United States District Court, D. Arizona
Mary E. Koriel, Plaintiff,
Carolyn W. Colvin, Defendant.
BRIDGET S. BADE, Magistrate Judge.
Mary E. Koriel (Plaintiff) seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner) denying her application for 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 benefits.
I. Procedural Background
On August 26, 2009, Plaintiff applied for supplemental security income under Title XVI of the Act. (Tr. 231-39.) Plaintiff alleged that she had been disabled since January 1, 2003. ( Id. ) Plaintiff later amended her disability onset date to August 14, 2009. (Tr. 25.) 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). After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 25-34.) This decision became the final decision of the Commissioner when the Social Security Administration Appeals Council denied Plaintiff's request for review. (Tr. 1-6); 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 Record
The record before the Court establishes the following history of diagnosis and treatment related to Plaintiff's health. The record also includes a lay opinion and opinions from state agency physicians who examined Plaintiff or reviewed the records related to her health, but who did not provide treatment.
A. Medical Treatment
1. Lauren Bonner, M.D.
On June 9, 2004, Plaintiff sought treatment from Dr. Bonner for symptoms of psychological disturbance. (Tr. 390-91.) Plaintiff reported that she was attending a drug diversion program and was taking prescribed medications secondary to intrusive memories of a rape. ( Id. ) Dr. Bonner assessed major depressive disorder, posttraumatic stress disorder (PTSD), opiate dependence in full remission, and somatization disorder. ( Id. ) Dr. Bonner assessed a Global Assessment of Functioning (GAF) score of 50. ( Id. ) Later that same month, Dr. Bonner assessed a GAF score of 47-48. (Tr. 384.)
On February 18, 2004, Plaintiff reported that she was afraid to attend counseling related to the drug diversion treatment because she had difficulty discussing her feelings with strangers. (Tr. 381.) On February 27, 2004, Dr. Bonner noted that Plaintiff exhibited passive behavior and symptoms of anxiety, depression, helplessness, and low self-esteem. (Tr. 379.) Plaintiff reported that she was paranoid, depressed, and had trouble sleeping. (Tr. 377.) Dr. Bonner noted that Plaintiff's compliance with medication was "poor" because she had taken more than the recommended dose of Klonipin. ( Id. )
On April 12, 2004, Dr. Bonner noted that Plaintiff's condition was not improving with medication. (Tr. 375-76.) On April 29, 2004, Plaintiff was tearful, irritable, and dysphoric. (Tr. 369-70.) Plaintiff wanted to change anti-depressant medication to try to reduce her symptoms. ( Id. ) Dr. Bonner continued to treat Plaintiff throughout 2004 for depression and PTSD, and a possible eating disorder. (Tr. 354-68.) She noted that Plaintiff often presented in a dysphoric mood, sometimes missed appointments, refused counseling except for a women's group, and self-adjusted her medication. ( Id. )
In July 2005, a nurse practitioner (NP) at NOVA examined Plaintiff and confirmed a history of anxiety, panic, anger, decreased concentration, and suicidal ideation. (Tr. 406-08.) Plaintiff reported auditory and visual hallucinations. ( Id. ) Plaintiff presented with an agitated labile affect, and was anxious and depressed. ( Id. ) She exhibited occasional loose associations, circumstantial speech, and a sense of diminished worth. ( Id. ) The NP opined that Plaintiff had bipolar disorder and possible negative effects from prescribed medications. (Tr. 409-10.)
On October 3, 2005, Plaintiff reported daily headaches, an inability to concentrate, tearfulness, and a flat, anxious, and agitated affect. (Tr. 401-02.) The NP diagnosed Plaintiff with bipolar disorder and schizoaffective disorder. ( Id. )
3. John Koryakos, M.D.
In 2004, Plaintiff began treatment with Dr. Koryakos for physical and psychological issues. (Tr. 493-94.) On June 24, 2004, Dr. Koryakos noted that Plaintiff had chronic pelvic pain, depression, insomnia, headaches, chronic lower back and hip pain, and gastrointestinal upset. ( Id. ) Dr. Koryakos continued to treat Plaintiff for these issues, and also noted insomnia and a possible eating disorder. (Tr. 476-92.)
In September 2005, Dr. Koryakos saw Plaintiff for a medication refill. (Tr. 473.) Plaintiff reported pain and numbness in her fingers of both hands, and tenderness in her lumbar paraspinal muscles. (Tr. 473.) On October 26, 2005, Dr. Koryakos noted that Plaintiff continued to experience insomnia, headaches, and side effects from her medications. (Tr. 474.) From November 2005 through January 2006, Dr. Koryakos found that Plaintiff also had ongoing pelvic pain, and gastroesophagel reflux disease (GERD) symptoms. (Tr. 471-72.)
In 2006, Dr. Koryakos continued treating Plaintiff for back and neck pain, body pain, joint pain, hip pain, and knee pain. (Tr. 469.) Plaintiff reported tingling and numbness in her left leg and the tips of her fingers. ( Id. ) An MRI of Plaintiff's cervical spine on April 5, 2006 showed "mild left neural foraminal narrowing at C5-6 secondary to degenerative disc disease and mild facet arthropathy." (Tr. 509-10.) Throughout 2006, Dr. Koryakos treated Plaintiff for pelvic and body pain, numbness and tingling in her left arm, insomnia, anxiety, and pain in her shoulders. (Tr. 459-68.)
On April 16, 2008, Dr. Koryakos treated Plaintiff for increased low back pain after a fall. (Tr. 453.) On May 9, 2008, Plaintiff reported diffuse pain in all of her joints. (Tr. 452.) She had positive trigger points in her thoracic and lumbar spine, and fatigue. ( Id. ) Dr. Koryakos "suspect[ed]" fibromyalgia. ( Id. ) On June 24, 2008, Dr. Koryakos noted that Plaintiff had stomach upset and heart palpitations from Neurontin, and noted that Neurontin was not controlling Plaintiff's pain. (Tr. 449.) Plaintiff continued to report chronic body and joint pain. ( Id. ) Dr. Koryakos assessed arthralgia, myalgias, and "F.M." (fibromyalgia). ( Id. )
Laboratory tests on October 9 and November 2008 showed that Plaintiff had low red blood cell counts, low hemoglobin, and low hematocrit. (Tr. 498-500.) On November 19, 2008, Dr. Koryakos noted that Plaintiff experienced pain in her arms and legs, headaches, bloating, positive trigger point tenderness, and bulimia. (Tr. 448.)
On March 6, 2009, Dr. Koryakos treated Plaintiff for a headache that had been present for two weeks and was not responding to Imitrex. (Tr. 447.) Dr. Koryakos treated Plaintiff for headaches and body pain on April 2, May 6, and May 18, 2009. (Tr. 444-46.)
In 2008 and 2009, Dr. Koryakos treated Plaintiff for headaches, fibromyalgia, bloating, abdominal pain, low iron levels, dizziness, medication side effects, upper back pain, GERD, and fatigue. (Tr. 517-45.)
In 2009, Dr. Koryakos continued treating Plaintiff for body pain, GERD, dizziness, balance problems, and fibromyalgia. He also noted that Plaintiff had lost her insurance and was having difficulty affording medication. (Tr. 713-26.)
In 2010 and 2011, Dr. Koryakos continued treating Plaintiff for fibromyalgia pain, joint pain, pelvic pain, ...