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Stinedurf v. Commissioner of Social Security

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

December 20, 2019


          SARA LIOI, JUDGE


          Thomas M. Parker, United States Magistrate Judge

         I. Introduction

         Plaintiff, Tracee Stinedurf, seeks judicial review of the final decision of the Commissioner of Social Security, denying her application for supplemental security income benefits (“SSI”) under Title XVI of the Social Security Act. This matter is before me pursuant to 42 U.S.C. § 405(g) and Local Rule 72.2(b). Because the Administrative Law Judge (“ALJ”) failed to apply proper legal standards in evaluating a treating-source opinion, I recommend that the Commissioner's final decision denying Stinedurf's application for SSI be VACATED and that Stinedurf's case be REMANDED for further consideration.

         II. Procedural History

         On November 23, 2015, Stinedurf protectively filed her application for SSI. (Tr. 452).[1]Stinedurf alleged that she became disabled on April 1, 1996, due to reflex sympathetic dystrophy syndrome (“RSD”), herniated disc, cervical radiculopathy and depression. (Tr. 452, 468). She later submitted an amended onset date of November 23, 2015. (Tr. 47). The Social Security Administration denied Stinedurf's application initially and upon reconsideration. (Tr. 385, 393). Stinedurf requested an administrative hearing. (Tr. 397). ALJ Gregory M. Beatty heard Stinedurf's case on May 17, 2018, and denied the claim in a June 20, 2018, decision. (Tr. 13-25). On January 25, 2019, the Appeals Council denied further review, rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-3). On March 5, 2019, Stinedurf filed a complaint to seek judicial review of the Commissioner's decision. ECF Doc. 1.

         III. Evidence

         A. Relevant Medical Evidence

         Stinedurf has been diagnosed with several conditions including lumbar discogenic disease, cervical radiculopathy, RSD, migraine headaches, anxiety, central sleep apnea and severe pain. She uses an implanted Medtronic infusion pump for pain medication. (Tr. 547).

         On January 19, 2009, an MRI of Stinedurf's lumbar spine showed minimal discogenic lumbar disease. (Tr. 532). A polysomnography in September 2009 showed obstructive and central sleep apnea with central apnea being far more severe. (Tr. 529). A titration study in October 2009 showed that Bi-Pap was largely ineffective at improving the central apnea (a small decrease from 275 apneas to 191 apneas occurred on titration; REM sleep was not achieved.) (Tr. 530). On September 21, 2011, an electromyelogram study of Stinedurf's upper right extremity was normal. (Tr. 537).

         On June 8, 2015, Stinedurf's pain pump was removed and replaced in a surgical resection, with extensive scar tissue. (Tr. 944). Following the surgery, Stinedurf reported increased problems with her RSD. On June 10, 2015, Stinedurf reported an increase in pain and limitation to her lower extremities and new pain problems in her upper left extremity. (Tr. 669-671). On examination she was very sensitive to light touch over her legs and left arm; she had decreased strength in her legs and left upper extremity (decreased grip strength); she had muscle spasms in her lumbar spine; positive facet loading testing; and decreased range of motion in all planes. Mentally, she had a restricted affect; she was irritable and tearful. (Tr. 670-671). Positive findings such as muscle spasms, weakness, decreased sensation, decreased range of motion and hypersensitivity in her legs and left arm continued. (Tr. 678, 682, 687). Examination findings also showed swelling in her legs, discoloration and weakness of her left upper extremity, abnormal coordination, and sensory deficits in her lower extremities and left upper extremity. (Tr. 697).

         At the end of 2015 and beginning of 2016, Stinedurf underwent a series of left stellate ganglion blocks to her left lower extremity. (Tr. 714, 722, 728). In February 2016, she went to the emergency room after falling on some steps. Examination showed decreased range of motion, tenderness to palpation, spasm and neurological hypersensitivity. (Tr. 782- 283). A CT scan of her cervical spine showed mild reversal of the cervical lordosis. (Tr. 888).

         On March 2, 2016, Stinedurf reported neck pain. She had some extremity weakness and sensory deficit, although she displayed symmetrical strength. She continued taking medications for her conditions. (Tr. 850). Notes from March 7, 2016 show that Stinedurf may have misplaced a prescription; she reported having short-term memory problems. (Tr. 953). Stinedurf's pain management physician, Dr. Tracy Neuendorf's, examinations in July and August 2016 showed tenderness to palpation, spasm, reduced range of motion with pain, positive straight leg raise testing bilaterally, positive Faber's testing and positive Facet's testing. (Tr. 830, 833).

