Melanie M. v. Berryhill

          OPINION AND ORDER (DOCS. 14, 16)

          Geoffrey W. Crawford, Chief Judge.

         Plaintiff Melanie M. brings this action under 42 U.S.C. § 405(g) of the Social Security Act, requesting reversal of the decision of the Commissioner of Social Security, after a 2017 remand, denying her two consolidated applications for disability insurance benefits (DIB). Pending before the court is Plaintiffs motion to reverse the decision of the Commissioner (Doc. 14) and the Commissioner's motion to affirm (Doc. 16). Plaintiffs motion is GRANTED, the Commissioner's motion is DENIED, and the matter is REMANDED for further proceedings and a new decision.

         Background

         Plaintiff was 33 years old on her alleged onset date of January 16, 2013. She testified at her November 19, 2014 hearing that she has experienced problems since a 2008 motor vehicle accident in which she was ejected from the vehicle and landed on her right side. (AR 770, 777.) At her April 25, 2018 hearing, Plaintiff stated that after the motor vehicle accident, her ribs healed wrong and that "messed up my whole shoulder mechanism." (AR 816.) She also states that she sustained a traumatic brain injury (TBI) in the 2008 accident. (AR 831.) She testified to numerous other medical and mental health difficulties, including "overbearing" and "permanent" pain (AR 766, 815), fatigue (AR 768, 782), migraines (AR 774, 813), hip pain (AR 777), depression, anxiety, and posttraumatic stress disorder (PTSD) (AR 779, 819, 832), short-term memory loss (AR 782), a left leg nerve problem with numbness (AR 807, 833), a hysterectomy and subsequent urinary problem that required surgery (AR 809-10), and total hearing loss in her left ear (AR 814).

         Plaintiff completed high school in three years and completed a four-year degree in psychology, with some coursework towards a master's degree in occupational therapy. (AR 764.) After college she worked in accounts payable for a building materials supplier and as a personal banker for a bank. (Id.) She worked part-time for Turning Point (an addiction recovery center) in 2013 and 2014 (AR 765, 826) and at Home Depot in 2015 and 2016. (AR 805.)

         Plaintiff testified at her 2014 hearing that in a typical day she would wake up after sleeping poorly, get dressed, and go to work at Turning Point at around 9:00 or 10:00 a.m. (AR 767-68.) She would return home after working for four hours and rest until her husband returned home. (AR 768.) If she felt well enough she might make a five-minute car ride to visit her grandmother. (AR 769.) At her 2018 hearing, Plaintiff testified that she left the part-time job at Turning Point because she physically could not do the job anymore. (AR 826.) She left the job with Home Depot on her doctor's orders. (AR 807.) She testified that she spends most of each day resting. (AR 823.) In good weather she tries to walk short distances or "swim for therapy in my pool." (AR 828.)

         Plaintiff filed an application for DIB on February 20, 2013. (AR 94.) That claim was denied initially on May 21, 2013 (id.) and on reconsideration on September 13, 2013. (AR 108.) She requested a hearing, and Administrative Law Judge (ALJ) Thomas Merrill conducted a hearing on November 19, 2014. (AR 762-800.) ALJ Merrill issued an unfavorable decision on February 27, 2015. (AR 859.) The Appeals Council denied her request for review on May 11, 2016. (AR1.)

         Plaintiff filed a subsequent claim for DIB on May 30, 2016. (See AR 891.) She also filed a complaint with this court on July 5, 2016, appealing the denial of the claim that she filed in February 2013. [Melanie M] v. Berryhill, No. 2:16-cv-190 (D. Vt. July 5, 2016). Acting on the Commissioner's assented-to motion to remand, the court reversed and remanded for further proceedings. (AR 885.) The Appeals Council accordingly remanded with instructions to (1) address a conflict between Plaintiffs reaching limitations and her past relevant work; (2) give further consideration to whether Plaintiff can perform her past relevant work; and (3) obtain supplemental evidence from a vocational expert to clarify the effect of the assessed limitations on Plaintiffs ability to perform past relevant work and, if appropriate, her occupational base. (AR 891.) The Appeals Council noted Plaintiffs separate May 30, 2016 claim and directed the ALJ to "consolidate the claim files, associate the evidence, and issue a new decision on the consolidated claims." (Id.)

