United States District Court, D. South Dakota, Southern Division
LINDA R. PERRIN, Plaintiff,
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY; Defendant.
REPORT AND RECOMMENDATION
VERONICA L. DUFFY United States Magistrate Judge.
Linda R. Perrin, seeks judicial review of the
Commissioner's final decision denying her payment of
disability insurance benefits under Title II of the Social
Security Act. Ms. Perrin has filed a complaint and has
requested the court to reverse the Commissioner's final
decision denying her disability benefits and to enter an
order awarding benefits. Alternatively, Ms. Perrin requests
the court remand the matter to the Social Security
Administration for further hearing.
appeal of the Commissioner's final decision denying
benefits is properly before the district court pursuant to 42
U.S.C. § 405(g). This matter was referred to this
magistrate judge pursuant to 28 U.S.C. § 636(b) and the
October 16, 2014, standing order of the Honorable Karen E.
Schreier, district judge.
Statement Of The Case
action arises from plaintiff Linda R. Perrin's
application for SSDI and SSI benefits filed on December 14,
2012, alleging disability since October 1, 2012, due to
severe degenerative disc disease, bursitis, depression,
Meniere's disease, arthritis, bulging disc, celiac
disease, and migraines. AR 103, 113, 384.
Perrin's claim was denied initially and upon
reconsideration. AR 177, 182. Ms. Perrin then requested her
first administrative hearing. AR 189.
Perrin received an unfavorable decision after her first
administrative law judge hearing on February 20, 2014, and
requested review from the Appeals Council, which remanded the
claim for clarification of the residual functional capacity
(“RFC”) and consideration of new and material
evidence. AR 149, 170, 172.
Perrin's second administrative law judge hearing was held
on October 8, 2015, by the Honorable Denzel R. Busick
(“ALJ”). AR 77. Ms. Perrin was represented by
other counsel at her first hearing and by her current counsel
at her second hearing where an unfavorable decision was
issued on November 27, 2015. AR 8, 31, 56.
One of the evaluation, the ALJ found that Ms. Perrin had not
engaged in substantial gainful activity (“SGA”)
since the alleged onset date of October 1, 2012, and that she
was insured for SSDI purposes through December 31, 2019. AR
Two, the ALJ found that Ms. Perrin had severe impairments of
Meniere's disease, degenerative disc disease - lumbar
spine, and obesity. AR 13.
also found that Ms. Perrin had medically determinable
impairments of obstructive sleep apnea, migraines, and other
headaches, type 2 diabetes, and depression, all of which he
determined were non-severe impairments. AR 13-14.
found that Ms. Perrin's depression caused mild limits in
activities of daily living, social functioning, and
concentration, persistence and pace, and had caused no
episodes of decompensation of extended duration. AR 14.
found that Ms. Perrin did not have an impairment that met or
medically equaled one of the listed impairments in 20 CFR
404, Subpart P, App 1 (20 CFR § 404.1520(d))
(hereinafter referred to as the “Listings”). AR
determined that Ms. Perrin had the residual functional
capacity (“RFC”) to perform:
less than a full range of light work as defined in 20 CFR
404.1567(b) and 416.967(b), as follows: She can lift and
carry 20 pounds occasionally and 10 pounds or less
frequently. She can sit a total of 6 hours, as well as stand
and walk, combined, 6 hours in an 8-hour workday. She has no
limits in reaching. She can climb stairs slowly, with a
handrail, but must avoid working on ladders, scaffolds and
ropes. She can balance frequently but crouch, kneel, stoop
and crawl only occasionally. She has no manipulation limits
with the hands or fingers, no visual limits with glasses, and
no communication limits. She must avoid concentrated exposure
to extreme cold, high heat, humidity, with no exposure
whatsoever to hazards, such as unprotected heights, fast and
ALJ's credibility finding regarding Ms. Perrin's
statements concerning the intensity, persistence and limiting
effects of her symptoms was that they were not
“entirely credible for the reasons explained
herein.” AR 15.
on the RFC determined by the ALJ, the ALJ found that Ms.
