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Simington v. Commissioner, Social Security Administration

United States District Court, D. Oregon, Eugene Division

July 25, 2017

COMMISSIONER, Social Security Administration, Defendant.


          Ann Aiken United States District Judge

         Plaintiff, Ashley Nicole Simington, brings this action pursuant to the Social Security Act ("Act"), 42 U.S.C. § 405(g), to obtain judicial review of a final decision of the Commissioner of Social Security ("Commissioner"). The Commissioner denied plaintiffs application for a Period of Disability and Disability Insurance Benefits ("DIB"). For the reasons set forth below, the Commissioner's decision is reversed and remanded for an immediate award of benefits.


         On January 7, 2013, plaintiff first filed for Social Security DIB. Plaintiff alleged disability beginning February 16, 2010. Tr. 17. Plaintiffs application was initially denied, and denied again upon reconsideration. Id. Plaintiff then filed a request for a hearing before an Adminstrative Law Judge ("ALJ") on October 16, 2013. Id. The hearing was held on September 26, 2014. Id. At the hearing, plaintiff amended the alleged onset date of her disability to June 22, 2010. Id. On December 8, 2014, the Commissioner denied plaintiffs application. Tr. 27. Plaintiff sought review of the ALJ's decision, which was denied by the Appeal Council on May 5, 2016. Tr. 1-3. Plaintiff filed the present complaint against the Commissioner in this Court on July 7, 2016.

         Plaintiff has a history of cervical neuralgia, recurring migraine headaches, depression, anxiety, insomnia, bulimia nervosa, and post-traumatic stress disorder ("PTSD"). Tr. 19-20, 258, 261, 263, 266. On February 16, 2010, plaintiff was in a car crash, which resulted in neck and back pain. Tr. 285-87. On March 1, 2010, plaintiff was diagnosed with cervical strain. Tr. 544-45. Her pain became more significant by March 11, 2010. Tr. 543. Plaintiff reported "lots of pain" sitting at a desk, and an inability to drive without pain. Id. Plaintiffs primary care doctor, Dr. Diana Bolduc, reported a limited range of motion and tenderness in the afflicted areas. Tr. 543-44, By the end of the month, the pain improved. Tr. 541. But in April, upon returning to work, the intense pain returned. Plaintiff began to miss work on account of the pain. Tr. 539-40. On August 4, 2010, Dr. Bolduc spoke via telephone with Eugene neurosurgeon Dr. Carmina Angeles, who acknowledged the possibility of a cervical spine fracture. Tr, 538, Dr. Angeles recommended plaintiff wear a hard neck collar, and undergo an x-ray. Plaintiff was pregnant at this point in time and unable to undergo an x-ray at such an early stage in the pregnancy. Dr. Angeles also recommended an MR1 as soon as her obstetrician felt comfortable with the procedure. Id.

         Plaintiff underwent the MRI in September of 2010. Dr. Angeles determined she did not have a fracture. Tr, 689. However, plaintiff continued to report pain, and even difficulty "laying down on the pillow." Tr. 679. Dr. Angeles diagnosed plaintiff with a C2 radiculopathy. Tr. 680. She recommended that plaintiff do an occipital nerve block, but noted that plaintiff would have to wait until after she had given birth. Dr. Angeles also identified occipital nerve ligation as a last resort option. Id. Plaintiff was referred to Dr. Gregory Moore. Tr, 673.

         In October, Dr. Moore noted that plaintiff reported her pain levels at 10/10, and she scored a Pain Disability Index score of 66. Id. Dr. Moore recorded "[t]enderness to palpation over the suboccipital region with referred pain and paresthesia across the occipital nerve", as well as limited cervical range of motion. Tr. 674. Dr. Moore reviewed plaintiffs September MRI, and noted small ossifications "in the midbody of the dens." Id. Dr. Moore ultimately diagnosed plaintiff with: (1) possible remote history of dens fracture; (2) occipital neuralgia; (3) mysfascial pain; and (4) cervical spondylosis, possible DRG-mediated pain. Tr. 675. Dr. Moore performed an occipital nerve block on plaintiff. Tr. 672.

