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Farrish v. Commissioner of Social Security

United States District Court, W.D. Virginia, Charlottesville Division

March 30, 2017

WENDY L. FARRISH, Plaintiff,


          Joel C. Hoppe United States Magistrate Judge

         Plaintiff Wendy L. Farrish asks this Court to review the Commissioner of Social Security's (“Commissioner”) final decision denying her applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act (the “Act”), 42 U.S.C. §§ 401-434, 1381-1383f. The case is before me by the parties' consent under 28 U.S.C. § 636(c)(1). ECF No. 9. Having considered the administrative record, the parties' briefs, and the applicable law, I find that the Commissioner's decision is not supported by substantial evidence and therefore REMAND the case for further administrative proceedings.

         I. Standard of Review

         The Social Security Act authorizes this Court to review the Commissioner's final decision that a person is not entitled to disability benefits. See 42 U.S.C. § 405(g); Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). The Court's role, however, is limited-it may not “reweigh conflicting evidence, make credibility determinations, or substitute [its] judgment” for that of agency officials. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Instead, the Court asks only whether the Administrative Law Judge (“ALJ”) applied the correct legal standards and whether substantial evidence supports the ALJ's factual findings. Meyer v. Astrue, 662 F.3d 700, 704 (4th Cir. 2011).

         “Substantial evidence” means “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971). It is “more than a mere scintilla” of evidence, id., but not necessarily “a large or considerable amount of evidence, ” Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence review takes into account the entire record, and not just the evidence cited by the ALJ. See Universal Camera Corp. v. NLRB, 340 U.S. 474, 487-89 (1951); Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984). Ultimately, this Court must affirm the ALJ's factual findings if “conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled.” Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (per curiam) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996)). However, “[a] factual finding by the ALJ is not binding if it was reached by means of an improper standard or misapplication of the law.” Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).

         A person is “disabled” if he or she is unable to engage in “any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a), 416.905(a). Social Security ALJs follow a five-step process to determine whether an applicant is disabled. The ALJ asks, in sequence, whether the applicant (1) is working; (2) has a severe impairment; (3) has an impairment that meets or equals an impairment listed in the Act's regulations; (4) can return to his or her past relevant work based on his or her residual functional capacity; and, if not (5) whether he or she can perform other work. See Heckler v. Campbell, 461 U.S. 458, 460-62 (1983); 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The applicant bears the burden of proof at steps one through four. Hancock, 667 F.3d at 472. At step five, the burden shifts to the agency to prove that the applicant is not disabled. See id.

         II. Procedural History

         Farrish applied for DIB and SSI on November 1, 2011, alleging disability caused by rheumatoid arthritis, irritable bowel syndrome (“IBS”), and Graves' disease. Administrative Record (“R.”) 66, 76, ECF No. 11. At the time of her alleged onset date of December 1, 2007, [1]she was thirty-eight years old, R. 66, 76, and had most recently worked as a school bus driver, R. 73, 83. Disability Determination Services (“DDS”), the state agency, denied her claims at the initial, R. 66-74, 76-84, and reconsideration stages, R. 86-95, 97-106. On September 19, 2013, Farrish appeared with counsel at an administrative hearing before ALJ Brian P. Kilbane, at which time the ALJ heard testimony from Farrish and Casey Vass, a vocational expert (“VE”). R. 46-65.

         ALJ Kilbane denied Farrish's claims in a written decision issued on October 25, 2013. R. 23-40. He found that Farrish had severe impairments of fibromyalgia, inflammatory arthritis, degenerative disc disease, and inflammatory bowel disease (“IBD”).[2] R. 26. Farrish's impairments of Graves' disease, anxiety disorder, and affective disorder were found to be nonsevere. R. 26-27. The ALJ next determined that none of Farrish's impairments, alone or in combination, met or medically equaled the severity of a listed impairment. R. 27-28.

         As to Farrish's residual functional capacity (“RFC”), the ALJ found that she could perform light work[3] with up to six hours of sitting and six hours of standing or walking in an eight-hour day; unlimited balancing; frequent stooping, kneeling, crouching, and climbing of ramps or stairs; and occasional crawling and climbing of ladders, ropes, or scaffolds. R. 28-37. He also determined that Farrish would need a restroom facility available in her place of work. Id. Based on this RFC and the VE's testimony, the ALJ found that Farrish could perform her past relevant work as a cashier and a receptionist, or alternatively, could perform other work existing in significant numbers in the national and regional economies, including hand packer, laundry worker, and office assistant. R. 38-39. He therefore concluded that Farrish was not disabled. R. 39. The Appeals Council denied Farrish's request for review, R. 1-3, and this appeal followed.

