United States District Court, C.D. Illinois, Springfield Division
SCHANZLE-HASKINS UNITED STATES MAGISTRATE JUDGE
Penny Koonce 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). Koonce filed a Motion for
Summary Reversal (d/e 19). The Defendant Commissioner filed a
Motion for Summary Affirmance (d/e 24). 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 May 14, 2018 (d/e 8). For the
reasons set forth below, the Decision of the Commissioner is
was born on March 7, 1973. She completed the 10th
grade. She previously worked at a Subway restaurant, two gas
stations, and a retail store. She worked as a cashier,
sandwich maker, and baker at these places. She has not worked
at any substantial gainful activity since January 18,
2013. She suffers from obesity, diabetes,
degenerative disc disease, degenerative joint disease, sleep
apnea, migraine headaches, fibromyalgia, depression, bipolar
disorder, and anxiety disorder. R. 18, 24, 31, 350, 363.
November 27, 2013, Koonce saw Nurse Practitioner Sandra
Brummet, FNP-BC, in the office of Dr. Manjeshwar B. Prabhu,
M.D. R. 545-46. Koonce said that she hurt her left knee
getting out of her van. She said her knee had been hurting
for a while. She said that it gave way and she often had to
catch herself to keep from falling. She reported that she had
a knee injury when she was in high school. She wore a splint
and said that it helped. She tried ice and ibuprofen but that
did not help much. On examination, Koonce weighed 217 pounds
with a body-mass-index of 39.93. Koonce had some crepitus
with extension of the left knee. She was “not overly
tender with palpation.” Brummet saw no sign of injury
to the knee. R. 545. Brummet prescribed meloxicam for pain
and recommended an MRI and physical therapy. Brummet said she
could not afford an MRI and, in the past, physical therapy
did not work and made things worse. R. 546.
March 31, 2014, Koonce saw Nurse Practitioner Brummet. R.
541. Koonce reported that she woke up about 4:00 a.m. with a
migraine headache. She was somewhat nauseous. She said that
she got one migraine a month. She normally got through a
migraine with some ibuprofen. She said she also had been
taking Depakote and propranolol. Koonce requested a Toradol
injection and Brummet gave her the shot. Brummet told Koonce
to go home and rest. R. 542.
2, 2014, Koonce saw Dr. Prabhu at an office visit for a
medication check. Koonce reported problems sleeping. On
examination, Koonce had normal strength, gait, and stance.
She had intact sensation. Dr. Prabhu renewed her medications.
He recommended avoiding caffeine and recommended an insomnia
class. R. 538-39.
9, 2014, Koonce went to the emergency room at Taylorville
Memorial Hospital (Taylorville Memorial) in Taylorville,
Illinois. R. 433. She saw Dr. Anna McCormick, M.D. She
complained of a headache that had lasted three days. She
reported that she had her last migraine headache over a month
earlier. Her migraine medication of Diproxen and Propranolol
did not help. She said that lights and sound bothered her.
She also said she was nauseous. She rated her pain at an 8
out of 10. R. 433. Her neurological examination was normal.
Her strength was 5/5. Dr. McCormick administered Toradol,
Reglan, and Benadryl intravenously followed by morphine and
Zofran. Dr. McCormick discharged her with a prescription of
Zofran and Imitrex. Koonce had a normal gait at discharge.
Dr. R. 434.
19, 2014, Koonce saw Dr. Prabhu for a follow up after
insomnia class. She reported getting up at night to go to the
bathroom and get a drink, but she said she fell back asleep.
She reported some daytime sleepiness. Dr. Prabhu said her
bipolar medication Seroquel could cause the daytime
sleepiness. On examination, she had normal, strength, gait,
and stance. Dr. Prabhu advised her on improving her sleep
habits. R. 536.
August 1, 2014, Koonce saw Dr. Mark Stern, M.D. Koonce
reported lower back pain with pain into the right buttock and
into both legs for the last four months. She reported that
she had difficulty with balance and that her legs gave out on
her. She said she fell four or five times. If she stood for
10 minutes, she started having pain in her legs. She had pain
sweeping and mopping. Dr. Stern said x-rays showed narrowing
of the L5 neural foramina. He said an MRI had already been
done that showed degenerative disc disease. Dr. Stern
suggested surgery or epidural steroid injections. On
examination, Koonce could walk on both her heels and her
toes. Straight leg test was negative. Her reflexes were 0/4
in knees and ankles. Dr. Stern recommended that her primary
care physician Dr. Prabhu refer Koonce for epidural steroid
injections and a surgical consultation. R. 527-28.
August 6, 2014, Koonce went to the emergency room at
Taylorville Memorial complaining of stress. She saw Dr. Paul
R. Pfeiffer, D.O. She denied any suicidal or homicidal
ideations and reported that she had chronic bipolar
depression. She did not have a headache, but said she had
migraines on and off for the last couple of days. She refused
to see a counselor and indicated she would talk to Dr. Prabhu
later. She asked for something to sleep and go home. The
doctor gave her Benadryl intravenously and discharged her. R.
same day, August 6, 2014, Koonce also saw Dr. Prabhu for
chronic low back pain and frequent falls. R. 525-26. Koonce
said her left knee was giving way. R. 525. On examination,
Koonce had no swelling in her legs and her motor strength,
gait, and strength were normal. The range of motion of her
knees and her back were preserved. She had crepitus in her
left knee, but no fluid. Dr. Prabhu stated that Dr. Stern
gave Koonce a cane for ambulation, but she was not using it.
