Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Bolyard Moore v. Berryhill

United States District Court, N.D. West Virginia, Wheeling

January 30, 2018

WHEELING DONNA LYNN BOLYARD MOORE, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          REPORT AND RECOMMENDATION

          MICHAEL JOHN ALOI, UNITED STATES MAGISTRATE JUDGE

         I. INTRODUCTION

         On December 9, 2016, Plaintiff Donna Lynn Bolyard Moore (“Plaintiff”), by counsel Brian Bailey, Esq., filed a Complaint in this Court to obtain judicial review of the final decision of Defendant Nancy A. Berryhill, Acting Commissioner of Social Security[1] (“Commissioner” or “Defendant”), pursuant to Section 205(g) of the Social Security Act, as amended, 42 U.S.C. § 405(g). (Compl., ECF No. 1). On February 10, 2017, the Commissioner, by counsel Helen Campbell Altmeyer, Assistant United States Attorney, filed an answer and the administrative record of the proceedings. (Answer, ECF No. 6; Admin. R., ECF No. 7). On March 6, 2017, and April 5, 2017, Plaintiff and the Commissioner filed their respective Motions for Summary Judgment. (Pl.'s Mot. for Summ. J. (“Pl.'s Mot.”), ECF No. 9; Def.'s Mot. for Summ. J. (“Def.'s Mot.”), ECF No. 11). Following review of the motions by the parties and the administrative record, the undersigned Magistrate Judge now issues this Report and Recommendation to the District Judge.

         II. PROCEDURAL HISTORY

         On September 19, 2013, Plaintiff protectively filed her first application under Title II of the Social Security Act for a period of disability and disability insurance benefits (“DIB”) and under Title XVI of the Social Security Act for Supplemental Security Income (“SSI”), alleging disability that began on July 30, 2013. (R. 200). Plaintiff's earnings record shows that she acquired sufficient quarters of coverage to remain insured through December 31, 2017 (R. 222). This claim was initially denied on December 23, 2013 (R. 105) and denied again upon reconsideration on March 13, 2014 (R. 131). On March 26, 2014, Plaintiff filed a written request for a hearing (R. 158), which was held before United States Administrative Law Judge (“ALJ”) Nikki Hall on October 8, 2015 in Morgantown, West Virginia. (R. 39). Plaintiff, represented by counsel Jennifer LaRosa, Esq., appeared and testified, as did Mary Beth Kopar, an impartial vocational expert. (Id.). On January 12, 2016, the ALJ issued an unfavorable decision to Plaintiff, finding that she was not disabled within the meaning of the Social Security Act. (R. 21). On November 2, 2016, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. (R. 1).

         III. BACKGROUND

         A. Personal History

         Plaintiff was born on September 14, 1963, and was forty-nine (49) years old at the time she filed her first SSI claim. (R. 200). She completed two years of college (R. 234). Plaintiff's prior work experience included working in advertising sales at a newspaper. (R. 225). She was married at the time she filed her initial claim (R. 200) and was married (R. 45) at the time of the administrative hearing. (R. 39). She has no dependent children. (R. 45). Plaintiff alleges disability based on rheumatoid arthritis, psoriatic arthritis, fibromyalgia, hearing loss, high blood pressure, diabetes, restless leg syndrome, and severe dry eye syndrome. (R. 86).

         B. Medical History

         The undersigned has reviewed the entirety of this record, including medical opinions, treatment notes, and test results from various providers and facilities. However, as Plaintiff's arguments do not turn on the medical evidence, and for the sake of brevity and relevance, the entirety of the medical evidence contained in the record is not related at length. Rather, Plaintiff's relevant treatment history is reviewed, with opinions specifically addressed below.

