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Hendrickson v. Commissioner of Social Security

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

September 5, 2019



          Thomas M. Parker, United States Magistrate Judge.

         I. Introduction

         Plaintiff, 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.

         II. Procedural History

         On March 15, 2016, Hendrickson applied for DIB. On March 23, 2016, she applied for SSI. (Tr. 215, 219).[1] 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.

         III. Evidence

         A. Relevant Medical Evidence

         On 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).

         On 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).

         On 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).

         On 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).

         Hendrickson 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).

         On 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. (Tr. 392).

         On 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. (Tr. 348).

         On 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. 548).

         On 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).

         A lab 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).

         On 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).

         The 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).

         On 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).

         On 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).

         On 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).

         Hendrickson 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).

         On 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).

         Between 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).

         On 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).

         On June 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. 652).

         On June 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).

         On June 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. 641).

         On July 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).

         On 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).

         On 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. 946).

         Hendrickson followed-up with Dr. Wojtowicz in June 2017. (Tr. 930-931). Dr. Wojtowicz continued with the ...

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