         On remand, ALJ Merrill convened a hearing on April 25, 2018. (AR 803-54.) Plaintiff appeared at the hearing and was represented by Margaret Sayles. Vocational Expert (VE) Louis LaPlante also testified. ALJ Merrill issued an unfavorable decision on June 22, 2018. (AR 720-45.) Plaintiff appealed to this court on September 14, 2018. (Doc. 3.)

         ALJ Decision

         Social Security Administration regulations set forth a five-step, sequential evaluation process to determine whether a claimant is disabled. Mclntyre v. Colvin, 758 F.3d 146, 150 (2d Cir. 2014). First, the Commissioner considers "whether the claimant is currently engaged in substantial gainful activity." Id. Second, if the claimant is not currently engaged in substantial gainful activity, then the Commissioner considers "whether the claimant has a severe impairment or combination of impairments." Id. Third, if the claimant does suffer from such an impairment, the inquiry is "whether the impairment meets or equals the severity of the specified impairments in the Listing of Impairments." Id. Fourth, if the claimant does not have a listed impairment, the Commissioner determines, "based on a 'residual functional capacity' assessment, whether the claimant can perform any of his or her past relevant work despite the impairment." Id.

         Finally, if the claimant is unable to perform past work, the Commissioner determines "whether there are significant numbers of jobs in the national economy that the claimant can perform given the claimant's residual functional capacity, age, education, and work experience." Id.; see 20 C.F.R. §§ 404.1520, 416.920. The claimant bears the burden of proving her case at steps one through four. Mclntyre, 758 F.3d at 150. At step five, there is a "limited burden shift to the Commissioner" to "show that there is work in the national economy that the claimant can do." Poupore v. Astrue, 566 F.3d 303, 306 (2d Cir. 2009) (per curiam).

         Employing the five-step sequential analysis in his June 22, 2018 decision, ALJ Merrill first determined that Plaintiff has not engaged in substantial gainful activity since January 16, 2013, the alleged onset date. (AR 723.) At step two, the ALJ found that Plaintiff has only one severe impairment: myofascial pain syndrome. (Id.) The ALJ noted other diagnoses in the record-including hearing loss, a vesicovaginal fistula, headaches, an affective disorder, and "various psychiatric diagnoses"-but concluded that none constituted a "severe" impairment. (AR 723-28.) At step three, the ALJ concluded that Plaintiff does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments. (AR 731.)

         Next, the ALJ determined that Plaintiff has the residual functional capacity (RFC) to perform "light work" as defined in 20 C.F.R. § 404.1567(b), ^[1] except as follows:

[S]he could lift and carry 20 pounds occasionally and 10 pounds frequently; stand or walk for six hours and sit for six hours total in an eight-hour day; occasionally push and/or pull with the right upper extremity; occasionally reach with the right upper extremity; never climb ladders, ropes, or scaffold but occasionally climb ramps or stairs, balance, stoop, kneel, crouch, and crawl; and avoid even moderate exposure to vibrations and hazards.

(AR 732.) Given that RFC, the ALJ found at step four that Plaintiff is unable to perform any past relevant work. (AR 743.) At step five, the ALJ considered Plaintiffs age, education, work experience, and RFC, and concluded that there are jobs that exist in significant numbers in the national economy that Plaintiff could perform, including companion, usher, furniture rental clerk, and surveillance system monitor. (AR 744.) The ALJ accordingly concluded that Plaintiff has not been under a disability, as defined in the Social Security Act, from January 16, 2013 through the date of the decision. (AR 745.)

         Standard of Review

         The Social Security Act defines disability, in pertinent part, as the "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A). Under the Act, a claimant will only be found disabled if his "impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." Id. § 423(d)(2)(A).

