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Brasseaux v. U.S. Commissioner, Social Security Administration

United States District Court, W.D. Louisiana, Lake Charles Division

February 7, 2018

PAMELA THIBODEAUX BRASSEAUX
v.
U.S. COMMISSIONER, SOCIAL SECURITY ADMINISTRATION

          JUDGE TRIMBLE

          REPORT AND RECOMMENDATION

          Joseph H.L. Perez-Montes United States Magistrate Judge

         I. Background

         A. Procedural Background

         Pamela Thibodeaux Brasseaux (“Brasseaux”) filed an application for disability insurance benefits (“DIB”) on December 26, 2013, alleging a disability onset date of October 1, 2012 (Doc. 5-1, p. 168/259) due to fibromyalgia, depression, and anxiety (Doc. 5-1, p. 190/259). That application was denied by the Social Security Administration (“SSA”) (Doc. 11-1, p. 80/259).

         A de novo hearing was set for March 2015 before an administrative law judge (“ALJ”). Brasseaux appeared with her attorney and a vocational expert (“VE”) (Doc. 11-1, p. 59/259). At the start of the hearing, Brasseaux amended her disability onset date from October 1, 2012 to January 1, 2007, and asked for a continuance in order to gather and submit additional medical records (Doc. 11-1, p. 64/259). The hearing was postponed (Doc. 5-1, p. 64/259).

         The rescheduled de novo hearing was held before an ALJ in May 2015. Brasseaux appeared with her attorney (Doc 5-1, p. 36/259). The ALJ found that Brasseaux met the insured status requirements through December 31, 2012, and through that date she had severe impairments of disorder of the cervical spine, disorder of the lumbar spine, fibromyalgia, and obesity (Doc 5-1, p. 21/259). The ALJ further found Brasseaux had the residual functional capacity to do the full range of light work and could perform her past relevant work as a sales counselor through the date last insured (Doc. 5-1, pp. 24, 27/259). The ALJ concluded that a finding of “not disabled” was directed by Medical-Vocational Rule 202.21 of 20 C.F.R. Pt. 404, Subpt. P, Appendix 2 ("the grids") (Doc. 5-1, p. 28/259). Therefore, Brasseaux was not under a "disability" as defined in the Social Security Act at any time from January 1, 2007 through December 31, 2012, the date last insured (Doc. 5-1, p. 28/259).

         Brasseaux requested review of the ALJ's decision, but the Appeals Council declined to review it (Doc. 5-1, p. 8/259). The ALJ's decision became the final decision of the Commissioner of Social Security (“the Commissioner”).

         Brasseaux next filed this appeal for judicial review of the Commissioner's final decision. The sole issue raised by Brasseaux on appeal is whether the Commissioner properly evaluated the post-hearing treating source medical opinions from Dr. Phillip Landry and Dr. Jason Morris, regarding Brasseaux's functional abilities prior to her date last insured (December 31, 2012) (Doc. 8).

         The Commissioner responded to Brasseaux's appeal (Doc. 9), and Brasseaux filed a reply (Doc. 10). Brasseaux's appeal is now before the Court for disposition.

         B. Medical Records

         From 2004 through 2010, Brasseaux was treated for depression and anxiety by Dr. Phillip A. Landry, a psychiatrist, and was prescribed Wellbutrin, Lexapro, Xanax, and Lunesta (Doc. 5-2, pp. 455-474, 789-796/998). In September 2005, Dr. Landry noted Brasseaux was “stressed out” from Hurricane Rita, her job (at a funeral home), overwhelmed, unable to handle stress, depressed, unable to sleep, and planning to resign from her job (Doc. 5-2, p. 472/998). Dr. Landry increased her Lexapro and Xanax (Doc. 5-2, p. 472/998).

         By January 2006, Brasseaux had successfully returned to her job, but was very depressed, anxious, and grieving from the recent death of her brother, having difficulty going to work, and having difficulty sleeping (Doc. 5-2, pp. 471, 789/998). Brasseaux planned to apply for short-term disability (Doc. 5-2, p. 471/998). In July 2006, Brasseaux was recovered from her depression, had resigned from her job at the funeral home, and planned to go to school to become a contractor (Doc. 5-2, p. 468/998). Dr. Landry found she was “doing very well” (Doc. 5-2, p. 468/998).

         In January 2007, Brasseaux was dysphoric due to menopause and having stress because her husband did not like that she was no longer working, but she was doing “extremely well” by July 2007 (Doc. 5-2, pp. 466-467/998). In 2008, Brasseaux began having problems with Lexapro, which she had been taking for five years, so she began trials of other medications, finally resuming taking Lexapro at a higher dosage (Doc. 5-2, pp. 459-64/998). The higher dosage of Lexapro finally returned her mood to normal (Doc. 5-2, pp. 458/998). In 2010, Brasseaux again became depressed (Doc. 5-2, p. 457/998). Wellbutrin was added to her medication regimen, and she became stable again (Doc. 5-2, pp. 454-457/998).

         Brasseaux received ongoing treatment for chronic sinusitis, vertigo, irritable bowel syndrome, gastroesophageal reflux disease, and hypothyroidism from Dr. Morris from 2004 through 2010 (Doc. 5-2, pp. 534-551, 705-731/998).

         Brasseaux was treated for recurrent urinary tract infections and urinary frequency from May 2006 to June 2011 (Doc. 5-2, pp. 570-585/998).

