Court: District Court, M.D. Tennessee; October 1, 2014; Federal District Court
Tammy G. Hoffman filed a legal action against Carolyn Colvin, the acting Commissioner of Social Security, under 42 U.S.C. § 405(g), seeking judicial review of the denial of her applications for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI). Hoffman claimed her disabilities stemmed from a chronic spinal disc disorder and mental impairments, with an alleged onset date of June 9, 2010. The Administrative Law Judge (ALJ) denied her claims after evaluating them through the sequential evaluation process outlined in 20 C.F.R. §§ 404.1520 and 416.920.
The ALJ’s findings included: (1) Hoffman had not engaged in substantial gainful activity since her amended onset date; (2) she suffered severe impairments such as lumbar degenerative disc disease, fibromyalgia, major depressive disorder, and bipolar disorder; (3) her impairments did not meet or equal the criteria for any listed impairments; (4) she retained the residual functional capacity to perform less than a full range of light work, with specific limitations including alternating between sitting and standing, limited postural activities, and restrictions from working at unprotected heights or performing complex tasks.
Despite not being able to return to past work, the ALJ determined that there were jobs available in significant numbers in the economy that Hoffman could perform, supported by vocational expert testimony which indicated she could work as a receptionist, motel clerk, and cashier, among other roles.
The Appeals Council upheld the ALJ's denial of benefits. However, the Court concluded in favor of Hoffman’s motion for judgment on the administrative record, citing the ALJ's failure to adequately weigh the opinions of her medical and mental health providers and recognizing the impact of her combined impairments. Hoffman, age 49, had a high school education and a work history primarily consisting of part-time unskilled labor, with frequent terminations due to her inability to perform job duties related to her pain.
From late 2010 to early 2011, Plaintiff worked part-time as a cafeteria worker, earning $1,002.38, but was terminated after three months due to her inability to perform physical tasks and emotional distress at work. She had previously stopped working from 2002 to 2004 after giving birth but resumed until her termination in May 2011 from her last position as a part-time on-call grocery stocker, again for similar reasons. In 2011, she undertook paid 'make work' for family members, but these were deemed not substantial gainful activities by the ALJ.
Plaintiff's medical history indicates increased back pain following a rear-end collision in March 2009. An MRI in April 2009 showed worsening disc bulges, and she was referred to neurosurgeon Dr. Eric Schlosser in June 2009, who noted pain radiating to her right hip. Despite receiving several epidural steroid injections from July to September 2009, her pain persisted, leading to a prescription for Percocet. Imaging in November 2009 indicated mild disc bulges and foraminal stenosis.
In December 2009, she underwent surgery (laminectomy, foraminotomy, discectomy) at L4/5, with diagnoses of lumbar disc displacement and radiculopathy. Post-surgery, Plaintiff reported continued pain that limited her ability to stand or sit for more than fifteen minutes, affected her personal care, and restricted her lifting capacity. Despite medication, she experienced significant sleep disturbances. By January 2010, she noted improvement in leg pain but persistent low back pain, alongside chronic elbow pain diagnosed as lateral epicondylitis. After unsuccessful steroid injections for her elbow, she underwent surgical intervention in February 2010. Throughout this period, she received additional treatments for her ongoing back pain, with multiple diagnoses including spondylosis and degenerative disc disease.
By April 2010, the Plaintiff was receiving physical therapy for her right arm and using a lower back brace (Lumbar Sacral Orthosis). She reported to Dr. Nwofia that her pain management had improved with medication, but she was experiencing numbness and tingling in her right leg, along with lower back pain affecting her sleep. Dr. Nwofia switched her from Percocet to Lortab and Neurontin and ordered a lumbar MRI and an EMG for her lower extremities. A follow-up MRI in late April revealed post-surgical changes and several disc bulges in the lumbar region. The May EMG indicated sub-acute bilateral SI radiculopathies. Subsequently, Dr. Nwofia prescribed a series of epidural steroid injections in June 2010, which alleviated some of the right leg pain but did not resolve the left leg pain, leading Plaintiff to agree to a lumbar discogram.
The discogram on July 28, 2010, showed abnormal but painless discs at L3/4 and L4/5, with complete posterior tears, accompanied by mild to moderate foraminal stenosis. Dr. Nwofia expressed skepticism about the efficacy of surgery and recommended continuing the current pain management regimen. By August 16, 2010, Dr. Nwofia diagnosed her with several conditions, including post-laminectomy syndrome and lumbosacral neuritis. In September, despite ongoing symptoms, a physical examination did not review her medical records, yet the ALJ accepted this examiner's RFC assessment.