Perrin was capable of performing her past relevant work as a
mailroom supervisor and policy holder-information clerk, both
as actually and generally performed, and denied the claim. AR
Perrin timely requested review by the Appeals Council (AR 7)
and submitted additional new evidence that was considered by
the Appeals Council consisting of:
a. S.D. Department of Social Services MAWD Information.
b. S.D. Freedom to Work MAWD FAQ.
AR 2, 4.
Appeals Council denied Ms. Perrin's request for review
making the ALJ's decision the final decision of the
Commissioner. AR 1. Ms. Perrin then timely filed this action.
Plaintiff's Age, Education and Work Experience
Perrin was born in 1960, making her 55 years old at the time
of the denial, and she completed the 12th grade in 1979. AR
ALJ's decision identified Ms. Perrin's past relevant
work as a mailroom supervisor and policy holder-information
clerk, both defined in the DOT as skilled, SVP 6 occupations.
Perrin had earnings in 2013 from Best Buy of $11, 113.93 and
in 2014 from Best Buy of $2, 613.81. AR 337, 354, 365.
Perrin had earnings in 2014 from a bingo hall of $6, 953. AR
Perrin had earnings in 2015 through September of $9, 633.89.
Relevant Medical Evidence
Midwest Ear Nose and Throat
Perrin saw Daniel Todd, M.D., on March 24, 2008, for
complaints of dizziness. AR 604. She reported a family
history of Meniere's disease. AR 604. Ms. Perrin denied
tinnitus or hearing loss. AR 604. Ms. Perrin reported that
the disability associated with the dizziness was severe, and
she constantly had to make adjustment to daily activities due
to the dizziness. AR 604. Associated symptoms included
nausea, falls and tremors. AR 604. Ms. Perrin also reported
headaches. AR 604. Dr. Todd noted a December 17, 2007,
balance test was normal. AR 604. An audiogram revealed normal
hearing in the left ear and mild hearing loss in the right
ear at 250 Hz and 8000 Hz. AR 606. Dr. Todd assessed
Meniere's disease and dizziness and light-headedness. AR
606. Videonystagmography (“VNG”) testing was
scheduled. AR 606.
2, 2008, Dr. Todd stated the VNG looked normal and showed
only some slight vestibular imbalance on the left side. AR
600, 616. Ms. Perrin stated that her balance was still an
issue and had been especially bad the past week. AR 600. Dr.
Todd indicated his overall suspicion was that allergies were
a primary player. AR 600.
Avera McGreevy Clinic
Perrin was seen by her primary care physician, Michelle
McElroy, MD, on May 17, 2012, for her Meniere's disease
and back and hip pain. AR 529. Ms. Perrin reported mild back
pain and bilateral hip pain rated 8, as well as bilateral
knee pain. AR 530. She also reported falling about a month
ago, and partially falling two to three times a week due to
her Meniere's, which caused balance issues. AR 530. Ms.
Perrin reported that pain made it difficult to get up out of
a chair, and it was worse after she walked or stood awhile.
AR 531. Examination revealed tenderness in the sciatic area
and the left trochanter area. AR 531. Ms. Perrin was referred
to Core Orthopedics for further treatment of her hips and
possible additional injections. AR 531. Ms. Perrin weighed
243 pounds at the time of the exam, and Dr. McElroy
recommended she lose twenty more pounds to help with her knee
pain. AR 529, 532.
Perrin was seen on August 7, 2012, for back and hip pain and
she wanted to be checked for fibromyalgia. AR 526. The
reported history noted Meniere's, GERD, celiac disease,
arthritis, headaches, and degenerative joint disease, and
spondolythesis at ¶ 4-5 treated by Dr. Watts with an
epidural injection in 2012. AR 526. The notes indicated that
an MRI had been obtained by Dr. Watts and an epidural given,
which helped with the pain that had been radiating into Ms.
Perrin's legs, but she still had low back pain and sharp
pain in her legs when working long shifts at her job at
Family Dollar. AR 527. She reported her pain was better when
working shorter 8-9 hour shifts, and worse with lifting. AR
527. Once the pain started it lasted for the day and she
walked hunched over. AR 527. Dr. McElroy noted that Ms.