         III. Facts

         A. Relevant Medical Records

         Farrish's treatment notes date back to February 2003. R. 614-17. Prior to her alleged onset date, she received periodic treatment (including inpatient hospitalization) for a variety of gastrointestinal (“GI”) symptoms such as diarrhea, abdominal pain, nausea, and rectal bleeding. See R. 614-17 (Feb. 21-24, 2003), 398-405 (Sept. 7, 2006), 438 (Oct. 21, 2006; Jan. 19, 2007), 380-88 (Jan. 17, 2007), 441-42 (Jan. 30, 2007), 437 (Feb. 23, 2007). Treatment notes from her February 2003 hospitalization state that Farrish had been diagnosed with Crohn's disease two years earlier, but this had not been confirmed by colonoscopy or biopsy. R. 614-16. Imaging of her abdomen and pelvis during this period revealed generally normal findings. See R. 425 (Feb. 24, 2004), 423 (June 11, 2004), 418-20 (Sept. 7, 2006), 411 (Sept. 8, 2006). But see R. 392 (Jan. 17, 2007, pelvic CT scan findings compatible with inflammatory enteritis, with primary consideration of Crohn's disease), 464-66, 469-70 (Jan. 30, 2007, colonoscopy revealing ileitis, proctitis, and internal hemorrhoids, and biopsies taken during colonoscopy, showing no acute ileitis or colitis, but focal ulceration with inflammatory exudates noted in rectal sample). Farrish was also evaluated during this time for anxiety, see R. 614-17 (Feb. 21-24, 2003); musculoskeletal pains in her neck and knees, see R. 614-17 (Feb. 21-24, 2003), 421 (May 23, 2006), 378 (May 16, 2007); and hematuria, see R. 377 (Sept. 18, 2007), with no remarkable findings.

         Following her alleged onset date, on December 5, 2007, Farrish reported to the emergency room at Prince William Hospital with complaints of nausea, vomiting, abdominal pain in the right upper quadrant, and diarrhea. R. 361-69. An ultrasound revealed sludge in her gallbladder, with no evidence of gallstones or gallbladder wall thickening, and mild dilation of the common bile duct of uncertain etiology. R. 375. During a surgical consultation on December 14, Farrish explained that the pain in her right upper quadrant was different that the pain she associated with Crohn's disease, which she reported had not bothered her for quite some time and was focused on her left side. R. 345-48. Because her signs, symptoms, and history of gallstones were consistent with cholecystitis, Farrish underwent a laparoscopic cholecystectomy (removal of the gallbladder). Id. On January 11, 2008, Farrish followed up with Arul Marathe, M.D., her gastroenterologist, and stated that she still had trouble keeping food down and experienced continuing problems with abdominal pain and diarrhea. R. 435.[4]

         Over the next few months, Farrish complained of other symptoms as well. On January 22, she reported having blood in her urine, frequent urination, pain and swelling in her legs and knees, lower back pain, and insomnia. R. 682-86. On February 26, she presented to Matthew Swartz, M.D., for evaluation of her GI symptoms and large and small joint swelling and pain in the lower extremities. R. 277-78. Dr. Swartz noted Farrish gained some relief from her joint pains through nonsteroidal anti-inflammatory drugs (“NSAIDs”), but she limited her use of these because they caused increased abdominal discomfort. R. 277. He also noted that in spite of her symptoms, Farrish “continue[d] to work full time as a county school bus driver.” Id.[5] She was tender in the right upper quadrant of her abdomen, exhibited trace crepitus in the knees, and had slight tenderness on range of motion of the lower extremities. R. 277-78. Dr. Swartz opined that these findings did not support inflammatory arthropathy, but he prescribed a low dose of prednisone for trial use while Farrish awaited workup of her GI issues and abnormal liver functioning. R. 278. On March 11, Dr. Swartz wrote a letter to Joseph Chambers, M.D., Farrish's primary care physician, explaining his doubt that Farrish's musculoskeletal symptoms were related to IBD because she did not exhibit overt synovitis. R. 276. He continued to recommend a course of low-dose prednisone for diagnostic and potential long-term treatment purposes, and he opined that Farrish's GI condition may benefit from use of a biologic. Id.

