Opinion
CV-20-00285-TUC-JAS (BGM)
07-29-2022
Marie Dolores Dorame, Plaintiff, v. Kilolo Kijakazi, Acting Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
Honorable Bruce G. Macdonald, United States Magistrate Judge.
Currently pending before the Court is Plaintiff Marie Dolores Dorame's Opening Brief (Doc. 29). Defendant filed her Answering Brief (“Response”) (Doc. 32), and Plaintiff replied (“Reply”) (Doc. 35). Plaintiff brings this cause of action for review of the final decision of the Commissioner for Social Security pursuant to 42 U.S.C. § 405(g). Compl. (Doc. 1).
Pursuant to Rules 72.1 and 72.2 of the Local Rules of Civil Procedure, this matter was referred to Magistrate Judge Macdonald for Report and Recommendation. Based upon the pleadings of the parties and the administrative record submitted to the Court, the Magistrate Judge recommends that the District Court grant Plaintiff's Opening Brief (Doc. 29). ... ... ...
I. BACKGROUND
A. Procedural History
On November 24, 2017, Plaintiff protectively filed a Title II application for Social Security Disability Insurance Benefits (“DIB”) alleging disability as of March 18, 2018,due to cervical stenosis/radiculopathy; lumbar radiculopathy-two (2) bulging discs (lower back) sciatic; migraines; carpal tunnel syndrome (both hands and arm pain); restless leg syndrome; hysterectomy/overactive bladder (incontinence); memory issues (including spelling and mathematical); depression; anxiety; and fibromyalgia. See Administrative Record (“AR”) at 13, 15, 40, 80, 83, 107, 109, 238, 539. The Social Security
Administration (“SSA”) denied this application on August 20, 2018. Id. at 13, 80-106, 135-38. On September 27, 2018, Plaintiff filed a request for reconsideration, and on January 8, 2019, SSA denied Plaintiff's application upon reconsideration. Id. at 13, 10734, 142-48. On February 15, 2019, Plaintiff filed her request for hearing. Id. at 13, 15051. On September 16, 2019, a video hearing was held before Administrative Law Judge (“ALJ”) Kelly Walls. AR at 13, 35-79. On January 3, 2020, the ALJ issued an unfavorable decision. Id. at 10-27. On March 2, 2020, Plaintiff requested review of the ALJ's decision by the Appeals Council, and on May 6, 2020, review was denied. Id. at 1-6, 236-37. On July 6, 2020, Plaintiff filed this cause of action. Compl. (Doc. 1).
B. Factual History
Plaintiff was forty-three (43) years old at the time of the alleged onset of her disability and forty-four (44) years old at the time of the administrative hearing. AR at 13, 25, 40-41, 80, 82, 91, 107-08, 207, 224, 238, 551, 610, 622. Plaintiff is a high school graduate and has a bachelor's degree. Id. at 25, 40, 80, 107, 540. Prior to her alleged disability, Plaintiff worked as a service representative, veteran advocate, caregiver, restaurant manager/owner, and finance technician. Id. at 104, 541, 554-59, 592-98.
1. Plaintiff's Testimony
a. Administrative Hearing
At the administrative hearing, Plaintiff testified that she currently lives in a house with her parents and sister. AR at 42-43. Plaintiff reported that her bedroom is on the second floor, and her difficulty going up and down the stairs causes her to limit the number of trips. Id. at 42. Plaintiff indicated that she has a driver's license, and although she is able to drive, she is not currently. Id. at 43. Plaintiff explained that she had an accident last year and between her medical conditions and anxiety she feels unsafe driving. Id. Plaintiff testified that her father drives her to doctor's appointments or errands, including the hearing that day. Id.
Plaintiff testified that she had received a bachelor's degree, and started a master's degree in business administration, but had to stop due to her memory and medical issues. AR at 43-44. Plaintiff denied any other vocational training but indicated that she had taken some classes for her own business when she previously owned a restaurant. Id. at 44. Plaintiff confirmed that she had been a finance technician while in the Army. Id. Plaintiff further testified that following her work in the Army, she was a customer service representative with Cox. Id. at 44-45. Plaintiff also testified that this work was followed by the position of caregiver first for Accent Care at Home, then United Cerebral Palsy of Arizona. Id. at 45. In between her care giving jobs, Plaintiff owned a restaurant. AR at 47-48. Next, Plaintiff worked for the State of Arizona as a veteran's advocate, and finally, for the Social Security Administration as a service representative. Id. at 45-48.
Plaintiff testified that she no longer works due to pain from her fibromyalgia, including joint pain from her feet, ankles, knees, and hips, lower and upper back pain, carpel tunnel syndrome, and migraines, as well as depression and anxiety. Id. at 48-49. Plaintiff reported that her pain medication, specifically Gabapentin, makes her drowsy and she suffers regular migraines and headaches. Id. at 49. Plaintiff explained that although head pain was part of the migraines that she suffers, the migraines differed in presentation from the more typical headaches she suffers. Id. at 49-50. Plaintiff indicated that she has been using a cane for approximately one (1) year and takes it everywhere. AR at 50-51. Plaintiff further testified that she wears splints on her arms and hands at night. Id. at 51. Plaintiff also testified that she receives mental health treatment from a psychiatrist at Veterans Affairs (“VA”). Id. at 51. Plaintiff reported that she had also received electroconvulsive therapy (“ECT”) at the VA; however, it made her memory issues worse. Id. at 51-52. Plaintiff explained that the VA doctors were still trying to determine the best course of treatment for her. Id. at 52. Plaintiff testified that in addition to her memory issues, her focus is very poor. AR at 52. Plaintiff indicated that she was taking Memantine to help her focus, but her memory is still poor. Id.
Plaintiff described having insomnia with restless legs, which made it hard for her to sleep or to have consistent sleep. Id. In recounting her typical day, Plaintiff testified that she does not wake up at the same time every day, but once she is awake, either she or her mother will make breakfast, she cleans up the dishes, rests for awhile, takes a shower, and rests or reads throughout the day. Id. at 52-53. Plaintiff noted that she feels tired a lot and ascribed this feeling to her inability to sleep. Id. at 53. Plaintiff further testified that she feeds her dog and plays with him and sits outside. AR at 53. Plaintiff noted that on a typical day she has appointments that she must go to, which occurs at least three times per week. Id.
Plaintiff reported difficulty with personal hygiene due to her back issues. Id. Plaintiff explained that she has trouble lifting her arms up and bending over is painful, which makes getting dressed and undressed difficult. Id. Plaintiff also has difficulty braiding her hair or doing things that require having her hands up or gripping due to hand pain and her hands falling asleep. Id. at 53-54. Plaintiff testified that although she used to cook when she owned a restaurant, now she does very little because the pots and pans are too heavy, and she has difficulty with seasoning due to memory issues. AR at 54-55. Plaintiff also testified that her memory problems also cause issue with caring for her dog, and explained that she has to keep a log of when she feeds the dog to make sure that it is fed but not overfed. Id. at 55. Similarly, she keeps a log regarding her medication so that she can keep track of whether or not she took it. Id.
Plaintiff testified that she goes to church on her better days, although she can no longer attend every Sunday like she once did. Id. Plaintiff further testified that she is able to sit through the hour and a half service but foregoes standing and kneeling. Id. at 56. Plaintiff indicated that sometimes she does need to stand up during the service to prevent becoming too stiff. AR at 56. Plaintiff also testified that previously she would go out to lunch or visit with friends, but it had been over a year since she was able to do that. Id. at 56-57. Plaintiff noted that she has been isolated and unable to manage chatting on the phone or otherwise visit. Id. at 57. Plaintiff reported having approximately a week to a week and a half of good days in a month. Id. Plaintiff testified that previously a good day involved activities such as going out to lunch, or socializing, or shopping with her mother. Id. At the time of the hearing however, Plaintiff identified a good day as sitting at her house, maybe outside with her dog, but generally just resting. Id. Plaintiff indicated that her bad days involve a similarly low level of activity. AR at 57-58. Plaintiff reported that she was involved in an accident the previous on return from visiting a friend in Mexico. Id. at 58. Plaintiff estimated that the trip took approximately five (5) hours. Id. Plaintiff testified that during the visit, she and her friend went to the beach. Id.
Plaintiff confirmed that she had undergone surgeries for a cervical spine fusion, repair of a bulging disc, and then placement of a spine stimulator. Id. at 59. Plaintiff reported that although the spine stimulator alleviated a lot of her pain, it did not relieve it completely. AR at 59. Plaintiff noted that she had received physical therapy for her back and neck; however, it aggravated her migraines and she had to stop. Id. at 59-60. Plaintiff explained that Dr. Hung Lee was her neurologist for approximately three (3) years who gave her Botox for her migraines and referred her to a surgeon for the cervical spine fusion. Id. at 60. Plaintiff opined that Dr. Lee had a very good understanding of her limitations. Id. Plaintiff testified that she continues to suffer from constant, sharp, right shoulder pain which radiates into the back of her shoulders. Id. at 61. Plaintiff noted that although the spinal stimulator helped alleviate some of this pain, it was still constantly present. AR at 61. Plaintiff noted that she has increased the level of stimulation over time to try to reduce the pain, as well as using a heating pad and light massage. Id. at 61-62. Plaintiff further confirmed that she has special gloves to wear at night for her carpel tunnel syndrome. Id. at 62. Plaintiff reported that the carpal tunnel surgeries reduced the excruciating pain at night but left her with a weak grip, which causes difficulties with tasks such as opening jars. Id. at 62-64. Additionally, computer work causes pain in her hands and gripping the wheel while driving causes numbness. Id. at 63. Plaintiff testified that she has foot pain in both feet, including her toes and ankles, with the right side being weaker than the left. AR at 64. Plaintiff explained that this pain prevents her from walking correctly, which results in her using a cane. Id. Plaintiff further explained that using a cane also aggravates the numbness and causes cramping in her hands. Id. Plaintiff testified that she uses bandages for pressure, creams, patches, and heating pads to try to alleviate her foot pain. Id. at 65. Plaintiff also testified that she developed urinary incontinence after her back surgery and then had vaginal sling surgery, which improved her symptoms somewhat but did not fully resolve the issue. Id. Plaintiff reported that she had a hysterectomy due to her endometriosis and thought that would alleviate several of her pelvic issues, but it did not, and Plaintiff continues to suffer from pain and incontinence. AR at 66.
Plaintiff confirmed that she had been in a rollover accident while in the military. Id. at 66-67. Plaintiff reported that although she did not notice any cognitive problems immediately after the accident, but within a few years became increasingly forgetful. Id. at 67. Plaintiff testified that she became acutely aware of the issue while at work when she was unable to remember her computer passwords and required daily assistance from either a supervisor or technician to change her password. Id. Plaintiff further described regressing at work, indicating that she could no longer remember or retain information that she had once learned. Id. at 67-68. Plaintiff also testified that she has difficulty being around people other than her immediate family. AR at 68. Plaintiff reported that her father takes her places, or she goes with her mother or sister, she does not attend larger family gatherings, and when seated somewhere in a more public setting she cannot have her back to the door. Id. at 68-69. Plaintiff described limiting her time in the grocery store and relying on the order online and pickup feature whenever possible. Id. at 69. Plaintiff also explained that another incident that occurred while she was in the military, where a neighbor drilled a hole in the wall of her apartment and spied on her, has had lasting negative effects on her ability to sleep and manage her social anxiety. Id. Plaintiff noted that she was hospitalized for thirteen (13) days in the year prior to the administrative hearing. Id. at 70. Plaintiff explained that her hospitalization occurred after the motor vehicle accident in Mexico. AR at 70. Plaintiff described being in pain, finding out that her insurance would not cover the accident, and becoming overwhelmed, at which point she took some pills. Id. at 70-71. Plaintiff's sister found her and took her to the hospital, after which she was admitted for in-patient treatment. Id.
b. Administrative Forms
i. Work History Reports
On June 10, 2018, Plaintiff completed a Work History Report. AR at 592-98. Plaintiff listed her work prior to the alleged onset of her disability to include service representative, veteran advocate, restaurant owner/manager, caregiver, and military finance technician. Id. at 592. Plaintiff described the position of service representative as full-time-eight (8) hours per day, five (5) days per week. Id. at 593. Plaintiff reported that the position required her to use machines, tools, or equipment; technical knowledge or skills; and to write, complete reports, or perform similar duties. Id. Plaintiff further reported that while working, she sat for approximately five (5) hours per day; stood for two (2) hours per day; and walked for one (1) hour per day. Plaintiff described the position to include speaking to clients, getting up to pick up copies for clients, looking up information and research on a computer, looking up information, and processing information through a computer database. Id. Plaintiff indicated that she frequently lifted less than ten (10) pounds, and this was also the heaviest weight that she lifted. AR at 593. Plaintiff noted that she did not supervise other people, was not a lead worker, and did not hire or fire employees. Id.