Perrin reported crying easily, feeling down, and was looking
at filing for disability because she was worried she would
end up in a wheelchair if she did not. AR 527. Dr.
McElroy's assessment included chronic low back pain and
depression, and Zoloft was prescribed. AR 527. Dr. McElroy
gave Ms. Perrin a 15 pound lifting restriction and she was
told to restrict her work shifts to 8-9 hours shifts. AR 528.
Ms. Perrin was seen on December 12, 2012, for some sinus
problems the record indicated she was now working part-time
at Best Buy. AR 523.
Perrin was seen on February 25, 2013, for migraines, problems
with her ears, and she was concerned she may be diabetic as
she was thirsty all the time. AR 544, 546. She also reported
sciatic pain with occasional radiation down the legs, and
increased issues with migraines. She had been avoiding
medications, but then reported having flares again. AR 546.
She said she wanted to avoid rebound headaches. AR 546. She
reported her balance was off and she thought she may need a
cane soon. AR 546. Ms. Perrin's gait was normal. AR 547.
Dr. McElroy approved her cane request and recommended a
four-prong cane, found her hgb a1c was slightly elevated and
recommended diet and exercise, told her to keep a headache
journal to look for pattern, and to try flexeril for
headaches. AR 548.
notes to the clinic on February 18, 2013, indicated that Ms.
Perrin no longer had health insurance (AR 553) and in March
she requested that her records be sent to Falls Community
Health. AR 549-50.
Perrin saw Dr. McElroy on December 30, 2013, and reported
headaches, back pain, and trouble falling. AR 576. She
reported worse bilateral back pain with radiation to her hips
and headaches rated 7/10, and she had fallen in the last
three months. AR 577-78. For her history of depression, it
was noted Zoloft (sertraline) worked. AR 578. Ms. Perrin
reported the pain was constant and sharp causing her to break
out in sweats, and she could not work a five-hour shift
without pain even when using tramadol and naproxen. AR 579.
She was only getting 4-5 hours' sleep per night due to
pain and had tried melatonin, but it did not help. AR 579.
She had been at the emergency room in September due to her
headaches, which caused tremors and numbness in her hands,
and she was taking amitriptyline, which reduced the
frequency, but she was still having headaches 3-4 times per
week. AR 579. Ms. Perrin reported only taking Excedrin
Migraine with the worst headaches to try to avoid rebound
headaches. AR 579. She said Dr. Shafer had prescribed
physical therapy, but it had not helped with her headaches.
AR 579. She also reported worsening back spasms and said she
was not lifting anything at work, but needed to sit after
standing only 15 minutes to relieve her back pain, which made
it difficult to work and to do things around the house. AR
579. She said she wanted to stay as active as possible, but
could not even finish her dishes without needing to take a
break. AR 579. Ms. Perrin also reported falling three times
at work, but had not reported it out of fear of losing her
job. AR 579. She said she typically was having 3-4 episodes
per day losing her balance, and very rarely had a day with no
balance episodes. AR 579. Examination revealed that Ms.
Perrin's mood was down, she cried easily, tenderness
across her low back, positive straight leg raise test, and
positive Romberg test. AR 580. Ms. Perrin's gait was
normal, her strength was 5:5 in the upper and lower
extremities, and her deep tendon reflexes were 2 normal in
the upper and lower extremities. AR 580. Her amitriptyline
dosage was increased, and she was told to keep a headache
journal to keep track of frequency. AR 581. Dr. McElroy
restricted her to 5hour maximum work shifts, discussed the
importance of using her cane of proper height, and increased
her dosage of tramadol. AR 581.