         In considering the Commissioner's disability decision, the court conducts "a plenary review of the administrative record to determine if there is substantial evidence, considering the record as a whole, to support the Commissioner's decision and if the correct legal standards have been applied." Brault v. Soc. Sec. Admin., Comm'r, 683 F.3d 443, 447 (2d Cir. 2012) (per curiam) (quoting Moran v. Astrue, 569 F.3d 108, 112 (2d Cir. 2009)); see also 42 U.S.C. § 405(g). Substantial evidence means "more than a mere scintilla"; it means "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019) (quoting Consol. Edison Co. of N.Y. v. Nat'1 Labor Relations Bd., 305 U.S. 197, 229 (1938)). The "substantial evidence" standard is even more deferential than the "clearly erroneous" standard; facts found by the ALJ can be rejected "only if a reasonable factfinder would have to conclude otherwise." Brault, 683 F.3d at 448 (quoting Warren v. Shalala, 29 F.3d 1287, 1290 (8th Cir. 1994)). The court is mindful that the Social Security Act is "a remedial statute to be broadly construed and liberally applied." Dousewicz v. Harris, 646 F.2d 771, 773 (2d Cir. 1981).

         Analysis

         On appeal, Plaintiff argues that the ALJ erred by (1) improperly evaluating opinions and medical evidence and (2) assessing an RFC that is unsupported by substantial evidence, particularly with respect to limitations for migraine headaches, hearing loss, mental health impairments, and Plaintiffs pain syndrome. (See Doc. 14 at 17-20.) The Commissioner maintains that substantial evidence supports the ALJ's decision and that it complies with the applicable legal standards. (Doc. 16 at 1.) .

         I. The Treating Physician Rule

         As part of her challenge to the ALJ's evaluation of opinion evidence, Plaintiff claims that the ALJ failed to consider treating physician opinions. The court accordingly begins with the treating physician rule. The treating physician rule "generally requires a measure of deference to the medical opinion of a claimant's treating physician." Halloran v. Barnhart, 362 F.3d 28, 31 (2d Cir. 2004) (per curiam); see also 20 C.F.R. § 404.1527.^[2]

         Under the treating physician rule, "the opinion of a claimant's treating physician as to the nature and severity of the impairment is given 'controlling weight' so long as it 'is well-supported by medically-acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record.'" Burgess v. Astrue, 537 F.3d 117, 128 (2d Cir. 2008) (alteration in original) (quoting 20 C.F.R. § 404.1527(c)(2)). Even when a treating physician's opinion is not given controlling weight, it is still entitled to some weight because treating physicians are "likely to be the medical professionals most able to provide a detailed, longitudinal picture of [the claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence." 20 C.F.R. § 404.1527(c)(2). If a treating physician's opinion is not given controlling weight, the weight to be given the opinion depends on several factors: (1) the length of the treatment relationship and the frequency of examination; (2) the nature and extent of the treatment relationship; (3) the relevant evidence supporting the opinion; (4) the consistency of the opinion with the record as a whole; (5) whether the opinion is of a specialist; and (6) other factors which tend to support or contradict the opinion. Id. §404.1527(c)(2)-(6).

         A. Dr. Welther

         1. Treatment and Opinions

         Dr. Michael J. Welther met Plaintiff as a new primary care patient on February 20, 2015-about two years after the alleged onset date and Plaintiffs 2013 DIB application, and shortly after Plaintiff concluded treatment with pain management specialist Dr. Brian Erickson (discussed below). (AR 3073.) Plaintiffs previous primary care physician, Dr. Therese Dranginis, treated her between February 2013 and January 2015. (See AR 416 (visit to establish care); AR 1365 (last appointment with Dr. Dranginis).) At the initial February 2015 appointment, Dr. Welther noted that Plaintiff had a long and complicated medical history related to an August 2008 motor vehicle accident. (Id.) He briefly recounted that history in pertinent part as follows:

[D]irect admission to Alb Med where she had multiple [fractures], ruptured spleen eventually removed, large scalp laceration, then post hosp[ital] complications of bowel obstruction and re surgery at SVMC [Southern Vermont Medical Center.] [S]ince then she has had chronic pain syndrome mostly of R shoulder neck R lower back, and has been to multiple providers and on multiple meds including methadone percocet etc[.] [M]ost recently been at pain clinic at UVM [University of Vermont] and on fentanyl patch and prn oxycodone with fairly reasonable control[.] [R]esulting depression, anxiety PTSD have required counseling and doing some cognitive relaxation counseling as well....

(Id.) Upon physical examination, Dr. Welther noted "R shoulder decreased ROM [range of motion] winging or R scapula, lower back tenderness not localized." (Id.) It is undisputed that Dr. Welther treated Plaintiff at regular appointments after the February 2015 appointment through at least January 18, 2018. (AR 3244.)

