United States District Court, D. Oregon, Eugene Division
OPINION AND ORDER
Aiken United States District Judge
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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
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.
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 ...