United States District Court, D. Arizona
Elizabeth N. Feliz, Plaintiff,
Carolyn W. Colvin, Acting Commissioner of Social Security Defendant.
BRIDGET S. BADE, Magistrate Judge.
Elizabeth N. Feliz (Plaintiff) seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner), denying her application for disability insurance benefits under the Social Security Act (the 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 an award of benefits.
I. Procedural Background
On October 21, 2009, Plaintiff applied for disability insurance benefits under Title II of the Act. 42 U.S.C. § 401-34. (Tr. 142.) Plaintiff alleged that she had been disabled since May 4, 2009, due to abdominal cutaneous nerve entrapment syndrome (ACNES). (Tr. 142-43, 177.) 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. 85-86.) After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 15-21.) 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.) Plaintiff now seeks judicial review of this decision pursuant to 42 U.S.C. § 405(g).
II. Medical and Opinion Evidence
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 either examined Plaintiff or reviewed the records related to her physical, but who did not provide treatment.
A. Treatment Records
In May 2009, Plaintiff saw Glenn Lipton, M.D., at Northern Arizona Interventional Pain Management (Arizona Pain Management) with complaints of abdominal pain. (Tr. 253-55, 273.) She reported to Dr. Lipton that she had a history of abdominal pain, and that it was exacerbated after she opened a door at work on May 4, 2009 (her alleged onset date). (Tr. 253.) Dr. Lipton noted that an April 2008 MRI and an April 2008 ultrasound of Plaintiff's abdomen both were normal. (Tr. 255.) He suspected chronic ACNES, prescribed medication for nerve pain (gabapentin), and ordered a lumbar MRI. (Tr. 253-55.) Dr. Lipton directed Plaintiff to "discontinue any activity which triggered an increase in her pain." (Tr. 255.) The MRI showed some joint disease (arthropathy), mild degenerative disc disease, some cysts, and mild scoliosis. (Tr. 256-57 (duplicated at Tr. 260-61).)
In June 2009, Plaintiff saw her primary care physician Daniel Goldsmith, M.D., and reported increased abdominal pain when opening and closing her car doors. (Tr. 272.) She also reported suffering from allergies and neck pain. ( Id. ) That same month, Plaintiff returned to Dr. Lipton for an evaluation of her abdominal pain. (Tr. 251.) Dr. Lipton increased her dosage of gabapentin and recommended that she continue using Lidoderm (a lidocaine patch). He also encouraged her to continue taking antidepressants that Dr. Goldsmith had prescribed and to undergo massage therapy treatments. (Tr. 251-52.) Dr. Lipton assessed Plaintiff with, among other things, severe abdominal pain and ACNES. (Tr. 251.)
In July 2009, Plaintiff went to the Maricopa Integrated Health System outpatient center with complaints of chronic abdominal pain. (Tr. 241-42.) A treatment note signed by medical assistant (MA) Susan King and John Porter, M.D., notes that Plaintiff had constant abdominal pain that was exacerbated by certain movements including pushing and pulling. (Tr. 421.) The treatment note further stated that MA King and Dr. Porter did not "see any significant resolution of the problem." (Tr. 242.) Plaintiff returned to Dr. Goldsmith with similar complaints that month. (Tr. 271.) Dr. Goldsmith noted that "all lifting" more than "approx[imately]" two pounds caused pain. ( Id. ) He also noted that Plaintiff had pain pushing and pulling objects such as doors and boxes, and that stepping up and down also caused pain. ( Id. ) Dr. Goldmsith noted that gabapentin was not helping Plaintiff's pain and that only a Lidoderm patch provided some relief. He described Plaintiff's prognosis as "poor." ( Id. ) In August 2009, Plaintiff returned to Dr. Lipton for follow up. He recommended that she pursue behavioral medicine to learn coping techniques for chronic pain. (Tr. 249-50.)
Plaintiff continued seeing Dr. Goldsmith for her abdominal pain approximately once a month for the remainder of 2009. (Tr. 267-70, 299.) Abdominal and renal ultrasounds during that time were normal. (Tr. 262.) During an August 10, 2009 appointment, Dr. Goldsmith noted that Plaintiff had "occas[ional]" abdominal pain and that she continued to experience pain when "pulling car door closed or pushing it closed, " when leaving the car, and when squatting. ( Id. ) Dr. Goldsmith advised Plaintiff to avoid painful activities but to "remain physically active as tolerated." (Tr. 270.)
In June 2010, Plaintiff went to the Center for Family Medicine with complaints of left ankle pain following activity on a treadmill the previous week. (Tr. 340-45 (duplicated at Tr. 346-47).) Later that month, Plaintiff reported that her ankle pain was gradually improving, and an ankle x-ray showed no obvious fracture. (Tr. 332-33.) Treatment notes from July 2010 indicate that Plaintiff had some left calf atrophy, but that she was walking well. (Tr. 322.) An MRI of Plaintiff's left ankle in August 2010 showed some tendonopathy and mild diffuse thickening. (Tr. 324-25, 332.)
In August 2010, Plaintiff returned to the Center for Family Medicine with complaints of abdominal pain related to constipation. Doctors recommended a stool softener. (Tr. 334-39.) In October 2010, a lumbar x-ray showed some moderate scoliosis and an exaggerated spinal curve (hyperlordosis). (Tr. 401.) Similarly, a lumbar MRI showed moderate to severe lordotic exaggeration at L3-S1, mild to moderate facet degenerative joint disease at L1-S1, and mild right narrowing (stenosis) at L4-L5, but no disc extrusion, narrowing, or direct nerve root impact. (Tr. 399-400.)
B. Opinion Evidence
1. Mark Brechelsen, D.O., State Agency Examining Physician
In December 2009, Mark Brechelsen, D.O., examined Plaintiff in connection with her disability application. The examination showed normal gait, normal ranges of motion in all joints, and full (5/5) motor strength in all of Plaintiff's extremities. Dr. Brechelsen opined that there was no objective evidence or diagnosis to support Plaintiff's alleged disability despite some positive pain findings. He added that he was not familiar with the ACNES condition or diagnosis and that he would defer to a specialist in that area for "possible weight restrictions associated with the condition." (Tr. 278-81.)
2. Terry Ostrowski, M.D., State Agency Reviewing Physician
In January 2010, Terry Ostrowski, M.D. reviewed Plaintiff's medical records and offered an opinion regarding her work-related physical limitations. He noted her complaints of ACNES, and also noted that records showed that she walked on a treadmill for forty-five minutes per day. He noted Dr. Brechelsen's opinion that Plaintiff did not have any work-related ...