BRIDGET S. BADE, District Judge.
Carrie Davis (Plaintiff) seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner), denying her applications for disability insurance benefits and supplemental security income benefits under the Social Security Act. The parties have consented to proceed before a United States Magistrate Judge pursuant to 28 U.S.C. § 636(b) and have filed briefs in accordance with Local Rule of Civil Procedure 16.1. For the following reasons, the Court reverses the Commissioner's decision and remands for further proceedings.
I. Procedural Background
In January 2010, Plaintiff applied for disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act (the Act). (Tr. 20.) Plaintiff alleged that she was disabled due to psoriatic arthritis, fibromyalgia, degenerative disc disease, and liver, skin, and nerve disorders. (Tr. 20, 43, 222.) She initially alleged that her disability began on October 14, 2009, but she later amended her alleged disability onset date to March 10, 2010. ( Id. ) After the Social Security Administration (SSA) denied Plaintiff's initial application and her request for reconsideration, she requested a hearing before an administrative law judge (ALJ). (Tr. 2.) After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 20-30.) This decision became the final decision of the Commissioner when the Social Security Administration Appeals Council denied Plaintiff's request for review. (Tr. 1-5); see 20 C.F.R. § 404.981 (explaining the effect of a disposition by the Appeals Council).
II. Medical Record
The record before the Court establishes the following history of diagnosis and treatment related to Plaintiff's physical health. The record also includes opinions from State Agency Physicians who examined Plaintiff, but did not provide treatment.
A. Michael J. Fairfax, D. O., Treating Physician
Plaintiff received treatment from rheumatologist Michael J. Fairfax, D.O. at Arthrocare Arthritis Care and Research P.C. (AAC&R), starting in January 2010, for complaints of generalized musculoskeletal pain and polyarthralgias. (Tr. 532-34.) Plaintiff received treatment approximately every one to two months. She had symptoms of psoriatic arthritis and fibromyalgia. (Tr. 533.) Plaintiff complained of fatigue and non-restorative sleep. She also reported pain in her knees, elbows, hands, shoulders, neck, low back, hips, and ankles. ( Id. ) She reported stiffness in her joints for approximately thirty minutes every morning. Plaintiff reported night sweats, a history of psoriasis, easy bruising, a history of Raynaud's phenomenon, dry eyes, dry mouth, tinnitus, muscle weakness, a history of depression, intermittent anorexia, and constipation. ( Id. ) A physical examination revealed scattered psoriasiform lesions, nail pitting, and oncholysis. ( Id. ) Plaintiff had abdominal tenderness and Dr. Fairfax noted that she was receiving treatment for a questionable mass. ( Id. ) Plaintiff had lumbar paravertebral tenderness and multiple tender points with light palpation over major muscle, bursal, and tendon groups. (Tr. 533.) Dr. Fairfax did not note any gross motor or sensory deficits or objective signs of muscle weakness. ( Id. ) Dr. Fairfax diagnosed Plaintiff with cutaneous psoriaisis, polyarthralgias with a history of psoriatic arthritis, degenerative disk disease of the cervical spine, ulnar neuropathy, a history of pelvic mass and right upper quadrant mass of questionable significance. ( Id. ) He recommended hand, knee, and ankle/foot x-rays. ( Id. )
Bilateral hand x-rays revealed normal bone anatomy, normal joint spacing, and normal soft tissue based on Plaintiff's age. (Tr. 537.) Bilateral foot/ankle x-rays revealed mild symmetrical osteoarthritis. (Tr. 538.) Bilateral knee x-rays revealed mild symmetrical loss of joint space height, representing mild osteodegenerative changes. (Tr. 539.) After reviewing the x-rays, in February 2010, Dr. Fairfax diagnosed cutaneous psoriasis, questionable psoriatic arthritis, and fibromyalgia. (Tr. 681.) He recommended medication for arthritis. ( Id. )
Dr. Fairfax examined Plaintiff again on April 10, 2010. (Tr. 684-686.) Plaintiff reported that she could dress herself, lift a cup, and turn regular faucets without any difficulty. (Tr. 684.). She also reported that she could get in and out of bed, walk on flat ground, wash and dry her entire body, get in and out of a car with "some" difficulty, and bend to the floor to pick up clothing with "much" difficulty. ( Id. ). Dr. Fairfax diagnosed fibromyalgia and questionable psoriatic arthritis and recommended that Plaintiff continue her current treatment. (Tr. 685.)
Dr. Fairfax saw Plaintiff on July 27, 2010 for a follow-up appointment. (Tr. 730-731.) Plaintiff reported increased pain and swelling in her feet and radiating back pain. (Tr. 730.) Examination revealed the absence of joint synovitis. ( Id. ) Plaintiff reported that she could turn regular faucets without any difficulty, dress herself, lift a cup, wash and dry her entire body with "some" difficulty, walk on flat ground and bend to the floor to pick up clothing with "much" difficulty, get in and out of bed and in and out of a car with "some" to "much" difficulty. (Tr. 731.) Dr. Fairfax diagnosed questionable psoriatic arthritis. (Tr. 730.)
Dr. Fairfax examined Plaintiff again on September 2, 2010. (Tr. 727-729.) Plaintiff presented with "arthralgias of the ankles and knees and worsening low back pain." (Tr. 727.) Dr. Fairfax noted that on examination Plaintiff had lumbar spine and paravertebral tenderness, but no joint synovitis. ( Id. ) Plaintiff reported that she could lift a cup without any difficulty, get in and out of bed, wash and dry her entire body, turn regular faucets, and get in and out of a car with "some" difficulty. (Tr. 729.) She also reported that she could walk on flat ground and bend to the floor to pick up clothing with "much" difficulty, and dress herself with varying degrees of difficulty. ( Id. ) Dr. Fairfax again diagnosed questionable psoriatic arthritis. (Tr. 727.) He ordered lumbar spine x-rays, which revealed mild abnormalities. (Tr. 737.)
Dr. Fairfax examined Plaintiff again on November 24, 2010. (Tr. 723-724.) Plaintiff reported that medication was somewhat effective in treating her symptoms. (Tr. 723.) Examination revealed the absence of joint synovitis. ( Id. ) Dr. Fairfax diagnosed generalized osteoarthritis and fibromyalgia and concluded there was no evidence of psoriatic arthritis. He recommended that Plaintiff continue her current treatment. (Tr. 723.)
On December 6, 2010, Dr. Fairfax completed a Medical Assessment of Ability to do Work-Related Physical Activities (Physical Assessment). (Tr. 739.) Among other limitations, Dr. Fairfax found that Plaintiff could sit, stand, and walk less than two hours in an eight hour day. (Tr. 739.) He further found that she could not crawl or kneel. (Tr. 739-740.) Dr. Fairfax completed a second Physical Assessment on April 2, 2011. He noted that Plaintiff had shortness of breath, chronic fatigue, and chronic pain. He noted that medication and rest with reclining or lying down reduced her symptoms, and that stress or physical activity increased them. (Tr. 742-43.)
Dr. Fairfax saw Plaintiff on July 20, 2011. (Tr. 829.) He reported that examination revealed tenderness with light palpation over major muscle, bursal, and tendon groups, reduced shoulder ranges of motion, and the absence of joint synovitis. (Tr. 829.) Dr. Fairfax diagnosed psoriatic ...