         A cervical spine MRI in June 2009 showed Brasseaux had bulging discs and osteophytic ridging at ¶ 2-3, C4-5, and C5-6, but there was no significant stenosis (Doc. 5-2, p. 420/998). Brasseaux was evaluated by Dr. Craig G. Morton, a physical medicine and rehabilitation specialist, in November 2009 (Doc. 5-2, p. 439/998). Dr. Morton noted her one-year history of neck and shoulder pain after falling (Doc. 5-2, p. 439/998). Dr. Morton also noted her history of chiropractic care, and prescribed physical therapy for cervical stabilization and occipital nerve release (Doc. 5-2, p. 426/998). Physical therapy improved Brasseaux's range of motion and decreased her pain levels (Doc. 5-2, pp. 435, 438, 450-51/998).

         Brasseaux had chiropractic treatment from September 2010 through December 2011 (Doc. 5-2, pp. 477-86/998). Brasseaux fell again in June 2011, which caused an acute exacerbation of her back pain (Doc. 5-2, p. 478/998).

         In December 2011, an MRI of Brasseaux's lumbar spine showed degenerative change in the facets at ¶ 4-5 with prominent osteophytes, but no significant spinal stenosis (Doc. 5-2, p. 422/998). Brasseaux also had milder degenerative change at the L3-4 and L5-S1 facets, and bilateral Tarlov cysts[1] at ¶ 2 (Doc. 5-2, pp. 422, 520/998). Brasseaux had some degeneration of the joints at ¶ 4-5 (Doc. 5-2, p. 422/998). Brasseaux was referred to Dr. Morton (Doc. 5-2, p. 422/998).

         In December 2011, Brasseaux complained of low back and buttock pain going to the right thigh, worse after having been on her feet (Doc. 5-2, p. 426/998). Brasseaux was still tender and restricted in range of motion as before (Doc. 5-2, p. 429/998). Brasseaux stated both her pain medication and the chiropractor gave her some relief (Doc. 5-2, p. 426/998). A lumbar MRI showed mild facet arthrosis at ¶ 4-5 with bulging discs, and degenerative changes at ¶ 5-S1 (Doc. 5-2, p. 429/998). Dr. Morton noted that fibromyalgia complicated her condition, and diagnosed mild foraminal stenosis at ¶ 4-5 (Doc. 5-2, p. 164, 425/998). Dr. Morton prescribed a TENS unit, a Medrol dose pack, and physical therapy (Doc. 5-2, pp. 164, 425/998).

         Brasseaux had chiropractic treatment in 2012 and 2013 for all-over pain and TMJ (Doc. 5-2, pp. 240-258/998).

         In January 2012, Dr. Morton sent Brasseaux to physical therapy, but Brasseaux only completed 9 of the 15 prescribed visits (Doc. 5-2, p. 160/998). Dr. Morton noted that Brasseaux was doing well with Neurontin and her leg pain had resolved, but continued to have dull low back pain with standing that improved with rest (Doc. 5-2, p. 161/998). Brasseaux's medication list included Lisinopril, Lexapro, Xanax, Santura, Armour Thyroid, Lunesta, and Medrol (Doc. 5-2, p. 162/998). Brasseaux was tender to palpation over the multifidus and lumbar paraspinals on the right, and the lumbar paraspinals, multifidus, and sacroiliac joint on the left (Doc. 5-2, p. 162/998). She also had mildly restricted forward flexion and moderately restricted right and left rotation/extension (Doc. 5-2, p. 162/998). Brasseaux had failed conservative care with chiropractics, so Dr. Morton prescribed physical therapy for cervical stabilization and occipital nerve release in December 2011 (Doc. 5-2, pp. 426, 477-86/998). Brasseaux noted improvement in her range of motion as well as decreased pain levels (Doc. 5-2, pp. 435, 450-51/998). Dr. Morton noted she was doing well with Neurontin, therapy was helping, and she rated her back pain a 4/10 (worse with standing, improved with rest) (Doc. 5-2, p. 161/998). Brasseaux's leg pain was resolved (Doc. 5-2, p. 162/998). Brasseaux's forward lumbar flexion was mildly restricted and her right and left lumbar rotations were moderately restricted (Doc. 5-2, pp. 161-62/998).

         In January 2012, Dr. Landry found Brasseaux was doing well on her medications and prescribed Xanax, Lexapro, and Wellbutrin (Doc. 5-2, p. 112, 117/998).

         From January 2012 through January 2015, Brasseaux underwent chiropractic treatment for neck and back pain at ¶ 5, C2, C3, C4, C5, C6, T7, and T8 (Doc. 5-2, pp. 232-258/998).

         In April 2012, Brasseaux was referred by Dr. Snow for acupuncture to treat her fibromyalgia pain (Doc. 5-2, p. 6/998). Brasseaux also reported pain in her right hip, right sided sciatica, lower back, and neck that is aggravated by wind, cold temperatures, and dampness (Doc. 5-2, p. 11/998). Treatments in April through July 2012 gave Brasseaux temporary relief (Doc. 5-2, pp. 6-24/998).

         In July 2012, Brasseaux's main complaint was fibromyalgia. Dr. Landry added a trial of Cymbalta (Doc. 5-2, p. 119/998). In June 2013, Dr. Landry added Halcion ...


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