Plaintiff described the position of veteran advocate as full-time-eight (8) hours per day, five (5) days per week-and included advocating for veterans, assisting with resumes, connecting with companies for referral of veterans for employment, and volunteering at homeless shelters, veteran courts, and unemployment seminars. Id. at 594. Plaintiff reported that the position required her to use machine, tools, or equipment; use technical knowledge or skills; and write, complete reports, or perform similar duties. Id. Plaintiff further reported that while working she walked for four (4) hours per day, stood for three (3) hours per day, and sat for one (1) hour per day. Id. Plaintiff also reported that she would frequently lift less than ten (10) pounds, and that this was also the heaviest weight she lifted. AR at 594. Plaintiff did not supervise, hire, or fire people, and was not a lead worker. Id. at 597.
Plaintiff described the position of restaurant manager/owner as more than fulltime-ten (10) hours per day, six (6) days per week. Id. Plaintiff reported using machines, tools, or equipment; technical knowledge or skills; and that she wrote, completed reports, or performed similar duties in this position. Id. Plaintiff further reported that she stood for six (6) hours per day, sat for two (2) hours, stooped for one (1) hour, and wrote, typed, or handled small objects for one (1) hour. Id. Plaintiff also reported that she frequently lifted twenty-five (25) pounds, with fifty (50) pounds as the heaviest weight she lifted. AR at 595. Plaintiff further reported that she supervised eight (8) people for ten (10) hours, and was responsible for hiring and firing, but was not a lead work. Id.
Plaintiff described the caregiver position as full-time-eight (8) hours per day, five (5) days per week-and included caring for patients with disabilities, cleaning, lifting patients for transfer, reporting and meal preparation. Id. Plaintiff reported that for this job she used technical knowledge or skill, and wrote, completed reports, or similar duties; however, she did not use machines, tools, or equipment. Id. Plaintiff further reported that the heaviest weight she lifted was in excess of one hundred (100) pounds, and she frequently lifted fifty (50) pounds or more. Id. at 596. Plaintiff indicated that she did not supervise, hire, or fire, employees. AR at 596.
Plaintiff described the military finance technician as full-time-eight (8) hours per day, five (5) hours per day-and included training for deployment, customer service, processed pay for active duty and reserve units, travel pay, updated policy and procedure handbook. Id. Plaintiff reported that in this position she used machines, tools, or equipment; technical knowledge or skills; and she wrote, completed reports, or performed similar duties. Id.
In closing, Plaintiff stated:
Although my positions have been in customer service[,] the stress has worsened my anxiety and I have had an increase in my panic attacks. My memory has also been affected and the fear of giving incorrect information and not being able to find information on my own has worsened my anxiety and depression. I feel like I can't function. I feel like I was asking questions to my co-workers like when I just started working 5 yrs ago. The pain, my memory, and my anxiety have affected the quality of work that I do. I had certain workloads other than my regular work and I had to stop for fear of making mistakes that would affect someone's pay.Id. at 598.
Plaintiff completed a second, undated, Work History Report. Id. at 554-64. Plaintiff listed her work prior to the alleged onset of her disability to include caregiver, United States Army finance technician, restaurant manager and owner, service representative, and veteran advocate. AR at 554. Plaintiff described the caregiving position as full-time or more-eight (8) hours per day, six (6) days per week. Id. at 555. Plaintiff did not provide any further details about this position. Id.
Plaintiff reported that as a finance technician in the United States Army, she was required to work fifteen (15) hours per day, seven (7) days per week but did not provide further details. Id. at 556.
Plaintiff reported that she worked eight (8) hours per day, five (5) days per week, as a service representative. Id. at 558. Plaintiff did not provide any further details regarding this position. AR at 558.
Plaintiff reported that she worked full time as a veterans' advocate. Id. at 559.
Plaintiff did not provide any further details regarding this position. Id.
ii. Function Report-Adult
On June 9, 2018, Plaintiff completed a Function Report-Adult. AR at 582-91. Plaintiff reported that she lived in a house with family. Id. at 582. Plaintiff described the limitations of her medical conditions as follows:
I am having trouble sitting, standing, & walking for long periods at a time. My neck & hand pain have gotten worse since I started working again after surgery. When facing forward any movement of my neck sideways causes shocking spasms, sitting forward or leaning back makes my pain worse for both my lower and upper back. My memory is affected & I am having issues at work and at home. I can't recall simple steps, I've had episodes where I have forgotten to spell, other episodes where I forget arithmetic problems & other episodes where I forgot where I was going in my vehicle. Due to this my stress has elevated substantially. With this episode I also had a panic attack and had to have my sister and father come for me. I am afraid to drive long distances for fear of this happening again. I am on pain medication, a[n]xiety & depression medication. With this combination it is very hard to perform at any decent level at work. I am not able to sleep & this causes me to be tired at work. The pain, feeling exhausted, and my memory are the primary reasons I am having trouble with work. If I take sleep aides, it is hard to get up. If I take the medication, I can't function due to the medication, if I don't take the medication, I can't function due to the pain.Id. at 582-83. Plaintiff described her usual day to include trying to wake up early, take a shower, get dressed, and eat breakfast. Id. at 584. For days when she has appointments, Plaintiff reported that her sister will come pick her up and bring her back home. Id. Plaintiff further reported that when she gets home, she makes lunch, and takes a nap. AR at 584. Plaintiff stated she has restless leg syndrome, which is worse at night, and her sleep is interrupted. Id. Plaintiff will talk on the phone if she receives a call. Id. Plaintiff indicated that she goes to bed around 11:00 p.m. but does not necessarily fall asleep, and generally has trouble sleeping. Id. Plaintiff reported that her insomnia, restless leg syndrome, neck and back pain, as well as her migraines, negatively impact her sleep. Id.
Plaintiff noted that she has dogs that she feeds, but relies on family members to walk them because she no longer can. AR at 584. Plaintiff identified her niece as her primary assistant with care of her dogs. Id. Plaintiff reported that prior to her illnesses, she worked, went to church, was taking classes toward her Master's degree, would take walks, and go to the gym. Id.
Plaintiff indicated that her illnesses negatively affect her personal care, noting she cannot lift her arms up for long periods of time and her hand begins to cramp while caring for her hair, and she has stress incontinence which has been attributed to her back issues. Id. at 585. Plaintiff also noted that her depression, anxiety, and pain cause her not to want to get out of bed, and she requires help from her family to shower and with other personal needs, including a pill box and verbal reminders. Id. Plaintiff stated that she can prepare soups, sandwiches, and microwave dinners and does so daily. AR at 585. Plaintiff reported that this takes her about twenty (20) to thirty (30) minutes. Id. Plaintiff also reported that the pain in her upper and lower back, as well as migraine headaches have caused a decrease in her appetite, and she finds it “too painful to do anything.” Id.
Plaintiff noted that she was previously able to rake her yard, but now just a few minutes of yard work results in days of pain and the inability to get up. Id. at 586. Plaintiff indicated that when she is feeling well, she attempts to clean and do laundry every other day; however, she feels lucky if she accomplishes these tasks once per week. Id. Plaintiff reported that her sister helps her with laundry and yard work. AR at 586.
Plaintiff indicated that she goes out for doctor appointments or when her sister picks her up for lunch. Id. Plaintiff noted that she does not go out much because of her constant pain. Id. Plaintiff reported that she can both drive and ride in a car, and is capable of going out alone. Id. Plaintiff noted that she only drives short distances, however, because she has forgotten where she was going, had a panic attack, and needed her sister and father to come pick her up. Id. Plaintiff indicated that she is able to shop in stores, but requires a list and the use of a mobility chair. AR at 586. Plaintiff estimated that she shops once per week, and it takes her approximately one (1) hour. Id.
Plaintiff reported that her ability to handle money has not been negatively impacted due to her illness, and she is able to pay bills, count change, handle a savings account, and use a checkbook or money orders. Id. at 587. Plaintiff indicated that she goes to church on Sundays and meet friends for dinner; however, she had to stop taking classes due to her memory issues, and her constant pain causes her to want to stay home. Id. Plaintiff reported that she spends time with her family, because she moved in with them since her conditions have worsened. Id. Plaintiff expressed embarrassment with her conditions and has isolated from co-workers, friends, and family as a result, as well as limited her social interactions. AR at 588.
Plaintiff reported that her illnesses affect her ability to lift, squat, bend, stand, reach, walk, sit, kneel, climb stairs, complete tasks, concentrate, understand, follow instructions, use her hands, and get along with others, as well as her memory. Id. Plaintiff stated that “[a]ny type of movement makes [her] pain worse[,]” and she “can only sit and walk a few minutes at a time.” Id. Plaintiff noted that she has a hard time remembering things and has to write everything down, which causes her hands to cramp. Id. Plaintiff described feeling “overwhelmed when people talk to [her]” and needing to have things explained to her several times. Id. Plaintiff reported being unable to finish what she starts and having trouble with written instructions. AR at 588. Plaintiff indicated that she required spoken instructions to be explained slowly and repeated, because she becomes overwhelmed and anxious. Id.
Plaintiff stated that she did not have any issues with authority figures or getting along with people at work. Id. at 589. Plaintiff described feeling overwhelmed and having panic attacks due to stress. Id. Plaintiff also indicated that she does not handle changes in routine well. Id. Plaintiff described trying to sit at someone else's desk, and having a hard time because she requires her things to be a certain way. AR at 589. Plaintiff reported having social anxiety, indicating that she does not like it when people stand behind her because it causes her to panic. Id.
Plaintiff reported that she uses a cane to walk long distance, at the grocery store, or when her pain is more severe. Id. Plaintiff noted that the cane has become necessary most of the time. Id. Plaintiff listed her medications to include Ropinirole HCl, Gabapentin, Oxybutynin, Cymbalta, and Sumatriptan. Id. at 590. Plaintiff indicated drowsiness, memory issues, confusion, slow speech, and sleepiness, among others as side effects of her medications. AR at 590. Plaintiff concluded her function report, as follows:
With all the medication I take[,] it is difficult to function. I have stopped going out of my home unless I have a doctors appointment because between the pain and the side affects of the medication it is difficult to do anything. If I stop the medication the pain takes over and I can't get out of bed. I can't seem to find a healthy balance and I am tired, exhausted, and hopeless. I can't remember the last time I was able to dress myself completely. Do my hair, put make up on and iron my clothes. I can barely put my hair in a ponytail grab whatever clothes is available and I don't even bother with makeup. I would just want my quality of life and my desire to complete things back.Id. at 590-91.
iii. Headache Questionnaire
On June 19, 2018, Plaintiff completed a Headache Questionnaire. AR at 607-09. Plaintiff listed eight (8) headaches in the two (2) weeks prior to completing the questionnaire. Id. at 607. Plaintiff described her headaches as migraines that lasted a few days at a time. Id. at 607-08. Plaintiff described her headache pain as occurring behind her eyes and temples, along her jaw, and at the back of her head. Id. at 607. Plaintiff also described having blurred vision with white specks and pain under her eyes. Id. Plaintiff reported that she throws up due to pain. AR at 607. Plaintiff further reported that she requires dark and quiet when having headache symptoms. Id. at 608-09. Plaintiff noted that talking on the phone and working on the computer exacerbated her headache symptoms. Id. at 608. Plaintiff reported that stress, weather, neck pain, allergies, and using the computer cause her headaches, although sometimes there is no apparent cause. Id. at 609. Plaintiff reported taking Topiramate, extended release, daily, for her headaches. Id. Plaintiff also indicated taking sumatriptan succinate. Id. Plaintiff further indicated that her medication caused drowsiness and affected her sense of taste, noting a “weird” taste in her mouth. AR at 609. Plaintiff reported having Botox injections to help with her migraines, but only received minimal relief. Id. ... ...
