United States District Court, D. Massachusetts
MEMORANDUM AND ORDER ON PLAINTIFF’S MOTION TO
REVERSE AND DEFENDANT’S MOTION TO AFFIRM THE DECISION
OF THE COMMISSIONER
Dennis Saylor IV United States District Judge
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.
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.
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.
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
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).
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.
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).
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).
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.).
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).
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.).
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.). 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).
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.
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).
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).
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).
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
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).
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).
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).
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.).
6, 2012, Lewis saw Pamela Caires, a nurse practitioner, after
a fall down stairs resulted in hand and shoulder pain.
(Id. at 992).
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.). 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.).
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.
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.).
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 “very challenging