         1. Medical History Pre-Dating Alleged Onset Date of July 30, 2013

         Plaintiff began seeing Clifford E. Bickerton, D.C., for chiropractic treatment of aches in her neck and upper dorsals on May 12, 1986. (R. 812). Dr. Bickerton noted crepitation in Plaintiff's upper spine when rotating her shoulders, limited rotation, pain when rotating her head, and left earache. (R. 813). Plaintiff also had bad headaches, located frontally and on the top of her head. Id. In August of 1997, Dr. Bickerton noted Plaintiff's movement had increased and she was doing well and working without pain. (R. 817). Plaintiff returned to Dr. Bickerton in fall 1998 complaining again of aches in her neck, the back of her head, and her lumbrosacral spine. Id. Dr. Bickerton did some adjustments. Id. Plaintiff returned in 2009 complaining of cervical and upper dorsal pain. (R. 818). She saw Dr. Bickerton a few more times in the Fall of 2009, reporting improvement after adjustment, but also that the aches tended to return after a while. Id. In July 2010 Plaintiff returned to Dr. Bickerton experiencing another flare-up, including neck and back pain, back spasms, decreased motion, joint pain, abnormal curvature, and degenerative joint disease. (R. 823). Dr. Bickerton's diagnoses included “thoracic or lumbosacral neuritis or radiculitis, unspecified” and “facet syndrome.” Id. Dr. Bickerton adjusted Plaintiff's C2, T2, T6, L5, and upper right sacroiliac joint. Id.

         Plaintiff was treated at Advantage Health and Wellness in September 2011 for psoriatic arthritis, reporting that her symptoms worsened a few weeks prior. (R. 833). She reported pain in her lower back after extended walking. Id. Plaintiff returned to Dr. Bickerton in August 2012 complaining of lumps and stiffness in her neck and shoulders. (R. 822). Diagnoses at that visit included “closed dislocation, fifth cervical vertebra” and “degeneration of cervical intervertebral disc.” (R. 825). Adjustment and interferential current were applied. Id. In January 2013, Plaintiff returned with flare-up and neck sprain, again treated with adjustment and interferential current. (R. 828).

         Plaintiff began seeing Neurologist Adnan Alghadban, M.D. on June 18, 2010 upon referral. (R. 473). Her complaints included pain and numbness in upper and lower extremities for the last few months, recently worsening. Id. Plaintiff had been on Embrel injections previously, but stopped those “a few years ago.” Dr. Alghadban restarted Plaintiff Embrel injections, prescribed Hydrocodone for pain and Voltaren (an anti-inflammatory medication), and did trigger point injections (R. 473-77). Dr. Alghadban referred Plaintiff to Dr. Hornsby for rheumatology, noting that she had already been seen in orthopedics. (R. 473).

         Plaintiff presented to Shelly Kafka, M.D. at Mountain State Rheumatology on September 13, 2010 pursuant to referral. (R. 768). Plaintiff's demeanor was noted as “tearful.” (R. 804). Musculoskeletal examination revealed tenderness over cervical and lumbar joints, shoulders, elbows, wrists, metacarpophalangeal joints, knees, and ankles; Plaintiff's proximal interphalangeal joints evidenced both tenderness and swelling on the right side. (R. 804). Dr. Kafka assessed psoriatic arthritis and fibromyalgia. Id. Dr. Kafka noted that Plaintiff “cannot afford Humera, ” so she prescribed Naproxen, and noted “will try to [obtain] pre-auth[orization] for Remicade. (R. 775). At follow-ups with Dr. Kafka, Plaintiff continued to complain of severe pain (R“9/10”) and evidenced swelling in her metacarpophalangeal joints (R. 807, 810); and pain in the wrist and inside joints of her left hand (R. 809).

         Because Plaintiff's pain was treated with conservative measures and had no significant improvement, Dr. Alghadban completed cervical injections in September 2012 at facet joint C5-6 and C4-5 levels bilaterally. (R. 450). In November 2012, Dr. Alghadban completed bilateral occipital nerve block injections for Plaintiff's headaches when more conservative treatment failed (R. 456), and started her on Topamax for her headaches as well. (R. 457). By February 2013, Plaintiff was prescribed Percocet for pain. (R. 458). In April 2013 Plaintiff received additional injections in her tendon for tendonitis (R. 459), and bilateral shoulder injections for arthritis pain. (R. 460).

         2. Medical History Post-Dating Alleged Onset Date of July 30, 2013

         Dr. Alghadban performed a left knee injection in August 2013. (R. 464-5). On August 27, 2013, Dr. Alghadban wrote a letter opining that Plaintiff:

has rheumatoid arthritis, psoriatic arthritis and fibromyalgia. She is on medications, Enbrel and anti-inflammatory medications, and she gets a steroid injection. She is also on pain medications. She is very limited due to her arthritis in terms of walking, sitting or standing.

(R. 466). Dr. Alghadban performed another tendon injection in January 2014. (R. 492).