2. Plaintiff's Medical Records
a. Treatment records
Plaintiff was in an “MVA in 2006 when in army during work . . . developed back and neck pain since then.” AR at 1903. On January 8, 2018, Hong Lei, M.D. completed a Medical Source Statement of Ability to Do Work-Related Activities (Physical) regarding Plaintiff. Id. at 1916-22, 2081-87. Dr. Lei opined that Plaintiff could lift and carry up to ten (10) pounds occasionally, but never more than that. Id. at 1916, 2081. Dr. Lei referred to Plaintiff's medical records regarding Plaintiff's cervical and lumbar degenerative spine disease, including surgeries, to support her opinions. Dr. Lei further opined that Plaintiff could sit for two (2) hours without interruption, for a total of six (6) hours in an eight (8) hour workday; stand for one (1) hour at a time, for a total of two (2) hours in an eight hour workday; and walk for thirty (30) minutes without interruption, for a total of one (1) hour in an eight hour workday. Id. at 1917, 2082. Dr. Lei indicated that Plaintiff required the use of a cane to ambulate and that it was medically necessary. Id. Dr. Lei further noted that Plaintiff could ambulate approximately twenty (20) feet without the cane and could use her free hand to carry small objects. AR at 1917, 2082. Dr. Lei opined that Plaintiff could reach (both overhead and otherwise) occasionally; frequently handle, finger, and feel; and never push or pull. Id. at 1918, 2083. This opinion was consistent bilaterally. Id. Dr. Lei further opined that Plaintiff could occasionally operate foot controls bilaterally. Id. Dr. Lei noted that Plaintiff reported numbness with prolonged sitting. Id. Dr. Lei also opined that Plaintiff could never climb stairs, ramps, ladders, or scaffolds, but could occasionally balance, stoop, kneel, crouch, or crawl. AR at 1919, 2084. Dr. Lei indicated that none of Plaintiff's impairments affect her hearing or vision. Id. Dr. Lei further opined that Plaintiff could never tolerate unprotected heights or moving mechanical parts, but could occasionally operate a motor vehicle, tolerate humidity, wetness, dust, odors, fumes, pulmonary irritants, extreme cold, extreme heat, and vibrations. Id. at 1920, 2085. Dr. Lei also opined that Plaintiff could tolerate moderate levels of noise. Id. Dr. Lei noted that Plaintiff could not walk a block at a reasonable pace on rough or uneven surfaces, but was capable of performing activities like shopping, traveling without a companion for assistance, ambulating without using a wheelchair, walker, or two (2) canes or two (2) crutches, using public transportation, climbing a few steps at a reasonable pace with the use of a single hand rail, preparing simple meals and feeding herself, caring for her personal hygiene, and sorting, handling, and using paper or files. Id. at 1921, 2086.
On February 2, 2018, Plaintiff was seen by A. R. Bullock, M.D. at the Pain Institute of Southern Arizona. AR at 2224-27. Plaintiff received a cervical epidural steroid injection the previous month, without relief. Id. at 2224. Dr. Bullock noted that Plaintiff complained of bilateral neck, shoulder, and arm pain, as well as migraines, that were constant and severe. Id. Plaintiff took ibuprofen and Tylenol #3 with minimal to moderate relief, and had completed physical therapy with increased pain and migraines. Id. Dr. Bullock noted that Plaintiff “has classic fibromyalgia.” Id. at 2226. Dr. Bullock further noted that “[i]t [wa]s very difficult with the widespread pain that [Plaintiff] experiences to tell exactly what other pain generators that she has.” AR at 2226. Dr. Bullock prescribed Cymbalta to treat her fibromyalgia symptoms, and indicated that he would “add either gabapentin or Lyrica at a later date.” Id. Dr. Bullock discontinued injection therapy until Plaintiff's widespread pain was better controlled and reiterated the failure of physical therapy in treating her pain. Id. On February 26, 2018, Plaintiff returned to Dr. Bullock. Id. at 2228-30. Plaintiff “complain[ed] of numbness and weakness in her upper extremities.” Id. at 2228. Dr. Bullock noted Plaintiff's “prior cervical fusion, C4 through C6, performed in September 2016 with persistent radicular pain and numbness following surgery.” AR at 2228. Dr. Bullock reported that Plaintiff's “EMG/NCV of right upper extremity demonstrates a chronic right C7 radiculopathy.” Id. Plaintiff reported that her pain ranged from 8/10 to 10/10 and was 10/10 at the appointment. Id. Dr. Bullock reported that Plaintiff had tried Cymbalta, but discontinued it due to nausea, and was currently taking gabapentin with minimal relief. Id. Dr. Bullock sent Plaintiff for magnetic resonance imaging (“MRI”) with contrast of her cervical region and re-prescribed Cymbalta beginning with a lower dose. Id. at 2230. Dr. Bullock reiterated Plaintiff's failed conservative therapies, including physical therapy and nonsteroidal anti-inflammatories. AR at 2230.
On March 15, 2018, Plaintiff requested a refill of her Cymbalta prescription and reported no adverse reactions. Id. at 2231. On March 21, 2018, Plaintiff returned to Dr. Bullock following a cervical MRI. Id. at 2233-36. Dr. Bullock noted that although Plaintiff's EMG/NCV “demonstrates a chronic C7 radiculopathy on the right, . . . her MRI fails to demonstrate a cause for the same.” Id. at 2233. Dr. Bullock reported that Plaintiff's MRI demonstrated “[c]ord signal abnormality at ¶ 5-6 likely reflecting myelomalacia without change”; “[i]nterval C4-C6 anterior fusion with improvement in the canal diameter over this extent[,] . . . [and] ¶ 5-6 posterior spurring . . . with mild canal narrowing and mild ventral cord contouring”; C6-7 degenerative disc disease with mild canal narrowing[,] [with] [n]o significant cord deformity[] [and] [p]atent foramina”; and “C3-4 trace grade I retrolisthesis and mild disc bulge[,] [with] [n]o significant stenosis.” Id. Dr. Bullock further reported that Plaintiff was taking Cymbalta and gabapentin, but recommended increasing dosages to optimum levels. AR at 2233, 2235. Dr. Bullock also recommended a trial of spinal cord stimulation following resolution of medication management. Id. at 2235.
On April 17, 2018, Plaintiff returned to Dr. Bullock and confirmed her decision to proceed with a trial of spinal cord stimulation. Id. at 2239. Dr. Bullock referred Plaintiff to Dr. Steven Marrinson for a psychological evaluation. Id. On April 18, 2018, Plaintiff was seen for a comprehensive assessment/psychiatric evaluation by Yanina Shames, MS BHMP PMHNP-BC at CODAC prior to her neurostimulator insertion. Id. at 1926-29, 2769-72. Plaintiff described a history of depression and anxiety spanning the previous fifteen (15) years. AR at 1926, 1929, 2769, 2772. Plaintiff reported “her depression [a]s 4/10, and anxiety 8/10.” Id. Plaintiff further reported persistent, chronic neck, shoulder, and back pain, even after two (2) spinal fusion surgeries. Id. Plaintiff indicated that “she is currently on tofranil 5-0 mg qd, Effexor ex 75 mg, Cymbalta 60 mg[,] and gabapentin 600 mg 3times [sic] a day.” Id. Plaintiff's “current meds we re [sic] prescribed in Mexico[.]” Id. Plaintiff reported an incident where a neighbor drilled a hole in the wall and was watching her, which continued to negatively impact her mental health, including nightmares, an inability to trust people, and inability to sleep in the dark. AR at 1926, 2769. NP Shames's description of Plaintiff was generally unremarkable. Id. at 1928, 2771. NP Shames described Plaintiff's appetite as fair, mood anxious, memory poor, concentration fair, affect neutral, and insight and judgment as good. Id. NP Shames's diagnoses included major depressive disorder, posttraumatic stress disorder, and generalized anxiety disorder. Id. NP Shames noted that Plaintiff was “in relatively stable mental condition,” but her anxiety was still high. Id. at 1929, 2772. NP Shames directed Plaintiff to taper off of Effexor and begin clonazepam and increase her Cymbalta dosage. AR at 1929, 2772. NP Shames opined that “there [wa]s no contradiction to neurostimulator treatment, [and] in fact, if the level of pain lowed, her depression and anxiety would significantly improve.” Id. NP Shames provided a letter regarding Plaintiff's continued treatment for major depressive disorder, generalized anxiety, PTSD, and chronic pain, specifically noting her functional limitations related to her memory and concentration issues. Id. at 2768.
On May 3, 2018, Plaintiff was seen at the Southern Arizona Veterans Affairs Healthcare System (“SAVAHCS”) by Irene B. Delorenzi, M.D. Id. at 949-54, 3427, 3452, 3517-21. Plaintiff's records indicate that she has suffered back pain since 2013, with a spinal fusion in her cervical spine in 2015. Id. at 949, 951, 3517, 3520. In November of 2017, Plaintiff had a repair of a bulging disc. Id. Her pain runs from her neck to low back, and includes shoulder pain, arm pain, and migraines. Id. Treatment records indicate that Plaintiff is scheduled for placement of a spinal cord stimulator on May 17, 2018. Id. Treatment records indicate that Plaintiff had been suffering with memory problems for months, as well as chronic migraines, depression, post-traumatic stress disorder (“PTSD”), and chronic pain. AR at 949, 951, 3517, 3520. Dr. Delorenzi's review of Plaintiff's systems and physical examination were generally normal, but noted she was ambulating with a cane and a pain score of 9. Id. at 949, 951. On May 9, 2018, Plaintiff returned to Dr. Bullock, complaining of “memory issues such as difficulty with word finding and with adding and subtracting” and indicated that “she [wa]s unable to perform her duties at work” and was unable to drive. Id. at 2241. Plaintiff attributed her difficulties to her medication, and Dr. Bullock deduced that the symptoms may have been due to the Cymbalta, as she was taking gabapentin prior to starting Cymbalta without incident. Id. As such, Dr. Bullock stopped Plaintiff's Cymbalta. Id. at 2243. On May 16, 2018, Dr. Delorenzi noted that she received notes from Dr. A.R. Bullock regarding Plaintiff's treatment for c-spine radiculopathy with a spinal cord stimulator, and that she had stopped Cymbalta and started physical therapy. AR at 2074. On May 30, 2018, Plaintiff returned to Dr. Bullock for a cervical spinal cord stimulator trial. Id. at 2244-45. Dr. Bullock performed “an uneventful and technically successful spinal cord stimulator trial[.]” Id. at 2245.
On June 13, 2018, Plaintiff was seen by Andrzej Honory, M.D. at SAVAHCS for supportive therapy and medication management. Id. at 2249-54, 3425-27, 3503-3508. Plaintiff indicated that she was “not doing well.” Id. at 2249, 3425, 3503. Plaintiff “report[ed] being in significant distress recently, mostly related to chronic pain in her back, her neck[,] and her shoulders.” AR at 2249, 3425, 3503. Plaintiff further reported that she was unable to work and was staying with her parents, which she described as “a very difficult situation as she used to be very independent.” Id. Plaintiff indicated that the weeklong trial of a spinal stimulator was apparently effective and decreased her pain level. Id. at 2249, 3426, 3503. Plaintiff described continuing to be depressed and anxious about her life, and “report[ed] significant memory impairment[.]” Id. Plaintiff described attributing the cognitive dysfunction to Cymbalta, which she had stopped taking, and Dr. Honory suggested that perhaps it was the gabapentin causing impairment. Id. at 2249, 3426, 3504. Dr. Honory also noted that Plaintiff's sleep was impaired by chronic pain and her energy was low. AR at 2249, 3426, 3504. Dr. Honory recommended that Plaintiff follow-up with her private psychiatrist for her medication renewal and provided information about support groups at the clinic to address her depressive symptoms. Id. at 2253, 3426, 3507. Dr. Honory also recommended follow-up with a primary care physician. Id. On June 19, 2018, Plaintiff saw her primary care physician at SAVAHCS, Dr. Delorenzi, regarding her memory loss. Id. at 3424-25, 3498-3502.
On August 20, 2018, Plaintiff was seen by J.C. Christiano, M.D. for an evaluation. Id. at 2364-65, 2567-68. Dr. Christiano reviewed Plaintiff's history of back issues and pain. AR at 2364, 2567. Dr. Christiano's review of Plaintiff's systems was generally unremarkable, except for jaw pain, right shoulder pain, and low back pain radiating to her legs. Id. Plaintiff's physical examination was also generally unremarkable, but exhibited a positive Hoffman's sign on the left. Id. Dr. Christiano's assessment included “[c]ervical radiculopathy, [status post] cervical surgery, [and] chronic pain syndrome with successful percutaneous spinal cord stimulator trial.” Id. Dr. Christiano opined that Plaintiff was a candidate for permanent lead placement. Id. at 2364, 2567. On August 22, 2018, Plaintiff was seen at the SAVAHCS Emergency Department regarding her hand and foot pain, as well as rash. AR at 3456-61. James D. Fox, M.D.'s physical examination showed synovitis of the wrists and diffuse tenderness to palpation of the hands, wrist, feet, and ankles. Id. at 3459-60. Dr. Fox also noted a malar rash suggesting an autoimmune phenomenon. Id. at 3460.