         Farrish visited Dr. Marathe again throughout March, complaining of increasing abdominal pain in the right upper quadrant, diarrhea, and nausea, and Dr. Marathe noted that her blood work showed elevated liver enzymes. R. 432-34. Imaging taken on March 19 showed a moderately dilated proximal common bile duct of indeterminate etiology. R. 327. On April 8, Dr. Marathe performed endoscopic retrograde cholangiopancreatography (“ERCP”) and sphincterotomy, revealing a dilated common bile duct with fusiform dilation, which raised a question of possible choledochocele abnormality. R. 285. The following day, Farrish reported to the emergency room with severe abdominal pain (distinct from her chronic pain in the right upper quadrant) and was hospitalized for acute pancreatitis secondary to the ERCP. R. 311-25, 461-62. Her Crohn's disease was noted to be relatively under control on Pentasa as she had not had diarrhea or bloody bowel movements. R. 315. She was discharged on April 11 once her pancreatitis resolved, with her chronic conditions diagnosed as sphincter of Oddi dysfunction and Crohn's disease. R. 309. Farrish visited Dr. Marathe again in late April and June, reporting continued episodes of abdominal pain in the right upper quadrant and diarrhea. R. 429-30. She also visited Dr. Swartz again on May 22, reporting that she had gotten some relief of her joint pain from prednisone, but discontinued it because it caused problems with her diet and her personality. R. 279. Dr. Swartz noted that Farrish's labs were negative for evidence of inflammatory process or immunologic disorder, and he deferred further treatment until her GI issues had resolved, commenting that anti-inflammatory drugs could be effective in treating joint pain, but would likely exacerbate the GI issues. Id.

         On December 12, Farrish reported to the emergency room at the University of Virginia (“UVA”) hospital with reports of diarrhea, nausea, vomiting, and exacerbation of her chronic abdominal pain over the past week. R. 597-613.[6] She claimed that her stool frequency had increased to ten to fifteen episodes per day, compared to her baseline of two to six per day. R. 598. The doctors mused that these symptoms must have “resolved upon arrival, ” noting that she had no bowel movements on the day of her admission and two bowel movements on the second day of her stay and that she felt nauseous during her stay, but did not have any reports of emesis. R. 600. On examination, Farrish was diffusely tender around her abdomen, particularly in the right lower quadrant and epigastric area, but she did not exhibit guarding, rebound, distension, or abnormal bowel sounds. R. 598, 600. CT imaging showed mild intrahepatic and extrahepatic biliary ductal dilation and thickening of the sigmoid colon and bowel wall suggestive of the sequelae of prior inflammatory change rather than an active inflammatory process. R. 599. The location of her pain away from the right upper quadrant suggested that her biliary dilatation was not the likely cause of pain. R. 600. Workup for IBD was ordered, but it was thought that IBS was a more likely diagnosis. Id.

         On December 22, 2009, Farrish began treating with Lien Dame, M.D., at UVA. R. 623- 25. She complained of depression, stating that she had trouble sleeping, was fatigued during the day, had occasional unprovoked crying spells, was sometimes irritable, and dealt with stress at home because of financial difficulties and taking care of her two young grandchildren. R. 623- 24. She also complained about pain in her lower back on the right side that occasionally radiated down her right leg, which she thought might be related to carrying her grandson around on her hip. R. 624. She did not take Tylenol or ibuprofen for her pain because of problems with her liver, but she did get relief from ThermaCare patches. Id. Dr. Dame prescribed a selective serotonin reuptake inhibitor (“SSRI”) for Farrish's depression and Aleve for her back pain. R. 625.

         Dr. Dame also noted that Farrish was being followed for Graves' disease by Christine Eagleson, M.D., in UVA's Endocrinology Department, and her GI issues were being followed by Dr. Brian Behm in Digestive Health. R. 624-25.[7] Farrish's Graves' disease was status post radioactive iodine ablation in April 2009, with resulting hypothyroidism, and she was awaiting the results of a recent blood test. Id. With regard to her digestive problems, Dr. Dame noted that Farrish's previous diagnosis of Crohn's disease had been modified to IBS after a series of colonoscopies were negative for Crohn's, and she ordered additional blood work to follow up on Farrish's history of abnormal liver function tests. Id. Almost one month later, Farrish was again evaluated by Dr. Dame and Joanne Coleman, N.P., for severe abdominal pain in the left upper quadrant. R. 622-23. She was referred to the emergency room at UVA, id., but there is no indication in the record as to whether Farrish followed through on this referral.

         Farrish followed up with Dr. Eagleson for treatment of her Graves' disease on April 14, 2010. R. 618-19. She was taking levothyroxine for treatment of hypothyroidism. R. 618. Farrish did not endorse hyperthyroid symptoms, but she did complain of some possible hypothyroid symptoms, including weight gain, constipation, cold intolerance, and dry skin. Id. Nonetheless, findings on physical examination were normal, and Dr. Eagleson noted that clinically Farrish appeared to be euthyroid. R. 618-19. Farrish does not appear to have treated with Dr. Eagleson again after this date, and ...

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