         Imaging studies on July 3, 2014 revealed no evidence of articular erosions of inflammatory arthritis. (R. 527). Rather, x-rays of Plaintiff's thoracic spine showed “prominently developed” endplate osteophytes (bone spurs) on the right ventral aspect of the T6-T10 vertebral levels. (R. 528). Plaintiff was seen at Pinewood Medical Center on July 14, 2014 to review imaging studies. Progress notes stated that Plaintiff:

saw [] rheumatology [] and was told that she had DISH [diffuse idiopathic skeletal hyperstosis] in [her thoracic] spine, but there was no evidence of psoriatic arthritis or rheumatoid arthritis. She does have severe osteoarthritis and is starting to get some deformity of her fingers. . . . Since she does not have psoriatic arthritis, she is not on her Enbrel, which did help her psoriasis of her fingernails when Dr. Jeffrey Jackson gave it to her in dermatology. She said she hurts all over in every bone of her body and also in all of her muscles and it is getting to where she cannot pick her feet up when she walks. She said she hides this from her husband since he was involved in a severe motorcycle accident not long ago ..... She said FLECTOR patches do help her, but her insurance does not cover them. . . . She has a history of depression and RLS.
OBJECTIVE: Vital signs stable, no acute distress noted. She does seem to have stiffer joints when moving around from the exam table to the floor. Especially her hips seem to be stiff. She does have psoriasis of all of her fingernails. She has tenderness all over her body to palpation. Her hair looks thinner than it did several months ago.

(R. 543). Certified Nurse Practitioner Judy Lipscomb's treatment plan included diclofenac gel, calcium and magnesium for arthralgia, referral to Dr. Jackson to restart Embrel, increased Glucophage for diabetes, restarting on vitamin D for deficiency, and physical therapy for DISH of thoracic spine. Id.

         In July 2014, Plaintiff was seen by Jeffrey Jackson, M.D. with Mountain State Medical Specialties for psoriasis on her fingernails. (R. 570). Dr. Jackson restarted Plaintiff's Embrel injections (R. 567), noting they were effective in keeping her “mostly clear.” (R. 563).

         Plaintiff tried physical therapy at Grafton City Hospital from July 21, 2014 through August 27, 2014. (R. 514-525, 529-531, 592-626). At initial assessment, she reported pain at nine or ten out of ten in all areas constantly. (R. 523). She reported that she had stopped Embrel in January per her neurologist. Id. She reported pain with standing, sitting, and lying; sweeping, mopping, vacuuming, reading, laundry, and dishes; and trouble with getting in and out of a car, climbing steps, and balance. Id. She reported relief from medications and massage, and temporary relief with heat or ice. Id. Plaintiff was seen by physical therapist Rayler Mace, P.T. who noted Plaintiff had poor to fair posture, with decreased lumbar lordosis and increased kyphosis in the upper thoracic spine. Id. Range of motion testing of the cervical spine revealed no loss at flexion, maximum loss at extension, minimum loss at SB, and moderate loss at rotation. Id. Plaintiff's prognosis was “guarded . . . due to increased pain in all joints and spine.” (R. 524). Muscle strength in hips was three out of five (3/5); Plaintiff's gait was antalgic with decreased step length and height, decreased trunk rotation, and decreased arm swing. (R. 531). Transfers, strength, balance, range of movement, joint mobility, and function were all impaired. Id. Plaintiff's treatment plan included manual therapy in conjunction with therapeutic exercises and activities. Id.

         Physical therapist Jeff Sapp PTA noted at next visit on August 1, 2014 that Plaintiff continued to have pain “all over her neck and back.” (R. 522). Upon exercise, Plaintiff experienced a “steady increase in [low back pain] that progressed to a sharp pain towards the end of the trial, ” but that subsided afterward with increased mobility. Id. She reported feeling better after with decreased pain overall at the next visit on August 4, 2014 (R. 521). By August 6, 2014 she reported another flare-up, with the physical therapist noting major loss of range of motion in the cervical spine on retraction, major loss on extension, moderate loss on side bend and rotation (right), and minimum loss on flexion. (R. 520). Plaintiff's thoracic spine evidenced moderate loss at flexion and extension, and major loss at rotation. Id. On August 11, 2014, Plaintiff reported improved symptoms after a recent trigger point injection with Dr. Alghadban, but also reported a renewed occipital headache and tightness in her shoulder blades. Id. Plaintiff was doing “a little better” on August 15, 2014, but continued to evidence range of motion deficits. (R. 518). At her last visit on August 27, 2014, she reported “hurting pretty bad” in her upper right trapezoid region. (R. 514). Continued decreased motion of spine was noted, with a two out of six (2/6) on the Paris Scale. Id.

