The opinion of the court was delivered by: Karen E. Schreier Chief Judge
ORDER REVERSING AND REMANDING THE DECISION OF Plaintiff, Sandra F. Gruseth, moves for reversal of the Commissioner of Social Security's (Commissioner) decision denying her application for social security disability insurance under Title II of the Social Security Act and payment of attendant Medicare benefits under Title XVIII. The Commissioner opposes the motion. The court reverses and remands.
On March 31, 2009, Gruseth filed for Title II and Title XVIII benefits with an alleged onset date of August 1, 1969. AR 148.*fn1 Gruseth's date-last-insured (DLI) was March 31, 1980. AR 156.
The state agency denied Gruseth's claim on May 8, 2009. AR 62. On August 6, 2009, the state agency issued a reconsideration denial. AR 69. Gruseth requested a hearing and submitted additional evidence. AR 71. Administrative Law Judge (ALJ) Donald J. Willy held a hearing on July 12, 2010. AR 21. The case was continued to seek additional medical evidence. AR 25-32.
On October 21, 2010, ALJ John D. Sullivan held a hearing on Gruseth's claim. AR 34. In a written opinion, the ALJ determined that Gruseth was not disabled as of her DLI. AR 10-16. On March 15, 2011, the Appeals Council affirmed. AR 1-3.
Gruseth was born on December 9, 1948, and she graduated from high school in 1967. AR 41. Gruseth has also taken some banking courses. AR 41. Beginning in 1967, Gruseth worked as a deputy in the Register of Deeds office at the Brookings County Courthouse while her husband attended college in Brookings. AR 44. Gruseth worked in that position until she was diagnosed with cancer in 1969. AR 44.
Gruseth also worked full time in 1972 and part of 1973 in a bank. AR 45. She worked in 1977 and 1978, including some full-time work in 1978. AR 47. She was unable to continue working full time because she was absent so often due to health issues. AR 42. She worked a small amount in 1980. AR 47. At some point in time, Gruseth sold Avon products part time and babysat while her husband was in college. AR 44. Gruseth last worked in 1995, when she worked for about three months. AR 182. Gruseth's medical history is described herein as her medical history before her DLI and her medical history after her DLI. I. Evidence Dated Before March 31, 1980 In August of 1969, when she was 20 years old and pregnant, Dr. Donald
Breit diagnosed Gruseth with "very extensive carcinoma of the cervix extending on in to the vagina and with some fixation." AR 475. The cancer was at least stage II and possibly stage III. AR 475. Gruseth did not have a hysterectomy or surgical therapy for her cancer because the cancer was inoperable. AR 217, 475.
In lieu of surgery, Gruseth underwent cobalt and radiation therapy, including a radium implant, from August to November of 1969. AR 475. Dr. Breit administered the radiation and cobalt treatments. AR 473-75. He reported that Gruseth handled the therapies "very well." AR 473.
Dr. Breit referred Gruseth to Dr. Russell Orr to handle the complications from her pregnancy and cancer treatments. AR 473, 475. The radiation killed Gruseth's two-and-a-half-month-old baby. AR 217. The radiation also stopped Gruseth's menstrual cycle. AR 217. By February of 1970, her biopsies showed cellular abnormalities, but these abnormalities were related to the radiation therapy and not the cancer. AR 489.
Gruseth saw Dr. Orr 10 times in 1969, 15 times in 1970, 7 times in 1971, 5 times in 1972, 3 times in 1973, 5 times in 1974, 3 times in 1975, 0 times in 1976, 2 times in 1977, 2 times in 1978, 3 times in 1979, and 2 times in 1980. AR 476-84. Dr. Orr's treating notes are sparse but state that Gruseth suffered from occasional aching, nausea, tiredness, nervousness, spotting when nervous, blurry vision, pain in the legs and arms, headaches bilateral with tightness, headaches with diarrhea, vaginal stricture and stenosis,*fn2 tightness in the vagina, and vaginal adhesions from a reaction to the radiation. AR 476-84. Gruseth received Premarin treatments*fn3 for her early on-set menopause. AR 217.
