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Windsor v. Saul

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

August 27, 2019

ANDREW SAUL, Commissioner of Social Security, Defendant.



         Plaintiff, Laura LT Windsor (“Plaintiff” or “Windsor”), challenges the final decision of Defendant, Andrew Saul, [1] Commissioner of Social Security (“Commissioner”), denying her applications for a Period of Disability (“POD”) and Disability Insurance Benefits (“DIB”), under Titles II of the Social Security Act, 42 U.S.C. §§ 416(i), 423, and 1381 et seq. (“Act”). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g) and the consent of the parties, pursuant to 28 U.S.C. § 636(c)(2). For the reasons set forth below, the Commissioner's final decision is AFFIRMED.


         In June 2015, Windsor filed an application for POD and DIB alleging a disability onset date of June 11, 2014 and claiming she was disabled due to a hysterectomy, anxiety, extreme bleeding prior to her hysterectomy, joint pain, celiac disease, parotid swelling, anemia, polyarthralgia, myofascial pain, dysfunction of eustachian tube, and tenosynovitis. (Transcript (“Tr.”) at 165, 194.) The applications were denied initially and upon reconsideration, and Windsor requested a hearing before an administrative law judge (“ALJ”). (Tr. 105, 112, 119.)

         On July 11, 2017, an ALJ held a hearing, during which Windsor, represented by counsel, and an impartial vocational expert (“VE”) testified. (Tr. 36.) On August 30, 2017, the ALJ issued a written decision finding Plaintiff was not disabled. (Tr. 8-30.) The ALJ's decision became final on May 8, 2018, when the Appeals Council declined further review. (Tr. 1.)

         On July 6, 2018, Windsor filed her Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 20, 21, 22.) Windsor asserts the following assignments of error:

(1) Whether the ALJ's analysis of treating physician Dr. Factor's medical opinion violated the treating physician rule.
(2) Whether the ALJ's RFC finding is supported by substantial evidence.

(Doc. No. 20.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Windsor was born in October 1976 and was forty years-old at the time of her administrative hearing, making her a “younger” person under social security regulations. (Tr. 22.) See 20 C.F.R. §§ 404.1563. She has a high school education and is able to communicate in English. (Id.) She has past relevant work as a cook and electronics assembler. (Id.)

         B. Relevant Medical Evidence[2]

         1. Mental Impairments

         On July 23, 2015, Windsor underwent a psychiatric evaluation with psychiatrist Thomas M. Robb, M.D. (Tr. 477.) She reported anxiety, excessive worry, and insomnia. (Id.) Dr. Robb diagnosed her with generalized anxiety disorder. (Tr. 478.) He prescribed Gabapentin and Klonopin and referred Windsor for psychotherapy. (Id.)

         Windsor underwent a diagnostic assessment with counselor Diane Maytas, LPCC, on July 28, 2015. (Tr. 525.) She indicated she was struggling with anxiety, worry, low motivation, and exhaustion. (Id.) She also described paranoia surrounding eating gluten. (Id.) On examination, Windsor appeared disheveled, had a flat and depressed affect, displayed a flight of ideas, with normal thought content, and no suicidal ideation. (Tr. 528.) She was oriented to person, place, and time, and her long term memory was intact. (Id.) Ms. Maytas noted Windsor's concentration was impaired and her judgment and insight were fair. (Tr. 528, 529.)

         Windsor subsequently began to see Ms. Maytas on a weekly basis for counseling. (Tr. 523, 522, 521.) She reported “keeping herself busy, ” by watching friend's pets, kayaking, bowling, and bike riding. (Tr. 523, 522.) She described being exhausted after performing small tasks. (Tr. 521.) Windsor displayed anxiety on examination. (Tr. 522.)

         Windsor returned to Dr. Robb on August 21, 2015, reporting mild depression and anxiety. (Tr. 485.) On examination, she had adequate judgment, insight, memory, and concentration. (Tr. 486.) She displayed no signs of depression or suicidal ideation. (Id.)

         Windsor continued to visit Ms. Maytas on a weekly basis in August and September 2015. (Tr. 519, 517.) She displayed some anxiety, but also reported she was staying active by riding her bike, planning for a vacation, and playing cards with friends. (Tr. 519, 518, 569.) On September 9, 2015, she reported short term memory deficits, but her concentration was adequate on examination. (Tr. 649.) On September 15, 2015, she relayed a recent vacation was “awesome” and she was able to relax and enjoy herself. (Tr. 517.) On September 22, 2015, she described several “bad days” the prior week, during which she felt overwhelmed and anxious. (Tr. 516.)

         On October 6, 2015, Windsor reported to Ms. Maytas she recently attended a concert with her sister and husband. (Tr. 568.) She reported her anxiety had improved, but described some short term memory issues. (Id.)

