six hours in an eight hour workday. ( Id. at 271.) Concerning postural limitations, the examiner assessed Pringle could only occasionally climb, but could frequently balance, stoop, kneel, crouch, and crawl. ( Id. at 272.) The examiner found no manipulative, visual, or communicative limitations. ( Id. at 273-74.) Based on her asthma, the examiner did indicate she should avoid exposure to fumes, odors, dusts, gases, and the like. ( Id. at 274.) Following the medical examination report, Dr. Jeffrey L. Wheeler, another state medical examiner, reviewed these findings and agreed with all noted limitations. ( Id. at 278-79.)
6. Dr. Brian Hunt, M.D. (5/1/03-4/22/04)
Pringle's principal complaint while under Dr. Hunt's care related to diarrhea. (D.I. 10 at 396.) Dr. Hunt also prescribed medication to treat Pringle's depression. ( Id. ) Dr. Hunt's treatment notes reference a fibromyalgia diagnosis, but do not explain the origins or reasoning for that diagnosis. ( Id. )
7. Dr. Stanley Mintz (Psychological Evaluation 6/30/04)
Dr. Mintz performed a mental status examination on behalf of Disability Determination Services ("DDS") on April 23, 2004. (D. I. 15 at 303.) In reviewing Pringle's health issues, Dr. Mintz noted stomach tenderness and swelling, fibromyalgia, hiatial hernia, allergies, asthma, depression, and daily diarrhea. ( Id. ) He described "some inconsistency in terms of the medical complaints she mentions" and felt she "may be augmenting medical and psychological complaints." ( Id. ) Pringle disclosed her primary care physician at the time, Dr. Hunt, had prescribed Zoloft and related increased depression since finding her deceased mother in their home. ( Id. ) Dr. Mintz recorded Pringle's daily activities as taking her children to school, cleaning, and cooking. ( Id. at 304.) During the examination, he reported Pringle was "somewhat slovenly in appearance" and did not appear "recently brushed or groomed." ( Id. ) His other impressions of Pringle included dependency, tendency to "externalize blame, " lack of work motivation, and entitlement to disability. ( Id. ) Dr. Mintz concluded Pringle "appears capable of being able to relate reasonably well to co-workers and supervisors, " can understand "simple and intermediate instructions, " and can adequately concentrate on tasks. ( Id. at 305.)
Dr. Lauren Cohen reviewed Dr. Mintz's examination to determine Pringle's psychological limitations. ( Id. at 308.) She categorized Pringle's limitations as not severe, but noted Pringle suffered from depressive disorder and dependent personality disorder. ( Id. at 311, 315.) Nonetheless, Dr. Cohen noted neither condition resulted in functional limitations to Pringle's daily life, social activities, or ability to concentrate. ( Id. at 318.)
8. Dr. Karen Owen (5/18/04)
Pringle sought mental health care from Dr. Owen beginning May 18, 2004. ( Id. at 376.) Dr. Owen noted Pringle's depressed mood and recommended coping mechanisms. ( Id. at 366.) After four visits, Pringle stopped all therapy with Dr. Owen. ( Id. at 359.)
9. Dr. John Spencer, M.D. (2/23/05-5/4/05)
Pringle began seeing Dr. Spencer as her primary physician on May 4, 2004 after leaving Dr. Hunt's care. ( Id. at 358.) During the first office visit, Dr. Spencer noted the prior diagnoses of fibromyalgia, GERD, and irritable bowel syndrome. ( Id. ) He recorded worsening pain, which concentrated in her knee, and resulted in reduced physical activity and weight gain. He described the crepitation in her knees as "rather severe." ( Id. ) To address her body and joint pain, Dr. Spencer prescribed Celebrex. ( Id. ) On May 19, 2004, two weeks after her first appointment, Dr. Spencer ordered a permanent disabled parking placard because of her arthritic, neurological, or orthopedic condition, and submitted a form to the Department of Social and Rehabilitation Services in Kansas. ( Id. at 152, 384.) Therein, he reported Pringle's depression, fibromyalgia, and GERD, as beginning in November 2002 and would last her lifetime, affecting her ability to participate in training and employment. ( Id. at 384) He explained her difficulties in concentrating, standing, and sitting limited her work opportunities. ( Id. )
Approximately six weeks later, Dr. Spencer examined Pringle again and noted Celebrex caused stomach upset, which prevented any improvement in joint pain. ( Id. at 357.) On August 4, 2004, Pringle complained of lower back pain resulting from a fall. ( Id. at 356.) She was previously seen in the emergency room, and prescribed Hydrocodone and Flexeril for the injury. ( Id. ) Dr. Spencer prescribed Vioxx and Skelaxin with instructions to continue with the Hydrocodone. ( Id. ) One week later, Dr. Spencer again examined Pringle's lower back for complaints of persistent pain and observed limited range of motion and tenderness. ( Id. at 355.) In addition to the pain medications previously prescribed, Dr. Spencer recommended physical therapy three times per week. ( Id. )
