United States District Court, D. North Dakota, Southwestern Division
Sandra K. Renschler, Plaintiff,
Carolyn W. Colvin, Acting Social Security Administration Commissioner, Defendant.
ORDER DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT; GRANTING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT
CHARLES S. MILLER, Jr., Magistrate Judge.
Plaintiff Sandra K. Renschler seeks judicial review of the Social Security Commissioner's ("Commissioner") denial of her application for Social Security Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("the Act"), 42 U.S.C. §§ 401-434. This court reviews the Commissioner's final decision pursuant to 42 U.S.C. § 405(g).
A. Procedural history
On August 21, 2008, Renschler protectively filed an application for DIB, alleging disability due to systemic lupus erythematosus ("SLE") with inflammatory polyarthropathy with an alleged onset date of September 2, 1999. (Tr. 64, 117-118, 159). Her date last insured under the Act was March 31, 2001. (Tr. 15, 155). Her claim was denied initially and upon reconsideration. (Tr. 64-74). She requested a hearing before an Administrative Law Judge ("ALJ"), which was held on December 21, 2010. (Tr. 21, 75). Renschler appeared and testified at the hearing and was represented by counsel. (Tr. 21-63).
On January 13, 2011, the ALJ issued a written opinion denying the claim at step two of the required five-step sequential analysis, concluding that Renschler did not have a severe impairment or combination of impairments that significantly limited her ability to work as of her date last insured. (Tr. 13-20). Renschler requested review of the ALJ's decision by the Appeals Council. (Tr. 5-8). On March 13, 2012, the Appeals Council denied the request for further review and adopted the ALJ's decision as the Commissioner's final decision. (Tr. 1-4). On May 11, 2012, Renschler commenced this action, seeking judicial review of the Commissioner's decision pursuant to 42 U.S.C. § 405(g). (Docket No. 1). The parties have filed summary judgment motions that have been fully briefed and are ripe for review. Both parties consented to disposition by a magistrate judge.
B. Factual background
1. Renschler's personal data, work history, and DIB application
Renschler was born in 1969. She was 29 years old on the alleged onset date, 38 years old when she first applied for DIB, and 41 years old on the date of her administrative hearing. She has been married since 1995 and has three children who, at the time of the administrative hearing, were seventeen, twelve, and eleven years old. (Tr. 26). She earned a bachelor's degree in social work in 1995 and was a licensed social worker from 1995 to 2008. (Tr. 28, 166).
Renschler has been employed as a cashier, a nurse aide, a daycare provider, and a social worker. She worked approximately 32 hours per week as a grocery store cashier from 1989 to 1990 and approximately 20 hours per week as a nurse aid from 1990 to 1993. (Tr. 160, 168). From 1995 to 1996, she operated a home daycare where she cared for approximately three to four children, including her own. (Tr. 150). From 1996 until August 1999, she worked approximately 20 hours per week as a child advocate social worker for the Abused Adult Resource Center. (Tr. 34, 160). After leaving that position, she again opened a home daycare where she cared for one or two children in addition to her own. (Tr. 30, 171-72). Renschler operated the home daycare until 2008. (Tr. 30). In addition, from September 2007 to October 2007, she worked approximately three eight-hour overnight shifts per week at Kohl's department store. (Tr. 30-31, 188-89). She was not working at the time of her administrative hearing. (Tr. 32).
Renschler was diagnosed with SLE in January 2008 and subsequently applied for DIB in August 2008. (Tr. 41-42, 117-19, 315-23). In her DIB application, Renschler stated she was disabled due to her SLE and described her disability as follows:
I have extreme fatigue. Major joint problems especially in hands and knees, writing and typing is impossible to do for very long. Trouble bending over, standing for long periods. I have to sit and take naps. I'm not supposed to lift things or anything to exert myself. Affects my ability to remembering and being able to say what I am thinking. Can't pull words out of my head.
