United States District Court, N.D. Ohio, Eastern Division
ANN M. HENDRICKSON, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
MEMORANDUM OF OPINION AND ORDER
M. Parker, United States Magistrate Judge.
Ann M. Hendrickson, seeks judicial review of the final
decision of the Commissioner of Social Security, denying her
applications for disability insurance benefits
(“DIB”) and supplemental security income
(“SSI”) under Titles II and XVI of the Social
Security Act. This matter is before me pursuant to 42 U.S.C.
§ 405(g) and the parties consented to my jurisdiction
under 28 U.S.C. § 636(c) and Fed.R.Civ.P. 73. ECF Doc.
11. Because substantial evidence supported the ALJ's
decision and because Hendrickson has not identified any error
of law in the ALJ's evaluation of her claim, the final
decision of the Commissioner must be AFFIRMED.
March 15, 2016, Hendrickson applied for DIB. On March 23,
2016, she applied for SSI. (Tr. 215, 219). Hendrickson
alleged that she became disabled on April 25, 2015. (Tr. 215,
219). The Social Security Administration denied
Hendrickson's applications initially and upon
reconsideration. (Tr. 93, 109, 126, 140). Hendrickson
requested an administrative hearing. (Tr. 166). ALJ Reuben
Sheperd heard Hendrickson's case on March 7, 2018, and
denied the claim in a May 9, 2018, decision. (Tr. 18-32). On
September 28, 2018, the Appeals Council denied further
review, rendering the ALJ's decision the final decision
of the Commissioner. (Tr. 1-3). On November 14, 2018,
Hendrickson filed a complaint seeking judicial review of the
Commissioner's decision. ECF Doc. 1.
Relevant Medical Evidence
August 19, 2014, Hendrickson saw Christine Spiroch, PhD,
PA-C, at the Cleveland Clinic Integrative Medicine department
for treatment of Hashimoto's disease. (Tr. 533). Dr.
Spiroch had difficulty completing an intake because
Hendrickson was late to her appointment and would not focus
on one symptom at a time. (Tr. 532). Dr. Spiroch ordered labs
and referred Hendrickson to endocrinology for a thyroid
evaluation. (Tr. 533). On September 22, 2014, Hendrickson saw
Dr. Lyla Blake-Gumbs for her Hashimoto's disease. (Tr.
529). Dr. Blake-Gumbs advised Hendrickson to avoid wheat and
dairy and to start a probiotic. (Tr. 531). On September 22,
2014, Hendrickson reported sleeping better since starting new
thyroid medication. She was advised to continue a gluten free
diet and to add supplements including fish oil, turmeric, and
vitamin D. (Tr. 454).
October 14, 2014, Hendrickson saw Dr. Susan Williams for her
thyroid. (Tr. 524). She complained of fatigue and
gastrointestinal issues. (Tr. 524). Dr. Williams noted that,
despite normal thyroid stimulating hormone (TSH) and Free T3
and Free T4 function lab results, a different provider had
prescribed additional thyroid medication to Hendrickson. (Tr.
524). Dr. Williams instructed Hendrickson to stop the
additional medication, take only Synthroid, and ordered more
lab tests in four weeks. (Tr. 525). A month later,
Hendrickson called to renew her Synthroid prescription. The
RN who took her call misunderstood Dr. Williams' notes
and refused to renew the prescription. Due to this
misunderstanding, several notes appear in the record
indicating that Williams had not complied with the
doctor's orders. (Tr. 517-518).
February 19, 2015, Hendrickson saw Dr Jennifer Wojtowicz,
D.O., for her Hashimoto's disease. (Tr. 363). Hendrickson
complained of “brain fog, bloating, fatigue, chills,
sinus headaches, asthma.” Dr. Wojtowicz diagnosed
chronic lymphocytic crisis or storm and “other malaise
and fatigue.” She ordered lab work and instructed that
she would prescribe Tirosint for Hendrickson's
thyroiditis. She recommended a low inflammatory diet and
encouraged Hendrickson to try a probiotic. (Tr. 364).
February 26, 2015, Hendrickson saw Dr. Mladen Golubic in
integrative medicine. (Tr. 515). Hendrickson reported that
she had eaten mostly organic, gluten-free for almost a year,
but she sometimes cheated. (Tr. 515). She reported that she
had started to meditate and read the Bible but had since
stopped completely. She drank two glasses of wine per day and
had difficulty staying asleep. (Tr. 515). Dr. Golubic told
Hendrickson to continue a gluten-free, wheat-free,
dairy-free, and casein-free diet, exercise more and meditate.