Perrin saw Dr. McElroy on March 5, 2014, complaining of
headaches, back pain and falling. AR 689. She reported daily
headaches with light sensitivity and tremors in her hands,
low back pain with radiation to the buttocks making sitting
and standing difficult. AR 689-90. Ms. Perrin reported
falling more despite using her 4-prong cane, and numbness in
her left arm/hand. AR 690. She was still working at Best Buy,
but her hours had been cut. AR 690. Examination revealed
tenderness over paraspinal regions in the L3-5 region, tremor
in the right hand less noticeable when not being observed,
and able to move short distances without her cane, but the
cane was needed when walking up and down the hall with slowed
gait. AR 690. Her strength was 5:5 in the upper and lower
extremities. AR 690. A neurology consult was recommended, but
Ms. Perrin declined due to lack of insurance, and her
amitriptyline was changed to nortriptyline, and hydrocodone
added for pain. AR 691.
Perrin was seen again on May 20, 2014, for follow-up on her
back pain and headaches with continued similar symptoms,
including low back pain radiating to her legs, numbness in
her hands and arms, and daily headaches, sometimes migraines
and sometimes regular headaches. AR 685. She was to continue
using her cane, taking Zoloft for her depression and her
nortriptyline dosage was increased for her headaches. AR 686.
Perrin was seen on July 31, 2014, and her condition and
symptoms continued largely unchanged with some added fatigue,
which Dr. McElroy felt may be due to her medications. AR 679.
She had normal gait, normal deep tendon reflexes, and 5/5
strength in the upper and lower extremities. AR 680. Ms.
Perrin had a left hand tremor more predominant when she
talked about it, but otherwise unnoticeable. AR 680. Dr.
McElroy also noted that she needed a neurology consult but
did not have insurance. AR 680. Dr. McElroy prescribed
Tramadol three times per day, Hydrocodone at bedtime along
with a muscle relaxant, and heat and ice. AR 680.
Perrin was seen on September 11, 2014, complaining of intense
pain rated 10/10 by her right back and right breast, and was
diagnosed with a shingles outbreak and acyclovir was
prescribed. AR 674-76. She continued to use her cane, but had
fallen the prior Tuesday. AR 670. Ms. Perrin stated she took
hydrocodone only at night. AR 670.
McElroy saw Ms. Perrin on December 18, 2014, with ongoing
back pain and headaches. Ms. Perrin also reported right arm
and back pain with hand tremors getting worse, and pain in
her right breast. AR 670.
McElroy assessed her mood as down and noted she cried at
times. AR 671. Dr. McElroy instructed her to continue to use
her cane, again noted that she needed a neurology consult,
and changed her nortriptyline to gabapentin. AR 671-72.
Perrin was seen on January 13, 2015, with ongoing symptoms of
back pain, headaches, and balance problems. AR 802. She
reported multiple falls despite using her cane, and had been
losing her balance more at work, forcing her to sit down
more. AR 803. Her medications were continued and blood
pressure medication was added. Dr. McElroy was concerned that
some of her headaches may be related to high blood pressure
or may have some rebound aspects also. AR 804.
Perrin was seen again on March 4, 2015, and reported ongoing
symptoms and also intermittent numbness in her legs and pain
in her feet. AR 791. She was working part-time at a bingo
hall. AR 791. Her hydrocodone and tramadol medications were
continued for pain and a stress echo was planned due to chest
pain. AR 792-93. The exam notes indicated that Ms. Perrin was
now on South Dakota Medicaid. AR 788.
seen on April 1, 2015, Ms. Perrin had just had her eyes
examined and was told she had the beginning of macular
degeneration, and needed to see a retinal specialist. AR 785.
Perrin had been diagnosed with diabetes some months earlier,
and when seen on June 1, 2015, for back pain and also
bilateral hand and foot pain she felt the hand and foot pain
was from diabetic nerve pain. AR 770, 772. She reported
severe foot and leg pain if she stood longer than a couple of
hours. AR 772. Ms. Perrin also reported some spells lasting
10-30 minutes where she could hear someone talking to her,
but could not understand what the words were. AR 772. Her
gait was slowed, but she was not using her cane at the exam.
AR 772. She continued working on her blood sugars and was
seeing improvement. AR 773. The plan included switching from
gabapentin to Lyrica for her neuropathy, physical therapy for
her back, and a neurology consult for her spells or possible
seizures. AR 773.