         In September 2014 Plaintiff returned to Pinewood for follow-up on depression and medication refills. (R. 545). She reported that her pain was “constant and [] getting worse every day.” Id. N.P. Lipscomb ed Lidoderm patches and increased Plaintiff's baclofen dose to twenty milligrams, noting that ten milligrams “was not controlling her pain completely.” Id. At next follow-up in December 2014, Plaintiff continued to complain of “severe myalgia and arthralgia, ” for which she was given Flector patches and Metanx samples for peripheral neuropathy. (R. 546). At follow-up in April 2015, Plaintiff reported having left her husband two days ago because he “has permanent brain damage from a motorcycle accident and is being verbally abusive to her.” (R. 549). N.P. Lipscomb noted Plaintiff's history of depression and anxiety, and that Plaintiff's other providers had “suggested she see a psychiatrist, ” and referred her to Dr. Nugent at Summit Center for counseling. (R. 549).

         In October 2014, Plaintiff returned to Dr. Alghadban for follow-up. (R. 582). Dr. Alghadban noted that a recent “EMG nerve conduction study was suggestive of neuropathy, ” and started Plaintiff on Neurontin. Id. She also received another bilateral occipital nerve block at that visit (R. 583), and again in April 2015. (R. 586). She continued to go to physical therapy at Grafton City Hospital, and continued to report paint and headaches throughout fall and winter of 2014 and into 2015. In February 2015, Plaintiff reported pain at eight out of ten (8/10), always in the neck but now in the shoulder blades, too. (R. 603). She reported that her TENS unit relieves the pain for about an hour after use. Id. Physical therapy progress notes in March 2015 note “subjectively little to no change in her overall symptoms” despite compliance, and that “chronic pain is starting to make her feel depressed.” (R. 600). Tom Copeland, PTA opined that there will “little gains to note in re: decreasing pain level or increasing functional activity.” (R. 599). Plaintiff “would benefit from a pain clinic consult for possible trigger point injections, ” and observed that Plaintiff was “still waiting on her [doctor] to contact her about the pain clinic.” (R. 600).

         By June 2015 Plaintiff reported “constant severe pain” rated at “15/10” at times. (R. 598). Accordingly, Plaintiff had a consult with Russell Biundo, M.D. at WVU Neurosurgery, Spine, and Pain Center on July 31, 2015. (R. 756). Dr. Biundo reviewed imaging studies and noted “degenerative changes and some bridging” in the thoracic spine, degenerative disease in the lumbosacral spine. Id. X-rays of the sacroiliac joint, hands, and wrist were “unremarkable.” Id. Dr. Biundo felt that Plaintiff's decreased range of motion of all joints seems consistent with either psoriatic arthritis or a systemic rheumatological disorder. Id. Dr. Biundo recommended Plaintiff see Dr. Hawkinberry for pain control, and six weeks of physical/pool therapy, after which they could reassess. Id.

         3. Medical Reports/Opinions

         a. Disability Determination at the Initial Level

         On December 21, 2013, agency reviewer Subhash Gajendragadkar, M.D. reviewed Plaintiff's records and completed physical residual functional capacity (“RFC”) assessment. (R. 90-92). Gajendragadkar found the following exertional limitations: Plaintiff could frequently lift and/or carry ten (10) pounds; occasionally lift and/or carry twenty (20) pounds; stand and walk for about four (4) hours in an eight (8) hour workday; sit for about six (6) hours in an eight (8) hour workday; and could engage in unlimited pushing and/or pulling (within her weight restrictions for lifting and carrying). (R. 90). Gajendragadkar noted that the limitations he articulated were supported by the “severity of [rheumatoid arthritis and] psoriatic arthropathy.” (R. 91).

         As to postural limitations, Gajendragadkar found that Plaintiff could occasionally climb ramps, and stairs; occasionally climb ladders, ropes, and scaffolds; and occasionally balance, stoop, kneel, crouch, and crawl. (R. 91). No manipulative, visual, or communicative limitations were found. Id. As to environmental limitations, Plaintiff could have unlimited exposure to extreme heat and noise; should avoid concentrated exposure to extreme cold, wetness, humidity, vibration, and fumes, odors, dusts, gases, poor ventilations, etc.; and avoid even moderate exposure to hazards. (R. 91).