By January 2011, Plaintiff reported worsening pain and numbness in her legs, leading Dr. Nwofia to suggest more steroid injections. Spinal fusion surgery was deemed inadvisable due to potential future complications. From January to April 2011, her primary care physician prescribed antidepressants, while a psychological evaluation in April noted significant mental health concerns and cognitive limitations. However, the ALJ dismissed the findings from the mental health consultant as Alice Garland was not recognized as an acceptable medical source, despite a psychiatrist's co-signature. In April 2011, Plaintiff received a second series of epidural steroid injections.
On April 18, 2011, a truck collided with the rear of the Plaintiff's vehicle, resulting in her being transported to Skyline ER due to back and neck pain. Although she could walk at the accident scene, she described feeling "shook up." In May 2011, her primary care physician referred her to Dr. Mohammad Ali for evaluation of chronic pain, fatigue, and sleep issues. Dr. Ali identified trigger points and diagnosed her with fibromyalgia, sciatica, and degenerative disc disease, later confirming fibromyalgia after blood tests and administering an injection for elbow pain. In June 2011, he prescribed Robaxin and Cymbalta for her underlying depression.
Simultaneously, Dr. Nwofia noted Plaintiff's fatigue and emotional distress, stating she averaged only 2-3 hours of sleep. He completed two Medical Source Statements in June 2011 and November 2012. On June 11, 2011, Plaintiff was admitted to Centennial Medical Center for depression and chronic pain, where she expressed dissatisfaction with her antidepressants and sought admission to Parthenon Pavilion but was unable due to insurance issues. The Mobile Crisis team evaluated her at the Crisis Stabilization Unit (CSU), but she left against medical advice for pain medication.
On June 16, 2011, she was admitted to Centerstone and diagnosed with severe recurrent major depressive disorder with psychotic features, with a Global Assessment of Functioning (GAF) score of 42. In July, her orthopedic surgeon referred her for physical therapy, which she attended from July 11 to September 9, 2011, aiming to reduce pain and improve physical functionality. Although her range of motion improved, her pain level remained high, and she continued to struggle with sleep and prolonged sitting or standing.
On July 12, 2011, she presented at Summit Medical Center ER, expressing suicidal thoughts and a history of attempts, with negative drug screen results. She was re-admitted to the CSU and discharged with medications for her condition, later returning to Summit ER on August 4, 2011, citing ongoing depression and suicidal thoughts despite treatment.
Plaintiff exhibited wrist marks from a plastic knife in the Summit ER waiting room and was subsequently admitted to Summit’s inpatient psychiatric unit for five days following a negative drug test. Dr. Michael Kolek assessed her as 'acutely depressed' with suicidal ideation and chronic low back pain. A mental status examination by Dr. Shahana Huda revealed symptoms including psychomotor retardation, depressed mood, poor concentration, and hallucinations. Upon discharge on August 9, 2011, she was diagnosed with Bipolar I disorder, severe with psychotic features, and chronic back pain post-surgery. Her psychiatric symptoms included hopelessness, insomnia, low energy, and passive death wishes. She was prescribed various medications for both psychiatric disorders and chronic pain.
On September 9, 2011, the Plaintiff followed up with her Centerstone therapist, confirming medication compliance and maintaining a diagnosis of Major Depressive Disorder (MDD), Recurrent, Severe with psychotic features, with a GAF score of 42. Subsequent therapy sessions from November 2011 to May 2012 included additional medications for her psychiatric conditions and insomnia. Dr. Amanda Bacchus previously evaluated her with the same MDD diagnosis and GAF score.
In September 2011, a rheumatologist, Dr. Ali, performed an examination that identified multiple tender points and diagnosed her with fibromyalgia, sciatica, and degenerative disc disease. Throughout therapy sessions, the Plaintiff reported persistent mood swings, depression, and anxiety, with her medications frequently adjusted. Despite changes in medication, her diagnoses and GAF score remained consistent. A December 2011 assessment indicated her fibromyalgia was unresponsive to certain treatments, and she reported significant pain and difficulty with daily activities.