(Tr. 517). On April 30, 2015, Hendrickson saw Dr. Golubic
again. She reported that she was busy with her photography
and was helping her parents clean their house and move. She
was also taking two extra college courses. (Tr. 514). She had
done a cleanse but was still drinking coffee, one to two
glasses of wine per night and continued to eat red meat. (Tr.
514). She was only occasionally doing relaxation practices.
(Tr. 514). Dr. Golubic noted that Hendrickson complained that
she was tired and stressed, but had not implemented the
stress reduction practices or seen a mind body therapist.
(Tr. 515). He told her to improve her diet and get more
exercise. (Tr. 515).
saw Dr. Jessica Hutchins on May 19, 2015. She told Dr.
Hutchins that she occasionally smoked and had an asthma
attack. Dr. Hutchins found that Hendrickson likely had
adrenal and mitochondrial dysfunction. (Tr. 455). On August
6, 2015, Hendrickson reported that her brain fog was worse,
and she stated she had low energy and bloating. She said she
had meditation tapes at home but wasn't using them. Dr.
Hutchins ordered more tests. (Tr. 455).
August 11, 2015, Hendrickson started treating with a new
personal care provider, Kristin Havens, CNP. Hendrickson
reported that she had a lot of food intolerances and had been
told she had leaky gut syndrome. She said she had recently
been diagnosed with chronic Lyme disease but did not have
copies of reports. She also reported B12 deficiency anemia.
August 18, 2015, Hendrickson saw allergist Dr. Mohan Durve.
(Tr. 348). She reported having Hashimoto's disease and
Lyme disease. (Tr. 354). She said her hobbies were tennis,
walking, reading and playing cards. (Tr. 354). Dr. Durve
listed Hendrickson's diagnosis as environmental allergy,
perennial allergic rhinitis, asthma, and chronic lymphocytic
thyroiditis. (Tr. 348). Dr. Durve prescribed azelastine
spray, a saline nasal gel, fluticasone spray and an inhaler.
August 28, 2015, Hendrickson returned to see Nurse Havens for
back pain following a fall while taking pictures. (Tr. 410).
Nurse Havens prescribed pain medication and ordered an MRI of
Hendrickson's brain. (Tr. 413). The MRI showed no
significant intracranial abnormality but mild chronic
inflammatory changes involving the paranasal sinuses. (Tr.
September 8, 2015, Hendrickson followed up with Dr. Wojtowicz
for her Hashimoto's disease. Hendrickson reported that
she had a good appetite and was able to do her usual
activities, but she still felt tired. (Tr. 362). She reported
having Lyme disease. (Tr. 361). She reported taking 50 mcg of
Tirosint. She had tried to add an additional 25 mcg, but it
made her feel worse. (Tr. 362). Dr. Wojtowicz told her to try
adding 13 mcg Tirosint instead of 25 mcg. She scheduled a
follow-up appointment in six months. (Tr. 362). On September
11, 2015, Hendrickson reported to Dr. Hutchins that she had
increased her Tirosint to 100 mcg on her own and felt
horrible. (Tr. 465).
test on September 30, 2015 showed that Hendrickson did not
have Lyme disease. (Tr. 545). Another lab test on October 20,
2015 was also negative for Lyme disease. (Tr. 541).
October 19, 2015, Hendrickson told Dr. Hutchins she felt 10%
better. She said she was worried about Lyme, mold, metals and
why she felt so horrible 3-4 weeks into candida treatment.
(Tr. 456). Hendrickson's lab results did not indicate
that her chronic inflammatory response syndrome
(“CIRS”) was from mold. On November 30, 2015, Dr.
Hutchins ordered additional tests and discussed that an
underlying chronic infection could possibly be causing
Hendrickson's inflammation/immune dysfunction. (Tr. 457).
record contains notes regarding many calls Hendrickson placed
to her medical providers. For example, in October and
November 2015, Hendrickson called her providers three times
about nasal spray prescriptions. (Tr. 487). She asked about
alternative prescriptions because of insurance denials and
provided information for an out-of-state pharmacy. In
mid-November, Hendrickson called four times, asking for
specific prescriptions; identifying a different provider and
pharmacy who would prescribe supplements; and indicating the
end period and how to write the prescription for insurance
approval. (Tr. 486-487).
December 14, 2015, Hendrickson saw Nurse Havens. Hendrickson
requested new lab work for her thyroid and ferritin. (Tr.
403). Havens agreed to recheck Hendrickson's labs but
told her that any medication changes and monitoring would
have to come from her endocrinologist. (Tr. 404). Havens
discussed with Hendrickson multiple provider issues and
appropriate delegation of services so that tests and
treatment were not duplicated. (Tr. 405).
January 14, 2016, Dr. Hutchins suggested that Hendrickson
start using glutathione nasal spray. (Tr. 459). On January
28, 2014, Hendrickson saw Dr. Jonny Su for a referral based
on elevated antinuclear antibody (“ANA”) levels.
