United States District Court, C.D. Illinois, Springfield Division
SCHANZLE-HASKINS, U.S. MAGISTRATE JUDGE.
Lisa Louise Jayne appeals from the denial of her application
for Social Security Disability Insurance Benefits (DIB) under
Title II and Supplemental Security Income (SSI) under Title
XVI of the Social Security Act (collectively Disability
Benefits). 42 U.S.C. §§ 416(i), 423, 1381a and
1382c. This appeal is brought pursuant to 42 U.S.C.
§§ 405(g) and 1383(c). Jayne filed a Motion for
Summary Judgment (d/e 16). The Defendant Commissioner filed a
Motion for Summary Affirmance (d/e 19). The parties have
consented to proceed before this Court. Consent to the
Exercise of Jurisdiction by a United States Magistrate Judge
and Reference Order entered November 9, 2018 (d/e 15).
For the reasons set forth below, the Decision of the
Commissioner is affirmed.
was born on July 27, 1966. She secured a GED. She previously
worked as an animal caretaker, home health attendant, and
security guard. She suffers from degenerative disc disease of
the cervical spine, right shoulder bursal surface tearing
with tendonitis and osteoarthritic changes; moderate
degenerative changes in the right hip; remote right knee
meniscus tear; and depression and anxiety. R. 22, 29, 75,
December 31, 2012, Jayne saw Dr. Daniel OConnor, M.D., to
establish care after her previous doctor retired. She
reported shoulder pain that did not radiate. She also
reported insomnia. She said the pain in her shoulder
interfered with her sleep. R. 318-19. On examination, Jayne
had no swelling or weakness, normal gait, normal mobility and
curvature in her spine, full range of motion in all her
extremities with no swelling, erythema, or effusion. She had
no sensory loss. Jayne was oriented and demonstrated
appropriate mood and affect. R. 321. Dr. OConnor renewed
Jayne's prescription for Norco
(hydrocodone-acetaminophen) at a reduced dosage. Dr. OConnor
noted, “No early refill, and maybe no refill at all. I
strongly recommend use of ibuprofen, but since she thinks she
gets no results, it seems unlikely that she will take
it.” Dr. OConnor discontinued the prescription for
tramadol because it made her “feel odd” and she
reported that it provided no benefit. R. 318.
January 23, 2013, Dr. OConnor wrote a letter regarding
Jayne's work limitations due to her condition. Dr.
OConnor recommended that Jayne should not lift more than 20
pounds and should not stand for more than two hours without a
10-minute break. R. 336.
March 11, 2013, Jayne saw Dr. OConnor. Dr. OConnor noted,
For a person in “severe” pain she sure looks
comfortable and is able to move pretty well. This is starting
to look like she may not need nearly so much medication, so I
think the next time she comes back, if her records don't
show some crippling radiography, we will begin scaling back
her narc supply.
R. 322. On examination, Jayne displayed normal spine mobility
and curvature, full range of motion in all extremities with,
“Seemingly no limitation of movement.” Her memory
was intact, she was oriented, and she demonstrated
appropriate mood and affect. R. 324. Dr. OConnor renewed her
prescription for hydrocodone-acetaminophen and added a
prescription for Ambien. R. 322.
1, 2014, Jayne saw Dr. Natalie Greene, D.O., for high blood
pressure. Dr. Greene noted that Jayne drank “about a 6
pack of beer per nigh (sic) especially on weekends.”
Dr. Greene also noted that Jayne was taking hydrocodone for
pain. R. 327. On examination, Jayne had normal pulses and no
edema. She was oriented; she had normal insight and judgment;
and she demonstrated appropriate mood and affect. R. 329. Dr.
Greene discontinued the prescriptions for hydrocodone and
Ambien. She prescribed meloxicam (an NSAID) and gabapentin.
15, 2014, Jayne saw Dr. Greene. Jayne reported right arm
pain. She said the pain was burning. She also felt numbness.
She said the pain went from her neck to her elbow. She said
the gabapentin made her “queezy (sic).” She said
she was taking Vicodin (hydrocodone-acetaminophen) that she
got from a friend. Dr. Greene did not order further testing
because Jayne did not currently have insurance. R. 331. On
examination, Jayne had normal gait, normal spine mobility and
curvature, sensation, and strength in both arms. She had
moderately reduced range of motion and severe crepitus in her
right shoulder. No. edema was present. Jayne was oriented,
had normal insight and judgment, and had appropriate mood and
affect. R. 334. Dr. Greene renewed her prescriptions for
meloxicam and gabapentin. Dr. Greene stated that if the NSAID
did not improve her shoulder in a month, she would give Jayne
a steroid injection. R. 331.
30, 2014, Jayne protectively filed for Disability Benefits.
She alleged that she became disabled on November 30, 2012. R.
