United States District Court, D. Arizona
ORDER
Leslie
A. Bowman United States Magistrate Judge
The
plaintiff filed this action for review of the final decision
of the Commissioner for Social Security pursuant to 42 U.S.C.
§ 405(g). (Doc. 1, p. 2)
The
Magistrate Judge presides over this case pursuant to 28
U.S.C. § 636(c) having received the written consent of
both parties. See Fed.R.Civ.P. 73; (Doc. 15)
The ALJ
in this case failed to give specific and legitimate reasons
for discounting the opinion of the treating physician. The
case is remanded for payment of benefits.
PROCEDURAL
HISTORY
On
January 17, 2014, Rector filed an application for disability
insurance benefits pursuant to Title II of the Social
Security Act. (Tr. 21) She alleged disability beginning on
March 22, 2013, due to fibromyalgia, pacemaker, chronic pain,
restless body syndrome, diverticulitis, anxiety, panic
attacks, cognitive problems, forgetfulness-poor memory, and
fatigue. (Tr. 179, 180)
Her
application was denied initially and upon reconsideration.
(Tr. 106-113) Rector requested review and appeared with
counsel at a hearing before Administrative Law Judge (ALJ)
Yasmin Elias on September 19, 2016. (Tr. 36) In her decision,
dated January 11, 2017, the ALJ found Rector was not disabled
because, considering her age, education, work experience, and
residual functional capacity, she could work as an accounts
investigator or a store facility rental clerk. (Tr. 21-29)
Rector
appealed, but on September 22, 2017, the Appeals Council
denied review making the decision of the ALJ the final
decision of the Commissioner. (Tr. 1-4) Rector subsequently
filed this action seeking review. (Doc. 1)
Claimant's
Work History and Medical History
Rector
was 44 years old at the hearing before the ALJ. (Tr. 42) She
has an associates degree in nursing and worked as a certified
nurse assistant, a registered nurse, and a nursing director.
(Tr. 42) She stopped working on March 22, 2013 after an
episode of pain, fatigue, lightheadedness, and dizziness.
(Tr. 42-43) She also was having cognitive or memory problems.
(Tr. 43)
Rector
subsequently sought treatment from her primary care
physician, Jeffery Bushman, D.O., for what she believed was
trouble with her pacemaker. (Tr. 340, 341, 343) On May 14,
2013, rheumatologist Augusto Posadas, M.D., observed 16 of 18
trigger points and diagnosed arthralgia (joint pain),
fibromyalgia, and fatigue. (Tr. 290)
On May
30, 2013, Bushman observed 16 of 18 trigger points and
diagnosed cardiac dysrythmia, fibromyalgia, restless leg
syndrome, and depression. (Tr. 338) The medical record
contains additional treatment notes from May of 2013 through
August of 2016. (Tr. 305-419, 458-487, 616-629) During this
time, Bushman prescribed a series of medications in the hopes
of ameliorating Rector's pain and other symptoms while
minimizing adverse side-effects. Id. At various
times, Rector was taking Cymbalta, Sinemet, Xanax, Norco,
Butrans patches, Nortriptyline, Zoloft, hydrocodone,
gabapentin, Fentanyl patches, Vicodin, Valium, Ambien,
lamotrigine, clonazepam, Oxycontin, alprazolam, Flexeril, and
Lyrica. (Doc. 18, pp. 3-7); see also (Tr. 26); (Doc.
17-3, p. 27)
Rector
was hospitalized from May 31 to June 3, 2014 for confusion
resulting from a two-week incident of diarrhea. (Tr. 492-502)
She presented to the emergency room on July 3, 2016 and again
on July 9, 2016 for low back pain radiating to her legs. (Tr.
546, 540)
On July
29, 2016, Rector was evaluated by Mateja de Leonni Stanonik,
M.D., Ph.D., for progressive memory loss for over three
years. (Tr. 693) Leonni Stanonik diagnosed idiopathic
epilepsy, amnesia, adjustment disorder with anxiety, and
cervical and lumbar spondylosis. (Tr. 694)
In
February of 2014, Bushman completed an assessment of
Rector's physical abilities. (Tr. 296) He opined that she
could lift and/or carry 20 pounds occasionally and less than
10 pounds frequently. (Tr. 296) She could stand and/or walk
for less than 2 hours in an 8-hour day. (Tr. 296) She could
sit for 4 hours in an 8-hour work day. (Tr. 296) She must
alternate between sitting and standing every 30-60 minutes.
(Tr. 296) She should never climb, balance, stoop, kneel,
crouch, or crawl. (Tr. 297) She should only occasionally
handle or reach with either hand. (Tr. 297)
In July
of 2014, Richard M. Palmer, M.D., examined Rector for the
state disability determination service. (Tr. 420) He
diagnosed fibromyalgia, implanted pacemaker, tachycardia by
history, chronic low back pain and left sciatica, chronic
right and left knee pain, chronic fatigue, sleep dysfunction,
and “overweight.” (Tr. 424) He opined that she
could lift 20 pounds occasionally and 10 pounds frequently.
(Tr. 424-425) She could stand and/or walk for 6-8 hours in an
8-hour day. (Tr. 425) She could sit for 6-8 hours in an
8-hour day. (Tr. 425) She should never climb ladders, rope,
or scaffolds. (Tr. 426) She should only occasionally climb
ramps or stairs, kneel, crouch, or crawl. (Tr. 426)
At the
hearing before the ALJ, Rector testified that she has pain
and fatigue. (Tr. 42) She has joint pain in her elbows,
wrists, hips, knees, and ankles. (Tr. 44-45) This joint pain
can flare up two or three times a month for typically two to
three days at a time. (Tr. 45) Rector testified that she has
good days as well as bad ones. (Tr. 46) But if she tries to
work around the house on one of her good days, she will be in
bed for the next day or so recuperating. (Tr. 46) Even on an
average day, she must lie down three to four times for 30
minutes to an hour each time. (Tr. 54)
Rector
also has cognitive or memory problems. (Tr. 43) She could
watch a movie with her husband and a week or two later forget
that she saw it. (Tr. 36) She forgot to pick up her son at
the bus stop a couple of times, thinking she already got him.
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