United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
MARIA VALDEZ, Magistrate Judge.
This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of Social Security denying plaintiff Carin Haeger's claim for Disability Insurance benefits. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Haeger's motion for summary judgment [Doc. No. 15] is granted in part and denied in part. The Government's motion for summary judgment [Doc. No. 23] is denied. The Court finds that this matter should be remanded to the Commissioner of Social Security for further proceedings.
I. PROCEDURAL HISTORY
Haeger originally applied for Title II Disability Insurance Benefits on October 15, 2008. (R. 234.) In her application, she alleged disability beginning January 1, 2003 due to temporomandibular joint dysfunction ("TMJ syndrome"), back and neck pain, myofacial pain, and headaches. (R. 270.) Haeger's initial application was denied on February 9, 2009, (R. 127-30, ) and again on reconsideration on June 8, 2009. (R. 132-34.) Haeger filed a timely request for a hearing by an Administrative Law Judge ("ALJ"), which was held on August 16, 2010, with a supplemental hearing held on March 10, 2011. (R. 28, 72.) At the supplemental hearing, Haeger personally appeared and testified and was represented by counsel. ( Id. ) A vocational expert ("VE"), Lee Knutson, and a medical expert ("ME"), Dr. Ashok Jilhewar, also testified at the supplemental hearing. ( Id. )
On April 29, 2011, the ALJ found that Haeger was not entitled to benefits because she was not disabled under the Social Security Act. (R. 19.) The Social Security Administration Appeals Council denied Haeger's request for review on April 20, 2012 (R. 1-5, ) leaving the ALJ's decision as the final decision of the Commissioner of Social Security and therefore reviewable by the District Court pursuant to 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005).
II. FACTUAL BACKGROUND
A. Claimant's History
Haeger was born on October 3, 1962. (R. 234.) She lives with her husband and their dog. (R. 280-81.) She completed high school and some college, and has received some special training in real estate. (R. 17, 275.) Prior to her injuries, Haeger worked as a paralegal from 1982 to 1997, and as a realtor from 1997 to 2002. (R. 271.)
B. Testimony and Medical Evidence
1. Claimant's Testimony
Haeger testified that she underwent jaw surgery at Louisiana State University in November, 2004. (R. 31, 33.) The surgery was done to replace a portion of her jaw with a titanium and plastic prosthesis. (R. 33.) Her ability to use her jaw has improved since the surgery was done, but she still feels significant pain above her ear, in her jaw, in her face, and in her neck. (R. 33-35.) Haeger sees a pain specialist once every two months. (R. 38.) She takes Fiorinal with codeine, Fioricet with codeine, and Zanaflex to alleviate her head and neck pain. ( Id. ) Haeger uses a Lidoderm patch for back pain. ( Id. ) She takes muscle relaxant medications as needed. (R. 37.)
Haeger's real estate license expired to 2007 and she is currently not working. (R. 35-36.) She has been unable to work since her jaw surgery in 2004. (R. 36.) Because she is not working, Haeger typically stays inside most of the day reading and doing puzzles. ( Id. )
2. Medical evidence
Dr. Mary Jo Curran treated Haeger for pain between 1999 and 2007. On June 30, 1999, she was treated with stereotactic decompression neurolysis of the medial branch nerve of the right posterior ramus at levels C2-C7. (R. 547.) The same day, she was given cervical facet injections at levels C2-C6. (R. 549.) Another stereotactic decompression neurolysis of the medial branch nerves on the left was administered August 25, 1999. (R. 544.) Haeger subsequently received a ganglionectomy to remove nerves on her right and left sides on September 29 and October 6, 1999, respectively (R. 538, 540.)
From October 1999 to February 2001, Haeger underwent a variety of nerve treatments intended to alleviate pain. These included spinal steroid injections, (R. 525, 527, 531, 534, 552, 560, 572, 578, ) targeted ganglionectomies, (R. 527, 551, 567, ) nerve blocks, (R. 562, ) and percutaneous radiofrequency rhizotomies (R. 553-55, 557-58.) On October 5, 2000, Haeger reported that the range of motion in her left shoulder and facial pain had improved. (R. 508.) On February 21, 2001 - the last record of Haeger's treatment with Dr. Curran - Haeger underwent left maxillary neurolysis and a steroid injection into her maxillary nerve. (R. 552.)
Dr. Curran gave deposition testimony in a civil case concerning a car accident Haeger was involved in on April 18, 2002. (R. 581-634.) During the deposition, Dr. Curran responded to a question about Haeger's ability to be employed as a realtor or elsewhere, stating, "it's my opinion that if she can work it would be some specialized job where she's - can take days off at a time and that kind of thing." (R. 624-25.)
Although documentation of Haeger's TMJ surgery were destroyed in Hurricane Katrina, a letter from the treating facility shows that the procedure was performed in 2004. (R. 357.) No further evidence of the procedure or Haeger's recovery exists in the record.
Beginning on April 20, 2007, Haeger began to see Dr. Ira Goodman for pain management. (R. 456.) Records of that visit show limited range of motion in Haeger's neck, tenderness in her cervical facets, and limited range of motion and pain in her lower back. (R. 457.) As a result of continued pain in her neck and back, Haeger underwent a series of injections in the fall of 2007. (R. ...