On September 4, 2018, Plaintiff established care with John J. Modrzejewski, FNP. Id. at 2349-53, 2390-95. NP Modrzejewski noted chronic back pain, cervical arthrodesis, degeneration of lumbar intervertebral disc, hypothyroidism, migraine, restless legs, urinary incontinence, generalized anxiety disorder, posttraumatic stress disorder, bipolar disorder, obesity, and multiple joint pain as diagnoses that he discussed with Plaintiff during her visit. Id. at 2350, 2353, 2393-94. NP Modrzejewski's review of Plaintiff's systems noted sweats, headaches, sinus pain, nausea, vomiting, diarrhea, incontinence, back pain and change in range of motion, depression, and anxiety. AR at 2393. Plaintiff's physical examination was generally unremarkable, but was positive for abnormal range of motion in her neck and back, neck tenderness, as well as a skin rash. Id. at 2394. On September 6, 2018, Plaintiff had radiographs of her lumbosacral spine. Id. at 2397. Lana Gimber, M.D. found “[m]oderate degenerative disc disease at ¶ 5-S1 without acute osseous abnormality.” Id. On the same date, Plaintiff saw Anita N. Pender, M.D. for a rheumatology evaluation of her joint pain. Id. at 3439-42. Plaintiff indicated that she had begun to experience pain and tingling in her feet, as well as pain in her hands, approximately two (2) weeks prior. AR at 3439. Plaintiff reported that her hands and feet were swollen, and her fingers were red and felt warm to the touch. Id. A couple days after the pain and swelling began, Plaintiff developed a rash all over her body. Id. Plaintiff showed Dr. Pender pictures of the swelling and rash. Id. Dr. Pender's physical examination was generally unremarkable; however, Plaintiff exhibited pain across her hands, knees, and feet. Id. at 3441. Dr. Pender assessed polyarticular inflammatory arthritis, a resolved rash, and chronic neck and low back pain. AR at 3442. Dr. Pender prescribed prednisone and an arthritis work-up. Id. On September 7, 2018, Dr. Christiano performed a permanent spinal cord stimulator placement for Plaintiff. Id. at 2602-2605. On September 19, 2018, Plaintiff was seen by Mateja de Leonni Stanonik, M.D., Ph.D. at Vita Medica Institute for a memory loss evaluation and mild cognitive impairment. Id. at 2354-60, 2841-48. Dr. Stanonik reviewed Plaintiff's history of cervical and lower back pain, migraines, stress, panic attacks, insomnia, painful jaw, eye twitching, trouble swallowing, memory loss, and mood disorders. Id. at 2355, 2842. Dr. Stanonik's physical examination of Plaintiff was unremarkable; however, her neurological evaluation revealed short term memory loss with difficulty recalling objects and performing serial 7. AR at 2356, 2843. Dr. Stanonik assessed anterograde amnesia; mild cognitive impairment; retrograde amnesia; other frontotemporal dementia; major depressive disorder; localization-related symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus; transient alteration of awareness; and other epilepsy, intractable, without status epilepticus. Id. at 2356-57, 2843-44. Plaintiff underwent a reference electroencephalograph (“rEEG”) with electrocardiogram (“EKG”) rhythm. Id. at 2361-62, 2849-50, 5469-70. Dr. Stanonik's impression noted the “EEG [wa]s within a wide range of normal limits[,] [n]o focal abnormality or seizure discharges were noted[,] [and] [t]he above-mentioned EEG variants have unknown clinical significance.” Id. at 2362, 2850, 5470. On the same date, Plaintiff also saw Anita N. Pender, M.D. at SAVAHCS for a rheumatology follow-up. Id. at 3418, 3435-37. Dr. Pender noted that Plaintiff presented with polyarticular joint pain, although no significant inflammatory arthritis was observed on examination; however, Plaintiff was still taking prednisone. AR at 3436. Dr. Pender recommended a trial of methotrexate. Id. On September 20, 2018, Amy Miltenberger, PA-C signed a work release indicating that Plaintiff should remain off work from July 1, 2018, through October 4, 2018. Id. at 2363. PA Miltenberger also saw Plaintiff for a postoperative follow-up after implantation of a spinal cord stimulator and implantable pulse generator. Id. at 2366, 2569. PA Miltenberger's examination of Plaintiff was generally unremarkable. Id. at 2366-69, 2571-72. PA Miltenberger noted that “[t]he spinal cord stimulator representative] worked with the patient at length[,] . . . [and] [Plaintiff] received good pain coverage.” AR at 2369, 2572. Plaintiff also had radiographs of her thoracic spine, confirming placement of the spinal stimulator. Id. at 2370, 2911. On September 25, 2018, Plaintiff was seen at the SAVAHCS podiatry clinic for an evaluation of painful feet. Id. at 2380-82, 3417-18, 3432-35. Plaintiff reported having been evaluated by rheumatology and finding some relief from a methotrexate trial in the previous two (2) weeks. Id. at 2380, 3417, 3432. Plaintiff's physical examination was generally unremarkable, and imaging did not show any acute osseous abnormality. Id. at 2382, 3433-34.
On October 2, 2018, Plaintiff followed up with NP Modrzejewski for a results review. AR at 2385-90. NP Modrzejewski noted Plaintiff had her spinal stimulator placed but was still having pain. Id. at 2388. Plaintiff reported that she was on the third level of the spinal stimulator and was scheduled to be moved up to the fourth level later in the week. Id. Plaintiff's laboratory results indicated elevated ANA results and a borderline RA level. Id. NP Modrzejewski noted Plaintiff's family history of lupus and rheumatoid arthritis. Id. Plaintiff complained of memory loss and indicated that she had an upcoming appointment with neurology. AR at 2388. NP Modrzejewski's review of Plaintiff's systems was generally unremarkable, but was positive for fatigue and malaise, joint pain, memory loss, depression, and anxiety. Id. at 2388-89. NP Modrzejewski's physical examination of Plaintiff was also generally unremarkable but noted healing from the spinal stimulator implantation. Id. at 2389. On October 4, 2018, Plaintiff followed up with PA Miltenberger. Id. at 2573-76. Plaintiff's stimulator had been reprogrammed the previous day and was providing pain coverage; however, Plaintiff's wound was draining. Id. at 2573, 2576. Plaintiff was prescribed antibiotics for possible infection. AR at 2576. On October 11, 2018, Plaintiff returned to PA Miltenberger for a follow-up visit including incision check. Id. at 2371-74, 2580-83, 2697-2700. PA Miltenberger noted that “[t]he stimulator has been providing pain coverage[,]” and the incisions were healing. Id. at 2371, 2373, 2580, 2697, 2699. PA Miltenberger's review of Plaintiff's systems was unremarkable. Id. at 2371, 2580, 2697. PA Miltenberger's physical examination of Plaintiff was similarly unremarkable. Id. at 2373, 2582-83, 2699.
On November 4, 2018, Plaintiff was admitted into the O'Rielly Care Center for inpatient treatment of her depressive disorder. AR at 2429-2565, 2638-89. Plaintiff was in a car accident in Mexico, with an airbag deployment and loss of consciousness, prior to her admission. Id. at 2431, 2442, 2446. Plaintiff complained of all over body pain and nausea, as well as indicating that she suffered from memory loss, migraines, and lupus. Id. at 2341. Plaintiff was admitted for treatment following an attempted pill overdose. Id. at 2431, 2442. Plaintiff indicated that her spinal stimulator was relieving the pain in her upper back but not the lower. Id. at 2442. On November 5, 2018, Plaintiff presented for a psychiatric evaluation with Jane Ackerley, PMHNP. AR at 2442-45, 2642-45. NP Ackerley discussed the multiple medications Plaintiff was taking and noted that Plaintiff denied any history of ADHD, despite being prescribed Adderall. Id. at 2442, 2642. NP Ackerley recommended discontinuing Adderall to see if that reduces Plaintiff's racing thoughts. Id. On November 8, 2018, Plaintiff underwent a head CT due to her car accident. Id. at 2730. Kim Burroughs, M.D. found no significant intracranial abnormality and polypoid mucosal thickening of Plaintiff's left sphenoid sinus. Id. On November 9, 2018, Plaintiff was seen by Mansoor A. Jatoi, D.O. for evaluation of her anterior neck pain following the motor vehicle accident. AR at 2446-51, 2646-51. Dr. Jatoi's physical examination of Plaintiff was generally unremarkable. Id. The computerized tomography (“CT”) scans of her cervical and thoracic spine showed mild canal narrowing at ¶ 4-5 and C5-6 due to posterior osseous ridging, moderate narrowing of the left neural foramen at ¶ 5-6 due to degenerative factors, and mild spondylosis at several of the thoracic disc levels without significant central canal stenosis. Id. at 2449-50, 2509-11, 2649-50, 2678-80, 2724, 2729. On discharge, Ian G. Thomas, PMHNP observed that “the general consensus amongst the team is that many of these issues are related to the vast number of medications that [Plaintiff] is currently prescribed[.]” Id. at 2439, 2639. NP Thomas observed that “between 4 and 6 different physicians . . . have prescribed her medications in the recent past with very little to no continuity between any of them.” Id.; see also AR at 2452. “In the end between the patient[,] . . . [NP Thomas] and Dr. Douglas it was decided that the patient would follow up with the neurology service at vita medica and work with their providers to optimize the medications that she is on.” AR at 2439, 2639. On September 19, 2018, Plaintiff saw Dr. Stanonik regarding her memory loss and mild cognitive impairment. Id. at 5439-46. Dr. Stanonik examination was generally unremarkable, but was significant for short term memory loss. Id. at 5441. Dr. Stanonik assessed anterograde amnesia; mild cognitive impairment; retrograde amnesia; other frontotemporal dementia; major depressive disorder, recurrent, mild; localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus; transient alteration of awareness; and other epilepsy, intractable, without status epilepticus. Id. at 5441-42. On November 20, 2018, Plaintiff was seen by David R. Siegel, M.D. for a follow-up after her inpatient treatment. Id. at 2835, 5433-38. Dr. Siegel outlined Plaintiff's extensive medical history, including her continued poor memory, chronic pain, headaches, restless leg syndrome, details regarding her motor vehicle accident in Mexico, and recent hospitalization. AR at 2835-37, 5433-35. Dr. Siegel assessed localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus; generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus; transient alteration of awareness; dizziness and giddiness; cervicalgia; other specified inflammatory spondylopathies, cervical region; paresthesia of skin; retrograde amnesia; spondylosis without myelopathy or radiculopathy, lumbar region; headache; migraine without aura, intractable, without status migrainosus; and low back pain. Id. at 2838, 5436. On November 23, 2018, Plaintiff saw Dr. Delorenzi for a follow-up after her car accident. Id. at 3407-11. Dr. Delorenzi reported Plaintiff had acute pain in addition to her chronic pain; Plaintiff was currently stable on her migraine medication; rheumatoid arthritis was managed by an outside provider; and noted Plaintiff had an upcoming mental health appointment. Id. at 3410. On November 26, 2018, Plaintiff saw Dr. Honory for supportive therapy and medication management. Id. at 3401-3407. Dr. Honory reviewed the events surrounding Plaintiff's hospitalization, as well as her multiple medical conditions. AR at 3401-3402. Dr. Honory assessed depression and anxiety, and possible bipolar disorder. Id. at 3406. Dr. Honory prescribed the resumption of lamotrigine and duloxetine, and opted to discontinue Adderall because Plaintiff had never been diagnosed with ADHD. Id. Dr. Honory also recommended group therapy. Id. On November 27, 2018, Plaintiff underwent NeuroTrax testing. Id. at 5459-68. Cognitive areas in need of improvement included memory, executive function, attention, visual spatial, verbal function, and working memory. AR at 5460. On November 30, 2018, Plaintiff had radiographs of her cervical spine which did not show any changes from her prior films. Id. at 2912.
