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Blanton v. Saul

United States District Court, N.D. Ohio, Western Division

August 8, 2019

TARA R. BLANTON, Plaintiff,
v.
ANDREW M. SAUL[1], COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

          REPORT AND RECOMMENDATION OF MAGISTRATE JUDGE

          GEORGE J. LIMBERT UNITED STATES MAGISTRATE JUDGE

         Plaintiff Tara Blanton (“Plaintiff”) requests judicial review of the final decision of the Commissioner of Social Security Administration (“Defendant”) denying her application for disability insurance benefits (“DIB”) and supplemental security income (“SSI”). ECF Dkt. #1. In her brief on the merits, filed on November 19, 2018, Plaintiff asserts that the administrative law judge (“ALJ”) failed to give good reasons for not adopting the opinions of both of her treating physicians, Dr. Singh and Dr. Desai. ECF Dkt. #12. On February 15, 2019, Defendant filed a brief on the merits. ECF Dkt. #16. Plaintiff subsequently filed a reply to Defendant's brief on March 1, 2019. ECF Dkt. #17.

         For the following reasons, the undersigned recommends that the Court VACATE the ALJ's decision and REMAND this case for further proceedings consistent with this Report and Recommendation.

         I. FACTUAL AND PROCEDURAL HISTORY

         A. Initial ALJ Decision

         On June 5, 2012, Plaintiff protectively filed an application for SSI alleging disability beginning June 4, 2012 due to depression, fibromyalgia, mental break down, migraines, pain all over, asthma, right knee issues, nerves, lower pain issues, and acid reflux. ECF Dkt. #11 (“Tr.”)[2] at 58, 69, 134, 153, 156. Plaintiff's application was denied initially on September 4, 2012 and upon reconsideration on November 28, 2012. Id. at 58-68, 70-82, 84, 90. On January 7, 2013, Plaintiff requested an administrative hearing. Id. at 92-94. Additionally, on August 28, 2013, Plaintiff protectively filed an application for DIB with the same alleged onset date of June 4, 2012. Id. at 151, 153.

         On January 29, 2014, a hearing was held before an ALJ in which Plaintiff, with counsel, and a vocational expert (“VE”) testified. Id. at 32-57. The ALJ issued his decision on April 23, 2014, finding Plaintiff not disabled and denying her applications for DIB and SSI. Id. at 6-23. Plaintiff requested a review of the hearing decision, and on July 19, 2015, the Appeals Council denied review. Id. at 1-5, 30-31.

         On September 11, 2015, Plaintiff filed suit, requesting judicial review of the final decision denying her applications for DIB and SSI. Blanton v. Comm'r of Soc. Sec., No. 3:15CV1864 (“Blanton I”), at 689-94.[3] After the case was fully briefed, a magistrate judge issued a Report and Recommendation on June 16, 2016 recommending “that the final decision of the Commissioner be vacated and that the case be remanded.” Blanton I, at 712-36. In his report, the magistrate judge found that the ALJ failed to include certain medical records as exhibits to the record and the ALJ violated the treating physician rule by failing to articulate “good reasons” for failing to assign controlling weight to the opinions of Plaintiff's treating physicians, Drs. Singh and Desai. Id. The Court accepted the magistrate judge's decision and vacated and remanded this matter to Defendant for further proceedings. Id. at 710-11.

         B. Subsequent ALJ Decision

         Following the August 15, 2016 remand of this matter to the ALJ, a second hearing was held on April 26, 2017. Tr. at 617-35. On May 17, 2017, the ALJ issued a decision, again finding Plaintiff not disabled and denying Plaintiff's applications for DIB and SSI for the period of June 4, 2012 through the date of the second decision. Id. at 590-606. In the section of his decision regarding jurisdiction and procedural history, the ALJ acknowledged that the District Court remanded the case “to review the opinions of Dr. Singh and Dr. Desai and provide [sic] good, articulated reasons for accepting or rejecting the opinions.” Tr. at 593.

         On July 30, 2018, Plaintiff filed the instant suit seeking review of the ALJ's second decision. ECF Dkt. #1. On October 18, 2018, Defendant filed an answer. ECF Dkt. #10. Plaintiff filed a brief on the merits on November 19, 2018. ECF Dkt. #12. On February 15, 2019, Defendant filed a merits brief. ECF Dkt. #16. Plaintiff filed a reply brief on March 1, 2019. ECF Dkt. #17.

