United States District Court, D. North Dakota, Southwestern Division
ORDER DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT AND GRANTING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT
CHARLES S. MILLER, Jr., Magistrate Judge.
The plaintiff, Andrea Wagner ("Wagner"), seeks judicial review of the Social Security Commissioner's denial of her application for Social Security Disability Insurance Benefits 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
Wagner filed an application for Social Security Disability Insurance Benefits ("DIB") on March 1, 2011, alleging an onset date of August 30, 2010. (Tr. 90, 171-177). Her application was denied initially and upon reconsideration. (Tr. 118-126).
An Administrative Law Judge ("ALJ") convened an administrative review hearing on August 10, 2012. (Tr. 32-89, 126). He issued a written decision denying Wagner's application on November 14, 2012. (Tr. 19-26). The Appeals Council denied Wagner's subsequent request for review and on November 20, 2012, adopted the ALJ's decision as the Commissioner's final decision. (Tr. 1-4, 284-88).
Wagner initiated the above-entitled action on January 21, 2014, seeking judicial review of the Commissioner's final decision pursuant to 42 U.S.C. § 405(g). (Docket No. 1). The parties have since filed summary judgment motions that are now ripe for review. They have also filed notice of their consent to the undersigned's exercise of jurisdiction over this matter.
B. Factual background
1. Wagner's personal data and work history
Wagner was born in 1966. (Tr. 90). She was 44 years old on the alleged onset date and 46 years old on the date of her administrative hearing. (Tr. 36, 90). She is married and has five children, two of whom are under the age of eighteen and none of whom live with her. (Tr. 38).
Wagner has an eighth or ninth grade education. (Tr. 42). She has at various times worked as a waitress, housekeeper/cleaner, dishwasher, and garment sorter. (Tr. 45-46). In the years immediately preceding her alleged onset date, she worked intermittently as a laborer in the food service industry. (Tr. 45, 207-210, 214, 224-231). She attempted to return to work on a part-time basis in 2012 but was unsuccessful. (Tr. 43-44, 207-210).
Wagner suffers from the following impairments: obesity; degenerative disc disease at multiple levels, chronic back and neck pain, left knee pain, a major depressive disorder, post-traumatic stress disorder, anxiety, a borderline personality disorder, and borderline intellectual functioning. (Tr. 13). She also has a history of polysubstance abuse, Hepatitis C, asthma, and uterine prolapse with grade 3-4 cystocele. (Tr. 13, 498-99). She has been fitted for and prescribed a pessary. (Tr. 498-99).
2. Summary of Wagner's relevant medical history
Wagner presented to the emergency room multiple times in mid-to-late March 2010 with complaints of dental pain and/or headaches. (Tr. 401-427).
On March 23, 2010, Wagner presented to a psychiatrist, Dr. Thomas Eick, who made the decision to discontinue Paxil, retry Zoloft, continue her on a lower dosage of Remeron, and increase her dosage of Klonopin. (Tr. 358).
On April 20, 2010, Wagner returned to Dr. Thomas Eick for a follow-up examination. (Tr. 356-57). According to Dr. Eick's notes, Wagner was tearful, anxious, and at times irritable when told he would no longer prescribe her Klonopin or other benzodiazpines. (Tr. 356).
On April 28, 2010, Wagner was placed in emergency detention after she presented for a psychiatric evaluation with symptoms of psychosis. (Tr. 302-09, 334-38). According to the admitting physician's notes, Wagner had been self medicating her mood with substances, was anxious over the fact that she had overused/exhausted her supply of Klonopin, was having troubled sleep, was withdrawing from benzodiazepines, was struggling to cope with traumatic events (both past and present) in her personal life, and was dealing with ongoing anxiety and depressive symptoms. (Tr. 305-06, 337-38).
By April 30, 2010, Wagner's mood had sufficiently stabilized to warrant her release from emergency detention. (Tr. 309). She was discharged with two-week prescriptions for Klonopin, Inderal, and Remeron and instructed to follow up with her primary care physician. (Id.)
On May 27, 2010, Wagner returned to Dr. Thomas Eick, seeking a refill of her Klonopin prescription. (Tr. 353). Dr. Eick unequivocally refused to prescribe her Klonopin given her past misuse. (Tr. 354). He did, however give her some samples of Lunesta, started her on Trileptal in an effort to stabilize her mood, and continued her on Neurontin and Zoloft. (Tr. 353).
On June 18, 2010, Wagner presented to Dr. Shelley Siefert at the Mid Dakota Clinic with complaints of neck pain. (Tr. 344-45). According Dr. Siefert's notes, Wagner was given Toradol at the clinic and further prescribed Soma and Flexeril. (Id.).
On June 21, 2010, Wagner reported to the emergency room with complaints of a "global headache." (Tr. 397). Radiology reports from St. Alexius Medical Center indicate that an MRI taken of Wagner's head on July 6, 2010, revealed no abnormalities. (Tr. 392-93).
Wagner returned to the emergency room on August 12, 2010, this time with complaints of chronic lower back pain. (Tr. 326). She was given pain medication, prescribed Flexeril and Lorcet, and instructed to follow up as needed with her primary care physician. (Tr. 327).
Wagner returned to the emergency room on August 14, 2010, again complaining of lower back pain. (Tr. 324). She was given pain medication and along with another prescription for Flexeril. (Tr. 325). She was also advised to limit her use of anti-inflammatories, ice or heat her lower back, and follow up with her primary care physician. (Id.).