On December 3, 2018, Plaintiff returned to PA Miltenberger following her motor vehicle accident in which her vehicle was totaled. Id. at 2584-87. PA Miltenberger's review of Plaintiff's systems was unremarkable, as was her physical examination with the exception of tenderness to palpation of Plaintiff's upper trapezius and paracervical muscles. Id. at 2584, 2587. Radiographs showed that the cervical leads had moved; however, after working with the spinal cord stimulator representative, Plaintiff received improved pain coverage. Id. at 2587. On December 5, 2018, Plaintiff had magnetic resonance imaging (“MRI”) of her head due to her headaches, head and neck pain, and memory loss. AR at 2591, 5456. Dr. Burroughs found no significant intracranial abnormality and paranasal sinus mucosal thickening. Id. On December 12, 2018, Plaintiff was seen by Tuan Vo, D.O. regarding her urinary incontinence. Id. at 2610-13. On December 17, 2018, Plaintiff followed up with Dr. Stanonik. Id. at 2828-34, 5426-32. Upon screening, Plaintiff showed mild depression. Id. at 2828, 5426. Dr. Stanonik reviewed Plaintiff's history including depression and anxiety, upper and lower back pain, migraines, memory loss, right leg numbness, jaw pain, eye twitching, and trouble swallowing. AR at 2829, 5427-29. Dr. Stanonik also noted Plaintiff's motor vehicle accident in Mexico. Id. at 2830, 5428. Dr. Stanonik's assessment included retrograde amnesia; migraine without aura, intractable, without status migrainosus; and mild cognitive impairment. Id. at 2832, 5430.
On January 21, 2019, Plaintiff underwent electromyography (“EMG”) and nerve conduction velocity (“NCV”)testing. Id. at 2861, 5458. Plaintiff's left superficial peroneal sensory nerve showed decreased conduction velocity. Id. Dr. Siegel's impressions noted “[n]o evidence of [lumbosacral] motor radiculopathy . . . [or] of peripheral neuropathy or nerve entrapment in the legs.” AR at 2861, 5458. On January 29, 2019, Plaintiff underwent a cervical spine MRI. Id. at 5453-54. Andrew Gyorke, M.D. observed “C4-C6 anterior discectomy with interbody fusion[,] [myelomalacia in the spinal cord at the C5-6 level on both sides[,] [and] [s]pinal stimulator dorsally extending up to the C2-3 level[;] ¶ 5-6 posterior ridging with mild central stenosis[;] [and] ¶ 6-7 moderate narrowing to the left neural foramen.” Id. at 5454. On January 30, 2019, Plaintiff underwent a lumbar spine MRI. Id. at 5450-51. Dr. Gyorke observed “L5-S1 interval right laminectomy[,] [with] [degenerative disc bulge resulting in moderate left and mild right foraminal stenosis[;] [and] ¶ 4-5 degenerative changes with mild foraminal stenosis[,] [but] [n]o central stenosis.” Id. at 5451. On January 31, 2019, Plaintiff returned to Dr. Siegel for review of her EMG and MRI results. AR at 2822-26, 5421-25. Dr. Siegel reported a detailed depression screening, as well as history of Plaintiff's current illnesses. Id. at 2822-25, 5421-24. Plaintiff's anxiety, depression, memory loss, migraines, neurological issues, and rheumatological ailments were prominent in her history. Id. Dr. Siegel's assessment included injury of nerve root of lumbar spine; retrograde amnesia; other specified inflammatory spondylopathies, lumbar region; migraine without aura, intractable, without status migrainosus; weakness; mild cognitive impairment; paresthesia of skin; pain in right wrist; and dysphagia, unspecified. Id. at 2826, 5424. On January 28, 2019, Plaintiff saw Martha P. Burkholder, M.D. at SAVAHCS for a psychiatric assessment. Id. at 3375-82. Plaintiff complained of ongoing anxiety and memory issues, and also indicated that Klonopin seemed to help. AR at 3375. Plaintiff indicated she has suicidal ideations without intent or plan, and although she is on medication, her anxiety and depression are not managed. Id. at 3376. Plaintiff also asked about ECT. Id. Dr. Burkholder assessed a mood disorder not otherwise specified, as well as anxiety, but questioned the accuracy of Plaintiff's previous bipolar diagnosis, as she had no clear cut history of mania. Id. at 3381. On January 30, 2019, Plaintiff was seen by Dr. Pender at SAVAHCS for a follow up regarding her joint pain. Id. at 3373-75. Dr. Pender observed multiple periarticular tender points and noted pain across Plaintiff's hands, feet, and ankles. AR at 3373. Dr. Pender recommended an increase in methotrexate if lab results were okay. Id. at 3374. On January 31, 2019, Plaintiff began physical therapy to treat her urine leakage and pelvic pain. Id. at 2883-88. Plaintiff received additional physical therapy during the month of February. Id. at 2879-82.
On February 4, 2019, Plaintiff had a teleconference with Shaelene Palmer, R.N. regarding her laboratory results and an increase of her methotrexate dosage. Id. at 336971. On February 6, 2019, Plaintiff was seen by Dr. Burkholder at SAVAHCS. AR at 3364-68. Plaintiff reported an improved mood with decreased anxiety and depression, and no evidence of mania or bipolar disorder. Id. at 3364. Dr. Burkholder decided to taper Plaintiff off Topamax. Id. at 3367. On February 27, 2019, Plaintiff returned to Dr. Burkholder for supportive therapy and medication management. Id. at 3358-64. Plaintiff sought ECT treatment for her depression because the propranolol was not helping. Id. at 3358. Dr. Burkholder reviewed Plaintiff's multiple medical issues including rheumatoid arthritis, chronic migraines, restless leg syndrome, chronic anxiety, and depressed mood. AR at 3358. Plaintiff admitted to having suicidal thoughts but denied a plan or intent. Id. Plaintiff agreed to bring in all of her pill bottles to her next appointment because she had difficulty recalling what she was actually taking, and Dr. Burkholder opined that clarification was necessary to be able to assess what medications were working and which were causing side effects. Id. at 3359. Dr. Burkholder also encouraged psychotherapy, noting propranolol will help with symptoms of anxiety but is not useful in treating depression. Id. Dr. Burkholder increased Plaintiff's Lamictal dosage. Id. at 3363. On the same date, Plaintiff had an initial consultation with Christopher B. Wiegand, M.D. regarding ECT. AR at 4984-87. Dr. Wiegand noted Plaintiff's presentation was consistent with very severe depression. Id. at 4984. Dr. Wiegand reviewed Plaintiff's psychiatric, medical, family, and social histories, as well as her current medications. Id. at 4984-85. Dr. Wiegand's diagnoses included major depressive disorder, recurrent severe without psychotic features, agoraphobia with panic disorder, personality disorder, unspecified, and bipolar disorder, unspecified but provisional. Id. at 4986. Dr. Wiegand opined that Plaintiff was an appropriate candidate for ECT. Id.
On March 1, 2019, Plaintiff saw Dr. Michael Hummel at Stem Cell Centers for treatment regarding her chronic pain and autoimmune disorders. AR at 2903-2905. Plaintiff received Exosomes IV and Myers/Amino Acids IV treatments. See id. On March 8, 2019, Plaintiff had a teleconference follow-up with Mary Sabey, Clinical Nurse Specialist, at SAVAHCS following a medication change by Dr. Burkholder. Id. at 335558. Plaintiff described “[persisting depression, amotivation, easily overwhelmed; anxious, panic episodes if she goes out of the home; shops at night for groceries to avoid crowds.” Id. at 3355. Plaintiff reported “a little” improvement with the increased lamictal dose. Id. On March 11, 2019, Plaintiff was seen at Arizona Gastroenterology regarding her dysphagia and gastroesophageal reflux disease. AR at 2889-92. On March 13, 2019, Plaintiff underwent her first ECT treatment without complication. Id. at 4988-91. On March 14, 2019, Plaintiff was seen by Natalie Marciales, PAC at Arizona Arthritis & Rheumatology Associates, PC. Id. at 5276-82. On physical examination, PA Marciales assessed eighteen (18) out of eighteen (18) total tender points. Id. at 5278. Plaintiff also exhibited tender joints and showed photographs of her hand swelling. Id. at 5278-79. PA Marciales opined that Plaintiff's symptoms are more consistent with systemic lupus erythematosus (“SLE”) than rheumatoid arthritis and ordered additional laboratory analyses. AR at 5279. PA Marciales recommended continuing Plaintiff's current treatment for fibromyalgia. Id. at 5280. On March 15, 2019, Plaintiff underwent pelvic sling placement. Id. at 5239-61. On March 18, 2019, Plaintiff returned to Dr. Wiegand for her second ECT treatment. Id. at 4993-95. The treatment was without complications. Id. at 4995. Plaintiff received additional ECT treatments from Dr. Wiegand on March 20th, 25th, 27th, and 29th, 2019, as well as April 1st, 5th, 2019. AR at 4996-5012. No complications were reported. Id. On March 29, 2019, Plaintiff was seen by Dr. Burkholder at SAVAHCS. Id. at 5397-5401. Dr. Burkholder noted that Plaintiff's memory was poor, and she had difficulty answering most questions. Id. at 5397, 5400. Plaintiff reported short and long term memory issues, and noted that she needs her father to drive her. Id.
On April 4, 2019, Plaintiff established care with Justin B. Chua, FNP-C at SAVAHCS. AR at 5388-94. NP Chua's review of Plaintiff's systems was generally unremarkable. Id. at 5389. NP Chua's physical examination was also unremarkable, but noted Plaintiff's poor recent and remote memory. Id. at 5391-92. NP Chua assessed amnesia, fibromyalgia, polyarticular inflammatory arthritis, migraines, and mood disorder. Id. at 5392. On April 25, 2019, Plaintiff had a follow-up with Dr. Pender. Id. at 5383-84. Plaintiff reported having some memory issues since starting ECT. AR at 5383-84. Dr. Pender's physical examination showed pain and tenderness on palpation in Plaintiff's hands, knees, ankles, and feet, as well as multiple periarticular tender points. Id. at 5384. Plaintiff reported feeling better with methotrexate, but indicated that she continues to have areas of pain. Id.
On May 3, 2019, Plaintiff contacted SAVAHCS and informed them that she had lost her private insurance and sought an EGD and GI consult, as well as a lumbar spinal stimulator placement. Id. at 5375. On May 9, 2019, Plaintiff saw Dr. Burkholder at SAVAHCS for supportive therapy and medication management. Id. at 5360-66. Dr. Burkholder noted that Plaintiff had been evaluated for psychotherapy, but her increased memory and concentration difficulties subsequent to ECT treatment delayed treatment. AR at 5360, 5365. Dr. Burkholder opined that Plaintiff's memory issues were limiting Plaintiff's ability to function on her own in the community, as were her chronic conditions including migraine, back pain, and arthralgias. Id. at 5364. On the same date Plaintiff saw NP Chua at SAVAHCS for a primary care follow-up. Id. at 5368-73. Plaintiff reported losing her private insurance and requested an approval for her community neurosurgeon for placement of a lumbar stimulator. Id. at 5368. NP Chua's review of Plaintiff's systems noted fatigue, migraine headaches, generalized joint and muscle pain, depression, and anxiety. Id. at 5369. NP Chua's physical examination showed “[m]ild tenderness with deep palpation.” AR at 5372. NP Chua's assessments included fibromyalgia, dysphagia, chronic low back pain, mild cognitive impairment, and depression. Id. NP Chua ordered an EGD to address Plaintiff's dysphagia. Id. Plaintiff also saw Dr. Siegel for a neurologic follow up. Id. at 5412-20. Dr. Siegel's examination was generally unremarkable, but significant for short term memory loss. Id. at 5417-18. Dr. Siegel assessed injury of nerve root of lumbar spine; retrograde amnesia; other specified inflammatory spondylopathies, lumbar region; migraine without aura, intractable, without status migrainosus; weakness; mild cognitive impairment; paresthesia of skin; pain in right wrist; unspecified dysphagia; and restless legs syndrome. AR at 5418. Dr. Siegel recommended facet joint injections, noting likely facet arthropathy at ¶ 5-S1. Id. at 5418-19.
On June 3, 2019, NP Chua reviewed Plaintiff's neurosurgery records and ordered a lumbar MRI and possible referral to neurosurgery at the VA. Id. at 5374. On June 12, 2019, Plaintiff saw Dr. Burkholder at SAVAHCS for supportive therapy and medication management. Id. at 5348-55. Dr. Burkholder reviewed Plaintiff's multiple medical issues and noted Plaintiff's frustration with the VA. Id. at 5349. Plaintiff continued to have memory issues, which was also exacerbated by the ECT sessions. AR at 5353.