Dr. Prabhu cited non-use of the cane as one reason she may be
falling. Dr. Prabhu ordered x-rays and scheduled an EMG/nerve
conduction study of her back. R. 525-26.
August 19, 2014, neurologist Dr. Claude Fortin, M.D.,
performed an EMG/nerve conduction study. The study showed
mild left L5 radiculopathy. R. 524.
August 29, 2014, Koonce saw Physician's Assistant Nicole
Venvertloh, PA-C in the offices of orthopedic surgeon Dr.
Diane Hillard-Sembell, M.D. R. 521-23. Koonce saw Venvertloh
for left knee pain. Koonce said she had the pain for the
preceding month and periodically since she was a child. She
said she tried physical therapy, but that made it worse. She
tried the heat and medication Dr. Stern prescribed, but they
did not work. She said the knee gave way. She denied numbness
or tingling down her legs. She said the knee popped and
caught on her. On examination, the left knee was tender to
palpation. The patella demonstrated crepitus and lateral
tracking. Range of motion was normal with pain with
extension. Stress testing was stable. Sensation was intact.
No. foot drop was present. Pulses were 2. Koonce had a
positive patellar apprehension. X-rays and MRI showed a
laterally tracking patella. Venvertloh administered an
injection into the knee. Venvertloh prescribed physical
therapy to strengthen and stretch Koonce's leg muscles.
September 15, 2014, Koonce went to the emergency room at
Taylorville Memorial. R. 586-87. She said she had elevated
blood sugars in the 300s. She reported diarrhea and fatigue.
She denied any vomiting or fevers. R. 586. Her examination
was unremarkable except for blood sugar level of 228. Dr.
McCormick gave Koonce insulin and discharged her. She was
feeling better. R. 587.
September 19, 2014, Koonce saw a physical therapist for an
initial evaluation for left knee pain and acute low back
pain. Koonce reported that she hurt her knee at age 13. She
said she fell six times in the past twelve months. She told
the therapist that her knee was “growing in”
probably because a disc in her lower back was gone, and her
hip was growing into her vertebra. Koonce reported that an
MRI and x-ray were both negative. R. 579, 582. On
examination, she had an antalgic gait, but she did not use
her cane when she walked. Koonce had limited range of motion
in her trunk. She had poor strength in her abdominal muscles.
Her left hip strength was 4-/5, her left knee strength was
4/5 and her left ankle strength was 4. R. 579-81.
physical therapist scheduled a course of four weeks of
outpatient physical therapy. R. 583. Koonce did not return
for any of the scheduled physical therapy appointments. After
three consecutive absences without any calls to cancel or
reschedule, the planned physical therapy sessions were
discontinued. R. 584-85.
September 25, 2014, Koonce saw Nurse Practitioner Brummet.
Koonce reported a migraine headache that started the day
before. Koonce said her insurance would not pay for Imitrex.
Koonce also had Depakote. Koonce asked about changing
medications. R. 624. Brummet gave Koonce a Toradol injection
and prescribed Imitrex to see if the insurance would now
cover the medication. R. 626.
September 30, 2014, Koonce saw Physician's Assistant
Venvertloh for a follow up. R. 623-24. Koonce said the
injection she received at the last visit on August 29, 2014,
helped with the pain slightly. Koonce said the shot lowered
the pain from 10/10 to 7/10. Koonce denied any numbness or
tingling; popping, catching, or locking; giving out or giving
way. On examination, Koonce's left knee was not inflamed,
but was tender to palpation. Her patella demonstrated
crepitus with a positive patellar apprehension test. Stress
testing was stable. Other tests were normal. Venvertloh
recommended viscosupplementation. R. 624.
October 4, 2014, Koonce saw state agency psychologist Dr.
Delores Trello, Psy.D., for a mental status examination. R.
557-61. Dr. Trello found that Koonce had bipolar disorder and
was depressed. Dr. Trello also found that she had anxiety
disorder and a history of drug and alcohol abuse. Koonce
stopped all illegal drug use in 1998. Dr. Trello found that
Koonce did well on her mental status examination. R. 561.
October 28, 2014, Koonce saw Physician's Assistant
Venvertloh, for her third Hyalgan injection into her
knee. Koonce reported some mild improvement from
the injections. Koonce had no post-injection inflammation. R.
October 29, 2014, Koonce saw state agency physician Dr.
Vittal Chapa, M.D., for a consultative examination. Koonce
said that she had back pain. She said she had narrowing of
the spine. She reported having no cartilage in her left knee.