         II. MEDICAL AND TESTIMONIAL EVIDENCE

         A. Medical Evidence

         Since Plaintiff's arguments are limited to the treating physician rule as it pertains to Drs. Desai and Singh, the undersigned will limit review of the medical evidence to those two treating physicians and related visits. Plaintiff's alleged disability onset date is June 4, 2012. Tr. at 134, 151.

         i. Dr. Singh

         Plaintiff's medical records suggest she has been a patient of Dr. Paraminder B. Singh, M.D., since approximately 2002. Tr. at 325. From 2002 to 2012, Plaintiff's medical records from Dr. Singh (as well as Dr. Muhammad Khan, M.D.) regularly document her history of migraine headaches. Tr. at 265-66, 272-76, 278, 283-85, 290, 295, 301, 304-05, 309, 311-13, 320-22, 324-25, 504, 507, 512, 525, 529, 537.

         In February 2010, Plaintiff presented to an emergency department for an accident in which she slipped on ice at a gas station, injuring her left hip and left knee. Id. 212-16. Plaintiff presented with Dr. Singh to get an MRI on her left knee and for follow up treatment. Id. at 217-19.

         In January 2012, Plaintiff presented to the emergency department complaining of migraine headaches. Id. at 225-30. She was discharged the same day in stable condition. Id. at 225. In September, October, and December 2012, Plaintiff presented to Dr. Singh with complaints of back pain, anxiety, myalgias (noted as starting 5 years prior), incapacitating and frequent headaches (noted as starting 10 years prior with episodes lasting 3-4 days), depression (noted as starting 1 year prior), and obesity. Id. at 504-05, 507-09, 515.

         On May 28, 2013, Plaintiff presented to Dr. Singh with issues on swallowing and a sore throat as well as back pain and myalgias. Id. at 510. On June 13, 2013, Plaintiff presented to Dr. Singh for a follow up visit after being in a car accident. Id. at 512. Plaintiff had pain in her left shoulder and left knee, neck pain, and headache symptoms. Id. Dr. Singh prescribed Vicodin and instructed Plaintiff to get an MRI and X-ray. Id. at 513. Dr. Singh also recommended physical therapy. Id. at 511. Plaintiff continued presenting with similar complaints pain, myalgias, depression, and headaches throughout 2013. Id. at 429-30, 432-34, 515-32. Also, beginning around December 2013, Dr. Singh treated Plaintiff for degenerative disc disease by prescribing her Vicodin. Tr. at 429-30, 1161-81. However, in December 2014, Plaintiff received an MRI of her lumbar spine, and the results were normal. Id. at 2028.

         Throughout 2014 and 2015, Plaintiff continued visiting Dr. Singh for the aforementioned symptoms as well as for various complaints of hypertension, shortness of breath, anxiety, asthma, joint pain, dyspnea, back pain, edema, and rashes. Tr. at 977-1080.

         On February 25, 2014, Plaintiff presented to Dr. Singh for a follow up visit with complaints of hypertension, anxiety, asthma, joint pain, and a “leaky bladder.” Tr. at 977. Subsequently, Dr. Singh referred Plaintiff for a Pulmonary Function Test (“PFT”), which Plaintiff underwent on February 28, 2014. Id. at 982-83, 1223-25. Her PFT results indicated that there was no noticeable significant obstruction or restriction, but she had impaired diffusion capacity, which raised suspicions for a pulmonary vascular disease, including emphysema related findings or interstitial lung disease. Id. at 1225. The report also noted that Plaintiff has a history of asthma and chronic smoking. Id. at 1223, 1225. During a July 28, 2014 visit, Plaintiff stated that her headaches have improved more than 50% since her last hospitalization. Id. at 1025.

         On March 4, 2015, Plaintiff was hospitalized overnight for chronic obstructive pulmonary disease (“COPD”) and breathing problems. Id. at 1090. On June 1, 2015, Plaintiff complained of chronic itching, which she described felt like bugs crawling all over her body, and Dr. Singh subsequently refilled her medications. Id. at 1119-25. Plaintiff visited an emergency department with complaints of a cough and chest pain during October 2015 and in February, April, May, and July 2016. Tr. at 1548-1675, 1836-72.

         On June 2, 2012, Dr. Singh opined about Plaintiff's medical conditions and listed Plaintiff's medical conditions as including myalgia, depression, joint pain in ankle and foot, asthma, malaise, and knee pain. Id. at 870-71. Dr. Singh further opined that Plaintiff “has all over pain caused from the myalgia and joint pain, ” and that she cannot bend, lift, twist, walk for long periods of time, becomes fatigued very easy, and her asthma causes her breathing problems. Id. Dr. Singh indicated that Plaintiff could stand or walk for one to two hours and she could carry up to 5 pounds frequently. Id. at 871. Dr. Singh concluded that Plaintiff “is completely disabled due to her conditions, ” and “the pain she suffers from affects her daily living.” Id.