Perrin was seen on July 10, 2015, following her neurology
consultation where it was felt her medication combination may
be causing some inflammation. AR 765. Dr. McElroy noted that
Ms. Perrin was depressed, stressed, and she reported she
could only stand 20 minutes at work without needing to sit or
lean on something to help with the back pain. AR 765. Dr.
McElroy noted that Ms. Perrin cried easily and was not
sleeping well. AR 765. She was scheduled for a sleep study,
physical therapy, and Zoloft was changed to Cymbalta for her
depression with a plan for a psychological consult if there
was no improvement. AR 765-66. The timing of her tramadol was
also changed based on the recommendation from the
neurologist. AR 766. Her gait was normal using her cane. AR
766. Ms. Perrin had 5:5 strength in the upper and lower
extremities, and there was no tremor noted. AR 766.
Perrin was seen on August 14, 2015, and reported that the
Cymbalta was helping; she had only had one or two breakdowns,
noting work was stressful. AR 758. She continued to report
back pain, and could only stand about five minutes before
needing to bend to get relief from the pain, and had to bend
and lean on the counter at work, which her employer did not
like. AR 758. She had been going to physical therapy and
using a TENS unit, which had helped some with the back pain
and her headaches. AR 758. Her Cymbalta dosage was increased
and a TENS unit prescribed. AR 759. Under the section,
Additional Plan Details, the exam note stated “2. needs
a note can only work 4 hours max in a day. No more than 4
shifts in a week. Will re-eval in 2 months.” AR 759.
Perrin was seen on August 27, 2015, complaining of abdominal
pain with diarrhea and vomiting, and also reported that her
headaches were coming back. AR 752. She was referred for a
colonoscopy. AR 752. Under the Diet and Exercise section, the
exam note stated under Duration, “60-90 minutes/day
(works 4 days/week for 4 hours. Walks all day at work,
babysits grandkids other days of the week).” AR 751.
McElroy completed a Medical Source Statement regarding Ms.
Perrin's limitations if she were to attempt full-time
sustained work on January 13, 2015. AR 699. In the form Dr.
McElroy indicated she agreed that since Ms. Perrin had not
been working full-time since October 1, 2012, her treatment
notes documented Ms. Perrin's condition at the time of
the examination not what it might have been had she been
working full-time, and also agreed that if Ms. Perrin
attempted sustained full-time work it would have an effect on
her symptoms. AR 699. Dr. McElroy indicated that if Ms.
Perrin attempted full-time sustained work she would be
limited to significantly less than 6 hours sitting per
workday and significantly less than 6 hours standing or
walking per workday, limited to rarely lifting less than 10
pounds, and never lifting more, rarely twisting or stooping,
and occasionally doing repetitive fingering, handling, or
reaching with “rarely” defined as 1%-5% of an
8-hour workday, and “occasionally” as 6%-33% of
an 8-hour workday. AR 700. Dr. McElroy also stated Ms. Perrin
was limited due to her medications, stating, “Has to
use narcotic type pain meds cautiously due to side effects -
has to time them.” AR 701.
McElroy also indicated in the January 13, 2015, Medical
Source Statement that Ms. Perrin had migraines severe and
frequent enough to more than minimally limit her basic work
activities, and when migraines occurred or during the
recovery period following the headache she would be unable to
perform basic work activities for a period of hours, and her
migraines are frequent enough that if she attempted full-time
sustained work they would cause absences or periods of
inability to work more than two days per month. Dr. McElroy
also indicated that to the extent her opinions were based on
subjective input from Ms. Perrin, the reported symptoms were
reasonably attributed to her diagnosis of chronic migraines
and reasonably consistent with available medical signs and
findings, and that she believed, based on her treating
relationship with Ms. Perrin and applying her professional
judgment, that Ms. Perrin's reported symptoms were
truthful and not exaggerated. AR 701.
McElroy also indicated in the January 13, 2015, Medical
Source Statement that Ms. Perrin's use of a cane was
medically necessary due to her medical impairments, and that
if she were to attempt full-time sustained work her medical
impairments would cause her to be absent in excess of two
days per month, her ability to concentrate would decline
through the day due to pain to the point she would be working
at 75% or less of a normal rate by the last two hours of a
workday, and would also routinely be off-task 10% of the time
or more due to pain. AR 702. Dr. McElroy noted that Ms.