She said that she used a cane because her left knee gave out
on her. Koonce stated she was told not to walk without a
cane. She said she had headaches two to three times a month
and they lasted for three days. On examination, Dr. Chapa
asked her to walk without a cane. She limped and complained
of left knee pain. Dr. Chapa stated that it appears that she
needs a cane for ambulation. Koonce's knee and ankle
reflexes were absent. Her triceps, biceps, and brachial
radialis reflexes were 1. Koonce had no joint redness or
heat. She had crepitation on palpation of the left knee
joint. The joint appeared to be stable. Koonce's hand
grip was 5/5 bilaterally and she could perform fine and gross
manipulation with both hands. Her lumbosacral range of motion
was limited. Koonce had full range of motion in all other
joints including her knees. Dr. Chapa said that subjectively
Koonce said she could not feel pinprick sensation in her
extremities and also her chest. Dr. Chapa assessed internal
derangement of the left knee. R. 562-64.
October 8, 2014, state agency psychologist Dr. Ronald Havens,
Ph.D., completed a Psychiatric Review Technique and Mental
Residual Functional Capacity Assessment. R. 177-78, 181-83.
Dr. Havens opined that Koonce had affective disorders and
anxiety disorders. He opined that these disorders resulted in
mild restrictions on daily living and moderate difficulties
in maintaining social functioning and concentration,
persistence or pace. Dr. Havens opined that Koonce did not
have any episodes of decompensation of extended duration. R.
177. Dr. Havens opined:
Claimant is fully oriented, free of thought disorder, free of
cognitive deficits, able to competently complete [activities
of daily living]. Claimant would have no difficulty
understanding and remembering well enough to engage in
detailed assignments but can only persist adequately enough
to perform repetitive, routine tasks. Claimant has adequate,
though limited, social skills but reports being anxious
around groups of people and should not be expected to deal
with the general public. Claimant can adjust to minor routine
changes in a routine work environment.
November 6, 2014, state agency physician Dr. Towfig Arjmand,
M.D., prepared a Physical Residual Functional Assessment of
Koonce. R. 179-81, 192-94. Dr. Arjmand opined that Koonce
could occasionally lift 10 pounds and frequently lift 10
pounds; stand and/or walk two hours in an eight-hour workday;
sit for six hours in an eight-hour workday; occasionally
stoop, crouch, and crawl; and never climb ladders, ropes, and
scaffolds; and she should avoid concentrated exposure to
hazards such as machinery or heights. R. 180-81.
November 10, 2014, Koonce saw orthopedic surgeon Dr. Stephen
Pineda, M.D., for an evaluation due to low back pain. R.
613-17. Koonce said she had back pain that went into her
legs. She had to use a cane to walk. She said the pain was so
bad she could barely move her leg. She said she received
injections from Dr. Stern, but they did not help. Dr. Pineda
said that her x-rays showed mild degenerative changes at
L5-S1. He noted, “There is a question of a L5
radiculopathy identified by Dr. Fortin on EMG.” R. 615.
On examination, Koonce could stand and walk. She fired her
hip, knee, and ankle flexion. She had intact light touch
sensation. Movement of her left leg generated pain. She had
4/5 strength. Dr. Pineda ordered an MRI. R. 616.
November 19, 2014, Koonce had an MRI of her lumbar spine. It
showed a mild disc bulge and hypertrophic facet progression
at L4-5, now with mild canal stenosis. R. 577.
November 24, 2014, Koonce saw Dr. Pineda for follow up on an
MRI of her lumbar spine. R. 609-11. Dr. Pineda said that the
MRI did not show any major canal or foraminal stenosis. He
said that good disc height was present. Dr. Pineda said that
the MRI was “nearly normal.” Dr. Pineda said that
her pain was not due to spinal etiology. He did not know the
source of her pain. He recommended seeing Dr. Fortin for pain
management. R. 612.
January 21, 2015, Koonce saw Dr. Fortin for back and leg
pain. Koonce reported that she had back and leg pain since
2003. She said that the pain had slowly worsened over time.
She was getting numbness and tingling in her foot. She had
heavy use of her cane in the past year. Her leg gave out and
she fell at times. Dr. Fortin reviewed a prior EMG study and
MRI. The EMG showed left L5 radiculopathy, and the MRI showed
mild spinal stenosis at L4-5. R. 606. On examination, Koonce
had normal muscle tone and bulk; 5/5 strength in all four
extremities without pathological reflexes; absent biceps,
triceps, brachiaroadialis and patellar reflexes; intact
sensation to pin touch; intact toe, heel gait; and normal
neurological examination. Dr. Fortin prescribed a lumbar
epidural steroid injection and another EMG study. R. 609.
January 27, 2015, Dr. Fortin gave Koonce a lumbar epidural
steroid injection. R. 573-74.
January 30, 2015, Koonce saw Physician's Assistant
Venvertloh for left knee pain. R. 603-05. Koonce reported
that she was doing well after a course of Hyalgan injections
completed in October 2014. She reported that she started
having pain after her consultative examination. She said she
felt something pop while the doctor manipulated her knee
during the examination. She said she had intermittent popping
and catching. She denied any numbness and tingling down her
leg. She also denied that her leg was giving way. R. 604. On
examination, sensation was intact, no drop foot noted, tender