         On December 20, 2013, agency reviewer Paula Bickham, Ph.D., reviewed Plaintiff's records and completed psychiatric review technique (“PRT”) assessment. (R. 88). Bickham found mild difficulties in maintaining concentration, persistence, or pace, and no significant limitations in Plaintiff's ability to maintain social functioning and no restriction of activities of daily living. Id. Her narrative explanation stated that

[Plaintiff] appears credible. The claimant is being prescribed medication from her pcp for depression although comments in the MER indicates depression and anxiety. In the recent ROC of 12/20/13, the claimant reported that she no longer believes she needs the medication. She alleged limits to concentration and memory on the AFR Claimant reported to the examiner that she believed her memory issues were menopause related and she is doing better since stopping work ADLs do not reflect severe limits w[ith] functioning. Nonsevere Impairment.

(R. 88-89).

         b. Disability Determination at the Reconsideration Level

         On March 11, 2014, agency reviewer Rogelio Lim, Ph.D. reviewed the prior PRT assessment and affirmed it as written, adding only the word “affirm.” (R. 116). On March 5, 2014, agency reviewer Joseph Richard, Ph.D. reviewed the prior PRT assessment and affirmed it as written, noting “there is no new significant [medical evidence] data to refute the evaluation [and] conclusions of 12/23/13 and that evaluation are [sic] affirmed as written. (R. 113).

         c. Treating Source Statement

         On September 23, 2013, Adnan Alghadban, M.D. completed a Medical Review Team (MRT) Physician's Summary pursuant to an application for Medicaid. (R. 478-479). Dr. Alghadban's diagnoses included lupus, psoriatic arthritis, and another condition that was illegible. (R. 478). He opined that Plaintiff's incapacity/disability was expected to last for ten (10) years, and that Plaintiff's prognosis was “guarded.” Id. Dr. Alghadban opined that Plaintiff was limited to lifting no more than twenty-five pounds, and could not stand for more than fifteen minutes. Id.

         d. Internal Medicine Consultative Examination

         On November 20, 2013, Himanshu Paliwal, M.D. completed a consultative examination (R. 480-487). Dr. Paliwal noted that due to Plaintiff's arthritis, she complained of “various joint pains including neck, lumbrosacral, shoulder and hand, [as well as] pain in [the] small joints of [her] hand and wrist.” Id. Plaintiff reported that pain and swelling in her hands made it hard for her to work. (R. 481). Though Plaintiff seemed to be doing better since starting on medication, she had “good and bad days.” Id. She also reported constant dull, aching neck and low back pain from fibromyalgia. Id. She reported being “able to do most of [her] daily activities except work, which requires her to bend or be on her knees.” Id. Results of a physical examination were generally normal, with the exception of Plaintiff's nails. (R. 482) (“distal half of nails are opaque white and separated from nail bed.”). Dr. Paliwal assessed obesity, psoriasis, psoriatic nails, rheumatoid arthritis, psoriatic arthropathy, lumbago, cervicalgia, fibromyalgia, and chronic fatigue syndrome. (R. 483-83).

         e. Other Opinion Evidence

         Plaintiff returned to Dr. Biundo for follow-up in September 2015. (R. 763-764). In response to Plaintiff's request for “a letter regarding her ability to work/question about possible disability, ” Dr. Biundo noted the following:

Regarding disability, the patient would be pain limited in terms of her ability to work manual type labor, but she could conceivably do a job/desk type work. I informed her if she wished to pursue disability, she would most likely need to be referred to an occupation medicine doctor for further evaluation and filling out of her paperwork. She declines that for now. She agrees to continue with physical therapy, and we will see her in 3 months or sooner if any problems. The patient is comfortable with these recommendations.

(R. 764).

         f. Treating Psychological Source

         On August 13, 2015, Plaintiff's treating psychologist Dr. Dana Nugent, Ed.D. wrote a letter to “address [Plaintiff's] ability to participate in gainful employment.” (R. 533). Dr. Nugent stated that Plaintiff had been diagnosed with Major Depressive Disorder, Moderate, for which she received treatment including psychotherapy since May 28, 2015. Id. Dr. Nugent elaborated that Plaintiff:

remains quite depressed due to the severity of her back pain, which is the consequence of her Psoriatic Arthritis. I have tried to work on increasing her activity level, including increasing social interaction and enjoyable activities. However, even visiting a friend is often too painful for her, because she is not able to alternate sitting and lying down as she needs. The tremendous loss of functioning the arthritis has caused has precipitated extended grieving over what she can no longer do. She has difficulty replacing former activities with new, more sedentary ones, like reading, because she can't even look down for long, because of her neck pain. We are addressing her mood disorder with medication, but so far are not seeing any improvement. If the current medical interventions she is pursuing reduce her back pain, we will have more to work with to address her depression, but we cannot anticipate if that will happen.