         On June 20, 2013, Dr. Singh completed a physical capacity evaluation and opined that Plaintiff can stand or walk a total of one hour and can sit for a total of two hours in an 8 hour workday. Tr. at 399-400. Dr. Singh also opined that Plaintiff can lift up to 10 pounds rarely and she is likely to have partial or full day unscheduled absences from work occurring 5 or more days per month due to her conditions. Id. Dr. Singh remarked that when Plaintiff is under stress, she “falls apart, ” and explained that Plaintiff cannot concentrate and forgets basic tasks, gets muscle spasms that worsen her pain, gets headaches that occur frequently (at least 2-3 times a day and Plaintiff needs the lights off and to rest), and gets severe depression. Id. at 400.

         On September 21, 2016, Dr. Singh opined in a letter that Plaintiff is permanently unable to work because she suffers from vulvar cancer, chronic degenerative disc disease, anxiety, chronic pain, myalgia, myositis, and hypertension. Tr. at 1717.

         ii. Dr. Desai

         Plaintiff's medical records suggest she has been a patient of Dr. Bipin M. Desai, M.D., since approximately January 2012. See Tr. at 252. On January 30, 2012, Plaintiff visited Dr. Desai with the chief complaint of depression. Tr. at 253. After evaluating her, Dr. Desai diagnosed Plaintiff with major depressive disorder that is recurrent and moderate. Id. Dr. Desai prescribed Celexa and instructed her to continue on Xanax. Id. at 254. Plaintiff continued seeing Dr. Desai on a monthly basis. Id. at 254-58, 377-84, 411-14. In February 2012, Plaintiff reported feeling better although the Celexa made her lethargic. Id. at 255. Dr. Desai instructed her to stop Celexa and start Prozac. Id. In April 2012, Plaintiff complained that she was feeling depressed, anxious, and irritable following a recent hysterectomy, and Dr. Desai prescribed her Risperdal. Id. at 256. In June 2012, Dr. Desai noted that Plaintiff applied for a medical card and SSD. Id. at 258. Also during this visit, Dr. Desai diagnosed Plaintiff with another disorder-pain disorder associated with psychological factors and a medical condition. Id. In July 2012, Dr. Desai prescribed Plaintiff Abilify and instructed her to stop taking Risperdal. Id. at 377. In September 2012, Dr. Desai prescribed her Pristiq and instructed her to stop taking Prozac. Id. at 381. In October 2012, Dr. Desai started Plaintiff on Cymbalta and instructed her to stop taking Pristiq. Id. at 382-83. In November 2012, Plaintiff reported feeling a little better and that she was coping better with her chronic pain. Id. at 384. However, in December 2012, Plaintiff reported that she could not stop crying. Id. at 411. Dr. Desai subsequently prescribed her Lexapro, and Plaintiff reported feeling better later that month. Id. at 412-13. Shortly thereafter, from December 27, 2012 until January 25, 2013, Plaintiff was hospitalized due to increased depression and having a “mental breakdown.” Id. at 386-87.

         In March, May, and August 2013, Plaintiff reported that she was feeling “pretty good” and was coping with stressors, as well as awaiting her SSD hearing. Tr. at 415, 417, 419. Plaintiff continued seeing Dr. Desai in 2014 through 2016 with visits noting that she reported either feeling good or that she felt anxious, depressed, or tired. Id. at 1928-67.

         On June 18, 2012, Dr. Desai completed a mental functional capacity assessment and marked Plaintiff as being moderately limited or markedly limited in almost every category. Tr. at 868-69. Additionally, Dr. Desai noted that Plaintiff had major depression that is moderate and recurrent, had pain that is chronic and due to physical and psychological factors, and had low energy. Id. at 869.

         On August 29, 2013, Dr. Desai filled out a questionnaire as to mental residual functional capacity and marked Plaintiff as being either moderate or marked limitations in each area. Tr. at 402-04, 425-27. Dr. Desai opined that Plaintiff would be likely to have partial or full day unscheduled absences from work occurring 5 or more days per month due to her diagnosed conditions and/or side effects of medication. Id. at 404, 427.

         Plaintiff continued seeing Dr. Desai regularly throughout 2014 to 2016, in which she consistently reported feeling “pretty good” and denied using substances or having manic symptoms, hallucinations, delusions, and other symptoms of psychotic process. Tr. at 1928-1967. In June 2016, Plaintiff reported feeling depressed and anxious, but subsequently reported that her depression and anxiety had decreased. Id. at 1956, 1958, 1960. In October 2016, she reported feeling very anxious and also reported that she was diagnosed with cancer of the vulva. Id. at 1966.

         B. Testimonial Evidence

         After the District Court remanded the case back to the ALJ, a second hearing was held on April 26, 2017, in which Plaintiff, with counsel present, and a vocational expert (“VE”) testified. Tr. at 617-35. Plaintiff testified that she has not worked at all since the prior hearing on January 29, 2014 and that her fibromyalgia and depression have worsened. Id. at 621. She also stated that she was hospitalized ...


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