Perrin would wear down and exacerbate balance issues and her
pain makes her have to change positions and she cannot stay
in one place for long. AR 702. Dr. McElroy also indicated
that at times lack of insurance and financial limitations
made Ms. Perrin reluctant or unable to seek or obtain care
when needed. AR 702.
August 14, 2015, Dr. McElroy wrote a letter and stated Ms.
Perrin should only work four-hour maximum shifts and only
four shifts per week. AR 911.
September 14, 2015, Dr. McElroy responded to an inquiry and
indicated that the limitations she had previously identified
for Ms. Perrin in the January 13, 2015, Medical Source
Statement were still substantially accurate. AR 904.
October 16, 2015, Dr. McElroy responded to an inquiry about
the effect Ms. Perrin's chronic pain and depression would
have on her ability to work on a sustained full-time basis.
AR 926. Dr. McElroy indicated that Ms. Perrin would be
moderately limited in her ability to maintain attention and
concentration for extended periods (the approximately 2-hour
segments between arrival and first break, lunch, second
break, and departure); moderately limited in her ability to
perform activities within a schedule, maintain regular
attendance and be punctual within customary tolerances; not
significantly limited in her ability to make simple
work-related decisions; and, markedly limited in her ability
to complete a normal workday and workweek without
interruptions from chronic pain or depression symptoms and to
perform at a consistent pace without unreasonable number and
length of rest periods. AR 927. “Moderately” was
defined as an impairment which more than slightly interferes
with the individual's ability to perform the designated
activity on a regular and sustained basis,
i.e., 8 hours a day, 5 days a week, or an equivalent
work schedule, and “Markedly” was defined as an
impairment which results in a substantial loss in the
individual's ability to function independently,
appropriately, or effectively in the designated area on a
regular and sustained basis, i.e., 8 hours a
day, 5 days a week, or an equivalent work schedule.
Perrin was seen by Dr. Watts at Core Orthopedics on June 11,
2012, for bilateral buttock pain radiating down her legs to
mid-thigh. AR 517. She reported constant pain with some
increased pain with standing, and she reported an episode two
months earlier of weakness with difficulty getting out of a
chair. AR 517. Examination revealed point tenderness along
the trochanteric bursa, but was otherwise normal. AR 517.
Pelvis and lumbar spine x-rays were obtained that revealed a
Grade 1 spondylolisthesis of L4-5 with degenerative changes
at ¶ 4-5 and L5-S1, and no degenerative changes were
noted of the hip. AR 517. An MRI was obtained on June 11,
2012, which revealed degenerative Grade 1 spondylolisthesis
of L4-5 secondary to facet arthropathy with minimal
broad-based annular protrusion and no nerve root impingement,
mild central spinal stenosis, mild annular disc protrusions
at ¶ 11-12 and T12-L1 with no impression upon the
thoracic spinal cord, and changes of mild multilevel
degenerative spondylosis and facet arthropathy. AR 516.
Perrin was seen again on June 13, 2012, to review the MRI
results and an epidural steroid injection to L4-5 was
planned, and later administered at Avera McKennan hospital on
June 18, 2012. AR 513, 637. Dr. Watts also restricted her to
no lifting greater than 10 pounds and no working longer than
8-hour workdays for the next month until her condition
hopefully calmed down due to the epidural and her back disc
herniation. AR 513-14.
Falls Community Health
Perrin was seen as a new patient at Falls Community Health on
March 14, 2013, for rectal bleeding and to review her
multiple medical problems. AR 557. She needed to get cheaper
medications and had recently lost her insurance. AR 557. Her
assessments included depression and her sertraline was
refilled. AR 559.
Perrin was seen again on April 18, 2013, after her records
had been transferred to Falls Community Health. AR 556. She
reported that her Meniere's had been worse lately, and
that she had been “hitting the wall most every day at
work.” AR 556. Charles Shafer, M.D., recommended she
get a cane at a pharmacy or a second hand store. AR 557.