(R. 533).

         g. Treating Rheumatological Source

         On February 24, 2016, Dr. Hornsby wrote a letter stating Plaintiff's diagnoses as “chronic low back pain, and [imaging] of [her] thoracic spine show changes most consisted with Diffuse Idiopathic Skeletal Hyperostosis (DISH).” (R. 840).

         C. Testimonial Evidence

         At the ALJ hearing held on October 8, 2015, [2] Plaintiff testified that she was married and had no dependent children. (R. 45). She has no income; she and her husband subsist on his disability payments. Id. She receives food stamps and a medical card (Medicaid). (R. 48). She obtained an associate's degree as a medical assistant. (R. 47).

         Plaintiff testified that she had been working up until about a week before she decided to apply for disability. (R. 48-49). She found herself going home throughout the day, once or twice a month at first. Id. Eventually, it got to the point where she was going home a couple of days every week. Id. Her boss told her that she could not “keep doing that, that [she needed] to face facts, that [she was] disabled and [] can't keep [] going home in the middle of [the] day.” (R. 49). She testified that her condition had not particularly changed in the week between leaving her job and applying for disability. Id. Plaintiff testified that, rather, “Mentally, I couldn't face facts, so finally when I realized that I am in dire pain and I can't continue that, that's whenever I just decided I had to face facts.” Id.

         Plaintiff testified that she had worked for the Mountaineer newspaper, and that her work history report accurately summarized her work there. (R. 50). Plaintiff testified in her own words that she feels she cannot work because:

most of my day, day and night, I'm in -- I am in severe pain. I can't hardly use my fingers, I can't hardly I can't even fix dinner like I used to. There's a lot of things that I used to do that I can't do anymore. And even if I try, my body, I just can't. My back is in such a mess and such pain that I just can't. I can't sit at a desk, I can't look down, I can't even hardly read a book.

(R. 51). As to her hands, Plaintiff testified that her “knuckles are going one way and [her] fingers are going the other [which] mak[es] it impossible to open things up or hold a knife to peel a potato or anything like that. And they hurt really bad.” Id. This started about a year to a year and a half ago. (R. 52). As to her back pain, Plaintiff testified that started getting bad around August. Id. She described her back pain as starting “right below the base of [her] skull, and [] between [her] shoulder blades and [her] very low tailbone.” Id. She testified that she at times will have limited movement and will not be able to move a certain way or reach for things. Id. She described the pain as “excruciating, ” stating “I'm at number 10 a lot.” Id. However, Plaintiff clarified that “sometimes it is worse than other times, ” and it is not always that bad. (R. 53).

         Plaintiff testified that she had tried physical therapy for probably three months or more, including deep tissue massage and range of motion machines, but those did not work or give her any more motion. Id. She was currently doing water therapy, and had five to six visits so far; though she had not noticed any improvement with that, either. (R. 56). She currently takes Hydrocodone and uses Flector patches for pain. Id. Plaintiff testified that she has discussed going to pain management to try to manage her pain with her doctors, but no surgeries have been recommended. (R. 57).

         Plaintiff testified that she could walk for probably about two minutes before she “start[ed] feeling the back pain.” (R. 56). She could stand for about five minutes and sit for about fifteen minutes before her back bothers her. Id. Plaintiff estimated she could lift ten pounds. Id.

         Plaintiff noted that although her diabetes had not been controlled in the past, it was “starting to be more controlled” since she started taking Novolog in addition to Lantus. (R. 58). Her sugar levels are typically “high, ” but are lower than they have been in the past. Id. When her sugar levels get high, she feels “dizzy and spacey, like [she] can't think;” her mouth gets dry and she starts shaking a little bit. (R. 59). Plaintiff testified that this has been happening more frequently, “probably every other day.” Id. Plaintiff testified that her acid reflux (GERD) and blood pressure are controlled with medications. (R. 63).