Whatever relief Wagner obtained appears to have been short lived as her medical records reflect that she was hospitalized from August 15-17, 2010, for "intractable low back pain" and "numerous psychiatric comorbidities." (Tr. 310). In his discharge summary, Dr. Biron Baker reported that Wagner was started on IV pain medications upon her admission to the hospital on August 15th, that "[t]hings resolved rather nicely for her, " and that she had been released from the hospital in good condition on August 17. (Tr. 310). He also noted that an MRI taken of Wagner's lumbar spine on August 16, 2010, showed "mild diskogenic disease at multiple levels" but "no evidence of canal stenosis or nerve root compression." (Id.).
On December 15, 2010, Wagner returned to Mid Dakota Clinic, where she was treated by Dr. Siefert for neck, arm and leg pain, a herpetic lesion on her right buttock, anxiety, and a sinus infection. (Tr. 341-43).
Wagner returned to Dr. Eick on December 28, 2010. (Tr. 349-50). During the course of her visit with Dr. Eick, she advised that she had been experiencing uncontrolled anxiety and PTSD symptoms and "wante[ed] to be hospitalized for six months so someone could come up with the correct diagnosis." (Tr. 349). She did, however, deny having any self harm thoughts and did not, in Dr. Eick's opinion, display any bizarre behavior. (Id.). Dr. Eick suggested that she retry Seroquel at bedtime, gave her samples of her current medications (Paxil and Xanax), and instructed her to follow up in four weeks. (Tr. 350).
Wagner presented to the emergency room on January 12, 2011, seeking treatment for a left knee injury. (Tr. 383-86). She was discharged with instructions to ice her knee intermittently, wear a knee immobilizer until better, bear weight as tolerated, and continue with her current pain medications (Tylenol with Codeine #3 and over-the-counter ibuprofen). (Tr. 387).
On April 12, 2011, Wagner reported to Dr. Eick for a followup exam. (Tr. 436). Dr. Eick observed that Wagner's mood had improved and that she appeared more stable than on her last visit. (Id.). His plan was to continue Wagner on Paxil until her prescription ran out and then start her on Wellbutrin, discontinue Seroquel and have her try Hyrdoxyzine for her anxiety, and start her on Ambien. (Tr. 436-37). Days later he discontinued her Ambien and started her on Temazepam. (Tr. 434).
Wagner presented to the emergency room on April 23, 2011, with complaints of pain in her left side. (Tr. 374). According to nursing progress notes, she was issued a prescription for Vicodin at the time of her discharge. (Tr. 376).
Wagner returned to the emergency room on April 23, 2011, with abdominal pain. (Tr. 374-79, 381). She was diagnosed with "probable left renal colic." (Id.). She was discharged with instructions to take her prescribed pain medication (Vicodin) every four hours as needed and over-the-counter pain medication (naproxin) in accordance with label instructions. (Tr. 378).
On May 10, 2011, Wagner presented to Dr. Eick. (Tr. 434). She reported that the Wellbutrin had helped her focus and mood. (Id.). Dr. Eick's noted that her mood continued to improve with appropriate affect. (Id.). His plan was to continue her on Wellbutrin and Hydroxyzine, increase her dosage of Restoril, and see her again in one month's time. (Id.).
Wagner followed up with Dr. Eick on June 7, 2011, reporting that she had been doing better overall and had "been doing a lot of sandbagging and helping out in the community which [made] her feel good." (Tr. 440). According Dr. Eick's notes, Wagner's mood was good, her affect was appropriate, and she exhibited no irritability. (Id.). Dr. Eick discontinued her hydroxyzine but continued her Wellbutrin and Restoril and instructed her to follow-up in approximately two months. (Id.).
On June 30, 2011, Wagner presented to the emergency room with complaints of moderate pain in her lower lumbar spine that radiated to her right lower extremity. (Tr. 451). On examination she exhibited no bladder dysfunction, sensory loss, motor loss, or weakness. (Tr. 451-52). Her gait, reflexes, mood, and affect were normal. (Id.). She was prescribed Vicodin for the pain and discharged with instructions to follow up with her primary care physician should her symptoms persist or worsen. (Tr. 452).
Wagner next followed up with Dr. Eick on August 16, 2011. (Tr. 464). According to Dr. Eick's notes, she presented with paranoia, pressured speech, racing thoughts, and an increase in mood swings. (Tr. 464-65). Although there was some talk of hospitalization, she made the decision to first try to see if she get could control of her symptoms with medication. (Tr. 464).
Wagner returned to Dr. Eick on August 30, 2011, to discuss problems she was having with her adult daughter. (Tr. 462). Dr. Eick reported that Wagner's affect was odd, her mood was elevated, her speech was rapid, and that she was easily distracted. (Id.).
On September 27, 2011, Wagner submitted to a consultative examination by Dr. Paul Jondahl. (Tr. 456-59). She reported to Dr. Eick for a follow up later that same day. (Tr. 460). In Dr. Eick's opinion, she appeared to have improved since her last visit. (Id.). Specifically, he noted that her speech was less pressured, her mood had improved, and her thoughts were a little more logical and coherent. (Id.). He adjusted her medication and instructed her to follow up in a month. (Id.).
On October 20, 2011, Wagner presented to the emergency room with complaints of neck pain and headache. (Tr. 470). A CT scan of her head and neck was negative. (Id.). She was issued prescriptions for Flexeril and ibuprofen 800 and discharged in stable condition. (Id.).
Wagner returned to the emergency room the following day with complaints of headache, muscle pain, cervical spinal pain, and nausea. (Tr. 470). She ...