         An x-ray of Stinedurf's right knee on September 9, 2016 showed mild medial compartment arthrosis and small joint effusion. During a pain management appointment with Dr. Neuendorf on November 6, 2016, Stinedurf complained of bilateral lower extremity pain and left arm discoloration. (Tr. 956). She had tenderness, significant muscle spasms and reduced range of motion in all three planes of her spine.[2] She was able to ambulate without an assistive device. She had unusual spasm, numbness and tingling of her legs and arms. (Tr. 958).

         On February 8, 2018, Stinedurf complained of ongoing low back pain radiating down her legs. She reported that her pain was aggravated with activity and controlled with her current pain medication and pain pump. (Tr. 979). Examination of her back showed tenderness, palpable spasms and decreased motion in her back with positive hyperreflexia. (Tr. 980). She displayed normal motor strength and a non-antalgic gait. (Tr. 980). Stinedurf declined physical and aquatic therapy referrals and continued her medication regimen. (Tr. 981).

         On March 12, 2018, at another pain management appointment for refill of her pain pump, Stinedurf reported ongoing low back pain. She described the pain as radiating from her back down her legs to her feet and in her left arm, with numbness and tingling. (Tr. 975). Examination showed cervical spine muscle spasms, multiple trigger points and texture, asymmetry, altered range of motion and tenderness changes. She also had tenderness in her trapezius and paraspinal muscles, limited neck range of motion due to pain, RSD spread to left arm with positive Spurling sign in the left arm, bilateral paraspinal muscle spasm, decreased range of motion in the back, positive RSD in the lower limbs, positive hyperreflexia, osteoarthritis of the right knee, and positive lumbar facet loading bilaterally. (Tr. 977-978).

         B. Relevant Opinion Evidence

         1. Treating Source Opinion-Tracy Neuendorf, D.O.

         On August 23, 2017, Dr. Neuendorf completed a medical source statement. (Tr. 965-966). He opined that Stinedurf was unable to lift more than 10 pounds; could stand and walk no more than an hour a day; could sit no more than two hours a day (Tr. 966); would rarely be able to reach, push/pull and perform gross manipulation; and would occasionally be able to perform fine manipulation. He opined that Stinedurf's pain was likely to cause absenteeism and off-task behaviors. He opined that she would require six hours of breaks beyond those normally allowed in a typical work environment. Dr. Neuendorf stated that his opinions were based on physical exam. He also opined that Stinedurf would be unable to engage in any meaningful employment. (Tr. 967).

         2. State Agency Consulting Examiner, Jennifer Haaga, Psy.D.

         On April 19, 2016, consulting psychologist, Jennifer Haaga, examined Stinedurf at the request of the state agency. (Tr. 772-779). Dr. Haaga diagnosed persistent depressive disorder, late onset with anxious distress with intermittent major depressive disorder. (Tr. 777). Dr. Haaga reported that Stinedurf would be limited to performing simple routine tasks; would likely need reminders and assistance (particularly when learning new jobs); would have some difficulty with attention and concentration, with her symptoms of anxiety and depression likely causing difficulties in this area or exacerbating those difficulties that she already had. She would likely also have increased symptoms if faced with pressure in a work situation particularly if she felt she was not able to complete tasks. (Tr. 778). Dr. Haaga also noted that Stinedurf was tearful, shifted in her chair at times and appeared uncomfortable. (Tr. 775).

         3. State Agency Reviewing Physicians

         On January 29, 2016, state agency reviewing physician, Stephen Sutherland, M.D., reviewed Stinedurf's records. He opined that Stinedurf could perform light work, but she could never climb ladders, ropes, or scaffolds; she could frequently stoop, kneel, crouch, crawl, and climb ramps or stairs; and she must avoid concentrated exposure to temperature changes, vibration and hazards. (Tr. 362-363).

         On April 28, 2016, a state agency psychologist, Judith Schwartzman, Psy.D., reviewed Stinedurf's records and opined that she was limited to simple, routine tasks without strict time or production standards, in a non-public environment where interactions with others were brief and superficial. She opined that supervisors must offer constructive criticism in a relatively static environment with advance notice and gradual implementation of major changes. (Tr. 363-365).

         Another state agency reviewing physician, Mehr Siddiqui, M.D., reviewed Stinedurf's records on September 7, 2016. She generally agreed that Stinedurf was limited to light work with the same postural limitations as Dr. Sutherland. However, she opined that Stinedurf could only stand and/or walk for four hours and must be able to alternate positions every thirty minutes due to her RSD. (Tr. 378). Dr. Siddiqui ...

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