(Tr. 159). Renschler alleged that she became unable to work due her disability on September 2, 1999. (Tr. 117). In order to qualify for DIB, Renschler must have been disabled by March 31, 2001, her date last insured.
2. Renschler's medical records
a. Prior to the alleged onset date of September 2, 1999
In May 1999, Renschler saw Dr. Jeffrey Orchard and was treated for a sore throat and minor cough. (Tr. 397).
b. Between the alleged onset date of September 2, 1999 and the date last insured of March 31, 2001
In October 2000, Renschler saw Dr. Jim Dungan and was treated for breast tenderness. Dr. Dungan noted that Renschler had been breast feeding for approximately two years with two different children, diagnosed a plugged mammary duct, and recommended that Renschler continue breast feeding, apply warm packs to treat her pain, and return if her symptoms continued. (Tr. 395-96).
In January 2001, Renschler saw Dr. John Witt for an annual exam. At that time, Renschler was 5 feet 2 inches tall, and weighed 171 pounds. Dr. Witt noted Renschler's desire to lose weight and prescribed a new method of birth control. After documenting these two items, Dr. Witt's notes state, "The patient's questions are all answered. She has no other complaints or concerns that she wishes to talk about at this time." (Tr. 393-94).
c. Following the date last insured of March 31, 2001
In May 2001, Renschler saw Dr. Shelly Seifert for headaches. Dr. Seifert noted that Renschler reported that the frequency of her severe headaches had increased from approximately five per year since her twenties to at least ten to that point in 2001. She prescribed Indocin for the headaches, noted that Renschler's blood pressure was elevated, and recommended that Renschler monitor her blood pressure and return for a checkup in two to three months. (Tr. 391-92). In October 2001, Renschler saw Dr. Seifert for abdominal pain. Dr. Seifert ran a complete blood count and urinalysis that came back normal, determined Renschler was likely experiencing menstrual pain, directed Renschler to return if the pain did not improve, and ordered a thyroid stimulating hormone test which returned within normal range. (Tr. 389-90, 439).
In May 2002, Renschler saw Dr. Seifert for an annual exam. At that time Renschler weighed 179 pounds, which she reported was the most she had ever weighed, including during her pregnancies. Renschler reported experiencing a number of symptoms, including hot flashes that started after she had her first child in 1998, dizziness upon bending over, fatigue, multiple aches and pains, and symptoms she associated with anxiety and depression. Dr. Seifert noted that "Patient has not felt well. She complains of hot flashes and fatigue and multiple aches and pains. She has had weight gain as described." (Tr. 387). Dr. Seifert ordered several lab tests, prescribed Renschler Indocin for migraines and Zoloft for anxiety, recommended that she exercise, and directed her to return in approximately six to eight weeks. (Tr. 385-88). In August 2002, Renschler saw Dr. Seifert for a recheck on the Zoloft. Renschler reported that her anxiety improved when she began taking the Zoloft and reported that she continued to experience hot flashes, dizziness, chest pain, and frequent headaches. Dr. Seifert noted that Renschler's blood pressure remained elevated, refilled her Zoloft prescription, prescribed Elavil for headaches, and directed her to exercise. (Tr. 382-84).
In January 2003, Renschler saw Family Nurse Practitioner Kristin Chaussee to discuss weight loss. Renschler weighed 182 pounds at the time of the visit and was provided with a weight management program that included diet changes and exercise. (Tr. 380-81). In February 2003, Renschler saw Dr. Witt for a second visit for her weight management program. She weighed 178 pounds. (Tr. 379). In May 2003, Renschler saw Dr. Witt and Chaussee for her third visit on the weight management program. Renschler reported that she "felt extremely fatigued and can hardly get off the couch at times, is taking naps during the day which is very abnormal for her." (Tr. 378). Dr. Witt ordered hemoglobin, mono, and thyroid simulating hormone tests, all of which came back normal, and recommended that Renschler continue with the weight management plan and follow up in approximately one month. (Tr. 378).