October 16, 2014, Jayne saw state agency psychologist Dr.
Stephen Vincent, Ph.D., for a mental status assessment. R.
351-53. Upon completing the examination, Dr. Vincent
concluded, in part:
She has co-morbid symptoms and signs of anxiety and
depression, with no history of any formal psychological
and/or psychiatric treatment. She currently takes no
prescribed antidepressant or anti-anxiety medications. She
has not been psychiatrically hospitalized. She is currently
not involved in any counseling efforts. She does prefer to
withdraw and isolate. Cognitively she is intact.
Vincent assessed clinical impression was major depression,
with anxious distress. R. 353.
same day October 16, 2014, Jayne saw state agency physician
Dr. Raymond Leung, M.D., for a consultative physical
examination. R. 354-57. Jayne denied any illegal drug use.
She said she drank six to eight beers on weekends. She said
she was taking meloxicam and hydrocodone. On examination,
Jayne walked with a minimal limp without her cane. With the
cane, “she would just lift the cane and was not using
it to walk.” She could walk 50 feet unassisted. She had
difficulties walking on her heels and on her toes. She could
squat ¼ of the way down. Straight leg raising
bilaterally was to 35 degrees. She had decreased range of
motion in her lumbar spine and shoulders. She had 5/5
strength in her left arm and hand. She had 4 strength in
her right arm and hand. She had 4 strength in her legs.
Her sensations were in normal limits. She had no edema. R.
356. Dr. Leung's mini mental examination results were
normal. R. 355. Dr. Leung assessed slight right arm weakness,
full range of motion in her cervical spine and limited range
of motion in her lumbar spine and walking with a slight limp
without her cane. 356-57.
October 24, 2014, Jayne prepared a Function Report-Adult
form. R. 245-52. Jayne reported that she lived alone in a
house. Jayne said she could not work because of her back,
neck, and shoulder pain. She also said she experienced nausea
and headaches when she left home. She said she had panic or
anxiety attacks when she was around a group of people or when
she had appointments. R. 245.
said that in a typical day she got up, made coffee, took her
meds, took care of her dog, watched television, took a nap,
and played games on her phone. She also read the newspaper.
She said that on a good day she would “try to tidy up
the house or make a ‘decent' meal.” She said
that two individuals Melissa Medders and Keith Vaughn help
her take care of her pets. R. 246. Jayne said she did
laundry, mowing, dusting, and cleaning once a week, but some
weeks she did not perform these activities due to fatigue or
pain. R. 247-49.
said she went outside once a day. She went out alone. She
said that she drove. She went shopping once a month for
groceries, toiletries, and cleaning supplies. She was able to
pay bills, count change, handle her savings account, and use
her checkbook. R. 248.
said that two or three times a week she communicated with
“a few people I associate with” by phone, email,
and text. She also attended occasional barbeques with others.
She said that twice a month she listened to music with close
friends. R. 249.
reported that lifting more that 20 pounds caused pain. She
said that squatting, bending, and kneeling caused pain and
she occasionally fell if she did not have something to hold
onto. She said that standing and walking caused pain and
fatigue. She indicated climbing stairs caused pain and
fatigue. She said she had trouble concentrating and
understanding. She could walk less than a block before she
had to rest for 20 to 30 minutes. R. 250. Jayne said she used
a cane to walk distances or when she was in a strange place.
She wore a knee brace when she drove her riding mower or when
she had to lift heavy objects. R. 251.
not follow written instructions well and she followed spoken
instructions fairly well if she looked directly at the person
who gave the instructions. R. 250. Jayne said she had issues
with authority figures in the past. She said that stress
caused nervousness, headaches, and vomiting. Changes in
routine made her paranoid. R. 251.
November 15, 2014, state agency psychologist, Dr. Donald
Henson, Ph.D., prepared a Psychiatric Review Technique. R.
85-56. Dr. Henson opined that Jayne suffered from an
affective disorder and an anxiety disorder. Dr. Henson also
opined that her mental impairments caused moderate
limitations on her activities of daily living, her ability to
maintain social functioning, and her ability to maintain
concentration, persistence, or pace. R. 85.
November 19, 2014, state agency physician Dr. Julio Pardo,
M.D., prepared a Physical Residual Functional Capacity
Assessment. Dr. Pardo opined that Jayne could occasionally
lift 50 pounds and frequently lift 25 pounds, could stand
and/or walk six hours in an eight-hour workday, and could sit
six hours in an eight-hour workday. Dr. Pardo found that
Jayne had no other physical functional limitations. R. 87-88.
January 5, 2015, Jayne saw Dr. Greene. Jayne reported that
she had pain in her neck, shoulders, and arms. Jayne said
pushing and rotation aggravated her condition. She described
the pain as aching, piercing, and tingling. She reported some
loss of grip strength. Jayne also said she just received her
medical card. R. 344-45, 381-82. On a review of symptoms, Dr.