On July 11, 2019, Plaintiff underwent an EMG and nerve conduction study for constant neck and arm pain, as well as loss of finger strength and numbness. Id. at 5457, 5488. Dr. Siegel reported decreased conduction velocity in Plaintiff's left and right median sensory nerves, as well as her right radial sensory nerve. Id. at 5457. Plaintiff's left ulnar nerve showed decreased conduction velocity, and right median/ulnar nerve showed prolonged distal peak latency, as well as abnormal onset latency difference. Id. Dr. Siegel further reported Plaintiff's EMG evaluation of her right triceps muscle showed increased motor unit amplitude, slightly increased polyphasic potentials, and diminished recruitment, and her left triceps muscle showed slightly increased polyphasic potentials and diminished recruitment. Id. Dr. Siegel findings included mild bilateral C7 motor radiculopathies and mild entrapment right median nerve at level carpal tunnel. AR at 5457.
On August 8, 2019, Plaintiff saw Dr. Siegel for a follow-up regarding her EMG results. Id. at 5480-87. Dr. Siegel reported symptomatic right carpel tunnel syndrome based on the abnormal NCV testing. Id. at 5486. On August 28, 2019, Plaintiff underwent an EGD. Id. at 5471-74. Patrick Dinning, M.D.'s impression included a mild Schatzki ring, dilated, and a medium-sized hiatal hernia. Id. at 5471. On September 19, 2019, Plaintiff saw Dr. Stanonik for carpal tunnel injections to treat severe, bilateral, carpal tunnel. AR at 5477-79.
b. Examining physician records
i. Jeri B. Hassman, M.D.
On August 1, 2018, Plaintiff was seen by Jeri B. Hassman, M.D. for a medical consultation upon referral from the Arizona Department of Economic Security (“AZDES”). AR at 2335-2342. Dr. Hassman reviewed Plaintiff's medical history, including an anterior cervical discectomy at ¶ 3-C4 and C4-C5 in 2016 and lumbar spine surgery in November 2017. Id. at 2335. Dr. Hassman noted that Plaintiff began suffering severe urinary incontinence after the lumbar spine surgery. Id. Plaintiff reported some decrease in pain from the lumbar spine surgery, and indicated her intention to have a permanent spinal cord stimulator implanted. Id. at 2335-2336. Plaintiff indicated that she “ha[d] frequent neck pain and low back pain[,] . . . occasional migraine headaches[,] . . . occasional nausea associated with headache and later vomiting[,] . . . occasional constipation[,] . . . occasional fatigue[,] . . . frequent depression and mild decrease in memory[,] . . . constant urinary incontinence[,] . . . cramping of both hands, right worse than left and numbness of the right third and fourth fingers most of the time, and has occasional tingling of the left fingers.” Id. at 2336. Dr. Hassman noted that Plaintiff “had a slightly antalgic gait, complaining of right lumbar and right buttock pain with standing and walking.” AR at 2336. Dr. Hassman further noted Plaintiff had a “normal stride length” and was able “to tolerate full weightbearing on either legs[,]” and had a cane at home, although she had not brought it with her to the appointment. Id. Plaintiff “complained of right lumbar and right buttock pain with heel walking and toe walking[,] . . . [and] could not hop on either foot because of low back pain.” Id. at 2337. Dr. Hassman indicated that Plaintiff “was able to perform bending and was able to reach her fingertips to the mid calf level, but could not perform kneeling because of low back pain.” Id. Plaintiff stated that she had jaw pain and that her migraine headaches were associated with the same. Id. Plaintiff also reported seeing spots when she has a migraine. AR at 2337. Dr. Hassman noted that Plaintiff had a “full range of motion of the cervical spine without pain and no tenderness over the cervical muscles.” Id. Dr. Hassman further indicated Plaintiff “had full range of motion of both upper extremities without pain[,]” as well as a “negative Phalen's test, negative Finkelstein's test, and a negative Tinel's sign of both wrists and elbows.” Id. Dr. Hassman observed “a very fine tremor involving both hands,” but opined that it “did not interfere with manual dexterity or with serial finger tapping.” Id. Dr. Hassman also observed “tingling over the right medial hand and tingling of the right third and fourth fingers.” Id. Dr. Hassman reported no Hoffman's reflexes and a negative Romberg's sign. AR at 2337. Dr. Hassman observed moderate tenderness in Plaintiff's low back and mild pain with lumbar range of motion, as well as a positive straight leg test on the right, with moderate difficulty sitting up from a supine position. Id. Plaintiff exhibited a full range of motion with both lower extremities, but had decreased strength in her right ankle, and decreased sensation of the right third, fourth, and fifth toes. Id. at 2338.
Dr. Hassman completed a Medical Source Statement of Ability to Do Work-Related Activities and diagnosed chronic neck and low back pain, chronic urinary incontinence, migraines, bilateral TMJ pain, and carpal tunnel syndrome. Id. at 2339. Dr. Hassman opined that Plaintiff's conditions would impose limitations for twelve (12) continuous months. Id. Dr. Hassman further opined that Plaintiff could carry ten (10) pounds occasionally and less than ten (10) pounds frequently. AR at 2339. Dr. Hassman indicated that Plaintiff would be able to stand and/or walk for two (2) to four (4) hours in an eight (8) hour workday. Id. Dr. Hassman also noted that Plaintiff did not use an assistive device. Id. Dr. Hassman opined that Plaintiff was able to sit for six (6) to eight (8) hours in an eight (8) hour day and was unlimited in her ability to see, hear, and speak. Id. Dr. Hassman further opined that Plaintiff could never climb ladders, ropes, or scaffolds; could never kneel or crouch; could occasionally climb ramps or stairs; could occasionally stoop, crouch, reach, or feel with her right hand; and could frequently handle and finger bilaterally, or feel with her left hand. Id. at 2340-41. Dr. Hassman also opined that Plaintiff was restricted in working around heights and moving machinery, but unrestricted working around extremes in temperature, chemicals, dust, fumes, gases, and excessive noise. AR at 2341. Dr. Hassman noted that Plaintiff required frequent changes of position. Id.
ii. Gwendolyn W. Johnson, Ph.D.
On August 14, 2018, Gwendolyn W. Johnson, Ph.D. saw Plaintiff for a psychiatric consultation upon referral from the Arizona Department of Economic Security (“AZDES”). AR at 2343-2348. Plaintiff reported lived with her parents and “prepare[d] meals and complete[d] household chores as she [wa]s able.” Id. at 2343. Dr. Johnson opined that Plaintiff was “able to manage ADL's independently” based on Plaintiff's statements that she could manage income, pay bills, and drive for appointment, shopping, and errands. Id. Dr. Johnson noted that Plaintiff “reported that she received her GED in 2014.” Id. Dr. Johnson reviewed Plaintiff's work history, noting Plaintiff's most recent position “as a service representative for the Social Security Administration[.]” Id. at 2344. Dr. Johnson went on to state that Plaintiff “had previously worked for the Arizona Department of Corrections for four years and served in the Army and Army Reserves for a total of eight years.” AR at 2344. Plaintiff “described her general health as ‘poor' due to chronic pain.” Id. Plaintiff reported receiving “mental services at SAVAHCS from 2007-2017 and saw private [sic] psychiatrist in Mexico for about one year ending in 10/2017[,] . . . [and] has been enrolled with CODAC for the past three months or so.” Id. Plaintiff further reported “that she is prescribed venlafaxine, clonazepam, and duloxetine, and that they are beneficial to her.” Id. Dr. Johnson's mental status examination of Plaintiff was generally unremarkable, although she exhibited a mildly depressed mood with an appropriate affect to mood state. Id. Plaintiff also reported a history of depression and anxiety dating back to age seventeen (17) or eighteen (18), reporting low motivation, low energy, and social withdrawal. AR at 2345. Plaintiff noted memory loss, as well as palpitations, tremors, and tearing. Id. Plaintiff also indicated that she attempted suicide at the age of nineteen (19), but did not currently suffer suicidal or homicidal ideations. Id. Plaintiff further reported sleep issues, both with onset and staying asleep due to chronic pain and restless leg syndrome. Id. Dr. Johnson opined that Plaintiff suffers “from an unspecified depressive disorder that has likely been aggravated by chronic health problems and concerns.” Id. Dr. Johnson estimated Plaintiff's “prognosis for a successful return to the work force . . . as good.” AR at 2345.
Dr. Johnson completed a Psychological/Psychiatric Medical Source Statement regarding Plaintiff. Id. at 2346-48. Dr. Johnson opined that Plaintiff's conditions would not be limiting for twelve (12) months. Id. at 2346. Dr. Johnson found no evidence of impairment regarding Plaintiff's understanding and memory; sustained concentration and persistence; social interaction; and adaptation. Id.
iii. Jill M. Plevell, Ph.D.
On December 11, 2018, Jill M. Plevell, Ph.D. saw Plaintiff for a psychological evaluation. AR at 2595-98. Dr. Plevell reviewed Plaintiff's medical history with her, including back issues, underactive thyroid, migraines, allergies, and possible lupus or rheumatoid arthritis, as well as memory issues. Id. at 2595. Plaintiff also provided her educational and occupational histories, as well as current activities of daily living, social functioning, and mental health history. Id. at 2596. Dr. Johnson assessed Plaintiff with the Wechsler Adult Intelligence Scale-IV (“WAIS-IV”), Wide Range Assessment of Memory and Learning, 2d edition (“WRAML2”), Trail Making Test (“TMT”), and Woodcock-Johnson IV (“WJ IV”). Id. at 2597. Dr. Johnson concluded that Plaintiff's “condition appeared to be most consistent with the diagnosis of: [u]nspecified neurocognitive disorder[] and [u]nspecified mood disorder.” Id. at 2598. Dr. Johnson further opined that “[t]he pattern of test results suggested relative difficulty with verbal processing, abstraction, and perseveration.” AR at 2598. On December 14, 2018, Dr. Plevell completed a Psychological/Psychiatric Medical Source Statement. Id. at 2599. Dr. Plevell opined that Plaintiff's condition would impose a limitation for twelve (12) months. Id. Dr. Plevell further opined that Plaintiff “appeared to be able to understand, remember, and carry out simple instructions[] [but that] [s]he may have difficulty with detailed instructions.” Id. Dr. Plevell also noted that Plaintiff's “[t]esting suggested perseveration[] [and] [persistence was unclear.” Id. Dr. Plevell observed that Plaintiff “appeared to be capable of detecting and responding to hazards, and maintaining a routine[,] [but] [s]he may require additional time to learn new tasks.” AR at 2599. Dr. Plevell indicated that Plaintiff was capable of managing any benefit payments. Id.
c. Reviewing physicians
i. Dennis Swena, M.D.
On August 6, 2018, Dr. Swena opined that Plaintiff had impairments including cervical stenosis/radiculopathy (spinal fusion); lumbar radiculopathy; migraines; carpal tunnel syndrome (both hands and arm pain), restless leg syndrome; overactive bladder (incontinence); and fibromyalgia. AR at 96, 102. Dr. Swena assessed Plaintiff's physical residual functional capacity. Id. at 99-102. Dr. Swena opined that Plaintiff could lift and/or carry twenty (20) pounds occasionally and ten (10) pounds frequently, and is otherwise unlimited in her ability to push and/or pull. Id. at 100. Dr. Swena further opined that Plaintiff could stand and/or walk, as well as sit, for approximately six (6) hours in an eight (8) hour workday. Id. Dr. Swena indicated that Plaintiff could frequently balance; occasionally climb ramps and stairs, stoop, kneel, and crouch; and never climb ladders, ropes, or scaffolds, or crawl. Id. Dr. Swena also opined that Plaintiff was unlimited in her ability to handle and finger, but limited in her ability to feel with her right hand and to frequently with her left hand. AR at 101. Dr. Swena's only environmental limitations for Plaintiff were to avoid concentrated exposure to noise, fumes, odors, dusts, gases, poor ventilation, and hazards. Id. ii. Randall J. Garland, Ph.D.