         Dr. Welther wrote a letter to "Whom it May Concern" regarding Plaintiff on October 28, 2016. (AR 3650.) The letter appears to be in support of vocational rehabilitation for Plaintiff. (See AR 2726.) It states:

In order for [Plaintiff] to work she would need to be restricted to no more than 4 hours a day. She should not have any prolonged standing or walking. She should have no bending. There should be no strain on her back from any activity. She should be able to sit and use her hands etc. No. lifting anything more than 10 pounds. No. stooping down kneeling recommended at this time. These restrictions may be modified over time depending on how she is functioning. She is still undergoing some testing and treatment to improve her mechanical back problems and neuropathy.

(Id.)

         Dr. Welther also supplied a medical opinion on April 4, 2018. (AR 3725-30.) He opined that Plaintiff is unable to work an eight-hour day and that work-related abilities are affected by pain. (AR 3726.) He further opined that Plaintiffs mental health interferes with her physical and cognitive functioning, and that she is unable to handle stressful situations. (Id.) He explained that his opinions regarding Plaintiffs limitations are supported by multiple surgeries causing pain and dysfunction; multiple medications impacting functioning; and failed attempts to work. (Id.) Dr. Welther stated that he assessed mental health limitations due to "anxiety," "low self esteem," "poor coping ability, [and] poor support system." (AR 3727.)

         Dr. Welther also offered opinions on Plaintiffs concentration, persistence, and pace. He opined that she does not have the ability to concentrate and focus on job-related tasks for continuous two-hour periods consistently throughout an eight-hour workday and five-day workweek. (Id.) He further opined that Plaintiffs impairments would interfere with her ability to complete job-related tasks in a timely manner or reduce her pace in performing work-related tasks. (Id.) In particular, he opined that the effects of Plaintiff s impairments would cause her to be off-task more than 20% of an eight-hour workday. (Id.) He stated that Plaintiff would need more than ordinary rest breaks during a workday or shift. (Id.) He articulated the following medical reasons for his opinions about concentration, persistence, and pace: "Pain, concentration, poor stamina, positioning difficulty." (Id.)

         Dr. Welther further opined that Plaintiffs medications-including a fentanyl patch- affect Plaintiffs alertness and concentration. (AR 3729.) He further opined that he expected Plaintiff to be absent from work because of her impairments "several days per month at best." (AR 3729.) In support of his conclusion about work absences, Dr. Welther listed Plaintiffs "previous failed attempts" at work. (Id.)

         2. ALJ's Failure to Explicitly Analyze Dr. Welther's Opinions

         ALJ Merrill's June 22, 2018 decision refers to Dr. Welther and some of his treatment notes between 2015 and 2017. (See AR 726, 736, 738, 739.) According to the ALJ, Dr. Welther's treatment notes support no more than a "mild" mental health limitation. (AR 726-28.) As to physical impairments, the ALJ further concluded that Dr. Welther's notes indicate "only mild pain and distress." (AR 736.) The ALJ's decision does not explicitly mention Dr. Welther's October 28, 2016 letter opinion or his opinion dated April 4, 2018. The ALJ did write that "[e]ven though a specific exhibit may not be mentioned, I have reviewed and considered all exhibits: 3, 729 pages." (AR 721.) Later is his decision the ALJ stated that he considered "all opinions within the record." (AR 743.) Introducing his analysis of opinion evidence, the ALJ stated that the opinions of Plaintiff s treating physicians "are not entitled to controlling weight." (AR 740.) The ALJ went on to discuss and assign weights to the opinions of several treating physicians and other opinion evidence, but Dr. Welther's opinions do not appear in that discussion.

         Plaintiff argues that the ALJ's failure to mention Dr. Welther's opinions is "clear reversible error." (Doc. 14 at 28.) Relying on the portions of the ALJ's decision stating that the ALJ considered "all exhibits" and "all opinions," the Commissioner maintains that the ALJ did consider Dr. Welther's opinions. (Doc. 16 at 15.) According to the Commissioner, the ALJ properly afforded those opinions no controlling weight on the grounds that they were not well supported and were inconsistent with other substantial evidence. (Id.) Plaintiff replies that the Commissioner cannot supply a post hoc rationalization for agency action and that the ALJ failed to supply adequate specificity for the court to decide whether the determination is supported by substantial evidence. (See Doc. 17 at 1-3.)

