Stancle v. Colvin

SHARON LYNN STANCLE, Plaintiff, v. CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.

CIVIL ACTION NO. 4:15-CV-00405-CAN

UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF TEXAS SHERMAN DIVISION

June 7, 2016

MEMORANDUM OPINION AND ORDER

Plaintiff brings this appeal under 42 U.S.C. § 405(g) for judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for disability insurance benefits [Dkts. 1; 10]. After reviewing the Briefs submitted by the Parties, as well as the evidence contained in the Administrative Record, the Court finds that the Commissioner's decision should be REMANDED.

BACKGROUND

I. Procedural History of the Case

On March 17, 2010, Sharon Lynn Stancle ("Plaintiff") filed her application for social security disability insurance benefits ("DIB") under Title II of the Social Security Act ("Act"), alleging an onset of disability date of July 1, 2009 [TR at 180-81, 218]. Plaintiff's application was initially denied by notice on October 7, 2010, and again upon reconsideration on August 17, 2011, after which Plaintiff requested a hearing before an administrative law judge ("ALJ"). Id. at 62-65, 87-91, 103-106. The ALJ conducted a hearing on May 21, 2012 ("Hearing I"), and heard testimony from Plaintiff and Vocational Expert Ann Young ("Ms. Young"). Id. at 26-27. Plaintiff was represented by counsel at Hearing I. Id. On July 13, 2012, the ALJ issued his decision denying benefits ("Determination I"), and found Plaintiff not disabled at step four of the prescribed sequential evaluation process. Id. at 66-78. On August 6, 2012, Plaintiff requested that the Appeals Council review Determination I, and on August 14, 2013, the Appeals Council remanded for further evaluation of Plaintiff's treating physician Dr. Lieman's opinion and the date last insured. Id. at 82-85, 147. The Appeals Council found Determination I did not contain an evaluation of Dr. Lieman's opinion or the weight given to his opinion. Id. at 84. On December 9, 2013, the ALJ conducted a second hearing ("Hearing II") and heard testimony from Plaintiff and Vocational Expert Bonnie Ward ("Ms. Ward"). Id. at 49-50. Plaintiff was also represented by counsel at Hearing II. Id. On February 28, 2014, the ALJ issued his decision again denying benefits ("Determination II"), and found Plaintiff not disabled at step four of the prescribed sequential evaluation process (discussed infra). Id. at 9-24. On April 9, 2014, Plaintiff requested that the Appeals Council review the ALJ's decision, and on May 23, 2015 the Appeals Council denied Plaintiff's request for review, making Determination II the final decision of the Commissioner. Id. at 1-8.

On June 15, 2015, Plaintiff filed her Complaint with this Court [Dkt. 1]. On September 4, 2015, the Administrative Record was received from the Social Security Administration ("SSA") [Dkt. 8]. Plaintiff filed her Brief on October 1, 2015 [Dkt. 10]. On December 7, 2015, the Commissioner filed her Brief in Support of the Commissioner's Decision [Dkt. 12], and on December 11, 2015, Plaintiff filed her Reply Brief [Dkt. 13]. On February 3, 2016, this case was assigned to the undersigned by consent of all Parties for further proceedings and entry of judgment [Dkt. 16].

II. Statement of Relevant Facts

1. Age, Education, and Work Experience

Plaintiff was born on April 28, 1960, making her fifty three years of age at the time of the Commissioner's final decision [TR at 180-81]. Plaintiff completed the twelfth grade, has a high school diploma, and has some advanced college training. Id. at 219-20. Plaintiff's past relevant work experience includes a daycare worker. Id. at 38-46.¹ Plaintiff asserts that her onset date of disability is July 1, 2009. Id. at 180.

2. Medical Record Evidence

Plaintiff's impairments include history of back and neck pain, history of bilateral knee pain, history of bilateral carpal tunnel syndrome, history of right arm weakness, history of abdominal surgeries, hyperlipidermia, overweight (5'4'' and 170 pounds), and history of frequent urination.² At issue herein, predominantly, is Plaintiff's urinary incontinence. Plaintiff's relevant medical records related to her urinary incontinence and residual functional capacity ("RFC") consist of reports from: (a) Dr. Berry Albright Fleming, M.D. ("Dr. Fleming") and Dr. Richard C. Kaye, M.D. ("Dr. Kaye") at Texas Health Presbyterian Hospital ("Texas Health") [TR at 505-70]; (b) Dr. Stephen J. Lieman, M.D. ("Dr. Lieman") at Baylor Medical Center ("Baylor") [TR at 571-89, 604-14, 625]; (c) Dr. David M. Bailey, M.D. ("Dr. Bailey") [TR 497-504]; and (d) Dr. James Baker, M.D. ("Dr. Baker") [TR at 598-603].