         Plaintiff sees Dr. Alghadban for both headaches and neuropathy, which affects her most in her feet. (R. 59). Her neuropathy affects her feet, and causes tingling and sharp pain - “feeling like my feet are cut” - when she walks on them. Id. She has had these symptoms for about a year. Id. She takes Neurontin for her neuropathy, and also walks on the sides of her feet so that the feelings are not as intense. Id. As to her migraine headaches, Plaintiff has a migraine “maybe once every other month, ” typically lasting for a day or more. (R. 62). Dr. Alghadban gives her injections to treat them; he used to prescribe medication, but Plaintiff does not take it any more because it made her “sick.” Id. When she has a migraine, she puts on an eye mask and lays down in a dark room. Id. Plaintiff stated that she thinks her migraines are exacerbated by her neck pain, for which she gets occipital nerve blocks - most recently the previous month. (R. 63).

         Plaintiff gets treatment at United Summit Center for depression. (R. 60). In addition to seeing a counselor weekly and a psychiatrist once a month, she is also prescribed Abilify, Celexa, and Trazodone. Id. There have been a few weeks where she has had to cancel her appointment because she “just couldn't get dressed.” (R. 70). Her depression symptoms include crying all of the time, feeling like everything is at its worst, and feeling extremely anxious and shaky. (R. 61). Plaintiff stated that “there's times I can't even hardly get out of bed and get dressed. I just can't do it.” Id. From a social standpoint, Plaintiff stated her depression causes her to not want to be around anyone and she finds it easier to be alone. Id.

         Plaintiff testified that she used to cook big dinners and loved to cook, but she has no interest in cooking or eating any more. Id. She has had these symptoms for about four months. Id. It had been “about five months” since she cooked a family meal; the most she might make now is a grilled cheese. (R. 64). She no longer cleans; her daughter has been doing it for the past couple of years. (R. 65). She is able to “dust a little bit, ” but cannot sweep, mop, or vacuum. Id. She goes shopping two to three times a week, close to home, for basics like snack foods, milk, cereal, bread, and lunch meat. Id. Her husband, daughter, and a friend help with shopping. Id. She has a driver's license, but does not drive much - “maybe two or three days a week, not very much, close to home.” (R. 46). She has a computer at home but stopped using it “probably about a year and a half ago.” (R. 47). She checks email or gets on Facebook with her cell phone. Id.

         Plaintiff testified that she tries to read, but has to be on her back because she cannot look down very well. (R. 66). She does not go to church as much as she used to, because she cannot sit and has to stand in the back of the church. Id. She goes to church “probably once a month” now. Id. She used to like to go watch movies, but she likewise cannot sit to watch a movie any more. Id. She used to have a “great big flower bed [she] always worked on, ” but has not been able to for the past couple of years because her hands are not strong enough to pull the weeds. Id.

         D. Vocational Evidence

         Also testifying at the hearing was Mary Beth Kopar a vocational expert. VE Kopar characterized Plaintiff's past work at Mountaineer newspaper as a classified ad clerk, Dictionary of Occupational Titles (DOT) number 247.367-010; skilled work with a specific vocational preparation of five (5), and sedentary exertion in the DOT, but light exertion as actually performed. (R. 72).

         With regards to Plaintiff's ability to return to her prior work, VE Kopar gave the following responses to the ALJ's hypothetical:

Q: Let's assume a hypothetical individual with the same age, education, and work background as the claimant who is capable of performing work at the light level as defined in the regulations. All posturals are occasionally, except never climb ladders, ropes, or scaffolds. The work should not require greater than occasional exposure to concentrated levels of extreme cold, wetness, humidity, vibration, or fumes, dust, odors, or pulmonary irritants. The work should not require exposure to unprotected heights or moving mechanical parts. Would such a person be able to perform the claimant's past work, either as she actually performed the work or as the work is generally performed in the national economy?
A Could do the past work, both per the DOT and as performed.

(R. 72-73).

         Incorporating the above hypothetical, the ALJ then questioned VE Kopar regarding Plaintiff's ability to perform other work at varying exertional but unskilled levels.

Q Could the hypothetical individual perform any other jobs, and if so, could you please give me a few examples with numbers of jobs in the nation for each occupation?
A Yes, your honor. Could do that of a sorter, DOT 222.687- 014, unskilled, SVP of 2, light exertion, with over 300, 000 positions in the national economy. Could do that of an order caller, DOT 209.667-014, unskilled, SVP of 2, light exertion, with over 200, 000 positions in the national economy. Could do that of a ticket seller, DOT 211.467- 030, ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.