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Lewis v. Colvin

United States District Court, D. Massachusetts

July 26, 2016

CAROLYN W. COLVIN, Commissioner, Social Security Administration, Defendant.


          F. Dennis Saylor IV United States District Judge

         This is an appeal of a final decision of the Commissioner of the Social Security Administration (“SSA”) denying Social Security Disability Insurance and Supplemental Security Income benefits. Plaintiff Nikki Elaine Lewis appeals the Commissioner’s denial of her request for benefits on the ground that the decision was not supported by “substantial evidence” pursuant to 42 U.S.C. § 405(g). Specifically, plaintiff contends that (1) the Administrative Law Judge (“ALJ”) ignored relevant medical evidence during the “Step Two” and RFC determination components of the Five Step Evaluation Process and failed to consider evidence of her chronic regional pain syndrome (“CRPS”) and severe anemia in his analysis; (2) the ALJ erroneously gave more weight to the opinions of non-examining medical consultants than those of the treating physicians; and (3) the ALJ failed to follow SSA policy in evaluating the evidence of plaintiff’s CRPS.

         Pending before the Court are plaintiff’s motion to reverse or remand the decision of the Commissioner, and Commissioner’s motion for an order affirming her decision. For the reasons stated below, the decision of the Commissioner will be affirmed.

         I. Background

         Nikki Elaine Lewis was born on November 28, 1974. (R. at 62). She was 34 years old on the alleged disability onset date of June 18, 2009. (Id. at 47). She is married and has five children, three of them minors living at home. (Id. at 62-63).

         Lewis earned her G.E.D. in 1993, and has training as a certified nursing assistant (“CNA”) in crisis prevention and intervention. (Id. at 317-18). In the past she has worked as a CNA and as a customer service manager at Walmart. (Id. at 324). She last worked in 2009, when she was employed at a psychiatric unit caring for geriatric patients. (Id. at 63). She ultimately resigned from that job as she could not properly care for the patients. (Id. at 64). After leaving her last job, Lewis looked for a position at various nursing homes, hoping to find clerical work, but was unsuccessful. (Id. at 65).

         At her hearing before the ALJ, Lewis reported being able to shop with the assistance of her children, drive short distances, watch television, use the computer, make medical appointments, and travel around her community. (Id. at 40, 41).

         A. Medical History

         On November 24, 2008, Lewis was seen by an emergency technician, Dr. Lawrence Hulefeld, for an injury to her right foot and hip. (Id. at 620). She was given pain medication and a note to stay out of work until cleared by orthopedics. (Id.). At that point, she had already been diagnosed with iron-deficient anemia and vitamin B12 deficiency, and was receiving iron infusions at a medical center. See, e.g., id. at 850-51, 871, 877, 1042.

         In January 2010, Lewis visited her primary-care physician, Dr. Laura Beeghly, for a “periodic health assessment.” (Id. at 556). Her medical problems were listed as asthma, eczema, and migraine headaches, as well as both pernicious and iron deficiency anemia, for which she was receiving iron infusions. (Id. at 556-557). She told Dr. Beeghly that she was going to school to become an EMT. (Id. at 557).

         In April 2010, Lewis “was moving furniture” when she slipped and fell down stairs, injuring her hand. (Id. at 443). X-rays of the wrist and hand were normal. (Id. at 442).

         On July 14, 2010, Lewis told Dr. Beeghly that she had leg numbness and that she had been having falls daily for two years. (Id. at 440). Dr. Beeghly’s examination did not reveal “significant enough findings . . . to explain daily falls, ” although she did find decreased vibratory senses in both legs and noted that she staggered unusually when attempting to walk on her toes. (Id. at 441). Dr. Beeghly referred Lewis to Dr. Andrew Leader-Cramer, a neurologist. (Id.).