a. Dr. Fleming & Dr. Kaye

On December 6, 2011, Plaintiff was seen by Dr. Fleming in the emergency room at Texas Health Plano for vaginal bleeding and syncope (temporary loss of consciousness caused by a fall in blood pressure) and light-headedness [TR at 506-13]. Plaintiff had been treated previously by Dr. Fleming for heavy menstrual bleeding and uterine fibroids. Id. at 514-15. Plaintiff was admitted the same day and received a blood transfusion; and, when her condition did not improve, Plaintiff underwent a partial hysterectomy on December 8, 2011. Id. at 506-22. On December 23, 2011, Plaintiff was seen in the emergency room for urinary leakage from the vaginal area, and was diagnosed with a vesico-vaginal fistula (an abnormal opening between the vagina and the bladder). Id. at 531-32. Dr. Kaye, at the direction of a "Dr. Lightfoot, urology," recommended delay in surgery pending Plaintiff's complete recovery from her partial hysterectomy, and Plaintiff was fitted with a Foley catheter. Id. at 532-50.³

b. Dr. Lieman

On January 9, 2012, Plaintiff was seen by Dr. Lieman at Baylor regarding her vesico-vaginal fistula and reported continued vaginal leakage [TR at 571-89]. On January 23, 2012, Plaintiff underwent an exploratory laparotomy, lysis of adhesions (cutting of scar tissue), a left ureteral reimplantation (fixing connection between kidneys and bladder), and a cysioscopy and bilateral retrograde pyelograms (diagnostic tests to examine the bladder and kidneys). Id. Plaintiff's post-surgery diagnosis was an uretero-vaginal fistula (an abnormal opening between the vagina and the ducts that carry urine from the kidneys to the bladder). Id. at 583. The record contains no records from Dr. Lieman between January 23, 2012 and June 4, 2012. Id. at 314-625.

Via letter dated June 4, 2012, Dr. Lieman wrote that:

[Plaintiff] is post ureteral reimplantation for an uretero-vaginal fistula on January 23, 2012. Due to her surgery she may have chronic bladder spasms with frequent urination.

Id. at 589. On November 8, 2012, Dr. Lieman saw Plaintiff for a follow up appointment, at which time he assessed female stress incontinence (unintentional loss of urine due to physical movement/activity) and difficulties with urinary retention and reported "has some SUI ["stress urinary incontinence"] and not sure emptying." Id. at 605-607.⁴ Dr. Lieman's assessments were similar at Plaintiff's November 26, 2012 follow up appointment. Id. at 608-10. On September 4, 2013, Plaintiff had a third follow up visit with Dr. Lieman, at which time he assessed female stress incontinence, urinary retention (resolved), and incontinence without sensory awareness. Id. at 611-13. Dr. Lieman reported Plaintiff "[h]as occ. SUI and insensible urine loss" and recommended TVT (tension-free vaginal tape surgery), kegels, and rehab prn (rehabilitation as needed). Id. On January 28, 2014, Dr. Lieman wrote:

[Plaintiff] is a patient I see for bladder issues. She has bladder spasms and frequent urination associated with severe incontinence. Due to her bladder instability and frequency of urination she should be excused from jury duty.

Id. at 625.

c. Dr. Bailey

On August 8, 2011, Dr. Bailey, a medical consultant, conducted a RFC assessment based on Plaintiff's medical records [TR at 497-504]. Dr. Bailey opined that Plaintiff could lift 20 pounds occasionally, ten pounds frequently, sit for about six hours in an eight hour workday, stand for six hours in an eight hour workday, and was unlimited in her capacity to push and/orpull (including operation of hand and/or foot controls). Id. Dr. Bailey assessed Plaintiff with no postural, manipulative, visual, communicative, or environmental limitations. Id. Dr. Bailey expressly stated that there were no medical source statements in the file at the time of Dr. Bailey's assessment. Id.⁵ In light of the date of Dr. Bailey's assessment, Dr. Bailey did not have the opportunity to review Dr. Fleming's, Dr. Kaye's and/or Dr. Lieman's medical records when making his findings. Id. at 497-504, 571-89, 605-13. 625.

d. Dr. Baker

On March 26, 2013, Dr. Baker saw Plaintiff for a medication check and laboratory appointment [TR at 598-603]. Dr. Baker stated that Plaintiff reported "she feels that she is doing well." Id. Dr. Baker reported that Plaintiff and he discussed micro urinary outlet obstruction and some of Plaintiff's mental health symptoms. Id. On March 31, 2013, Plaintiff was seen for a follow up visit regarding labs and for a rash on her back. Id. Dr. Baker reported kidney/back pain but negative for dysuria, fever, and pyuria. Id. Dr. Baker made no comment or notes regarding Plaintiff's frequency of urination, or activities of daily living or job activities restrictions or limitations. See id. at 314-625.

3. Hearing Testimony

a. Plaintiff's Testimony

At Hearing I before the ALJ on May 21, 2012, Plaintiff testified that she is married and lives with her husband in Tulsa, Oklahoma [TR at 29-42]. Plaintiff reported leg swelling and muscle spasms in her spine, neck, and back stemming from an incident where she broke the fall of a patient at St. John's Medical Center. Id. at 31-35. Plaintiff also testified that her back locks up requiring muscle relaxants and pain medications at least once every three to six months....