Tramadol was prescribed for pain, and her records from Core
Orthopedics were requested. AR 557.
Perrin was seen on June 20, 2013, to discuss her sciatica,
restless leg syndrome, falling problems, and migraines. AR
567. Ms. Perrin also inquired about a handicap sticker for
days when having trouble walking. AR 567. She reported that
she felt the tramadol was helping her get a little more
sleep, her daughter thought she had been moody, so she had
stopped taking sertraline, she was having more migraines
lately, almost daily, and had been taking at least four
Excedrin Migraine daily. AR 567. She also reported that her
back pain had been more of an issue lately. AR 567. Ms.
Perrin's exam findings were largely normal. AR 568. Her
straight leg raising test was negative. AR 568. Her tramadol
dosage was increased to help with her sciatica. AR 568. Dr.
Shafer also directed her to continue using a cane for
balance, and completed a handicap parking form for
intermittent use. AR 569.
Perrin was seen on September 17, 2013, for follow up on her
migraines. AR 565. She had recently been to the emergency
room with right hand tremors, which had not returned since
that time. AR 565. Dr. Shafer prescribed amitriptyline and
physical therapy, which he hoped would help with her MSK
(musculoskeletal) contribution to her headaches, which he
suspected were mainly “tension” type. AR 567.
Perrin was seen on November 18, 2013, for physical therapy
and she reported no upper back pain and no neck pain with any
motion exam. AR 565. She reported having headaches 2-3 times
per week and felt they were migraines and sometimes caused by
her sinuses, but did not think her neck caused her headaches.
AR 565. The physical therapist's diagnosis was migraine
type headaches and that they did not seem cervicogenic in
nature, she had no dysfunction or pain in the neck, and he
also noted chronic low back pain from degenerative disc
disease. AR 565. No physical therapy treatment was planned.
Perrin was seen at Neurology Associates on June 23, 2015, for
spells when she would find someone talking to her, but she
was unable to understand what the words were. AR 733. She
reported that she felt lightheaded and had nausea during the
spells, which lasted 10-30 minutes. AR 733. She also reported
issues with falls, use of a cane for the last year, and
chronic migraines with tremulous following a severe migraine
a year earlier. AR 733. Her exam was largely normal except
her gait and balance, which had a positive Romberg, and she
could not stand unassisted, she ambulated with a cane, her
gait was wide-based, and her sensory was mildly diminished to
vibratory sensation in the feet bilaterally. AR 735. Dr.
Boyle's assessment was that the spells could be partial
seizures, TIA, or migrainous phenomenon; she also had a gait
disturbance likely caused by Meniere's, and diabetic
peripheral neuropathy. AR 736. An electromyography
(“EMG”) showed the beta activity found in the EEG
was likely a medication effect, the episodes of theta
activity was most likely due to alpha hypersynchrony, and
there was no evidence for an underlying seizure disorder or
focal central nervous system lesion. AR 738. An MRI of the
brain was negative. AR 740. A chest x-ray revealed no
cardiopulmonary process. AR 742.
Avera McKennan Hospital
earliest hospital record in the appeal record from July 17,
2008, a perfusion scan, indicated that Dr. McElroy was Ms.
Perrin's treating physician at that time. AR 663.
Perrin received physical therapy treatment due to right SI
joint/hip pain beginning June 4, 2010, and ending with four
sessions on June 14, 2010, with goals met and 95%
improvement. AR 645, 647.
Perrin was given an epidural injection ordered by Dr. Watts
on June 18, 2012. AR 637. During that procedure she reported
that she also noticed some increased pain with prolonged
sitting, and said that the onset was ongoing, but symptoms
had increased recently. AR 636.