         On October 25, 2010, Dr. Leader-Cramer examined Lewis for pain in her legs and feet. (Id. at 471). Lewis complained of longstanding coldness in both feet with discoloration and cyanosis, as well as “stabbing pain in both feet” that had started a week previously but had since “abated considerably.” (Id.). Dr. Leader-Cramer suggested neurological testing, a rheumatic evaluation, and a vascular assessment. (Id. at 472).

         On November 8, 2010, Lewis underwent an arterial exercise test on her legs. (Id. at 580). The test “was terminated at 3 minutes due to dizziness.” (Id.). The test results appeared to show significant peripheral vascular disease in a “mild to moderate claudication category.” (Id.).[1]

         On December 20, 2010, Lewis complained to Dr. Beeghly that she had been experiencing chest pain since early November, which was occurring with increasing frequency to the point that it had become a daily event. (Id. at 430). She had also recently experienced an episode of syncope. (Id.).[2] Testing revealed low glucose and ferritin levels, though Dr. Beeghly opined that “anemia is not why [Lewis] fainted because [she was] not anemic.” (Id. at 427-28).

         At an April 2011 “periodic health assessment, ” with a nurse practitioner, Lewis reported “falling [and] weakness in legs, ” which the nurse practitioner interpreted as “MS like” symptoms. (Id. at 418).

         On June 15, 2011, Lewis met with Dr. Beeghly for injuries due to falling. (Id. at 408). She reported a two-year history of falls and swelling in both legs, which turned blue. (Id.). A stress test showed “poor exercise capacity, ” as Lewis experienced symptoms in her legs and stopped the test. (Id.). Dr. Beeghly recommended that Lewis consult with a rheumatologist. (Id. at 409).

         On August 5, 2011, Lewis first met with a rheumatologist, Dr. Robert Sands. (Id. at 404). She reported a “2-year history of constant swelling, falling twice per week, injuring herself not infrequently, though so far no fractured bones, ” as well as “chronic dizziness, ” swelling and discoloration of the legs, and pain about the knees and more recently the hips. (Id.). Dr. Sands observed a “somewhat tentative and delivered gait, ” and wrote, “in summary, the cause for her symptoms is not clear, ” noting a “quite atypical history of Raynaud’s.” (Id. at 405-06). He also noted that Lewis “has had a negative neurologic and laboratory evaluation largely, ” and “partial vascular flow tests for her lower extremities and further evaluation from that perspective with her doctors seems [like] a good idea.” (Id. at 406).

         At a follow-up examination on September 19, 2011, Dr. Sands noted that there was “no clear indication of a rheumatic disease being present, ” and that Lewis’s complaints of “diffuse pain and fatigue” led him to “wonder if she has fibromyalgia.” (Id. at 505). Dr. Sands further noted that “[t]he cause for the falling is not fully clear - I wonder if foot drop is playing a role however.” (Id.). He observed a “somewhat slow and deliberate gait, ” full range of motion of all joints without swelling or deformity, “diffuse trigger pt [point] tenderness present, ” and a normal neurological examination, except that the dorsiflexors of the right foot showed some weakness and “giving way.” (Id. at 504). He recommended that Lewis obtain an ankle/foot orthotic device to help prevent falling and that she see an orthopedic. (Id. at 505, 507).

         On September 16, 2011, Lewis met with Dr. Beeghly after an emergency-room visit for a seizure-like episode. (Id. at 509). Dr. Beeghly scheduled a follow-up appointment with Dr. Leader-Cramer and instructed Lewis not to drive until cleared by neurology. (Id. at 509-10).

         On September 23, 2011, Lewis saw Dr. Leader-Cramer for the follow-up examination. (Id. at 469). Dr. Leader-Cramer’s impression was of a “[l]oss of consciousness. The etiology of [which] remains unclear.” A CT scan of the brain was normal. (Id. at 470).