Greene said that Jayne was negative for anxiety and
depression. R. 345, 382. On examination, Jayne's cervical
spine was tender and had mildly reduced range of motion. Her
thoracic spine was tender. Jayne had positive compression
tests right and left. She had normal grip strength
bilaterally. Her gait was normal. She had mildly decreased
sensation. She was oriented, had normal insight and judgment,
and had normal mood and affect. R. 346, 383. Dr. Greene
discontinued the prescriptions for meloxicam and
hydrocodone-acetaminophen and continued her prescription for
gabapentin. Dr. Greene ordered an MRI of Jayne's neck. R.
January 14, 2015, Jayne had an MRI of her cervical spine. The
MRI showed multilevel degenerative changes in her cervical
spine with most pronounced foraminal and canal stenosis at
¶ 5-C6 with right worse than left. No. definite cord
signal abnormality was identified. R. 349.
February 12, 2015, Jayne completed another Function
Report-Adult form. R. 266-73. She said she could not work
because she could not sit or stand for long periods; she
could not lift or bend; she could not walk long distances;
and she could not drive for any length of time. R. 266.
During a typical day she made coffee, took medications,
watched television, showered, did light housework, let her
pets outside, and ate. R. 267. Jayne prepared meals with a
microwave and crockpot. She had no desire to make major
meals, and reheated leftovers daily. R. 268. She also played
games on her cell phone and occasionally read. R. 270. She
said she could not do major housework. R. 267. She left the
house to check the mail, mow, and go to appointments. She
drove, but had difficulty getting in and out of the car. She
went shopping twice a month. R. 269 She said she had problems
with her sleep because of pain, anxiety, and panic attacks.
R. 267. She later reported that she did all the housework,
but no ironing or home repairs. She mowed with a riding
mower. She said she did a little housework every day. R. 268.
She chatted daily with friends over the phone and on her
computer and friends sometimes visited her in her home. R.
said she could pay bills, count change, handle a savings
account, and use a checkbook. She did not need reminders to
go places and did not need anyone to go with her. She did not
have any problems getting along with others. She said that
she finished what she started, and she understood written and
spoken instructions. R. 269-71.
said that her condition limited her ability to lift, stand,
walk, bend, sit, concentrate, and climb stairs. She became
short of breath when she climbed stairs. She did not know how
far she could walk. She had to rest over 30 minutes after a
walk and did not know how long she could pay attention. R.
271. She said she used a back brace and a cane. The devices
were not prescribed but suggested. R. 272.
reported that she did not handle stress or changes in routine
well. She said that she was terminated from a job at Global
Security because she had problems with co-workers. She had
fears of dying or sickness. R. 272.
March 23, 2015, Jayne saw Dr. Greene. R. 384-86. Dr. Greene
noted a history of moderate neck pain. She reported that she
saw an orthopedic surgeon who told her she was not a
candidate for surgery. R. 384. On a review of symptoms, Dr.
Greene stated that Jayne was negative for anxiety and
depression. R. 385. On examination, Jayne had normal gait,
normal spine, and normal extremities. She was also oriented
with normal judgment and insight, and appropriate mood and
affect. R. 386. Dr. Greene scheduled Jayne an appointment
with Pain Management. Dr. Greene discontinued prescriptions
for gabapentin and prescribed tramadol. R. 384.
April 8, 2015, state agency psychologist Dr. David L.
Biscardi, Ph.D., prepared a Psychiatric Review Technique for
Jayne. R. 111-12. Dr. Biscardi opined that Jayne suffered
from an affective disorder and an anxiety disorder. Dr.
Biscardi opined that her mental impairments caused mild
limitations in her activities of daily living and her ability
to maintain social functioning, and moderate limitations in
her ability to maintain concentration, persistence, or pace.
April 23, 2015, Jayne saw Dr. Greene. Jayne said she went to
pain management. The pain management heath care professional
offered her physical therapy, but she refused. The pain
management health care professional refused to give her
narcotic pain medication because Jayne had a history of
cocaine addiction in her past. The pain management providers
also set Jayne up for spinal injections. Jayne complained of
continuing pain in her right shoulder. She reported that she
could not lift her right arm above her head. R. 388. On a
review of symptoms, Dr. Greene said that Jayne had little
interest or pleasure in doing things, but did not feel down,
depressed, or hopeless. R. 389. On examination, Jayne's
gait, spine, and extremities were normal, except her
shoulders. Jayne's right shoulder had decreased range of
motion and crepitus and her left shoulder had crepitus but
better range of motion. Jayne was oriented with normal
insight and judgment and appropriate mood and affect. R. 390.
Greene ordered an MRI of her right arm and also started Jayne
on Zoloft for depression. Jayne was also taking trazadone ...