The opinion of the court was delivered by: LARIMER
This is an action brought pursuant to 42 U.S.C. § 405(g) to review the final determination of the Commissioner of Social Security that plaintiff was not disabled, and therefore, was not entitled to disability benefits. This Court finds that the Commissioner's decision was not supported by substantial evidence and accordingly remands the matter to the Commissioner for further administrative proceedings.
Plaintiff Kimberly Amidon ("Amidon") was born on July 31, 1959 and is presently thirty-eight years old. (T. 56).
On May 30, 1994 Amidon applied for Social Security disability and Supplemental Security Income ("SSI") benefits. (T. 129-31, 154-58).
She claimed that she was unable to work since November 3, 1993 due to migraines and a herniated disc in her back. (T. 185). SSA denied these applications initially and upon reconsideration. Plaintiff requested a hearing before an Administrative Law Judge ("ALJ") and it was held on July 13, 1995.
On January 23, 1996, the judge issued a decision in which he found that plaintiff was not entitled to disability benefits. (T.12-21). On November 8, 1996, SSA's Appeals Council notified plaintiff that it refused to review the ALJ's decision. (T. 7-8). On November 20, 1996, after the Appeals Council received additional documentation from plaintiff's attorney, the Appeals Council notified Amidon that the new data did not change their opinion that Amidon was not disabled. (T. 5-7). The ALJ's decision thus became the Commissioner's final decision, and plaintiff commenced this action. Presently before the Court is defendant's motion for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. Plaintiff appears pro se at this time and has not submitted any documentation in response.
Amidon's current claim involves allegations of severe headaches and back pain. In August 1983, Amidon sought treatment for headaches from Dr. Eswara, a neurologist. (T. 204). At that examination, Amidon relayed a history of headaches for many years, with an onset of bad headaches as a result of a fall in February 1992. Id. Dr. Eswara diagnosed common migraine headaches. Amidon visited Dr. Eswara several times in the next few months, and the doctor continued to seek a cure for her headaches and pain. (T. 206-10). On November 4, 1993, Amidon was treated at the St. James Mercy Hospital emergency room for blacking out during a headache at work. (T. 201, 37). On November 10, 1993, Dr. Eswara referred Amidon to Dr. Gilmore, a neurologist at the Headache Clinic at Strong Memorial Hospital in Rochester, New York. Dr. Gilmore examined Amidon and noted Amidon's complaints of headaches and numbness in her left leg and formed the impression that Amidon was suffering from an analgesic overuse syndrome. (T. 220). Dr. Gilmore suggested that Amidon's headaches had some "migrainous components but also had a component of muscle tension with forward flexion..." Id. The doctor revamped Amidon's medications - ending the use of analgesics - and suggested a repeat visit within the next month. Id.
By January 1994, Amidon reported almost no improvement in her symptoms, and Dr. Gilmore abandoned the diagnosis of analgesic overuse. (T. 222). Instead, Dr. Gilmore stated: "it appears that analgesic overuse is not a predominant precipitant for her headaches at this point. She appears to have idiopathic new onset chronic daily headache. There also appears to be some component of psychogenic overlay, although meralgia paresthetica could potentially explain the sensory symptoms in the left lower extremity."
(T. 222). In February 1994, Dr. Gilmore continued to treat Amidon for her headaches and back pain. Dr. Gilmore noted that Amidon had some slight decrease in her headache symptoms, but the doctor also noted that her headaches were not improved overall. In addition, Amidon now complained more about back pain. Dr. Gilmore again changed the medication for headache relief, and added Imitrex to be taken "in order to help prevent her from going to the emergency room." (T. 224).
After a visit in April 1994, Dr. Gilmore reported that Amidon seemed to have some slight improvement in her symptoms. (T. 225). In May, Dr. Gilmore noted no change in Amidon's back and leg pains, but also recorded Amidon's feelings that the headache symptoms had improved somewhat. (T. 226). The doctor noted that Amidon had dull constant head pain, but Amidon reported fewer severe exacerbations, and they were relieved by Imitrex. Id. Dr. Gilmore's reports continued over the next several months with minimal variations in symptoms. (T. 227-29). On February 21, 1995, Dr. Gilmore completed a "Physical Capacities Evaluation" form apparently prepared by Amidon's hearing representative. (T. 236-37). Dr. Gilmore limited Amidon to sitting for one hour at a time with a total of four hours during a full work day. (T. 236). Dr. Gilmore also limited Amidon to standing/walking for one hour and up to a total of two hours in a full day. Id. The report also indicated that Amidon could not perform repetitive pushing and pulling with her hands. Id. In a part of the form questioned by the ALJ, Dr. Gilmore reported that Amidon should only occasionally lift between five and nine pounds. Id. Dr. Gilmore stated that due to headaches which caused blurred vision, Amidon should not work at heights or around moving machinery and finally, that Amidon's pain had a moderate effect on her ability to function. (T. 237).