         On October 7, 2015, Ms. Maytas filled out a “Daily Activities Questionnaire” on behalf of Windsor. (Tr. 532-533.) She noted the following:

• Windsor has good relationships with family and friends and regularly socializes;
• She displayed difficulty with short term memory recall;
• She has anxiety symptoms in the morning;
• Her finds her dietary needs draining, overwhelming, and challenging at times;
• She requires additional rest throughout the day;
• She tires easily and becomes overwhelmed with housework;
• She plans shopping throughout the week in order to avoid feeling overwhelmed;
• She takes public transportation to and from appointments; and
• Her husband and sister assist her when needed.


         Windsor's October and November 2015 therapy notes from Ms. Maytas indicated she continued to stay busy by socializing and going for walks. (Tr. 567, 564, 562.) She expressed worry over Dr. Robb possibly discontinuing her medications because she felt they were working well. (Tr. 566, 562.)

         In December 2015, Windsor continued to feel anxious in the morning, had short term memory issues, and often felt exhausted and overwhelmed. (Tr. 558, 559, 557, 556.) She indicated she was providing a great deal of assistance to her sister and other individuals in her life, which frustrated her. (Tr. 557.)

         Windsor continued to regularly attend counseling sessions Ms. Maytas in 2016. On January 14, 2016, Windsor reported she was often worried and her hair was falling out. (Tr. 555.) Windsor appeared tired on examination. (Id.) On February 3, 2016, Windsor reported she recently went to Detroit for a trip and attended a concert. (Tr. 624.) She described low motivation and excessive sleep. (Id.) On February 19, 2016, she described anxiety and difficulty waking in the morning. (Tr. 623.) However, by March 23, 2016, Windsor indicated her mood and fatigue improved a decrease to her Gabapentin dosage and discontinuing her acid reflux medication. (Tr. 621.) She also reported her morning anxiety had improved. (Id.)

         In April 2016, Windsor continued to express frustration and stress over providing so much support to the people in her life. (Tr. 619.) Ms. Maytas noted Windsor had trouble setting boundaries with her family. (Id.) In May 2016, Windsor attended a gluten free convention in Chicago with her husband. (Tr. 643, 642.) At that time, Ms. Maytas observed Windsor had “come to the realization that when she gets out of the home and does something she feels fine.” (Tr. 642.)

         On June 24, 2016, Windsor returned to Dr. Robb for medication management. (Tr. 647.) Dr. Robb noted Windsor continued to have anxiety, but it was managed by medication. (Id.) Windsor denied suicidal ideation and displayed adequate concentration in conversation. (Id.)

         On July 21, 2016, Windsor reported to Ms. Maytas that she did not feel “too bad” and her motivation had increased. (Tr. 638.) On August 4, 2016, Ms. Maytas observed Windsor appeared “to be doing well and progressing when utilizing coping skills.” (Tr. 637.)

         On August 18, 2016, Windsor underwent an updated diagnostic assessment and treatment plan with Ms. Maytas. (Tr. 634.) Ms. Maytas concluded Windsor had made good progress with episodic setbacks. (Id.) Windsor reported she was struggling with short term memory retrieval, reading, and concentration. (Tr. 635.) She described low motivation in the morning due to her lack of employment. (Tr. 636.)

         Windsor then began to see Ms. Maytas every few weeks rather than on a weekly basis. (Tr. 661, 660.) On September 1, 2016, Windsor reported she had gone on a weekend camping trip with her husband and had been walking a great deal in the evenings. (Tr. 661.) She again described low motivation. (Id.) On September 15, 2016, Windsor reported increased anxiety and low motivation. (Tr. 660.) On September 28, 2016, Windsor indicated that since discontinuing her Gapapentin, she felt more aware and was able to multi-task. (Tr. 659.) However, Windsor's anxiety levels increased in October 2016. (Tr. 658.) Her memory had improved. (Id.)

         In November 2016, Ms. Maytas observed Windsor was learning coping skills. (Tr. 739.) Windsor reported feeling exhausted by household chores. (Tr. 738.) Windsor continued to express frustration and stress with her family in December 2016. (Tr. 737, 736.)

         On December 9, 2016, Windsor followed up with Dr. Robb, reporting continued anxiety. (Tr. 680.) She indicated she was able think clearer after discontinuing her Gabapentin and her stomach felt better as well. (Id.) On examination, she had adequate concentration and displayed anxiety. (Id.)

         Windsor continued to treat with Ms. Maytas and Dr. Robb in 2017. On January 3, 2017, Windsor indicated she had gone out of town for New Years and enjoyed herself. (Tr. 735.) She relayed that while she was doing well, it took a lot of effort. (Id.) She expressed a desire to possibly work in a gluten free restaurant. (Id.) On January 17, 2017, Ms. Maytas noted Windsor had shown progress in “expanding her comfort zone.” (Tr. 734.) Windsor denied any issues with her memory on January 31, 2017. (Tr. 733.)