(Tr. 463). Dr. Su thought that Hendrickson's elevated ANA
test was most likely due to thyroid antibodies. An MRI on
February 4, 2016 returned unremarkable results. (Tr. 535).
February 1, 2016, Hendrickson called the Cleveland Clinic for
approval of a lab test. (Tr. 468). From February 12 to 16,
Hendrickson called six times and e-mailed requesting specific
blood work from a specific lab. (Tr. 461-462).
followed up with Dr. Wojtowicz on March 10, 2016. (Tr. 359).
She reported that she was told she had Lyme disease by a
“functional doc.” (Tr. 359). Hendrickson reported
a good appetite and that she was able to do her usual
activities. (Tr. 360). Dr. Wojtowicz ordered thyroid labs and
told Hendrickson to check the levels in the morning before
taking Tirosint. (Tr. 360). On March 23, 2016, Hendrickson
told Dr. Hutchins that her brain fog was improving with the
glutathione spray. (Tr. 459).
March 29, 2016, Dr. Durve completed a questionnaire. He noted
that Hendrickson's allergies improved with injections but
she stopped receiving them because she said her class
conflicted with her injections and she was not open to
self-administration. (Tr. 337). Dr. Durve opined that
“very dusty or moldy environments would most likely
trigger allergic/asthmatic symptoms” but Hendrickson
did not have any physical limitations. And, he opined that
she had no clear deficit in her ability to concentrate and
think clearly. He noted that she was able to repeat
instructions back to nursing staff. (Tr. 337).
March 28, 2016 and March 31, 2016, Hendrickson called Dr.
Hutchins' office at the Cleveland Clinic three times
requesting a prescription for B12 shots. (Tr. 452).
April 28, 2016, Hendrickson saw Dr. Hutchins who believed
Hendrickson's breathing issues were likely caused by
mycotoxin CIRS. (Tr. 670). Hendrickson called the Cleveland
Clinic several times in early May regarding her labs and sent
“MyChart” messages. (Tr. 662). On May 25, 2016,
Hendrickson told Dr. Hutchins that she thought the
glutathione spray was helping. (Tr. 661).
1, 2016, Dr. Su returned Hendrickson's call and told her
that her lab results showed no evidence of lupus. (Tr. 653).
On June 10, 2016, Hendrickson reported that the glutathione
was helping her “brain fog.” Dr. Hutchins noted
that the brain fog was improving with detox support. (Tr.
22, 2016, Hendrickson saw Dr. Scarlet Soriano in mind-body
medicine. (Tr. 642). Hendrickson said she was reading
“The Healing Code, ” and had read “Radical
Remission.” She had meditation tapes but had not used
them. (Tr. 642). Dr. Soriano assessed anxiety and dysthymia
and recommended an elimination diet, more exercise and
referred Hendrickson to therapy. (Tr. 643).
23, 2016, Hendrickson saw Dr. Su who opined again that
Hendrickson's positive ANA test was likely due to her
Hashimoto's disease and suggested that her vitamin D
levels be checked as a potential cause for her fatigue. (Tr.
5, 2016, Hendrickson was a no-show for her psychology
appointment at the Cleveland Clinic. (Tr. 637). On July 6,
2016, Dr. Soriano diagnosed attention and concentration
deficit and encouraged Hendrickson to remain on a gluten,
dairy and sugar-free diet and to avoid alcohol. (Tr. 636).
Dr. Soriano told Hendrickson to do energy routine exercises
twice a day and to follow-up in a few weeks. (Tr. 636-637).
September 14, 2016, Hendrickson told Dr. Hutchins that she
still felt scattered and her B12 shots were causing extreme
fatigue. (Tr. 871). On October 17, 2016, Hendrickson told Dr.
Hutchins that her symptoms improved when she was on a strict
diet and then worsened when she didn't follow the strict
diet. (Tr. 891). On October 27, 2016, Dr. Wojtowicz added
Vitamin D for Hendrickson's fatigue and increased her
dosage of Tirosint for her thyroid. (Tr. 934).
January 10, 2017, Hendrickson requested new thyroid and
ferritin lab tests from Nurse Havens. (Tr. 938). Havens told
Hendrickson that there was no need to continually check her
thyroid panels, but she ordered the lab work because
Hendrickson was adamant. (Tr. 940). The lab work was
completed on January 13, 2017. Nurse Havens reviewed the
results and noted that Hendrickson should be told that her
thyroid, iron and cholesterol levels looked good/stable. (Tr.
followed-up with Dr. Wojtowicz in June 2017. (Tr. 930-931).
Dr. Wojtowicz continued with the ...