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West v. Astrue

November 23, 2009

STEPHANIE L. WEST, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, DEFENDANT.



The opinion of the court was delivered by: Jeanne E. Scott United States District Judge

OPINION

JEANNE E. SCOTT, U.S. District Judge

Plaintiff Stephanie L. West (West) appeals from a final Decision of the Social Security Administration (SSA) denying her application for Supplemental Social Security Income (SSI) under Chapters II and XVI of the Social Security Act, 42 U.S.C. §§ 423 and 1381a. West brings this appeal pursuant to 42 U.S.C. § 405(g). Pursuant to Local Rule 8.1(D), West has filed a Motion for Summary Judgment (d/e 12) and Brief in Support of Plaintiff (d/e 13). The Commissioner has filed a Motion for Summary Affirmance (d/e 16) and Commissioner's Memorandum in Support of Motion for Summary Affirmance (d/e 17).

For the reasons set forth below, the Court determines that the SSA's Decision is not supported by the evidence. West's Motion for Summary Judgment is GRANTED, and the Commissioner's Motion for Summary Affirmance is DENIED. The Commissioner's Decision is REVERSED, and this case is remanded pursuant to 42 U.S.C. § 405(g), Sentence 4, for further proceedings consistent with this Opinion. FACTS*fn1

I. GENERAL BACKGROUND

West is a twenty-five-year-old woman who applied for SSI on January 27, 2004, when she was nineteen years old. Social Security Transcript (Tr.) (d/e 10), 20. She attended high school through her sophomore year. Id. at 16. She has worked as a retail cashier, salesperson, general merchandise worker, fast food worker, hostess, and material handler. Id. She has a two-year-old son and lives with her parents. West has suffered from serious medical problems, both physical and mental, for years. She has diabetes mellitus and chronic pancreatitis due to a cystic fibrosis gene mutation; she also has had bouts of severe depression and anxiety attacks. Id. at 17. West has had some episodes of illegal substance abuse, which have, by her own admission, tended to worsen her medical conditions.

Doctors diagnosed West with diabetes when she was three years old. Tr. at 126. They diagnosed her with pancreatitis when she was thirteen. Id. at 270. In 2000, doctors treated West's pancreatitis by performing a sphincterotomy and placing a stent in her pancreas. Id. at 258-70.

II. MEDICAL HISTORY PRIOR TO JANUARY

2004 Some background information before the relevant period is helpful to put West's illnesses in context. The record demonstrates that West has been treated for pancreatitis since at least 1999. Tr. at 270. In June 1999, West was hospitalized and treated for pancreatitis; her symptoms included vomiting and severe abdominal pain that radiated into her back. Id. She was hospitalized for the condition again in 2000 and 2001.

West also received psychological treatment. In September 2000, she visited Dr. John Beck at the Carle Pavilion in Champaign, Illinois. Dr. Holly Mirell, West's outpatient psychologist, referred her for treatment based on the fact that West's recent complaints of abdominal pain had not been attributable to her chronic pancreatitis; Dr. Mirell was concerned that the psychological aspects of her disease were contributing to stomach pain.

Id. at 275. West said that she felt very sad because her boyfriend had recently broken up with her, and admitted that she frequently smoked marijuana. Id. Dr. Beck relayed that West had difficulty in school and that her high school grades were suffering because of her frequent hospitalizations. Id. at 276.

In 2001, West visited Dr. James Whisenand at the Carle Pavilion. Id. at 272. She complained of depression and anxiety due to recurring episodes of pancreatitis and complications with diabetes. Id. Dr. Whisenand indicated that West was taking too much Vicodin, and that her previous bout of hospitalization due to abdominal pain was probably caused by West's inability to control her diabetes, and not by pancreatitis as had been the case in the past. Id. He assigned her a GAF score of 35 to 40.*fn2 Id. at 273.

In 2003, the State of Illinois Disability Determination Services had West evaluated physically and mentally. Dr. Hima Atluri performed the physical evaluation, and found that West suffered from diabetes, anxiety, depression, and pancreatitis. Id. at 282-85. Dr. Stephen Vincent performed a psychological evaluation. He noted that she had a long history of depression due to her severe illnesses, and that she smoked cigarettes and used to snort Ritalin to help her cope with pain. Id. at 287-89. Dr. Vincent diagnosed West with major depression and general anxiety disorder characterized by panic attacks. Id. at 289.

III. MEDICAL HISTORY AFTER JANUARY 2004

West was hospitalized at Carle Foundation Hospital in Urbana, Illinois, for three days in February 2004 with an episode of acute pancreatitis. Tr. at 303. The doctors noted that West "never exhibited inappropriate request[s] for narcotics," and that she only used morphine during flare ups. Id. at 307. After she was released from the hospital, West saw Dr. Nasreen Syed for follow-up treatment. Id. at 301. Dr. Syed noted that West was suffering from anxiety and depression, and that although she was taking medication for these conditions, she had stopped seeing her counselor because of financial concerns. Id. Dr. Syed encouraged West to be more consistent in testing her insulin levels, as noncompliance with medication for diabetes had been a problem for West. Id. at 302. Dr. Syed increased her dosage of Lexapro, put her on clonazepam, and tried to arrange for her to see a psychiatrist free of cost. Id.