         In February 2017, Windsor was planning a trip to Florida. (Tr. 731.) She continued to struggle with motivation, but demonstrated progress in setting boundaries with her family members. (Tr. 731, 732.)

         Windsor returned to Dr. Robb on March 10, 2017, displaying good insight, adequate judgment, adequate concentration in conversation, and no suicidal ideation. (Tr. 789.) On March 14, 2017, Windsor described exhaustion after completing household tasks, but had made progress in reaching out to others for support and talking with friends. (Tr. 730.) On March 28, 2017, Windsor indicated to Ms. Maytas she struggled to pay attention and could not handle stress. (Tr. 842.)

         In April 2017, Windsor reported frustration with her celiac disease. (Tr. 841, 839.) In May 2017, Windsor's sleep was improved, but she still felt exhausted most of the time. (Tr. 838, 837.) On June 20, 2017, Windsor reported she had recently attended a concert and was planning a trip with her husband. (Tr. 835.) She relayed her anxiety increased when she felt overwhelmed and had a lot of events to attend. (Id.)

         2. Physical Impairments

         On May 27, 2014, Windsor visited her gynecologist, Soghra Hornafar, M.D., for a surgical consultation. (Tr. 380.) She reported heavy bleeding and requested a hysterectomy. (Id.) Windsor underwent a hysterectomy on June 11, 2014. (Tr. 419.)

         On January 8, 2015, Windsor visited primary care physician Virginia Mateo Factor, D.O., for a new patient visit. (Tr. 361.) She reported anxiety, menopausal symptoms, and joint pain and stiffness. (Tr. 361-362.) On examination, Windsor had a full range of motion in her elbows, crepitus in her right elbow, no obvious swelling in her joints, and a normal gait and station. (Tr. 364.) Dr. Factor diagnosed generalized anxiety disorder and polyarthralgia, and referred Windsor to a rheumatologist. (Tr. 365.)

         Windsor initially visited rheumatologist Inderprit Singh, M.D., on February 16, 2015. (Tr. 262.) She reported pain in her left shoulder, wrists, hands, left ankle, and left foot. (Id.) On examination, she displayed skin hyperextensibility and ankle joint hypermobility. (Tr. 265.) The remainder of her musculoskeletal examination was normal, with no swelling and a normal range of motion in her shoulders, elbows, wrists, hands, hips, knees, and ankles. (Tr. 265, 266.) Her gait and station were normal, with full strength and no muscle atrophy. (Tr. 267.) Dr. Singh ordered blood work. (Tr. 269.)

         On February 24, 2015, gastroenterologist Mehrdad Asgeri, M.D., reviewed this labwork and diagnosed Windsor with celiac disease. (Tr. 307.) Windsor reported fatigue and anemia since her hysterectomy. (Tr. 305.)

         Windsor followed up with Dr. Factor on March 2, 2015, reporting her anxiety medications were effective. (Tr. 366.) On examination, she had edema in her lower extremities, but a normal gait and station and normal mood and affect. (Tr. 369.) Dr. Factor noted a “significant improvement” in Windsor's anxiety. (Id.)

         On March 19, 2015, Windsor underwent an EGD and had biopsies taken. (Tr. 303.) She followed up with Dr. Asgeri on March 23, 2015. (Tr. 289.) She reported mild abdominal bloating and pain, but indicated she felt “a little better” since starting a gluten-free diet. (Id.) Dr. Asgeri referred her to a dietician. (Tr. 291.)

         Windsor visited dietician Margaret Zeller, R.D., on March 31, 2015 for a nutrition consultation. (Tr. 354.) She reported abdominal pain, bloating, and gas. (Id.) Ms. Zeller observed Windsor had already made dietary changes and provided her with nutrition education. (Tr. 355.)

         Windsor returned to Dr. Factor on June 1, 2015, again reporting her anxiety medications were working “very well.” (Tr. 370.) She saw Dr. Singh that same date, reporting her recent diagnosis of celiac disease. (Tr. 269.) Windsor indicated she was a “lot better” on her gluten free diet. (Tr. 270.) On examination, her shoulders, elbows, hips, knees, and ankles were normal, with no swelling and a normal range of motion. (Tr. 272, 273.) Dr. Singh did observe De Quervain's tenosynovitis on the right side, but Windsor's gait and station were normal. (Tr. 274.)

         On June 17, 2015, Windsor visited Dr. Singh, again reporting improvement on her gluten free diet. (Tr. 277.) She reported no side effects from her Gabapentin, other than drowsiness. (Id.) She rated her pain as 2/10, but 5/10 after activity. (Id.) On examination, her shoulders, elbows, hips, knees, ankles, and feet displayed no swelling and a full ...

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