         The regulations require the Social Security Administration to "consider all evidence in [a claimant's] case record when [making] a determination or decision whether [the claimant is] disabled." 20 C.F.R. § 404.1520(a)(3). Here, although the ALJ's decision does not discuss Dr. Welther's opinions, the court can reasonably infer that the ALJ did at least consider those opinions. The ALJ stated that he considered "all exhibits" and "all opinions." The ALJ admitted numerous documents into evidence, the range of which includes Dr. Welther's opinions. (See AR 759, 803-04.) The court therefore concludes that the ALJ's statement that he considered all opinions is "sufficient to establish that the ALJ considered [Dr. Welther's opinions], even though [the ALJ] did not address [those specific opinions]." McKinstry v. Astrue, ~No. 5:10-cv-319, 2012 WL 619112, at *5 (D. Vt. Feb. 23, 2012).

         Although the court can infer that the ALJ considered Dr. Welther's opinions, the court must also analyze whether the ALJ's failure to discuss those opinions constitutes reversible error. The regulations dictate that, "[r]egardless of its source, we will evaluate every medical opinion we receive." 20 C.F.R. § 404.1527(c). In addition, the Social Security Administration must "always give good reasons in our notice of determination or decision for the weight we give your treating source's medical opinion." Id. § 404.1527(c)(2). In light of those requirements, the court concludes that the ALJ's failure to discuss or otherwise evaluate Dr. Welther's opinions was error. See Estrella v. Berryhill, 925 F.3d 90, 95 (2d Cir. 2019) (if the ALJ decides that a treating physician's opinion is not entitled to controlling weight, then the ALJ must "explicitly" apply the relevant factors; failure to do so is "procedural error"); Bautista v. Berryhill, No. 3:18CV01247(SALM), 2019 WL 1594359, at *6 (D. Conn. Apr. 15, 2019) (ALJ's failure to "discuss or otherwise evaluate" treating physician's opinion was error).

         But "[f]ailure to address evidence is harmless error if consideration of the evidence would not have changed the ALJ's ultimate conclusion." McKinstry, 2012 WL 619112, at *5. As the Second Circuit has explained:

If "the Commissioner has not [otherwise] provided 'good reasons' [for its weight assignment]," we are unable to conclude that the error was harmless and consequently remand for the ALJ to "comprehensively set forth [its] reasons." ... If, however, "a searching review of the record" assures us "that the substance of the treating physician rule was not traversed," we will affirm.

Estrella 925 F.3d at 96 (brackets in original) (quoting Halloran v. Barnhart, 362 F.3d 28, 32-33 (2d Cir. 2004) (per curiam)). The court accordingly proceeds to conduct a harmless error analysis.

         3. Harmless Error Analysis

         Regarding specialization, the ALJ noted that Dr. Welther is a primary care provider. (AR 736.) There is no indication that Dr. Welther is a specialist in pain management, mental health treatment, or any other relevant area. Plaintiff does not contend otherwise.

         Regarding the frequency, length, nature, and extent of treatment, the ALJ's discussion of Dr. Welther's treatment notes from 2015 through 2017 demonstrate that the ALJ was aware of the multi-year treatment relationship. The Commissioner does not dispute Plaintiffs assertion that Dr. Welther saw and treated Plaintiff on at least a monthly basis. (See AR 818 (testimony that Plaintiff sees Dr. Welther at least once a month).) The ALJ observed that Dr. Welther made notations relevant to Plaintiffs mental and physical health during the course of treatment. (See AR 726, 736.) The ALJ also recognized that Dr. Welther prescribed opioid medications to Plaintiff. (AR 734.) At the hearing, the ALJ heard evidence that Dr. Welther administered pressure point injections and cortisone injections in Plaintiffs neck. (AR 808.) The ALJ further recognized that Dr. Welther referred Plaintiff to specialists to address complaints of pain. (See AR 736.)