In April 2004, West had another episode of acute pancreatitis and spent five more days in the hospital. Id. at 293. Her sugar levels were elevated, and she was experiencing extreme abdominal pain. Id. The doctors gave her morphine for pain and Humalog to counteract high blood sugar. Id. at 297. By the time she was discharged, West was in stable condition, and her pain had subsided. Id. at 293.

Dr. Sandra Bilinsky reviewed West's medical records on behalf of the state agency in July 2004. Id. at 596. Dr. Bilinsky found that West could perform "light work," defined as lifting and/or carrying twenty pounds occasionally and ten pounds frequently, and sitting, standing, and/or walking for six hours in an eight-hour period. Id. at 597. A clinical psychologist was also supposed to evaluate West, but she failed to attend the examination. Id. at 581-82. That same month, West spent four days in the hospital after another episode of severe abdominal pain. Id. at 1554. Dr. William Schuh diagnosed her with recurrent pancreatitis, and gave her morphine for pain and insulin to help control her diabetes. Id.

In August 2004, Dr. Syed wrote a letter to the state agency, explaining that West's chronic pancreatitis and diabetes were responsible for her recent hospitalizations. He also noted that her condition was a "financial burden." Id. at 509. Dr. Mirell, West's psychologist, also provided the state agency with an evaluation of West. Dr. Mirell stated that West met Listings 12.04 and 12.06. Id. at 514. Specifically, under Listing 12.04 Dr. Mirell indicated that West had marked difficulties in social functioning and in maintaining concentration, persistence or pace. Id. at 515. Under Listing 12.06, Dr. Mirell found that West had recurrent panic attacks, affecting her ability to maintain social functioning and concentration. Id. at 516.

In January 2005, West went to the emergency room complaining of abdominal pain. Id. at 1555. She spent four days in the hospital. Id. at 1558. She was given morphine and Phenergan, which temporarily relieved West's pain. Id. at 1555. The doctors put her on a diet to help control her diabetes, and discharged her. Id. at 1558.

West was hospitalized twice in February 2005. She was admitted on February 3, 2005, for pancreatitis and poorly controlled diabetes, and discharged on February 5, 2005, in stable condition. Id. at 1619. She was readmitted on February 11, 2005, with abdominal pain. Id. at 1654. She indicated that she had celebrated her twenty-first birthday with several alcoholic drinks the night before, and she tested positive for amphetamines, benzodiazepines, and cannabis. Id. She also tested positive for pregnancy. Id. She was discharged six days later, on February 17, 2005. Id. at 1657.

In April 2005, West was admitted to Carle Hospital. Id. at 1836. Dr. John Peterson noted that West had been hospitalized six times since January due to her chronic pancreatitis, including in March 2005. Id. Dr. Peterson noted that West was "agitated with screaming, crying, and rocking the bed back and forth." Id. Dr. Peterson gave West morphine for her pain, but West was so agitated that the nurses had difficulty getting an IV going; West managed to punch one of the nurses and was "extremely uncooperative." Id. at 1836, 536.

The next month, West was taken to the hospital via ambulance after an argument with a friend left her so upset that West was threatening to kill herself. Id. at 529. She denied that she had been using illegal drugs, but tested positive for cocaine and cannabis. Id. West was on probation for a drug offense and was assisting law enforcement, according to her mother, but doctors were concerned about West's substance abuse, and also thought she should seek psychological treatment. Id.

West visited Dr. Georgia L. Cuddeback in August 2005 for a psychological evaluation at the request of the state agency. Id. at 550. Dr. Cuddeback indicated that West had been hospitalized twenty times since January 2005, and that she was preparing to undergo treatment for cervical cancer. Id. at 551. West said that she did chores around her parents' house, like vacuuming, washing dishes, and laundry. Id. at 552. Dr. Cuddeback found that West was "severely depressed with suicidal ideation," and that she had no job skills due to her lack of employment history. Id. at 553. Dr. Cuddeback found that West's drug problem was in remission, and gave her a GAF score of 52. Id. at 553.

The state agency had West evaluated by nurse Harriet Steahly on October 20, 2005. West told Steahly, "I just don't know what it feels like to feel well. I never feel good." Id. at 112. West was taking Wellbutrin for depression and Klonopin for anxiety attacks. Id. Because she had no income, West moved back in with her parents; her financial problems also lead her to go to the emergency room for treatment if she ran out of insulin. Id. She admitted to smoking marijuana and crack cocaine in the past, but stated that she had quit using marijuana months ago and had not used crack for almost one month. Id. Steahly noted that West had a long history of serious medical problems, including depression. Id. at 112-13.

Also in October 2005, the state agency completed a Psychiatric Review Technique form on West, finding that she had impairments that fell under Listings 12.04 (Affective Disorders) and 12.09 (Substance Addiction Disorders), but that these impairments were not ...


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