In April 1994, Amidon underwent an MRI examination in conjunction with her back and leg pain. That exam concluded with the finding of "left posterolateral disc protrusion at L5-S1 with leftsided neural foraminal encroachment and left nerve root impingement." (T. 235).
At her hearing Amidon reported that Dr. Gilmore had transferred, so Amidon was scheduled to see a different physician at the Neurology Service of the Rochester General Hospital, where she had previously seen Dr. Gilmore. (T. 42). At Amidon's first visit with Dr. Honch, Dr. Gilmore's replacement, he completed an SSA form entitled "Medical Source Statement". On July 27, 1995, Dr. Honch reported that Amidon could frequently lift and/or carry less than ten pounds, "but with difficulty because will worsen pain"; occasionally lift and/or carry less than ten pounds; stand and/or walk less than one hour and "must rest frequently because of pain"; and sit for a total of less than one hour but "must get up and move around". (T. 238). Dr. Honch reported that these activities were impaired due to pain. (T. 239). Finally, Dr. Honch reported that the principal clinical and laboratory findings from which he reached his conclusions were Amidon's subjective complaints of pain; an MRI of the cervical spine which revealed multiple disc bulges and an MRI of the lumbosacral spine which revealed L5-S1 disc protrusion on the left side. Id.
On August 2, 1995, Dr. Honch sent a report about Amidon to another physician. (T. 265-66). Dr. Honch went through Amidon's treatment history and her complaints of headaches and back pain. (T. 265). He noted that her severe headache symptoms occurred about three times a week but were relieved within fifteen minutes by Imitrex. Id. However, she continued to suffer from daily headaches. Id. Dr. Honch stated that he had completed forms for SSA, and concluded with the following: "She has no objective findings on exam, care of this patient is difficult, tedious, and without solution." (T. 266).
In November 1995, after a follow-up medical visit on October 31, Dr. Honch referred Amidon to Dr. Maurer for possible neurosurgical intervention of her lower spine condition. (T. 263-64). Dr. Honch reported that Amidon's headaches were somewhat relieved with use of a surgical collar, although he expressed some doubt as to why this should be so.
(T. 263). Dr. Maurer reported back the results of his examination in December 1995. (T. 261-62). He stated that recent MRI testing showed "a modicum of degenerative change" in the C4 through C6-7 region of her cervical spine, with no significant evident impingement on the cord or associated structures. (T. 262).
Dr. Maurer gave the following impression:
Ms. Kimberly Amidon presents with a history of cervical and lumbar discomfort which is suggestive of mechanical as opposed to neurologic origin although it is noteworthy that she does have a "numbness" which courses in a polyradicular fashion in the left upper extremity as well as a similar sensation which is now present in the left lower extremity. She is moderately hyper-reflexic but I did not find any further corroborating upper motor neuron release suggestive of a frank myleopathy. I suspect that this will prove to be a mechanical issue without any clearly evident surgical issue, but given the refractory nature of the problem, I think it would be appropriate to make a definitive evaluation with intrathecal contrast CT of the lumbar and cervical regions.
Amidon under went a cervical mylogram in January 1996. (T. 258-60). The results were "normal". A CT scan revealed "minimal degenerative changes in the C4-5 and C5-6 disc spaces. No evidence of significant disc bulges, spinal stenosis, nor foraminal narrowing." (T. 259). A mylogram of the lower back demonstrated "Extradural defect on the left side consistent with spondylolisthesis and foraminal involvement from the boney changes. No significant extradural defect is seen." Id. The CT scan of Amidon's lower back concluded with impressions of:
Bilateral pars interarticularis defects at the L5-S1 level. Grade I subluxation of L5 on S1, approximately 10 mm. of anterior subluxation. Degenerative disc disease at this level which is slightly eccentric and likely secondary to the asymmetric anterior subluxation, greater on the left than the right. No definite evidence of a disc herniation is associated with this disc space. Left foraminal narrowing associated with the degenerative facet change.
As a result of this testing, Dr. Maurer again noted in February 1996 that "a significant portion" of Amidon's complaint was "mechanical lumbar discomfort" which might not benefit from surgical intervention. Dr. Maurer referred Amidon for an evaluation for possible surgical intervention, but only "to fuse her spondylolisthetic segment". (T. 274).
After this report and a subsequent examination of Amidon, Dr. Honch wrote one final letter on May 22, 1996. (T. 284-85). Dr. Honch reported that Amidon now wore a back brace but she was unsure whether it was helping. Amidon reported that she still experienced a bad headache twice a week, but these were still relieved with Imitrex - although in a stronger dosage. (T. 284). Dr. Honch concluded that he would ...