         On December 23, 2011, Lewis was taken to the emergency room after a fall down stairs. (Id. at 569). At a follow-up appointment on December 27, 2011, Dr. Leader-Cramer noted no further episodes of loss of consciousness and doubted that her symptoms represented seizures. (Id. at 468). Lewis also mentioned feeling a “pop” in her head, but the feeling stopped after she discontinued her Cymbalta medication, which made her head feel “clearer.” (Id. at 468, 494).

         On February 17, 2012, Lewis met with Dr. Beeghly and reported that she continued to have falls and was “tired all the time, ” and that her iron infusions always made her feel sick. (Id. at 1016). Dr. Beeghly noted that recent MRI, EEG, TTE (ultrasound of the heart), and stress tests were normal. (Id.). She further noted that the etiology of the falls was unclear, and that neurological testing revealed the “opposite of what is expected for foot drop . . . not sure why she needs an AFO [ankle-foot orthotic] brace.” (Id. at 1017).

         On April 21, 2012, Dr. Sands saw Lewis in a follow-up examination for falling, foot drop, fatigue, and “diffuse total body pain consistent with fibromyalgia without defined rheumatic illness.” (Id. at 1001). Dr. Sands noted that “the number one problem for her is pain, ” noting that Lewis had rearranged her home furniture so as to allow herself to grab something before she falls. (Id.). His impression was that “she has a very therapeutically challenging situation - there is diffuse pain consistent with fibromyalgia, foot drop the etiology of which is not clear to me, depression, financial and family stress that is very substantial. All of these combined have very adversely affected her quality of life, and she is feeling overwhelmed.” (Id. at 1002). He recommended tai chi, water aerobics, and participating in a pain management program. (Id.).

         On June 6, 2012, Lewis saw Pamela Caires, a nurse practitioner, after a fall down stairs resulted in hand and shoulder pain. (Id. at 992).

         On July 30, 2012, Lewis met Dr. Beeghly for a follow-up examination. (Id. at 984). Dr. Beeghly noted that Lewis has a history of CRPS, writing that “Dr. Meleger who saw her this past spring feels she has an atypical version of [CRPS].” (Id.).[3] Dr. Beeghly further noted that Lewis “can sit for an [hour] or so and then she needs to stand up can walk 10 min[utes] or so around the house. . . . [Lewis] [c]an also get dizzy at any time. [She] [f]eels she can lift 10 [pounds] ‘unless I’m dizzy.’” (Id.). Dr. Beeghly found good range of motion of the spine, normal motor strength in the bilateral upper extremities (no corresponding assessment for the lower extremities), an ability to stand on toes and heels with ankle-foot orthotic brace in place on the right side, and an inability to squat. (Id.).

         On August 13, 2012, Lewis was examined at an advanced neurology clinic by Dr. Nagagopal Venna for “a complex gradually worsening but chronic problem of pain, spasms, weakness, and recurrent falls along with daily changes in skin color from bluish to purplish, affecting the right lower extremity and now beginning at the left lower limb.” (Id. at 891). On examination, Dr. Venna could not feel the dorsalis pedis, posterior tibial, popliteal, or femoral pulses. (Id.). He noted that “there is a component of complex regional pain syndrome as well, that is currently being treated with the gabapentin, which we agree with.” (Id.). Further testing was recommended. (Id.).

         On December 5, 2012, examining neurologist Dr. Tracey Cho reported an “essentially normal” examination, with “some give way weakness of the right foot and an antalgic gait.” (Id. at 923). She noted that Lewis was “quite tearful and defensive throughout the visit, ” which included pain descriptions that were “poorly characterized.” (Id.). Dr. Cho found no evidence of a permanent or progressive neurologic disease process, and instead “suspect[ed] that her symptoms are related to a fibromyalgia-like process, exacerbated by depression.” (Id.).

         On March 2, 2013, Lewis returned to Dr. Sands, who noted that Lewis reported diffuse pain consistent with myofascial pain disorder, with foot drop and frequent falls. (Id. at 972). His impression was of a ‚Äúvery challenging situation ...

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