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Woodyard v. Berryhill

United States District Court, E.D. Kentucky, Southern Division, London

March 16, 2018

TAMMY ROSE WOODYARD, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          DANNY C. REEVES UNITED STATES DISTRICT JUDGE

         This matter is pending for consideration of cross-motions for summary judgment filed by Plaintiff Tammy Woodyard (“Woodyard” or “the Claimant”) and Defendant Nancy A. Berryhill, Acting Commissioner of the Social Security Administration (“the Commissioner”). [Record Nos. 7, 9] Woodyard argues that the Administrative Law Judge (“ALJ”) assigned to her case erred in concluding that she was not disabled within the meaning of the Social Security Act (“Act'). Specifically, she asserts that the ALJ failed to properly consider the opinion of her treating physician. Woodyard requests that this matter be remanded with instructions that she be awarded benefits. Woodyard has also filed a motion for leave to file a reply memorandum in support of her motion. [Record No. 10]

         The Commissioner contends that the ALJ properly evaluated the evidence and that the ALJ's decision should be affirmed because it is supported by substantial evidence. For the reasons that follow, the Claimant's motion for summary judgment will be granted, in part, and the matter will be remanded for further consideration. The Claimant's motion for leave to file a reply memorandum will be denied, as additional briefing is not needed to resolve this matter.

         I.

         Woodyard filed a Title II application for a period of disability and disability insurance benefits (“DIB”) on July 15, 2014. [See Administrative Transcript, hereinafter “Tr., ” 152-53.] She alleged an onset of disability date of November 6, 2013. [Tr. 152, 42] After the application was denied initially and on reconsideration, Woodyard requested a hearing before an administrative law judge. [Tr. 113-14, 119, 130] She appeared before ALJ Dennis Hansen at a hearing in Middlesboro, Kentucky in April 2016. [Tr. 68-87] ALJ Hansen denied benefits in a written decision on June 17, 2016, which the Appeals Council affirmed. [Tr. 49-58, 1-4] Accordingly, the Claimant has exhausted her administrative remedies and this matter is ripe for review under 42 U.S.C. § 405(g).

         II.

         Woodyard was 42-years-old at the time of the ALJ's decision. [See Tr. 71, 58] She worked at Wal-Mart for more than 15 years, where she processed items that had been returned. [Tr. 72-73] Her position required her to unload items from shopping carts, place them on pallets, shrink-wrap the pallets, and load the pallets on a truck weekly. [Tr. 73] Woodyard estimated that she lifted or carried up to 50 pounds. Id. She testified that she stopped working in 2013 because she was no longer able lift, stand, squat and bending in performing her duties. [Tr. 73-74]

         Woodyard reported that her inability to work was caused by rheumatoid arthritis, osteoarthritis, systemic lupus erythematosus, osteoporosis, Raynaud's phenomenon, mixed connective tissue disease, sleeping problems, moodiness and anxiety. [Tr. 208] When questioned about her inflammatory arthritis, Woodyard testified that her hands were most affected and that she was unable to grip. [Tr. 74-75] She also reported that her fingertips turn blue and she has no feeling in them. [Tr. 78] Woodyard reported that the severity of her symptoms fluctuated, but her hands had not been “normal” for a long time. [Tr. 75] She also reported swelling in her knees and feet, which limited her ability to bend or squat. [Tr. 76, 81] Woodyard testified that lupus had also “affected [her] lungs.” She testified that she had suffered from pleurisy about three times and that the condition had been treated with prednisone. [Tr. 76-77] She reported that her use of prednisone had caused swelling in her face and that she had gained approximately 45 pounds since she began taking the medication. [Tr. 81]

         At the time of the hearing, Woodyard believed that she could stand or sit for thirty minutes before changing positions. [Tr. 79] She believed she could lift “five pounds, maybe.” Woodyard reported driving, but did not help with the cooking and cleaning, other than occasionally loading the washer or dishwasher. [Tr. 72, 80, 205] She accompanied her husband to the grocery store and sometimes out to lunch. [Tr. 80] Woodyard reported that, on a normal day, she watched television to pass the time. Id. The only social activity she reported was visiting her mother. [Tr. 205]

         Gina Bingham, M.D., was Woodyard's primary care physician and provided treatment beginning in December 2009. Bingham treated Woodyard for hypertension and occasional problems such as a cold or urinary tract infection. [Tr. 414, 422, 434] Bingham performed testing in May 2013 which revealed that Woodyard had osteoporosis. [Tr. 428, 487] Bingham also ordered an “arthritis workup, ” which was positive for ANA, “Smith AB, ” and rheumatoid factor.[1] [Tr. 476, 479] She referred Woodyard to a rheumatologist, Mansoor Ahmed, M.D., based on these results. [Tr. 476]

         Ahmed saw Woodyard for the first time on September 13, 2013, noting that she presented with “bilaterally asymmetric polyarthritis, ” which caused pain and tenderness in the joints of both hands, wrists, knees, and toes of both feet. [Tr. 282-83] Ahmed prescribed Plaquenil at Woodyard's next visit in October 2013. [Tr. 288] The following month, Amhed increased the dosage, noting that Woodyward had “ synovitis” at the metacarpophalyngeal joints and wrist. [Tr. 291]

         Woodyard requested a second opinion. It appears that this request was triggered, at least in part, by Ahmed's refusal to provide Woodyard with a work excuse. [Tr. 463, 582] Bingham referred Woodyard to Shannon Florea, M.D., in November 2013, but it is unclear if Woodyard ever saw Dr. Florea. [Tr. 463, 582, 587] Woodyard began treating with another rheumatologist at the University of Kentucky, Thomas Howard, M.D., in December 2013. [Tr. 685] Howard noted that Woodyard suffered from fatigue but, other than valgus knees, her joints appeared normal. [Tr. 583-84] By July 2014, Howard described Woodyard as having systemic lupus erythematosus, with manifestations of arthritis including pleurisy and “Ð, SM, [and] RnP.” [Tr. 630] She presented with a maculopapular rash involving her feet and hands and reported that methotrexate was not helping her joint pain. Id. Howard described Woodyard's digits, nails, joints, bones, and muscles as abnormal, with tenderness upon palpation of her fingers. [Tr. 632] Other symptoms included shortness of breath with prolonged standing or walking up stairs. [Tr. 625]

         Woodyard also began taking prednisone to manage her symptoms. She experienced a significant increase in pain and swelling when she tried to taper off of that medication. [Tr. 652] She tried another medication (Imuran) without much success. Id. In March 2015, Woodyard had been using prednisone again due to increase hand and wrist pain, with an erythematous rash overlying the dorsal aspects of her hands. [Tr. 643, 646] Despite her fear of injections, Woodyard began treatment with Humira. [Tr. 649] By May 2015, Woodyard still suffered malaise and fatigue, but the rash on her hands was improving. [Tr. 641] Although Howard did not detect synovitis during that visit, he noted that the arthritis was not controlled without prednisone. Id. Woodyard was advised to keep her entire body warm. Id.

         Woodyard had tapered off prednisone and was “doing well overall” in July 2015, but still had some hand joint pain and new bilateral foot swelling. [Tr. 662] She also developed a new rash on her chest. This was thought to be caused by the Humira, so she discontinued it. [Tr. 692] A few months later, her rash had worsened and spread to her upper arms. [Tr. 692] Although her hand pain was “tolerable, ” she advised Howard that she felt best while taking prednisone and she resumed taking a tapered dose of that medication. [Tr. 695] Woodyard followed up with Howard in February 2016 and reported pain in her hands, wrists, and knees that was “much better” ...


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