         The Commissioner argues that there is no support for Dr. Welther's "overly restrictive" opinions. (See Doc. 16 at 16.) The Commissioner points to Dr. Welther's statement in his April 4, 2018 opinion that Plaintiff is unable to work an eight-hour day. (AR 3726.) Somewhat similarly, Dr. Welther stated in his October 28, 2016 letter that Plaintiff was limited to working no more than four hours per day. (AR 3650.) The Commissioner asserts that a medical source's statement that a claimant is unable to work is not a medical opinion and is not entitled to any significant weight. (Doc. 16 at 16.)

         The Commissioner is correct that a medical source opinion that a claimant is "unable to work" is not a medical opinion and is not entitled to any special significance. 20 C.F.R. § 404.1527(d); see also Tanya L. v. Comm'r of Soc. Sec, No. 2:17-cv-136, 2018 WL 2684106, at *6 (D. Vt. June 5, 2018) (treating psychiatrist's opinion that plaintiff was unable to work was not entitled to any significant weight because it was on an issue reserved to the Commissioner); Savage v. Comm'r of Soc. Sec, No. 2:13-cv-85, 2014 WL 690250, at *5 (D. Vt. Feb. 24, 2014) (doctor's statement that plaintiff could not work "full time" was not a medical opinion). At the same time, the ALJ cannot discount a medical opinion in its entirety solely because the opinion includes a statement about the plaintiffs ability to work. Thomas v. Berryhill, No. 1:17-CV-0042-LJV-RJA, 2019 WL 2264966, at *2 (W.D.N.Y. May 28, 2019). It is necessary to review the support for the other statements in Dr. Welther's opinions.

         The Commissioner also seizes on Dr. Welther's statement-written immediately after his statement that Plaintiff is unable to work an eight-hour day-that Plaintiff is "unable to stand walk lift reach." (AR 3726.) If that statement was intended to be unqualified, the court would agree with the Commissioner that it is unsupported. Indeed, Plaintiff herself testified that she can walk (albeit with a limp) for a short distance before getting "really tired" and starting to hurt. (AR823.) She also stated that she can lift up to five pounds. (See AR 806.) And Dr. Welther himself opined that Plaintiff is capable of "short lasting sit reach." (AR 3726.) There is no support for an opinion that Plaintiff categorically cannot stand, walk, lift, or reach.^[3]

         But Dr. Welther's statement about standing, walking, lifting, and reaching was in response to a compound question that asked about the effects of Plaintiff s impairments on those functions and for an opinion regarding "how long during an 8-hour day you would expect that she could perform the function on a regular and continuing basis consistently over 40 hour work weeks." (AR 3726.) Read in that context, Dr. Welther's opinion about standing, walking, lifting, and reaching is less restrictive than the Commissioner suggests. Although Dr. Welther did not supply a quantitative estimate of length of time that Plaintiff could perform those functions, he plainly opined that Plaintiff is unable to perform those functions on a regular and continuing basis consistently over a 40-hour work week.

         Finally, the Commissioner argues that Dr. Welther's opinion is inconsistent with other opinion evidence. (Doc. 16 at 16.) The court reviews the other opinion evidence below. For the reasons discussed below, based on its searching review of the record, the court is unpersuaded that the ALJ complied with the substance of the treating-physician rule when considering Dr. Welther's opinion.

         B. Dr. Erickson

         1. Treatment and November 2014 Opinion

         Dr. Brian Erickson-a pain management specialist with the Tilley Pain Clinic in South Burlington, Vermont-began treating Plaintiff on April 7, 2014. (AR 569.) At the first visit, Dr. Erickson compiled a thorough account of Plaintiff s history of present illness. (Id.) He noted, among other things, that Plaintiff had previously been seen in the clinic, initially on September 27, 2013, and that she had been referred from her orthopedic surgeon Dr. Nathan Endres. (Id.)

         Dr. Erickson's impression was as follows. He noted Plaintiffs injuries from the 2008 accident and that "[s]he continues with significant physical pain despite a variety of anesthetic interventions, medication regimens." (AR 571.) She reported "optimal functioning when she was on low-dose Fentanyl patch and Percocet p.r.n." (Id.) Dr. Erickson noted that "[c]omorbid problems may include traumatic brain injury and possible cognitive impairment, as she describes no longer having a photographic memory, having short-term impairment." (Id.) He also noted that Plaintiff "may have a comorbid posttraumatic stress disorder history." (Id.) He recommended a treatment plan that included "augmenting ...