On August 20, 2018, Randall J. Garland, Ph.D. recognized Plaintiff had the medically determinable impairments of depressive, bipolar, and related disorders, as well as anxiety and obsessive-compulsive disorders. AR at 97-98. Dr. Garland opined that Plaintiff “has no significant limitations due to a medically determinable mental impairment that interfere with sustained activities in a competitive, remunerative work context. Id. at 97.
iii. Reconsideration
On November 15, 2018, S. Pak, M.D. found the medical source statement of a less than sedentary residual functional capacity overly restrictive. AR at 130. Dr. Pak found it “reasonable to affirm the initial decision of light RFC with benefit of the doubt given for this younger clmt.” Id. On January 9, 2019, S. Khan, M.D. agreed with the initial decision and recommended adoption of the initial decision as written. Id. at 124.
3. Vocational Expert Gretchen Bakkenson's Testimony
Ms. Bakkenson testified as a vocational expert at the administrative hearing. AR at 13, 71-77. Ms. Bakkenson described Plaintiff's past relevant work as a caregiver, Dictionary of Occupational Titles (“DOT”) number 355.674-014, as having a Specific Vocational Preparation (“SVP”) of 4, and exertional level of medium but heavy to very heavy as described. Id. at 72. Ms. Bakkenson next described the job of financial technician with the Army, DOT number 215.137-014, as having an SVP of 7, and sedentary exertional level. Id. Ms. Bakkenson also described the customer service representative with the cable company position, DOT 249.362-026, semi-skilled, with an SVP of 4, and sedentary exertional level. Id. at 73. Ms. Bakkenson described Plaintiff's veterans' advocate position under a job development specialist title, DOT number 166.267-034, skilled, with an SVP of 5, and a sedentary exertional level, although Plaintiff described it as a light exertional level. Id. Finally, Ms. Bakkenson described the position of service representative for Social Security under an insurance customer service representative title, DOT number 205.567-018, semi-skilled, with an SVP of 4, and sedentary exertional level. AR at 73.
The ALJ asked Ms. Bakkenson to consider a hypothetical individual of Plaintiff's age, education, and work history; who retained a residual functional capacity to perform sedentary work with additional limitations; who could sit for a maximum of two (2) hours at a time, could stand for one (1) hour at a time; who could walk for thirty (30) minutes at a time; who could occasionally push, pull, and operate foot controls; who could occasionally climb ramps and stairs; who could never climb ladders, ropes, or scaffolds; who could occasionally balance, stoop, and crouch; who could never kneel or crawl; who could occasionally reach overhead and frequently handle, finger, and feel; who must avoid hazards, including moving machinery and unprotected heights; who could perform simple routine tasks; who could make simple work-related decisions; who required an environment with few changes and free from production rates and quotas; and who could have occasional and superficial interaction with co-workers and the public, such that the interaction is brief, casual, and incidental to the task performed. Id. at 73-74. Ms. Bakkenson opined that such an individual would be employable as a ticket checker, DOT number 219.587-010, sedentary exertional level, unskilled, and with an SVP of 2, and of which there are approximately 30,000 jobs in the national economy. Id. at 74. Ms. Bakkenson further opined that such an individual would be employable as an addressing clerk, DOT number 209.587-010, sedentary exertional level, unskilled, with an SVP of 2, and of which there are approximately 35,000 jobs in the national economy. Id. at 74-75. Ms. Bakkenson also opined that such an individual would be employable as a document preparer, DOT number 249.587-018, sedentary exertional level, unskilled, with an SVP of 2, and of which there are approximately 50,000 jobs in the national economy. Id. at 75. Ms. Bakkenson opined that such an individual would be able to be absent no more than one (1) day per month. AR at 75.
Upon questioning by Plaintiff's counsel, Ms. Bakkenson realized that the hypothetical individual would be unable to perform the requirements of the ticket checker position and rescinded that job from her opinion. Id. at 75-76. Counsel also inquired about the availability of the two (2) remaining jobs where the hypothetical individual was off task for fifteen (15) to twenty (20) percent of an eight (8) hour day and limited to occasional fingering, feeling, and handling. Id. at 76. Ms. Bakkenson opined that based on the Bureau of Labor Statistics and direct contact with employers, if an individual were off task more than ten (10) percent there would be no work. Id. Ms. Bakkenson further opined that occasional manipulatives or occasional reaching in any direction would preclude both jobs. Id. at 76-77. Ms. Bakkenson confirmed that this opinion was based on her employment as a vocational expert, labor market consultant, and vocational rehab counselor. AR at 77.
4. Lay Witness Testimony-Angelica M. Meza
On June 18, 2018, Plaintiff's sister, Angelica M. Meza, completed a Function Report-Adult-Third Party. AR at 599-606. Ms. Meza indicated that they spent approximately four (4) hours per day together. Id. at 599. Ms. Meza described Plaintiff's living situation as a house with family. Id. Ms. Meza reported that Plaintiff tries to wake up early to shower and dress but struggles because her chronic pain, restless leg syndrome and other medical issues interfere with her sleep. Id. Ms. Meza further reported that Plaintiff feeds her pets, and when she is feeling okay will walk them. Id. at 600. Ms. Meza noted that her daughter will occasionally help Plaintiff with feeding her pets. AR at 600. Ms. Meza reiterated that Plaintiff's insomnia, restless leg syndrome, migraines, and chronic pain interfere with her sleep. Id. Ms. Meza indicated that Plaintiff generally did not have any problems with personal care, although numbness and cramping in her arms made it difficult to care for her hair because she had difficulty holding her arms up for long periods. Id. Ms. Meza reported that Plaintiff tends to isolate due to depression and anxiety, and requires reminders because she will forget to shower. Id. at 601. Ms. Meza further reported that Plaintiff requires a pill box and phone alarms to remind her to take her medications. Id.
Ms. Meza indicated that Plaintiff can prepare her own food, including sandwiches, frozen dinners, soups, and re-heating leftovers, and estimated that it takes Plaintiff between fifteen (15) and thirty (30) minutes. AR at 601. Ms. Meza observed that Plaintiff used to cook full meals, but now cooks very little. Id. Ms. Meza reported that Plaintiff only does laundry and housework when she feels up to it, due to the limitations of her chronic pain. Id. Ms. Meza noted that Plaintiff does these chores weekly, and it can take her all day. Id. Ms. Meza further noted that Plaintiff works a little better with company from family. Id. Ms. Meza also reported that Plaintiff does not do any yard work because of her pain. AR at 602. Ms. Meza observed that if Plaintiff does do yard work, she ends up “in bed for days.” Id.
Ms. Meza reported that Plaintiff goes outside daily, and family members drive her. Id. at 602. Ms. Meza indicated that Plaintiff's anxiety and memory loss cause her inability to go out alone. Id. Ms. Meza noted that Plaintiff does drive short distances but is limited to her immediate area due to recent memory loss. Id. Ms. Meza further reported that Plaintiff shops in stores for groceries and home supplies, which Ms. Meza estimated to take her about an hour. AR at 602. Ms. Meza indicated that Plaintiff is able to pay bills, handle a savings account, count change, and use a checkbook or money orders. Id.
Ms. Meza listed Plaintiff's hobbies to include watching television, such as programs on Netflix. Id. at 603. Ms. Meza indicated that Plaintiff watches television daily, and that she has isolated herself more, as well as sleeping more, since she has trouble sleeping at night. Id. Ms. Meza reported that Plaintiff does not spend time with others, but indicated that she does go to the store, has lunch out, and goes to church on Sundays, as well as attends her doctors' appointments. Id. Ms. Meza further reported that Plaintiff needs reminders about her doctors' appointments and to have someone accompany her. AR at 603. Ms. Meza reiterated that Plaintiff has become “non-social” since the onset of her illnesses and chronic pain. Id. at 604.
Ms. Meza indicated that Plaintiff's conditions affect her ability to lift, squat, bend, stand, reach, walk, sit, kneel, talk, climb stairs, remember, complete tasks, concentrate, understand, follow instructions, use hands, and get along with others. Id. Ms. Meza again attributed these effects on Plaintiff's chronic pain, depression, anxiety, and restless leg syndrome. Id. Ms. Meza reported that Plaintiff could walk a few blocks before requiring rest, and estimated that she needed five (5) to ten (10) minutes before being able to resume walking. Id. Ms. Meza further reported that Plaintiff is unable to finish what she starts, but is able to follow written instructions well; however, she requires repetition of spoken instructions. AR at 604. Mr. Meza described Plaintiff as being able to get along with authority figures well, and reported that she has never been fired or laid off from a job because of conflicts with other people. Id. at 605. Ms. Meza also reported that Plaintiff does not handle stress well due to anxiety or panic attacks. Id. Ms. Meza indicated that Plaintiff is able to handle changes in routine reasonably well, but emphasized her social anxiety. Id. Ms. Meza reported that Plaintiff requires a cane to move around the house and to go out. Id.
Ms. Meza described feeling sad and helpless regarding her sister's illnesses. AR at 606. Ms. Meza noted that Plaintiff's memory issues are frightening, because they have caused her to become lost while out of the house. Id. In those situations, Ms. Meza had to go find her. Id. Ms. Meza also reported that Plaintiff has panic attacks due to the fear of getting lost. Id. Ms. Meza described Plaintiff as being independent prior to her illnesses, and now she is very reliant on her family for assistance. Id.
II. STANDARD OF REVIEW
The factual findings of the Commissioner shall be conclusive so long as they are based upon substantial evidence and there is no legal error. 42 U.S.C. §§ 405(g), 1383(c)(3); Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008). This Court may “set aside the Commissioner's denial of disability insurance benefits when the ALJ's findings are based on legal error or are not supported by substantial evidence in the record as a whole.” Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999) (citations omitted); see also Treichler v. Comm r of Soc. Sec. Admin., 775 F.3d 1090, 1098 (9th Cir. 2014).
Substantial evidence is “‘more than a mere scintilla[,] but not necessarily a preponderance.'” Tommasetti, 533 F.3d at 1038 (quoting Connett v. Barnhart, 340 F.3d 871, 873 (9th Cir. 2003)); see also Garrison v. Colvin, 759 F.3d 995, 1009 (9th Cir. 2014). Further, substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Parra v. Astrue, 481 F.3d 742, 746 (9th Cir. 2007). Where “the evidence can support either outcome, the court may not substitute its judgment for that of the ALJ.” Tackett, 180 F.3d at 1098 (citing Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir. 1992)); see also Massachi v. Astrue, 486 F.3d 1149, 1152 (9th Cir. 2007). Moreover, the court may not focus on an isolated piece of supporting evidence, rather it must consider the entirety of the record weighing both evidence that supports as well as that which detracts from the Secretary's conclusion. Tackett, 180 F.3d at 1098 (citations omitted).
III. ANALYSIS
A. The Five-Step Evaluation
The Commissioner follows a five-step sequential evaluation process to assess whether a claimant is disabled. 20 C.F.R. § 404.1520(a)(4). This process is defined as follows: Step One asks is the claimant “doing substantial gainful activity[?]” 20 C.F.R. § 404.1520(a)(4)(i). If yes, the claimant is not disabled. Step Two considers if the claimant has a “severe medically determinable physical or mental impairment[]” 20 C.F.R. § 404.1520(a)(4)(ii). If not, the claimant is not disabled. Step Three determines whether the claimant's impairments or combination thereof meet or equal an impairment listed in 20 C.F.R. Pt. 404, Subpt. P, App.1. 20 C.F.R. § 404.1520(a)(4)(iii). If not, the claimant is not disabled. Step Four considers the claimant's residual functional capacity and past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If claimant can still do past relevant work, then he or she is not disabled. Step Five assesses the claimant's residual functional capacity, age, education, and work experience. 20 C.F.R. § 404.1520(a)(4)(v). If it is determined that the claimant can make an adjustment to other work, then he or she is not disabled. Id.