Perrin was seen at the Emergency Room on September 14, 2013,
complaining of tremors in her right hand. AR 627. She
reported the tremors had started that day and she had been
having headaches the last two weeks lasting longer than her
migraines typically did. AR 627. She was observed to be
somewhat teary and anxious. AR 627. Examination revealed her
right hand had “almost like a pill rolling
tremor” and with finger-nose it continued. AR 628. The
emergency room doctor noted that when she was engaged it
seemed like the tremor was less and then with attention it
might be a little more, but the doctor was unsure what that
meant. AR 628. Ms. Perrin was given something for her
headache and a head CT was performed after waiting quite a
while that revealed hyperostosis frontalis interna, but was
otherwise normal. AR 628. The tremor resolved and the doctor
felt it may have been an atypical migraine or an incidental
tremor, but he did not think it was a partial seizure. AR
Perrin received physical therapy due to back pain beginning
June 9, 2015, and was using a quad cane at the time due to
balance issues. AR 853. She was working at the bingo hall and
reported limitations with prolonged standing, sitting or
walking and difficulty sleeping. AR 853. The Oswestry back
questionnaire scored 64%, placing her in the severe
disability category. AR 854. She was using her quad cane to
ambulate and was observed to have significant decreased
balance with tendency to lose balance towards side of leaning
and was unable to stand on one leg for more than one second.
AR 854. Ms. Perrin had a positive slump test bilaterally. AR
Perrin was seen on June 26, 2015, at the hospital for a brain
MRI due to spells, gait disturbance and falls, ordered by Dr.
Boyle of Neurology Associates. AR 856-58. The MRI was
negative. AR 860.
Perrin was referred to the Avera Dizziness and Balance Clinic
for physical therapy and treatment of imbalance and falls by
neurologist, Dr. Boyle, beginning on July 8, 2015. AR 876.
She stated she had a long history of increasing balance
issues and falls. AR 876. She stated she was working at
Burnside Game Place. AR 878. The balance exam revealed mild
sway with eyes open, significant sway in all directions with
eyes closed and feet apart, and loss of balance with eyes
closed and feet together. AR 878. The compliant surface test
with eyes open showed mild sway, and with eyes closed loss of
balance in less than 4 seconds, and the single leg stance
revealed significant sway with either foot held one second.
AR 879. Her composite postural stability score was
significantly below expected norm. AR 879. The assessment
found difficulty in all testing utilizing vestibular and
somatosensory input for balance when visual system was
altered by either movement in her visual field, eyes being
closed, or low light situations. AR 880. Ms. Perrin's
dizziness handicap inventory was 38% impairment and her
dynamic gait index was 46% impairment and her rehab potential
was fair to good with limiting factors possibly being her
long-term balance issues. AR 881.
Perrin was discharged from the Dizziness Clinic on August 17,
2015, after four therapy sessions. AR 888. Her balance tests
had all improved and she was ambulating without an assistive
device with no evidence for gait abnormality. AR 889. Her
composite stability score had improved to a normal range and
her dynamic gait index had improved from a significant fall
risk to 4% impairment. AR 889. The notes indicated that Ms.
Perrin reported she was no longer having dizziness or
imbalance related to her vestibular dysfunction. AR 889.
Avera Behavioral Health
Perrin attended counseling on September 15, 2015, and
September 29, 2015, and reported issues coping with her
medical conditions and that her chronic back pain limited her
employment opportunities. AR 914. She reported struggling
with her view of herself and being depressed regarding her
inability to contribute after being limited by her
disabilities. AR 913-14. Cognitive behavioral therapy was
recommended. AR 914. She reported pain due to her back and
headaches, rated 6/10. AR 917.
Pulmonary & Sleep Consultants
Perrin was tested and diagnosed with moderate obstructive
sleep apnea on June 17, 2008, and a CPAP was recommended. AR
Perrin was tested and diagnosed with mild obstructive sleep
apnea on June 30, 2015, and a CPAP was recommended. AR 723.
South Dakota MAWD Program Records
Perrin applied for and was found eligible for the South
Dakota Medical Assistance for Workers with Disabilities
Program (“MAWD”) effective July 1, 2014. AR 704.
The notice also stated she was approved for Medicaid
effective July 1, 2014. AR 704. The MAWD determination notice
stated that the MAWD disability determination team reviewed
the medical evidence and work/social history concerning Ms.
Perrin and found that she could not perform her past relevant
work and a decision of disabled was directed per
“Vocational Rule 200.00.” AR 705. The
determination was ...