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Smith v. Saul

United States District Court, D. New Hampshire

November 13, 2019

Shannon C. Smith
Andrew Saul,[1] Commissioner, Social Security Administration

          Janine Gawryl, Esq.

          Michael L. Henry, Esq.



         Shannon Smith challenges the denial of her claims for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) pursuant to 42 U.S.C. § 405(g). She contends that the Administrative Law Judge (“ALJ”) erred by (1) failing to properly analyze her mental impairments at step two and thereafter; (2) failing to follow the Social Security Administration's (“SSA”) Ruling on the Evaluation of Fibromyalgia, SSR 12-2p, 2012 WL 3104869 (July 25, 2012); and (3) improperly giving greater weight to non-examining state agency consultants than to Smith's treating and examining medical sources. The Commissioner, in turn, moves for an order affirming the ALJ's decision. For the following reasons, I grant Smith's motion and remand this matter to the Commissioner for further proceedings consistent with this order.

         I. BACKGROUND

         A. Procedural Facts

         Smith is a forty-four-year-old woman who has previously worked as a gas station attendant and cashier and currently works part time at a Dunkin' Donuts. See Administrative Transcript (“Tr.”) at 297, 305. She alleges that she has been disabled since January 12, 2016, due to a combination of fibromyalgia, Chiari malformation, [2] migraines, depression, and anxiety. Tr. at 18-19.

         Smith filed claims for DIB and SSI on November 30, 2016. Tr. at 271. After an initial denial on March 16, 2017, Tr. at 121, she testified at a hearing before ALJ Thomas Merrill on November 13, 2017. Tr. at 39-80. The ALJ denied Smith's applications, Tr. at 32, and the SSA Appeals Council denied her request for review. Tr. at 1-3. As such, the ALJ's decision constitutes the Commissioner's final decision, which Smith now appeals.

         B. Medical Evidence

         In this section, I decline to recite a full history of Smith's medical treatment, opting instead to focus on the treatment records necessary to provide context in this case.

         Prior to Smith's alleged disability onset date, she was diagnosed and/or treated by various providers for migraines, e.g., Tr. at 389, 404, 416, 686; anxiety/panic disorder, e.g., Tr. at 389, 416, 429, 436, 686, 687, 695, 703; depression, e.g., Tr. at 389, 436, 686, 695; Chiari malformation, Tr. at 389; and fibromyalgia, e.g., Tr. at 429; as well as other ailments not claimed as a basis for her disability, e.g., Tr. at 389, 397-98, 422.

         Following the alleged onset date, Smith continued to seek treatment for fibromyalgia, anxiety, and depression from her primary care physician, Dr. Nanyee Keyes on February 24, 2016. Tr. at 441-42. That June, Smith discussed with a physician assistant how her fibromyalgia interfered with her sleep, which in turn exacerbated her fibromyalgia symptoms. Tr. at 446. Another doctor, Dr. Mitchell Young, diagnosed Smith as having fibromyalgia affecting her shoulder on September 24. Tr. at 474. Smith returned to Dr. Keyes on November 18, who noted 14 positive fibromyalgia tender points (out of a possible 18) and scores of 15 and 14 on the depression and anxiety scales, respectively. Tr. at 468, 479-80. That same day, in support of Smith's application for DIB and SSI, Dr. Keyes completed a physical medical source statement listing diagnoses of fibromyalgia, depression, and anxiety. Tr. at 465-68.[3] She also submitted a mental impairment source statement, which noted diagnoses of anxiety and depression. Tr. at 469-72. Dr. Keyes checked boxes for thirty-four “signs and symptoms, ” Tr. at 470, and for various functional limitations at varying levels of severity, Tr. at 471. On January 11, 2017, Smith sought treatment for fibromyalgia from a physician assistant, Tr. at 492, and again from Dr. Keyes on January 18, Tr. at 493. On November 23, Smith saw Dr. Jing Ji about her headaches. Tr. at 481-82. Dr. Ji found “no major concern” regarding Chiari malformation, but noted that Smith could have hemiplegic migraines. Tr. at 484. Dr. Ji saw Smith for a follow-up three months later. Tr. at 506-07.

         She was evaluated by Dr. David Kamen, a consultative psychologist, on February 1. Tr. at 510-15. Dr. Kamen noted both positive and negative aspects of Smith's functioning, including several depression and anxiety symptoms that Smith presented during the evaluation. Tr. at 510. Ultimately, he concluded that he did “not believe that [Smith] is able to sustain an ordinary routine and regular work attendance . . . .” Tr. at 514.

         Smith also had a fibromyalgia evaluation conducted by Dr. Prachaya Nitichaikulvatana on April 4, Tr. at 877, and spoke with Dr. Sumathi Rajanna on June 2 following a panic attack and self-harm incident at work, Tr. 884. She had an initial evaluation at Greater Nashua Mental Health Center on July 18, during which she reported symptoms “indicative of a diagnosis of Major Depressive Disorder, moderate, recurrent with anxious distress.” Tr. at 526. She was also given a rule-out diagnosis of borderline ...

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