Dr. Ali prescribed Robaxin and a Kenalog injection for pain in the Plaintiff's right ankle, along with other medications including Percocet, morphine, Ambien, lithium, and Ultram. On December 22, 2011, Dr. Robert Fogolin examined the Plaintiff for right elbow pain, diagnosing her with lateral epicondylitis and chronic pain following surgery. In April and October 2012, she sought treatment for fibromyalgia, fatigue, and insomnia, with examinations confirming fibromyalgia and the continuation of Robaxin. In June 2012, Dr. Fogolin noted swelling and pain in the Plaintiff's right ankle, leading to an MRI that revealed a high-grade partial tear of the peroneus brevis tendon and severe tenosynovitis. Subsequently, on July 11, 2012, she underwent surgery to repair the tendons, followed by six weeks in a cast and weight-bearing restrictions. Post-surgery diagnoses included right ankle peroneal brevis tendon tear and peroneal longus tenosynovitis.
On July 19, her pain was moderately severe, and by August 21, she transitioned to a CAM boot and began physical therapy, which she found challenging. During therapy, she expressed frustration over her limitations and reported sleep disturbances, leading to an updated diagnosis of Major Depressive Disorder (MDD), recurrent and severe, with a Global Assessment of Functioning (GAF) score of 50. In October 2012, after medication adjustments, her GAF improved to 55. However, by November 11, her depression worsened, accompanied by passive suicidal ideations. Her treatment regimen included Effexor XR, Trazodone, lamotrigine, and Lunesta.
Dr. Nwofia assessed her pain as severe, limiting her ability to lift over ten pounds and requiring frequent position changes and breaks throughout the workday. He indicated she would likely have multiple unscheduled absences each month due to health issues, with an onset date for her conditions set as June 2011. Despite receiving three facet joint injections on October 21, 2012, her pain persisted, rated at 10/10 before medication, decreasing to 6/10 afterward.
An MRI and CT scan of the Plaintiff's lumbar spine conducted in October 2012 showed various findings: at T12-L1, there was a minimal disc bulge; at L2-3, contrast was mostly contained but extended into the inner annulus fibrosis; at L3-4, a mild disc bulge was noted, causing mild bilateral foraminal stenosis, with more significant effects on the left side; at L4-5, there was a left foraminal disc protrusion post-right laminectomy with moderate facet hypertrophy and an enhancing epidural scar, leading to mild central stenosis; and at L5-S1, mild facet hypertrophy and spurring were observed, with some contrast extension into the right annulus fibrosis.
In November 2012, Dr. Nwofia referred the Plaintiff to a neurosurgeon for potential spinal cord stimulator trial consideration if surgery was not viable. On November 27, 2012, Turner Jernigan conducted a disability assessment, evaluating the Plaintiff’s capacity to perform work-related activities in a competitive environment. Jernigan noted the Plaintiff's psychiatric diagnoses as Major Depressive Disorder, Recurrent, Severe without Psychotic Features, and Panic Disorder with Agoraphobia, with a Global Assessment of Functioning (GAF) score of 40.
The Plaintiff exhibited several severe symptoms, including sleep and mood disturbances, panic attacks, feelings of guilt or worthlessness, and social withdrawal. Jernigan's clinical observations indicated marked anxiety and emotional distress, with the Plaintiff reporting significant impairment in daily activities and experiencing depressive episodes that led to job losses. The prognosis for the Plaintiff was rated as 'Fair,' with expected duration of at least twelve months. Jernigan noted that the Plaintiff would likely be absent from work more than three times a month due to her mental health conditions.
Functional assessments revealed marked limitations in activities of daily living, interpersonal functioning, and concentration, indicating the need for frequent assistance and significant difficulties in executing daily responsibilities, especially during periods of severe depression.
Marked limitations in adaptation to change require frequent assistance for daily routines, exacerbating stress and leading to significant mood deterioration and increased anxiety, culminating in psychiatric hospitalization in August 2011. The ALJ posed hypothetical scenarios to a vocational expert, initially asking about an individual with Plaintiff's profile, capable of performing light work but needing to alternate positions and avoid hazards. The expert identified past relevant jobs as receptionist, motel clerk, and cashier, but the ALJ later ruled these did not qualify as 'past relevant work' under regulations. In subsequent hypotheticals, the ALJ introduced additional limitations, including the ability to perform only simple tasks and adapt to occasional workplace changes. The vocational expert reiterated that frequent unscheduled breaks and excessive absenteeism would render the Plaintiff unable to perform any past work. The Social Security Act defines 'disability' as an inability to engage in substantial gainful activity due to physical or mental impairments lasting at least 12 months. Judicial review is confined to assessing the evidence supporting the Commissioner’s decision, which is upheld unless not backed by substantial evidence. The Plaintiff contends that the ALJ undervalued the opinions of her treating medical professionals.