In August 2003, Renschler saw Dr. Seifert for treatment of dizziness that had lasted for approximately 24 hours. She weighed 189 pounds. Dr. Seifert directed Renschler to taper off her antidepressant, ordered a complete blood count and an expanded metabolic panel, directed Renschler to return if her symptoms persisted or worsened, and indicated Renschler would be contacted if any of her lab results were abnormal. (Tr. 376-77). In October 2003, Renschler saw Dr. Seifert for a bladder infection and was prescribed an antibiotic and an antifungal tablet. (Tr. 375). In December 2003, Renschler saw Dr. Seifert for a complete physical. She reported continued anxiety as well as pain in her feet and right knee. Dr. Seifert noted, "The patient just doesn't feel well. She is fatigued a lot of the time. She has various aches and pains. Chart review shows that her weight continues to climb. She is now up to 201 pounds. In May of last year she weighed 179 pounds." (Tr. 373). Dr. Seifert prescribed an antidepressant, determined that Renschler's foot pain could be due to plantar fasciitis, provided Renschler with physical therapy treatments that could improve the condition, and directed Renschler to attempt to lose weight through diet and exercise. (Tr. 372-74).
In January 2004, Renschler saw Dr. Seifert for treatment after she cut her finger. (Tr. 371).
In May 2005, Renschler saw Dr. Seifert for treatment of an upper respiratory infection and enlarged lymph nodes behind her right ear. Dr. Seifert discussed Renschler's elevated blood pressure and encouraged her to lose weight. (Tr. 369-70). Approximately one week later, Renschler saw Dr. Louise Murphy for an annual exam. Dr. Murphy noted the exam was unremarkable with the exception that Renschler was overweight, ordered a thyroid panel to determine whether Renschler's weight gain and fatigue could be related to hypothyroidism, and recommended that Renschler return in approximately one month to recheck her hemoglobin and blood pressure. (Tr. 366-68). In July 2005, Renschler saw Dr. Murphy for a blood pressure recheck and reported fatigue and a sore throat. Dr. Murphy noted that Renschler's recent hemoglobin and thyroid tests were within normal limits, increased the dosage of her antidepressant, prescribed a blood pressure medication, recommended that she try Claritin for her sore throat, recommended that she reduce her intake of alcohol and caffeine and exercise more frequently, and directed her to return for a recheck of her blood pressure, fatigue, and sore throat in approximately four to six weeks. (Tr. 364-65). In September 2005, Renschler saw Dr. Murphy for a blood pressure recheck and reported sinus congestion. Dr. Murphy noted that Renschler's blood pressure was normal and prescribed a course of treatment for her sinus symptoms. (Tr. 362-63).
On October 3, 2005, Renschler saw Dr. Robert Roswick for a cough that had persisted for approximately three weeks. Dr. Roswick determined Renschler likely had bronchitis and prescribed Zithromax. (Tr. 359). Renschler sought treatment for her cough from Dr. Douglas Moen on October 14, 2005, and from Dr. Murphy on November 15, 2005. (Tr. 356-58). On November 16, 2005, Renschler saw Dr. Darwin Lange for her cough and was prescribed a course of treatment. (Tr. 257). On December 7, 2005, Renschler saw Dr. Lange for a recheck of her cough, which had resolved. Dr. Lange advised that she continue to use Singulair and a rescue inhaler and ordered a pulmonary function test, which showed normal lung function. (Tr. 256, 286).
On December 29, 2005, Renschler saw Dr. Lange for swollen hands and feet. He prescribed a blood pressure medication, ordered a thyroid-stimulating hormone test, a complete blood count, a metabolic panel, a sedimentation rate test, and a c-reactive protein test, encouraged Renschler to exercise, and recommended that she return in four to six weeks. (Tr. 254). The tests showed slightly elevated inflammatory markers. (Tr. 253, 281, 283). In February 2006, Renschler saw Dr. Lange for continued swelling and stiffness in her hands and feet. He ordered tests for sedimentation rate, c-reactive protein, rheumatoid arthritis, and antinuclear antibody ("ANA"). The tests showed elevated inflammatory markers and were positive for ANA. Dr. Lange referred Renschler to Dr. Lynne Peterson to evaluate the results. (Tr. 253, 273-78).
