United States District Court, D. Kansas
MEMORANDUM AND ORDER
KATHRYN H. VRATIL, District Judge.
Brenda McKinsey appeals the final decision of the Commissioner of Social Security to deny disability benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq. For the reasons set forth below, the Court reverses the judgment of the Commissioner.
I. Procedural Background
On June 18, 2009, plaintiff filed her disability application with the Social Security Administration. See Transcript Of Administrative Record (Doc. #7-2) filed September 12, 2013 ("Tr.") at 125. She alleged a disability onset date of November 16, 1996, and was last insured for benefits on December 31, 1999. Tr. at 18. Plaintiff's benefit application was denied initially and on reconsideration. Tr. at 71-74, 78-85. Plaintiff testified at a hearing on October 27, 2010, and on September 16, 2011, an administrative law judge ("ALJ") concluded that plaintiff was not under a disability as defined in the Social Security Act and that she was not entitled to benefits. Tr. at 13-68. On May 13, 2013, the Appeals Council denied plaintiff's request for review. Tr. at 1-7. The decision of the ALJ stands as the final decision of the Commissioner. See 42 U.S.C. § 405(g). Plaintiff appealed to this Court the final decision of the Commissioner.
II. Factual Background
The following is a brief summary of the relevant evidence presented to the ALJ.
A. Medical Evidence From Examining And Treating Physicians
In 1994, plaintiff began treatment for depression with Judith M. Bowen, M.D., at the Menninger Clinic. See Tr. at 879. Dr. Bowen diagnosed plaintiff with major depression, recurrent, moderate and assessed a GAF of 55. Tr. at 882.
In August 1994, plaintiff had a comprehensive examination and reported history of back pain, leg pain, irritable bowel, and abdominal and chest pain. Tr. at 866-70. In November of 1994, plaintiff's nerve conduction and EMG showed no abnormalities, so P.C. Amaraneni, M.D., at the Menniger Clinic, suggested "further work-up with the possible diagnosis of fibromyalgia to rule out any associated rheumatological or other systemic causes." Tr. at 856. On December 28, 1994, Robert Thomen, M.D., prescribed medication to relieve leg and back pain and irritable bowel symptoms. Tr. at 259.
On December 27, 1995, plaintiff went to the emergency room ("ER") at Labette County Medical Center reporting overall pain, vomiting and intermittent rectal bleeding. Tr. at 750. Doctors diagnosed her with pyelonephritis, hemorrhoids, fibromyalgia and Epstein-Barr virus. Tr. at 752. Plaintiff received Demerol and Phenergan for pain control. On December 31, 1995, after her condition improved, plaintiff was discharged. Id . Plaintiff was directed to follow up in seven to ten days. Id.
On January 12, 1996, plaintiff saw Dr. Bowen and reported that her mood was not depressed, she was not irritable with her mother and she was sleeping well. Tr. at 816. She reported, however, that she was still quite tired and that her energy level was still low due to her physical symptoms. Id.
Between 1996 and 1999, plaintiff required regular urethral dilation and cystoscopy for urinary tract infections and dysuria. Tr. at 251-56, 306, 308, 309, 726-28, 734-35.
On March 6, 1996, plaintiff went to the ER at Labette County Medical Center for urinary retention and exacerbation of her fibromyalgia. Tr. at 743-48. She was given a catheterization and discharged. Tr. at 745.
On June 23, 1996, plaintiff was again admitted to the ER at Labette County Medical Center, for a flare-up of fibromyalgia. Tr. at 740. The doctor noted two trigger points in her thoracic region and lower back and gave plaintiff injections at these points. Id . Plaintiff reported not sleeping well and total body aches. Id . Less than a month later, plaintiff was in the ER at Labette County Medical Center for pain in her back and legs. Tr. at 738. She reported a migraine headache and fibromyalgia, and she received trigger point injections. Tr. at 738.
On October 7, 1996, plaintiff went to the Labette County Medical Center ER due to nausea and vomiting. Tr. at 732. Doctors discovered moderate fecal retention, but no bowel obstruction or free intra-abdominal air. Id.