In the instant case, the ALJ found that Plaintiff had not engaged in substantial gainful activity since her alleged onset date of March 18, 2018. AR at 15. At step two of the sequential evaluation, the ALJ found that “[t]he claimant has the following medically determinable impairments: lumbar degenerative disc disease (DDD), status post right L5-S1 microdiscectomy; fibromyalgia; cervical DDD with radiculopathy and a history of a C4-6 fusion; thoracic spondylosis; systemic lupus erythematosus (SLE); right carpal tunnel syndrome (CTS); major depressive disorder (MDD); posttraumatic stress disorder (PTSD); unspecified depressive disorder; adjustment disorder with anxiety; generalized anxiety disorder (GAD); unspecified neurocognitive disorder; unspecified mood disorder; agoraphobia without panic disorder; and an unspecified personality disorder (20 CFR 404.1520(c)).” Id. at 15. At step three, the ALJ further found that “[t]he claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525 and 404.1526).” Id. at 16. Prior to step four and “[a]fter careful consideration of the entire record,” the ALJ determined that “the claimant has the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a), except that she can sit for only two hours at a time, stand for one hour at a time, and walk for 30 minutes at a time[;] [s]he can occasionally push, pull, and operate foot controls[;] . . . [she] is able to climb ramps and stairs occasionally, but can never climb ladders, ropes or scaffolds[;] [s]he can occasionally balance, stoop, and crouch, but can never kneel or crawl[;] . . . [she] is able to reach overhead occasionally and handle, finger, and feel frequently[;] [s]he must avoid hazards, including moving machinery and unprotected heights[;] . . . [she] can perform simple, routine tasks and make simple, work related decisions in an environment with few changes and free from production rates and quotas, like those found in assembly line work[;] [and] [s]he can have occasional and superficial interactions with coworkers and the public, such that the interaction is brief, casual and incidental to the task performed.” Id. at 19. At step four, the ALJ found that “[t]he claimant is unable to perform any past relevant work (20 CFR 404.1565).” Id. at 25. At step five, the ALJ found that after “[considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform (20 CFR 404.1569 and 404.1569(a)).” AR at 26. Accordingly, the ALJ determined that Plaintiff was not disabled. Id. at 27.
B. Plaintiff's Symptoms
Plaintiff asserts that “[a] review of the ALJ's decision fails to show that the ALJ identified any specific symptoms that the ALJ felt lacked credibility, much less any specific evidence in the record that was thought to undermine those reported symptoms.” Opening Br. (Doc. 29) at 21. Plaintiff contends that “[w]ithout any effort to connect the discussion of the medical evidence to a finding that any specific part of the symptom testimony lacked credibility, the ALJ committed legal error.” Id. at 22 (citations omitted). Defendant counters that “the ALJ made sufficiently specific findings, and if substantial evidence supports the ALJ's findings, a court may not engage in second-guessing.” Response (Doc. 32) at 5 (quotations and citations omitted). The Court finds the ALJ failed to provide clear and convincing reasons for discounting Plaintiff's testimony, thereby committing legal error.
1. Legal Standard
An ALJ must engage in a two-step analysis to evaluate a claimant's subjective symptom testimony. Lingenfelter v. Astrue, 504 F.3d 1028, 1035-36 (9th Cir. 2007). First, “a claimant who alleges disability based on subjective symptoms ‘must produce objective medical evidence of an underlying impairment which could reasonably be expected to produce the pain or other symptoms alleged[.]'” Smolen v. Chater, 80 F.3d 1273, 128182 (9th Cir. 1996) (quoting Bunnell v. Sullivan, 947 F.2d 341, 344 (9th Cir. 1991) (en banc) (internal quotations omitted)); see also Ghanim v. Colvin, 763 F.3d 1154, 1163 (9th Cir. 2014). Further, “the claimant need not show that her impairment could reasonably be expected to cause the severity of the symptom she has alleged; she need only show that it could reasonably have caused some degree of the symptom.” Smolen, 80 F.3d at 1282 (citations omitted); see also Trevizo v. Berryhill, 871 F.3d 664, 678 (9th Cir. 2017). “Nor must a claimant produce ‘objective medical evidence of the pain or fatigue itself, or the severity thereof.'” Garrison v. Colvin, 759 F.3d 995, 1014 (9th Cir. 2014) (quoting Smolen, 80 F.3d at 1282). “[I]f the claimant meets this first test, and there is no evidence of malingering, ‘the ALJ can reject the claimant's testimony about the severity of her symptoms only by offering specific, clear and convincing reasons for doing so.'” Lingenfelter, 504 F.3d at 1036 (quoting Smolen, 80 F.3d at 1281); see also Burrell v. Colvin, 775 F.3d 1133, 1137 (9th Cir. 2014) (rejecting the contention that the “clear and convincing” requirement had been excised by prior Ninth Circuit case law). “This is not an easy requirement to meet: ‘The clear and convincing standard is the most demanding required in Social Security cases.'” Garrison, 759 F.3d at 1015 (quoting Moore v. Comm'r of Soc. Sec. Admin., 278 F.3d 920, 924 (9th Cir. 2002)).
The Ninth Circuit Court of Appeals has “repeatedly warned that ALJs must be especially cautious in concluding that daily activities are inconsistent with testimony about pain, because impairments that would unquestionably preclude work and all the pressures of a workplace environment will often be consistent with doing more than merely resting in bed all day.” Garrison, 759 F.3d at 1016 (citations omitted). Furthermore, “[t]he Social Security Act does not require that claimants be utterly incapacitated to be eligible for benefits, and many home activities may not be easily transferable to a work environment where it might be impossible to rest periodically or take medication.” Smolen, 80 F.3d at 1287 n. 7 (citations omitted). The Ninth Circuit Court of Appeals has further noted:
The critical differences between activities of daily living and activities in a full-time job are that a person has more flexibility in scheduling the former than the latter, can get help from other persons . . ., and is not held to a minimum standard of performance, as she would be by an employer. The failure to recognize these differences is a recurrent, and deplorable, feature of opinions by administrative law judges in social security disability cases.Garrison, 759 F.3d at 1016 (quoting Bjornson v. Astrue, 671 F.3d 640, 647 (7th Cir. 2012)) (alterations in original). “While ALJs obviously must rely on examples to show why they do not believe that a claimant is credible, the data points they choose must in fact constitute examples of a broader development to satisfy the applicable ‘clear and convincing' standard.” Id. at 1018 (emphasis in original) (discussing mental health records specifically).
2. ALJ findings
The ALJ acknowledged the two-step process for assessing Plaintiff's symptom testimony. AR at 19. The ALJ remarked that “[t]he claimant's testimony is only accepted to the extent her testimony is consistent with the conclusion she can do the work described herein[;] [s]pecifically, the self-asserted limitations described in the claimant's testimony have been considered within the residual functional capacity stated herein.” Id. at 19. The ALJ then found “[a]fter careful consideration of the evidence, the undersigned finds that the claimant's medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record for the reasons explained in this decision.” Id. at 20. The ALJ went on to review the medical records, contemplate Plaintiff's medications and activities of daily living, and weigh the opinion testimony of certain medical professionals. See id. at 20-25.
“[A]n ALJ may not disregard [a claimant's testimony] solely because it is not substantiated by objective medical evidence[.]” Trevizo, 871 F.3d at 679 (citations omitted). Moreover, “the claimant need not show that her impairment could reasonably be expected to cause the severity of the symptom she has alleged; she need only show that it could reasonably have caused some degree of the symptom.” Smolen, 80 F.3d at 1282 (citations omitted); see also Trevizo v. Berryhill, 871 F.3d 664, 678 (9th Cir. 2017). “Nor must a claimant produce ‘objective medical evidence of the pain or fatigue itself, or the severity thereof.'” Garrison v. Colvin, 759 F.3d 995, 1014 (9th Cir. 2014) (quoting Smolen, 80 F.3d at 1282). The ALJ's finding that objective medical evidence did not support the alleged severity of the symptoms is inconsistent with Plaintiff's burden.
a. Medications
The ALJ noted that “[t]he claimant continued to present with anxiety, depression, and memory difficulties in January 2019[;] . . . [h]owever, she continued to take what was described as an ‘unusual combination of medications, including Adderall, Lamictal, clonazepam and duloxetine[.]” AR at 22 (citations omitted). The ALJ failed to acknowledge that NP Thomas at O'Reilly Care Center observed that “between 4 and 6 different physicians . . . have prescribed [Plaintiff] medications in the recent past with very little to no continuity between any of them.” Id. at 2439, 2639; see also AR at 2452. “In the end between the patient[,] . . . [NP Thomas] and Dr. Douglas it was decided that the patient would follow up with the neurology service at vita medica and work with their providers to optimize the medications she is on.” Id. at 2439, 2639. Plaintiff cannot be faulted for following the treatment plans of her various providers. She required someone to oversee and manage the different medications that had been prescribed, but was clearly unable to advocate for that assistance on her own. The ALJ's opinion that this is a failure of Plaintiff, rather than the medical system she is navigating, is without merit.
b. Activities of daily living
The ALJ is reminded that “[t]he Social Security Act does not require that claimants be utterly incapacitated to be eligible for benefits, and many home activities may not be easily transferable to a work environment where it might be impossible to rest periodically or take medication.” Smolen, 80 F.3d at 1287 n.7 (citations omitted). Although Plaintiff can generally care for herself without assistance, she lives with family and requires someone to drive her to appointments. See Garrison, 759 F.3d at 1016 (impairments that would preclude work are often consistent with doing more than spending each day in bed). Plaintiff further testified that she has become more isolated over time. AR 56-57. Plaintiff was examined by Dr. Johnson and Dr. Plevell in August and December of 2018, respectively. Id. at 2343-48, 2595-98. By May 9, 2019, Dr. Burkholder opined that Plaintiff's memory issues were limiting her ability to function on her own in the community, as were her chronic conditions including migraine, back pain, and arthralgias.” Id. at 5364. Plaintiff's treatment is ongoing. Review of the evidence does not support the ALJ's finding that Plaintiff “has engaged in a somewhat normal level of daily activity and interaction.” Id. at 23.
c. Conclusion
Based upon the foregoing, the Court finds that the ALJ failed to provide specific, clear and convincing reasons for discounting Plaintiff's testimony which is supported by substantial evidence in the record. See Lingenfelter, 504 F.3d at 1036; Tommasetti v. Astrue, 533 F.3d 1035, 1040 (9th Cir. 2008).
D. Remand
“‘[T]he decision whether to remand the case for additional evidence or simply to award benefits is within the discretion of the court.'” Rodriguez v. Bowen, 876 F.2d 759, 763 (9th Cir. 1989) (quoting Stone v. Heckler, 761 F.2d 530, 533 (9th Cir. 1985)). “Remand for further administrative proceedings is appropriate if enhancement of the record would be useful.” Benecke v. Barnhart, 379 F.3d 587, 593 (9th Cir. 2004) (citing Harman v. Apfel, 211 F.3d 1172, 1178 (9th Cir. 2000)). Conversely, remand for an award of benefits is appropriate where:
(1) the ALJ failed to provide legally sufficient reasons for rejecting the evidence; (2) there are no outstanding issues that must be resolved before a determination of disability can be made; and (3) it is clear from the record that the ALJ would be required to find the claimant disabled were such evidence credited.Benecke, 379 F.3d at 593 (citations omitted). Where the test is met, “we will not remand solely to allow the ALJ to make specific findings. . . . Rather, we take the relevant testimony to be established as true and remand for an award of benefits.” Id. (citations omitted); see also Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1995). “Even if those requirements are met, though, we retain ‘flexibility' in determining the appropriate remedy.” Burrell v. Colvin, 775 F.3d 1133, 1141 (9th Cir. 2014).
Here, the ALJ committed legal error in rejecting Plaintiff's symptom testimony. “Allowing the Commissioner to decide the issue again would create an unfair ‘heads we win; tails, let's play again' system of disability benefits adjudication.” Benecke v. Barnhart, 379 F.3d 587, 595 (9th Cir. 2004) (citations omitted). The Court finds that the record is well developed, and no outstanding issues must be resolved before a determination of benefits can be made. The Court further finds that it is clear from the record that the ALJ would be required to find the claimant disabled were such evidence properly credited.
IV. CONCLUSION
Based on the foregoing, the Court finds the ALJ committed legal error in assessing Plaintiff's symptom testimony. Because the record is well developed and without further issues to be resolved, the ALJ's decision should be reversed and remanded for an award of benefits.
V. RECOMMENDATION
For the reasons delineated above, the Magistrate Judge recommends that the District Judge enter an order GRANTING Plaintiff's Opening Brief (Doc. 29) and REVERSING and REMANDING the Commissioner's decision for calculation and award of benefits.
Pursuant to 28 U.S.C. § 636(b) and Rule 72(b)(2), Federal Rules of Civil Procedure, any party may serve and file written objections within fourteen (14) days after being served with a copy of this Report and Recommendation. A party may respond to another party's objections within fourteen (14) days after being served with a copy. Fed.R.Civ.P. 72(b)(2). No replies shall be filed unless leave is granted from the District Judge. If objections are filed, the parties should use the following case number: CV-20-0285-TUC-JAS.
Failure to file timely objections to any factual or legal determination of the Magistrate Judge may result in waiver of the right of review.