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Koonce v. Saul

United States District Court, C.D. Illinois, Springfield Division

November 21, 2019

PENNY KOONCE, Plaintiff,
ANDREW SAUL, Commissioner of Social Security, [1] Defendant.



         Plaintiff 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 AFFIRMED.


         Koonce 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.[2] 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.

         On 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.

         On 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.

         On June 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.

         On June 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.

         On June 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.

         On 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.

         On 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. 482-83.

         On the 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.

         On August 19, 2014, neurologist Dr. Claude Fortin, M.D., performed an EMG/nerve conduction study. The study showed mild left L5 radiculopathy. R. 524.

         On 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. R. 522.

         On 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.

         On 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.

         The 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.

         On 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.

         On 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.

         On 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.

         On October 28, 2014, Koonce saw Physician's Assistant Venvertloh, for her third Hyalgan injection into her knee.[3] Koonce reported some mild improvement from the injections. Koonce had no post-injection inflammation. R. 617-18.

         On 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.

         On 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.

         R. 183.

         On 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.

         On 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.

         On 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.

         On 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.

         On 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.

         On January 27, 2015, Dr. Fortin gave Koonce a lumbar epidural steroid injection. R. 573-74.

         On 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 to ...

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