On December 4, 1996, plaintiff saw Ray L. Carlson, D.O., at the Erie Clinic for a check-up. Tr. at 290. Dr. Carlson noted that plaintiff was "quite a complex patient." Tr. at 290. He noted that she felt that her antidepressant medication was not helping and she was feeling "more down than ever." Id . She also reported having more migraines and taking Imitrex injections and Ibuprofen, which irritated her stomach. Id . The doctor recommended that she not take Ibuprofen, but continue the Imitrex. Id . He diagnosed her with fibromyalgia, dysthymic disorder, chronic fatigue syndrome and migraine headache. Tr. at 289-90. He also changed her depression medication. Tr. at 289.
On January 2, 1997, plaintiff returned to Dr. Carlson. Id . He noted that plaintiff was recovering from a UTI and that she seemed to be doing well and adjusting better, despite her depression. Id . He further noted that plaintiff had flu-like symptoms and was sleeping all the time. Id . Dr. Carlson diagnosed her with fibromyalgia, major depression and flu-like symptoms, and he increased her dosage of Paxil. Tr. at 292. Shortly thereafter, on February 5, 1997, plaintiff reported abdominal pain and a colon attack at the Erie Medical Clinic. Tr. at 291. Her condition was assessed as irritable bowel syndrome ("IBS"), gastritis and possible diverticulitis. Id.
On February 11, 1997, plaintiff again saw Dr. Carlson. Id . Plaintiff reported being very tired, but she seemed "to be doing well" and "very happy." Id . Dr. Carlson noted generalized tenderness in plaintiff's abdomen and diagnosed IBS, adjustment disorder with mixed emotional features, chronic fatigue syndrome and fibromyalgia. Id . Dr. Carlson gave plaintiff a Vitamin B12 injection. Id . Later that month, on February 26, 1997, plaintiff saw Dr. Carlson again. Tr. at 294. Though plaintiff stated that she was not depressed about anything in particular, she did report feeling more tired than she had for several months, that she had no energy, tired easily, was eating more and was "itchy all over." Id . She also reported muscle aches and acid reflux. Id . Dr. Carlson prescribed medication and advised plaintiff also to continue other current medications. Tr. at 293-94. Dr. Carlson noted that if plaintiff did not improve, she would have to be admitted to the hospital. Tr. at 294. Plaintiff returned to Dr. Carlson the next day. He noted that she was doing well on her medications, and that her fibromyalgia and depression had improved. Tr. at 293. He also noted that plaintiff should continue her medications and be monitored closely. Id.
On March 6, 1997, plaintiff reported a migraine headache and possible allergic rhinitis, and Dr. Carlson gave her a Nubain shot. Tr. at 296. Dr. Carlson saw plaintiff again on March 31, 1997. Tr. at 295. He noted that she seemed to be doing better and that her energy level was increasing. Tr. at 295. He noted that her symptoms were "still pretty severe, " however, and that they were very variable from day to day. Id . Dr. Carlson diagnosed plaintiff with obesity, fibromyalgia and depression. Tr. at 298.
On April 5 and June 9, 1997, Dr. Carlson completed forms for the Kansas Farm Bureau Life Insurance Company. Tr. at 913-14. He opined that plaintiff was totally disabled due to Epstein Barr and fibromyalgia and that she could not lift, bend or stoop and had difficulty with chronic pain. Id.
On June 16, 1997, plaintiff saw Dr. Carlson to receive trigger point injections due to severe pain from fibromyalgia. Tr. at 300. Dr. Carlson noted 12 tender points on exam. Id . Plaintiff reported feeling much better after the injections. Id.
On July 28, 1997, plaintiff saw Dr. Carlson for a follow-up examination and trigger point injection for fibromyalgia. Tr. at 302. About a week later, on August 8, 1997, a doctor at Erie Medical Clinic gave plaintiff a Vitamin B12 injection. Tr. at 301. On August 19, 1997, she returned to the ER due to a migraine, and received medications. Tr. at 724. She received another Vitamin B12 injection on August 25, 1997 at the Erie Medical Clinic. Tr. at 301. On October 15, 1997, plaintiff again saw Dr. Carlson for a checkup. Tr. at 304. She reported that she "was really feeling pretty good" but that her depression was worsening, and her medications were causing hair loss. Id . She also reported ...