         Dr. Angeles saw plaintiff again in January, 2011. Dr. Angeles reported that plaintiff had not felt any relief from the occipital nerve block procedure. Tr. 670. Plaintiff gave birth to her child in mid-February, 2011. Tr. 273. As she was no longer pregnant, more treatment options became available, and, on March 1, 2011, plaintiff sought more aggressive treatment to address her pain. Tr. 670. The next week, plaintiff again visited Dr. Angeles. Dr. Angeles reported plaintiff had head pain, which radiated to her shoulders when she lay on the back of her head. Tr. 669. She also reported a continued limited range of cervical motion. Id. Dr. Angeles recommended a suboccipital pain stimulator for pain relief. Id. On March 25, 2011, plaintiff underwent an occipital nerve ligation and a cranioplasty procedure. Tr. 667. At the end of April, 2011, Dr, Angeles reported that plaintiffs migraine headaches and pain had improved. Tr. 666. But by June 1, 2011, plaintiff was again suffering from persistent headaches and neck pain. Tr. 665. Dr. Angeles directed plaintiff to take Tylenol with codeine to address the pain. Id.

         In mid-July 2012, plaintiff began seeing a new primary care provider, Paul Leppert, ANP. Plaintiff reported to Mr. Leppert that she still had recurring headaches, as well as increased feelings of depression. Tr. 360. On July 18, 2012, plaintiff began counseling sessions with Gladys Shade, LCSW, per a referral by Mr. Leppert. Tr. 347. Ms. Shade noted plaintiff had symptoms of PTSD "related to ongoing childhood...sexual abuse". Ms. Shade further described plaintiffs symptoms as: "[d]epressed/sad mood, anhedonia, poor functioning level, extreme lack of energy, intrusive memories, nightmares, poor sleep, extreme hypervigilance (dead bolts her bedroom door at night), paranoid feelings/thoughts, angry outbursts, extreme fear for her 2 year old daughter ..." Tr. 347-48. Additionally, plaintiff felt "panic symptoms often, " a fear of people and leaving her home, and feelings of anger upon physical contact with her husband. Tr. 348. Plaintiff had few people to talk with about her problems and was no longer employed. Id. Ms. Shade diagnosed plaintiff with depressive disorder, PTSD, panic disorder with agoraphobia, and bereavement. Tr. 349. Ms. Shade ordered further counseling and psychiatric medication. Id.

         On December 13, 2012, plaintiff visited her original primary care provider, Dr. Bolduc. Plaintiff complained of continued pain from chronic headaches, mood disorder, and neck pain. The neck pain was reported to be not as severe as it once was, but still present. Her headaches had worsened. Tr. 531-32. Plaintiff reported that taking Imitrex alleviated her headaches for a day, but that her nine pills per month prescription was insufficient. Dr. Bolduc declined to increase her prescription. Id. Plaintiff continued to take Topamax, but asserted that it did little to alleviate her headaches. Tr. 532.

         In early January 2013, plaintiff again met with Dr. Bolduc regarding her chronic headaches and mood disorder. Tr. 530. Plaintiff reported frustration that she had not been able to keep any employment since 2010 on account of her symptoms. Plaintiff said she had headaches three days per week. Id. She also reported severe insomnia and anxiety while using Topamax. Dr. Bolduc prescribed Cymbalta instead. Id. Following up with plaintiff at the end of the month, Dr. Bolduc noted plaintiff had an adverse reaction to Cymbalta. After this, plaintiff only used Imitrex to treat her headaches. Tr. 529. Plaintiff also began to take Zoloft to regulate her mood. She had taken Zoloft in the past, but stopped because of its negative side effects. Plaintiff stated that she was "rather tired of not having her mood control". Id.

         On January 30, 2013, plaintiff again visited Dr. Angeles regarding her pain. Plaintiff reported to Dr. Angeles "tremendous" pain when combing her hair on the left side of her head, and upon turning her head 45 degrees to the side. Tr. 663. She claimed to be "unable to tolerate steroid injections of pain medications. She is feeling desperate and . . . can no longer live with her pain." Id. Dr. Angeles recommended an x-ray and an MRI. Plaintiff indicated interest in pursing surgical treatment. Tr. 664. Dr. Angeles performed a bilateral C2 nerve ligation on plaintiff on March 3, 2013. Tr. 652. By mid-May, plaintiff reported abatement of sharp cervical pain. Tr. 708. However, she complained her neck was "tight" and "heavy" and that she had trouble sleeping as a result. Id. In June 2013, plaintiff reported she had "hand and feet numbness since her last neck surgery, " Tr, 706.

