Fischer v SSA

2014 DNH 227
District Court, D. New Hampshire·Decided October 30, 2014·No. 13-cv-463-PB·Published·Cited by 3 cases

Opinion

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE

Gloria Gean Fischer

v. Civil No. 13-cv-00463-PB Opinion No. 2014 DNH 227

Carolyn Colvin, U.S. Social Security Administration, Acting Commissioner

MEMORANDUM AND ORDER

Gloria Gean Fischer seeks judicial review of a ruling by the Commissioner of the Social Security Administration (“SSA”) denying her application for Disability Insurance Benefits (“DIB”). For the reasons I discuss below, I conclude that the Administrative Law Judge (“ALJ”) erred by failing to consult a medical advisor before determining that Fischer was not disabled as of her date last insured. Thus, I vacate the Commissioner’s decision and remand for further administrative proceedings.

I. BACKGROUND1

A. Relevant Medical and Other Documentary Evidence Fischer was 41 years old when her insured status expired on

1 Sections A and B of the background section are taken substantially from the parties’ Joint Statement of Material Facts (Doc. No. 10). See L.R. 9.1(b). Minor stylistic and substantive changes have been made, and citations to the administrative transcript have been omitted.

March 31, 1998, and she was 56 years old on June 28, 2013, when the ALJ denied her claim. Fischer has a GED and she previously worked as a hairdresser, a retail store owner, and an operator of a small basket-making company.

1. Medical Evidence On October 1, 1996, Fischer visited the Exeter Hospital Pain Clinic complaining of increasingly severe left buttock and left leg pain that began when she was injured after a fall in June 1996. The pain was worse with standing or sitting, and it woke her up at night. She also described transient paresthesias2 in L4-5 and S13 distributions. On examination, Fischer had full range of motion in the lumbar spine,4 tenderness in the spinous process in T2-T55 and at L4-5, and unusual paraspinal tenderness.

2 Paresthesia is an abnormal touch sensation, such as burning, prickling, or formication, often in the absence of an external stimulus. Dorland’s Illustrated Med. Dictionary (Dorland’s) 1404 (31st Ed. 2007). 3 The symbols L4 and L5 refer to two of the five vertebrae that comprise the lumbar vertebrae, which are the five vertebrae between the thoracic vertebrae and the sacrum, a wedge-shaped bone lodged between the two hip bones. Dorland’s, supra note 2, at 1362, 2079. The symbol S1 refers to one of the five fused sacral vertebrae that form the sacrum. Id. at 1362. 4 The lumbar spine is that portion of the spine comprising the lumbar vertebrae. Dorland’s, supra note 2, at 1774. 5 The symbols T2 and T5 refer to two of the twelve vertebrae that comprise the thoracic vertebrae, which are situated between the

She had good flexion and extension of her lower extremities, and she was able to toe and heel walk. Straight leg raise testing was positive at 90 degrees on the right and left. An MRI showed a bulge at L4-5. The attending physician diagnosed Fischer with sciatica6 secondary to lumbar strain and administered an epidural steroid injection.7 On January 6, 1998, Fischer underwent an MRI of her cervical spine to assess neck pain that was radiating to her left shoulder. The MRI was normal.

Fischer’s insured status expired on March 31, 1998.

In October 1998, Fischer underwent an X-ray of her left hip and pelvis to rule out a bone abnormality or sacroilitis.8 That

lumbar and cervical vertebrae, giving attachment to the ribs and forming part of the posterior wall of the thorax. They are designated by the symbols T1 through T12. Dorland’s, supra note 2, at 2079. 6 Sciatica is a syndrome characterized by pain radiating from the back into the buttock and into the lower extremity along its posterior or lateral aspect, and most commonly caused by protrusion of a low lumbar intervertebral disk; the term is also used to refer to pain anywhere along the course of the sciatic nerve. Dorland’s, supra note 2, at 1703. 7 “Epidural” means situated upon or outside the dura mater, which is the outermost, toughest, and most fibrous of the three membranes covering the brain and spinal cord. Dorland’s, supra note 2, at 580, 639. 8 Sacroiliitis is inflammation in the sacroiliac joint, which is located between the sacrum (the triangular bone just below the

study was also normal.

On March 31, 2004, Fischer visited Dr. Frank Graf, complaining of poor results from epidural blocks. 9 On examination, Fischer exhibited marked sensitivity in the sciatic notch on her left side, and she also had pain on passive range of motion of the hip joints. Dr. Graf noted that her X-rays and MRIs did not indicate any hip joint problem or sacroiliac joint problem, and her MRI of the lumbar spine suggested some degenerative disc changes with annular bulge but no disc herniation. 10 He recommended a pelvic examination with her internist, Dr. Braese, and an appointment with a physical therapist.

On May 27, 2004, Fischer underwent a physical therapy evaluation for a questionable diagnosis of piriformis syndrome11.

lumbar vertebrae) and ilium (the expansive superior portion of the hip bone). Dorland’s, supra note 2, at 1362, 1687. 9 An epidural block is regional anesthesia produced by injection of the anesthetic agent into the epidural space. Dorland’s, supra note 2, at 230. 10 Herniation is the abnormal protrusion of an organ or other body structure through a defect or natural opening in a covering, membrane, muscle, or bone. Dorland’s, supra note 2, at 862. 11 Piriformis syndrome is compression of the sciatic nerve by the piriformis muscle, causing pain. The Merck Manual 2635 (18th

Under the History section of the report, it was noted that Fischer had fallen off of a ladder seven years earlier onto her left hip with a twisting motion as she fell, and she had experienced problems with her left buttock and leg ever since. She had been treated with physical therapy, which did not help a great deal. Fischer complained that over the preceding few days she felt a constant pain in the left buttock and down into the lateral aspect of the leg, which she rated at a 7 on a scale of 0-10. While attempting to work out the pain, she had also been experiencing numbness and tingling in her left arm. She also noted that she began taking Ambien during the past week because the pain was making it difficult for her to sleep. The therapist administered a number of specific low back tests, including a piriformis test that yielded a “markedly positive” result on her left side and a straight leg raise that was positive for left lower back burning.

On August 14, 2004, Fischer underwent an MRI of the lumbar spine to evaluate complaints of left flank pain that radiated to the left leg. Fischer then underwent a second MRI of the lumbar spine on December 15, 2005.

Ed. 2006).

On December 7, 2006, Fischer underwent an operation to implant a dual Octrode lead for a spinal cord stimulation trial.

On September 4, 2009, Fischer’s treating primary care physician, Dr. Braese, noted that Fischer reported to him that she had two jobs and was happy and active.

In 2010, Fischer began to regularly visit the Rye Interventional Spine Medicine seeking treatment for her back, leg, and foot pain. At these visits, Fischer would usually complain of a persistent pattern and history of back and left- sided leg and foot pain that had originated around 1995 and 1996. For example, during her April 20, 2011 visit, Fischer complained of low back pain that had been occurring in a persistent pattern for 15 years without change. She described the pain as a moderate to severe dull aching in the lower back, left flank area, left buttock, and left dorsal foot. The pain, Fischer said, radiated to the lateral aspect of her left leg and left foot. The back pain was aggravated by sitting.

Additionally, the Rye Interventional Spine Medicine report dated August 27, 2012 states:

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