On June 10, 1978, Gruseth was admitted to Sioux Valley Hospital, where Dr. R. R. Seidel treated her. AR 216. Dr. Seidel noted that Gruseth suffered from migraine headaches, and myalgia, and that she had been treated for cancer. AR 216.
Dr. Seidel noted that Gruseth suffered from two types of headaches. AR 217. First, Gruseth suffered from migraine headaches for the past three to four years. AR 217. Dr. Seidel noted that the frequency of the migraines was decreasing. AR 217. The migraine headaches were severe and caused Gruseth to vomit. A R217. When she experienced a migraine, Gruseth had to lie down. AR 217. Bright lights or loud noises made the migraines worse. AR 217. Gruseth took Excedrin and pain pills prescribed by Dr. Orr to treat the migraines. AR 217.
Second, Dr. Seidel noted that Gruseth suffered from sinus headaches. AR 217. At the time of her appointment with Dr. Seidel, Gruseth's sinus headaches had been present for two years. AR 217. The sinus headaches manifested as a swollen feeling behind Gruseth's eyes. AR 217. She also felt pressure with those headaches. AR 217. Gruseth often treated the sinus headaches with Alka-Seltzer. AR 217. Dr. Seidel suggested that Gruseth try Novahistine or Dimetapp for her sinus headaches. AR 219.
Dr. Seidel also noted that Gruseth had suffered from muscle aches for approximately three months as of June 10, 1978. AR 217. The pain did not involve the joints but rather was a constant, steady aching. AR 217. Dr. Seidel stated that this was a "myalgia type feeling[.]" AR 219. Dr. Seidel prescribed four to six aspirins a day for the myalgia. AR 219.
Dr. Seidel further noted that Gruseth had suffered from "colitis*fn4 type symptoms," but she was not experiencing diarrhea at that time. AR 217. Dr. Seidel noted that Gruseth's bowel sounds were "normal in regards to frequency and pith. No abdominal bruits heard." AR 218.
On December 10, 1977, Dr. M.F. Petereit saw Gruseth after she fell down some stairs. AR 233. In determining whether Gruseth fractured or broke any bones, Dr. Petereit noted that Gruseth's "bones appear a little osteoporatic for patient's age." AR 234.
II. Evidence After March 1, 1980*fn5
After March 1, 1980, Gruseth continued to seek medical treatment for her chronic diarrhea, vaginal atrophy with associated urinary problems, colon stricture, and pelvic adhesions, which caused her abdominal pain. AR 259, 270, 440-41. Gruseth's medical treatment regarding these issues is set out in reverse chronological order according to each medical professional who saw her.
Dr. Christopher Hurley performed a colonoscopy on Gruseth on June 25, 2007. AR 273. He noted that "[i]n the region of the rectosigmoid junction there was slight stricturing of the colon and there was a somewhat fixed sensation to the distal sigmoid colon and rectosigmoid region[.]" AR 273. The biopsies from that colonoscopy were returned as benign. AR 274.
On July 22, 2009, Dr. Troy Schmidt, a gastroenterologist, evaluated Gruseth "for follow-up evaluation of painful defecation, loose stools, and hematochezia."*fn6 AR 248. Gruseth complained of continued diarrhea and "rather significant pain, and a burning sensation in the perineum and/or rectal area." AR 249. Gruseth told Dr. Schmidt that it was not uncommon for her to see blood in her stools or in the toilet water. AR 249. Gruseth reported that she has a bowel movement after almost every time she eats. AR 249. For example, Gruseth told Dr. Schmidt that she had recently eaten a hamburger and a baked potato at a restaurant. AR 249. She had three bowel movements before leaving the restaurant and another six bowel movements when she returned home. AR 249. While eating makes her bowel movements worse, she will have bowel movements even when she is fasting. AR 249. Gruseth reduced her oral intake of food, but she continued to gain weight. AR 249. Gruseth stated that it hurts her to sit or walk for 15-20 minutes after a bowel movement. AR 249.
Dr. Schmidt noted that Gruseth's baseline for diarrhea was five bowel movements a day but that baseline had recently increased. AR 249.
Dr. Schmidt stated that Gruseth has "chronic problems with diarrhea."