         In mid-June 2013, plaintiff returned to Dr. Bolduc for exasperated mental health issues. Tr, 705. Dr. Bolduc increased plaintiffs Zoloft prescription, prescribed clonidine, and recommended further therapy. Id. The next week, Plaintiff saw Dr. Mark Ramirez, a neurologist. Tr. 701. Based on her headache symptoms. Dr. Ramirez prescribed Gabapentin, Fioricet, and permitted her to continue taking Sumatriptan, which she had been prescribed previously. Tr. 704. That same day, Plaintiff followed through with Dr. Bolduc's recommendation to seek therapy, and saw Janis Petrie, CNS. Plaintiff reported panic attacks twice a week and suicidal thoughts. Tr. 692. Ms. Petrie took plaintiff off Zoloft, and in place, prescribed Lexapro, Trazadone, Prazosin, and Buspar. Tr. 693, On June 27, 2013, plaintiff returned to Dr. Angeles. She reported diminished sharp cervical pain, but instead a burning pain. Tr. 647. Dr. Angeles increased her Gabapentin dosage, and noted that the burning "can be explained by retrograde denigration of the C2 nerve." Tr. 648. Over the next couple of months, plaintiff was unable to attend multiple therapy appointments because of the status of her mental health. Tr. 941-63. Plaintiff was able to make an August 2, 2013, follow-up visit with Dr. Ramirez. Tr. 697-701. Dr. Ramirez took note that her ongoing headaches, which occur at least once per week, typically last two to three days each. The headaches carried symptoms of nausea, vomiting, photophobia, and phonophobia. Tr. 697. Additionally, plaintiff had "tension type headaches" about three times per week which last the whole day. Tr. 697-98. Dr. Ramirez prescribed plaintiff Maxalt to alleviate headache pain.

         On August 9, 2013 plaintiff reported to a therapist that she attempted suicide two weeks prior by overdosing on prescription medications. Tr. 839. Plaintiff also reported manic episodes, lasting up to two days, in which her husband had to take off work, her child had to go to her grandparents' house, and ultimately her husband and father had to physically restrain her. Tr. 839. Plaintiff also stated that she could not work due to her severe neck pain. Id.

         In September 2013, plaintiff began seeing Mary Frodermann, FNP, Ms. Frodermann saw plaintiff on a regular basis, and she reiterated the presence of plaintiff s ongoing symptoms. Tr, 876-892. In October 2013, plaintiff reported to psychiatric nurse practitioner Toni Dame wood that she had hallucinations for two weeks. Tr. 858. In December 2013, Ms. Frodermann recorded that plaintiff is still depressed, and stopped taking most of her medications. Tr. 883. Ms. Frodermann "encouraged her to continue counseling." Id. In January, 2014, plaintiff reported to Ms. Frodermann that she was going to see a neurosurgeon at UC Davis. In anticipation of the trip, some of her medications were restarted, and some dosages were increased. Tr. 881. Additionally, plaintiff was prescribed Rizatriptan and Mataxalone. Tr. 882.

         In March 2014, plaintiff again saw Dr. Angeles. Plaintiff complained that her pain was the same as it was prior to the nerve ligation surgery. Tr. 867. Dr. Angeles noted that there was nothing surgical she could do to alleviate the symptoms at this point. Tr. 869. In April 2014, plaintiff visited Toni Damewood, a psychiatric nurse practitioner. Ms. Damewood noted that plaintiff suffered from ongoing depression, anxiety, panic attacks 3-4 times per week, chronic pain, forgetfulness, an inability to drive, an inability to sleep, an inability to cook and do laundry, and a preference to stay in bed all day, Tr. 852. By this point, Ms. Damewood had diagnosed plaintiff with Bipolar Disorder. Tr. 853. Ms. Damewood prescribed Divalproex, in addition to plaintiffs other medications. Id. On May 7, plaintiff reported to psychiatric nurse practitioner Janus Maybee that she had again attempted ...

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