On March 22, 2006, Renschler saw Dr. Lynne Peterson for evaluation of her persistent cough, joint pain, and positive ANA. Renschler reported that she had experienced joint pain for approximately six years and thought the pain had worsened in the last year. Dr. Lynne Peterson concluded that Renschler's hand pain was likely median neuropathy or carpal tunnel syndrome and that her foot pain was likely related to plantar fasciitis. Dr. Lynne Peterson ordered several lab tests and a CT scan and referred Renschler to a physical therapist for an orthotic evaluation. (Tr. 250-52). On March 27, 2006, Renschler saw Dr. Lange for a recheck, Dr. Gregory Peterson for further testing of carpal tunnel syndrome, and Dr. Lynne Peterson, who performed a steroid injection to both of Renschler's wrists. (Tr. 247-49). On April 4, 2006, Renschler saw physical therapist Jeff Wetzel for plantar fasciitis and was instructed to perform stretches and ice massage, to wear orthotic inserts, and to return for a recheck in approximately one week. (Tr. 244-45). On April 19, 2006, Renschler saw Wetzel and reported that her pain was worse than at her previous visit. Wetzel used phonophoresis and deep tissue massage during the visit and directed Renschler to continue stretching, icing, and wearing the orthotics and to begin to attend physical therapy twice per week. (Tr. 243). Renschler saw Wetzel for physical therapy on May 2, May 4, and May 11, 2006, and reported that her pain continued. (Tr. 237-42). In August 2006, Renschler saw Dr. Lynne Peterson for a second steroid injection in her wrists. (Tr. 236). In November 2006, Renschler saw Dr. Lange for an annual exam. (Tr. 235).
In January 2007, Renschler saw Dr. Dale A. Klein for a sore throat and was treated for sinusitis. (Tr. 234). In February 2007, Renschler saw Dr. Lange for a sore throat and cough and was treated for bronchitis. (Tr. 233). On July 8, 2007, Renschler saw Dr. Donald J. Kosiak and was treated for a cough, shortness of breath, sore throat, ear pain, headache, and fatigue. (Tr. 232). On July 13, 2007, Renschler saw Dr. Seifert for a blood pressure recheck. Dr. Seifert noted, "The patient has a bunch of symptoms that she thinks are due to her high blood pressure. She feels extremely fatigued. She feels like just sleeping all of the time. She does not have any energy. She feels short of breath at times. Upon questioning this is sounding more like an anxiety type of situation." (Tr. 355). Dr. Seifert ordered a thyroid simulating hormone test and an expanded metabolic panel, changed Renschler's antidepressant, and directed Renschler to return in approximately one month. (Tr. 354-55, 360-61). The metabolic panel showed elevated transaminases. (Tr. 353, 426). In October 2007, Renschler saw Dr. Seifert for a blood pressure recheck and a liver panel, as the elevated transminases indicated possible liver function issues. Renschler reported the new antidepressant was controlling her anxiety and depression to her satisfaction and was directed to return to discuss the results of the liver panel in approximately one month. (Tr. 353). In November 2007, Renschler saw Dr. Seifert to discuss the results of her liver panel which was positive for ANA and anti-Smith antibody. Dr. Seifert referred Renschler to Dr. Prashant Kaushik for evaluation of the results. (Tr. 351-352, 404).
In January 2008, Renschler saw Dr. Kaushik, who determined the most plausible diagnosis was systemic lupus erythematosus and prescribed a course of treatment. (Tr. 315-23). Following her SLE diagnosis, Renschler continued to seek treatment for her SLE ...