United States District Court, D. Vermont
MEMORANDUM AND ORDER (Docs. 6, 8)
J. GARVAN MURTHA, District Judge.
Plaintiff Wanda Allard Powers (Powers) brings this action under 42 U.S.C. § 405(g) of the Social Security Act, requesting review and reversal of the Commissioner of Social Security's (Commissioner) denial of her application for disability insurance benefits and supplemental security income. Pending before the Court are Powers' motion seeking an order reversing the Commissioner's decision (Doc. 6 (Doc. 6-1 Memorandum)), and the Commissioner's motion seeking an order affirming her decision (Doc. 8). For the reasons set forth below, Powers' motion to reverse is granted, the Commissioner's motion to affirm is denied, and the matter is remanded for further proceedings and a new decision.
On April 17, 2012, Powers filed an application for disability insurance benefits, and on April 30, 2012, she filed for supplemental security income benefits alleging she became disabled as of November 30, 2011. (A.R. 202-11, 214-15.) She later amended her onset date to March 23, September 28, 2012, were denied again on reconsideration, id. at 56-62. Powers filed a timely request for an administrative hearing, id. at 154-55, which was held by Administrative Law Judge ("ALJ") Paul Martin on December 27, 2013, id. at 63-106. She appeared with a representative at the hearing and testified. Id . On January 31, 2014, the ALJ issued a decision concluding Powers was not disabled from the revised alleged disability onset date. Id. at 17-35. The Appeals Council denied her timely request for review on May 19, 2015, and the ALJ's decision became the final decision of the Commissioner. Id . 1-5.
On July 17, 2015, Powers timely filed this action. (Doc. 1.) She raises three challenges to the ALJ's decision (1) the ALJ erred by using lay knowledge to assess her residual functional capacity ("RFC"); (2) the ALJ failed to consider her proctalgia fugax in combination with other impairments; and (3) the ALJ erred in his credibility assessment. (Doc. 6-1.)
Powers was born on March 16, 1969. (A.R. 318.) She has a high school education and past relevant work as a short-order cook, deli worker, cashier, hospital cleaner, and baker helper. Id. at 28. From March 29 to April 6, 2005, she was admitted for inpatient care for depression after complaining of suicidal thoughts. Id. at 291-92, 303. On February 2, 2012, she underwent surgery to remove her gallbladder. Id. at 608.
On March 23, 2012, Powers saw nurse practitioner ("NP") Boseung Halliwell who diagnosed bipolar I disorder, most recent episode depressed, and post-traumatic stress disorder ("PTSD"), and assessed a global assessment of function ("GAF") score of 50. (A.R. 384.) On March 28, she first saw Jessica Dambach, a licensed mental health counselor, who recommended weekly therapy sessions. Id. at 389. The record contains Dambach's progress notes spanning March 28, 2012 through May 6, 2013. See id. at 389-411, 483-92, 511-12, 519-22, 645-93.
Also on March 28, Powers treated with her primary care physician, Dr. Sepinoud Bazel, for hemorrhoids, complaining it felt "like her bottom is on fire" and of painful defecation with blood in her stool. (A.R. 318.) She had a small external hemorrhoid and likely internal hemorrhoids as well. On May 3, she treated with Dr. David Butsch for painful bowel movements and a "shooting pain from the rectum that goes up." Id. at 705. Upon examination, she had tenderness with the suggestion of a small sentinel pile and was assessed with internal hemorrhoids and a posterior anal fissure. Id . She stated she had to be home to have a bowel movement. Id. at 707.
On September 28, 2012, state agency medical consultant Dr. Elizabeth White reviewed the evidence of record and opined Powers' only medically determinable physical impairment was hypothyroidism and that it was non-severe. Dr. White noted there was minimal updated medical evidence of record. She stated Powers was seen in July 2012 for an infected toe nail and there were "[n]o other complaints;" there is no indication Dr. White reviewed Dr. Butsch's diagnosis of anal fissure. (A.R. 121.) Also on September 28, state agency medical consultant Dr. Shapiro reviewed the evidence of record and opined Powers had severe medically determinable psychological impairments of affective and anxiety disorders with moderate restriction of activities of daily living, difficulties in maintaining social functioning, and difficulties in maintaining concentration, persistence or pace. Id. at 122.
On October 8, 2012, Powers contacted Dr. Butsch's office regarding her worsening anal fissure. (A.R. 703.) She saw Dr. Butsch again on October 17, stating walking bothered her and the pain came with the sensation of and having a bowel movement. Id. at 706. Upon examination there was marked tenderness and the anal fissure was as before. Id . On November 7, Dr. Butsch noted Powers had "diffuse anal tenderness consistent more [with] spasm than fissure, " and assessed proctalgia fugax. She complained of bowel movements feeling like razor blades and throbbing in a vein. Id . The government describes proctalgia fugax as a "severe, episodic, rectal and sacrococcygeal pain." (Doc. 8 at 12 n.5 (citing Wikipedia).)
On January 14, 2013, Powers told Dr. Butsch she "would like to figure out what is going on" because she was "healed" but she stopped diazepam and the pain came back with diarrhea, frequent bowel movements, and blood in her stool. Upon examination, he noted anal spasm/tenderness as before but not so severe. (A.R. 704.) On March 1, Powers reported she had not taken her valium lately, as it had run out, but that it "certainly helped, " and she felt "slightly uncomfortable at times" but "nothing like before." Id. at 702, 704. Upon examination, Dr. Butsch noted circumferential spasm and tenderness as before, again assessing Powers with proctalgia fugax. He prescribed valium one to two times per day. Id. at 702. On March 4, Powers' therapist Dambach noted she was in pain from the anal fissure and that it causes her stress. Id. at 670.
On July 24, 2013, Powers treated with Dr. Bazel complaining of bowel movement problems, shooting pains and blood in her stool. Regarding urology, she reported noticing some odor to her urine and that it was ...