AR 250. He noted that, in the past, "there had been some concern that
diarrhea might be related to radiation enteropathy,"*fn7
and that "[w]e know that she has radiation
proctopathy."*fn8 AR 250. He opined that her pain,
diarrhea, and bloody stools could be due to persistent radiation
proctopathy, inflammatory bowel disease, and/or internal hemorrhoids.
AR 250. Gruseth agreed to an upper endoscopy and colonoscopy at the
conclusion of the visit. AR 250.
On August 3, 2009, Dr. Schmidt performed a colonoscopy. AR 252. He noted that Gruseth's internal hemorrhoids were "very minor." AR 253. He encountered difficulty in maneuvering the equipment through parts of Gruseth's colon, especially in the sigmoid region. See AR 253 (stating that Dr. Schmidt encountered "considerable resistance" in performing the procedure in the sigmoid region). Dr. Schmidt observed that "[c]olonoscopy was unusually difficult secondary to sigmoid stenosis." AR 254. He noted that "[t]he entire colonic and rectal mucosa are normal except for some granularity in the sigmoid region and some scarring in the rectum." AR 253. He found "severe sigmoid stenosis related to previous radiation therapy and cobalt therapy." AR 254. The results of the biopsies taken during the colonoscopy were either within normal limits or benign. AR 258.
During an August 17, 2009, appointment, Dr. Schmidt noted that Gruseth suffered from osteoporosis, chronic, intermittent diarrhea, and severe sigmoid stenosis related to radiation and cobalt therapies. AR 264. Regarding her diarrhea, Dr. Schmidt noted that Gruseth has to spend about half an hour on the toilet every time she has a bowel movement, and that Gruseth's diarrhea is worse when she eats beef, fresh fruits, or fresh vegetables. AR 265. Gruseth reported that she has intermittent episodes of rectal pain, but her rectal bleeding was improving. AR 265. Because she had "maximal radiation exposure for treatment of her cervical cancer," Gruseth stated that she had been advised to avoid any unnecessary radiation unless it was absolutely necessary. AR 265. Thus, she declined Dr. Schmidt's suggestion that she undergo a CT enterography. AR 265. Dr. Schmidt was unsure of the reasons for her bowel issues but could not "yet exclude the possibility that some of her symptoms are related to the abnormal sigmoid anatomy." AR 265.
In the impressions section of the August 17, 2009, medical record, Dr. Schmidt noted Gruseth suffered from chronic diarrhea. AR 265.
Dr. Schmidt had not yet "found any specific cause for her diarrhea." AR 265. He stated that he was "not yet convinced that treating this will bring about resolution of symptoms[.]" AR 265. Dr. Schmidt suggested that Gruseth undergo a small bowel examination. AR 265.
On August 19, 2009, Gruseth underwent a small bowel study. AR 262. The examination showed a "tiny sliding hiatal hernia" in the lower half of the esophagus. AR 262. The examination further showed a rapid small bowel transit time of 20 minutes. AR 263. The study was otherwise unremarkable. AR 263.
On September 30, 2009, Dr. Schmidt saw Gruseth and discussed the
results of Gruseth's colonoscopy. AR 377. Dr. Schmidt noted that
Gruseth tested positive for the helicobacter pylori*fn9
antibody, and he placed her on a Prevpac therapy course. AR
377. The biopsies collected during the colonoscopy were within normal
limits. AR 377. Dr. Schmidt again noted that Gruseth had "[s]evere
sigmoid stenosis related to previous radiation therapy and cobalt
therapy." AR 377. He further noted that she might have some
intestinal bacteria growth, but she was not receiving any treatment for this
condition. AR 377. Dr. Schmidt noted that since her last visit, she
had been taking the prescription drug Elavil, which was improving her
symptoms. AR 378. In the impressions section of the September 30
record, Dr. Schmidt stated that he thinks Gruseth "has diarrhea
predominant irritable bowel syndrome. Thus far, we have not found any
other signs for inflammatory bowel disease, significant colitis and/or
radiation proctopathy, malabsorptive process, etc." AR 378.
On December 8, 2009, Gruseth again saw Dr. Schmidt for a routine evaluation. AR 375. Gruseth reported that Elavil was alleviating ...