Dr. Nwofia is recognized as the claimant's primary treating physician, specializing in pain management, and has provided regular treatment to the Plaintiff for over five years. His findings are supported by other medical professionals, including Dr. Fogolin, the orthopedic surgeon, and Dr. Ali, the rheumatologist. Despite various treatments—such as a December 2009 Laminectomy and Discectomy, trigger-point injections, transforaminal epidural steroid injections, medial nerve blocks, and multiple radio frequency lesioning procedures—the Plaintiff continues to experience persistent low-back and leg pain.
Dr. Nwofia's treatment notes indicate that the Plaintiff suffers from poor sleep due to pain, leading to her departure from work in 2011. After physical therapy sessions in 2011, she reported an increase in range of motion but continued pain that hindered her ability to sleep, stand, and sit comfortably. The Plaintiff also underwent right ankle surgery in 2012, following a spontaneous tendon rupture, which resulted in an altered gait.
Diagnostic tests corroborate Dr. Nwofia's assessments, revealing disc bulging, stenosis, and annular tears in the lumbar region. An MRI in June 2011 showed evidence of mild neural foramen encroachment and scar tissue from prior surgery. Further imaging in October 2012 confirmed the presence of disc bulges and foraminal stenosis. Overall, the medical records reflect ongoing pain management challenges and significant impact on the Plaintiff's daily functioning and quality of life.
L5-S1 imaging reveals mild facet hypertrophy and spurring, with contrast observed in the nucleus pulposus extending into the inner third of the right posterior lateral annulus fibrosis. The 'Treating Physician Rule' mandates that Administrative Law Judges (ALJs) must adhere to specific standards when evaluating medical evidence in disability claims, requiring them to give controlling weight to a treating physician's opinion if it is well-supported and consistent with other substantial evidence. This rule recognizes that treating physicians possess a comprehensive understanding of a claimant's condition that cannot be fully captured through objective medical findings alone. Even when a treating physician's opinion is not controlling, ALJs must consider factors such as the treatment relationship's duration, the supportability of the physician's conclusions, and the physician's specialization.
Failure to follow these guidelines can lead to a remand unless deemed a harmless error. The Court found that the ALJ erred by not deferring to the treating physician's assessments regarding the plaintiff's physical limitations affecting her ability to work. Supporting evidence includes specialist opinions and objective tests corroborating the treating physician’s findings on the plaintiff’s pain and restrictions. Dr. Huda's mental examination indicated severe cognitive and mood impairments, assigning a GAF score of 21-30. Similarly, Dr. Amanda Bacchus diagnosed the plaintiff with severe recurrent Major Depressive Disorder with psychotic features and a GAF score of 42. Additionally, assessments from Jernigan, the plaintiff's primary therapist over 12 months, noted significant cognitive and emotional difficulties, also resulting in a GAF score of 42.
The ALJ's dismissal of the Centerstone records due to electronic signatures was also challenged; the Court confirmed that all these records had valid electronic signatures from treating providers. The ALJ's rejection of a specific section regarding the plaintiff's lowest level of functioning was also scrutinized.
The assessment form provides an opinion on the plaintiff's capacity to perform daily work-related activities continuously in a competitive environment, considering limitations under a full-time schedule. The Court finds the Administrative Law Judge (ALJ) erred in rejecting the opinions of the plaintiff's treating physicians and Centerstone records. It emphasizes that the ALJ must evaluate the plaintiff's impairments both individually and collectively. The evidence indicates that the plaintiff's physical and mental conditions preclude her from performing light work, as reflected by her Global Assessment of Functioning (GAF) scores of 42-50, which indicate severe psychological symptoms and significant impairment in functioning. The plaintiff challenges the ALJ's determination that she could perform her previous job as a "cleaner," arguing it contradicts the vocational expert's testimony, which stated that her limitations would prevent such work. The Court concurs with the plaintiff's position on the misinterpretation of the vocational expert’s insights. Consequently, the Court grants the plaintiff's motion for judgment and awards benefits, clarifying that references to the Administrative Record correspond to its original page numbers. Additional medical terms like spinal enthesopathy and tenosynovitis are defined, highlighting their implications for the plaintiff's treatment and recovery.