After a week of physical therapy, Pringle returned to Dr. Spencer reporting little change. ( Id. at 354.) He injected the sacroiliac region, which showed significant tenderness with Depo-Medrol, and instructed her to continue with the pain medications. ( Id. ) Dr. Spencer noted Pringle's difficulty in obtaining medications because of Medicaid authorization delays. ( Id. at 353.) Approximately one month later, Pringle returned complaining of back problems, after another fall about three weeks earlier. ( Id. at 352.) While Dr. Spencer noted she was "doing okay, " he continued prescribing Hydrocodone. ( Id. ) During her next appointment two months later, Dr. Spencer recorded "she is feeling a little better, " but is "still having a lot of pain" and continued with the Hydrocodone. ( Id. at 351.) After four months without improvement, Dr. Spencer ordered an MRI of the lumbosacral area. ( Id. at 350.) The MRI, taken on December 2, 2004, evidenced some disc desiccation and a possible annular tear at L5-S1, without any bulge, protrusion, or extrusion. ( Id. at 343.) After the MRI, Pringle visited Dr. Saba from Fort Scott Orthopedic Services for her results and a physical evaluation on December 10, 2004. (D.I. 15 at 663.) Dr. Saba reported Pringle had attended physical therapy eleven times and received a cortisone shot without improvement. ( Id. ) Dr. Saba observed limited range of motion and facial expressions revealing severe pain on motion. ( Id. ) Although he noted her symptoms suggested herniation nucleolus pulposus ("HNP"), Dr. Saba concluded evidence of HNP was lacking, and further commented "there were many signs suggesting symptoms magnifications." ( Id. ) He attributed the back pain to a possible disk injury to the L 4/5 or L 5/S1, which did not warrant surgical intervention. ( Id. ) No follow up appointment was scheduled, however Dr. Saba referred Pringle to a pain clinic. ( Id. )
Pringle first visited the pain clinic on December 20, 2004, where Dr. Landers administered a steroid epidural injection. ( Id. at 681.) He reported straight leg motion of seventy degrees and standing for approximately thirty minutes aggravated her back pain. ( Id. ) Without noting any change in symptoms, Dr. Landers administered another steroid epidural injection on December 27, 2004, and Dr. Pau, of the same pain clinic, administered a caudal epidural on January 6, 2005. ( Id. at 674, 677.) In letters to Drs. Saba and Spencer, Dr. Pau reported no pain relief from the three injections, and since Pringle was not a surgical candidate, recommended pain management using Neurontin. ( Id. at 666, 669.)
While attending the pain clinic, during an office visit, Dr. Spencer noted Pringle was doing well, but acknowledged she remained on pain medications, and a cortisone injection failed to alleviate her back pain. (D.I. 10 at 348.) On February 2, 2005, Dr. Spencer increased the Neurontin dosage. ( Id. at 347.) On February 23, 2005, Dr. Spencer submitted a Medical Source Statement to ALJ Stanley noting the following: Pringle could frequently lift and/or carry less than five pounds, occasionally lift and/or carry five pounds, continuously stand and/or walk thirty minutes, stand and/or walk two hours throughout an eight hour workday, sit continuously for thirty minutes, and sit for two hours throughout an eight hour workday, but must lie down for thirty minutes every two or three hours to alleviate pain. ( Id. at 381-82.) He reported Pringe could never balance, crouch, or crawl, and could occasionally climb, stoop, kneel, reach, and handle, and had difficulty concentrating while on Zoloft. ( Id. at 382.)
On February 23, 2005, Dr. Spencer again increased the Neurontin dosage for back and leg pain. (D. I. 15 at 725.) On May 4, 2005, Dr. Spencer noted significant pain, although the Neurontin and Flexeril "seem[ed] to be helping some." ( Id. at 724.) Pringle returned to Dr. Spencer on September 14, 2005 complaining of burning in her feet that worsens while standing. ( Id. at 722.)
10. Unsigned and Undated RFC Assessment
Another RFC assessment was conducted after Pringle requested reconsideration of the denial of DIB and SSI benefits. (D. I. 10 at 323.) Although the assessment reduces the weight she could occasionally lift to twenty pounds and frequently lift to ten pounds, it contains no other changes. ( Id. ) The examiner also noted Dr. Spencer's request for a disabled parking placard based on depression, fibromyalgia, and GERD. ( Id. at 324.) The examiner emphasized the lack of medical evidence supporting a diagnosis of fibromyalgia, and no new evidence demonstrated "any significant limitations" in Pringle's ability to "perform her day-to-day activities." ( Id. )
11. Consultative Psychological Examination (12/28/05)
Dr. Todd Schemmel performed a consultative psychological examination on December 28, 2005. (D. I. 15 at 685.) He reported poor attention span and concentration, adequate short-term memory, and below average long-term memory. ( Id. at 686.) He found Pringle "demonstrated her depression through a depressed mood, slow thought processes, feelings of loss and sadness over the death of her mother two years ago, low energy, tearfulness, and poor concentration." ( Id. ) Dr. Schemmel ...