United States District Court, D. South Dakota, Southern Division
NEIL T. LARSON, Plaintiff,
ANDREW SAUL, Commissioner of the Social Security Administration; Defendant.
MEMORANDUM OPINION AND ORDER
VERONICA L. DUFFY, UNITED STATES MAGISTRATE JUDGE.
Neil T. Larson seeks judicial review of the
Commissioner's final decision denying his application for
disability insurance benefits under Title II and supplemental
security income under Title XVI of the Social Security
Mr. Larson has filed a complaint and now moves to reverse the
Commissioner, requesting the court to reverse the
Commissioner's final decision denying him disability
benefits and to grant an award of benefits outright without
remanding to the agency. In the alternative, Mr. Larson seeks
an order reversing and remanding to the agency for a de
appeal of the Commissioner's final decision denying
benefits is properly before the court pursuant to 42 U.S.C.
§ 405(g). The parties have consented to this magistrate
judge resolving the case pursuant to 28 U.S.C. § 636(c).
Based on the facts, law and analysis discussed in further
detail below, the court remands for further consideration at
the agency level by the Commissioner.
Statement of the Case
record shows Mr. Larson filed prior Social Security
disability claims in January 2005, June 2008, and June 2009.
AR103. On November 18, 2010, an ALJ denied Mr. Larson's
claims from 2009. AR65-75. Mr. Larson did not appeal the
ALJ's unfavorable decision on November 18, 2010. AR264.
current claim begins with Mr. Larson's filing for
disability insurance benefits (“DIB”) and
supplemental security income (“SSI”) benefits on
May 25, 2011, alleging disability since August 15, 2007.
AR225, 232. The state agency denied his claim on July 26,
2011, (AR25) and after reconsideration on March 12, 2012.
AR132, 135. The case went to hearing before an administrative
law judge (“ALJ”) on March 20, 2013. AR10.
April 2, 2013, the ALJ denied the claim. AR20. Mr. Larson
requested Appeals Council review, submitting additional
medical evidence. AR314-18. On August 21, 2014, the Appeals
Council made the evidence part of the record (AR4) but
“found no reason under our rules to review the
Administrative Law Judge's decision … This means
that the [ALJ's] decision is the final decision of the
Commissioner ….” AR1.
Larson was born in 1970. AR225. He was adopted at three weeks
of age. AR556. Circumstances of his birth and congenital
defects are noted at ¶ 359, 511, 514, 556 and elsewhere
in the record. He grew up on a farm near Beresford. AR399. He
felt that he did not fit in at home or at school and was
teased and bullied all his life. AR398, 556.
Larson was 1.5 credits short of the number needed to graduate
from high school and has a general equivalency degree
(“GED”). AR556. He started but dropped out of a
course in architectural drafting and building construction at
Mitchell Technical Institute. AR399, 1197. He started an
electromechanical technology course at Southeast Technical
Institute, dropping out in 1994. Id.
technical school, Mr. Larson went to work for Tomacelli's
Pizza. AR277. During the next 13 years, he worked mainly as a
pizza-delivery driver, typically part-time, often holding two
jobs. AR269, 243-45. From 1995-2000, he worked for Little
Caesar's. AR269, 277. He worked for Denucci Pizza from
1997-99. AR269, 277. In 1999-2000, he painted commercial
grain dryers. AR277, 284. From 2000-04 he worked for Papa
John's Pizza. AR277. From 2004-06, he worked for Quiznos,
a sandwich shop. AR277, 1998. At the same time he worked for
Pizza Hut. AR244-45, 277. In 2007 he worked part-time for
Pizza Hut. AR245, 269.
Larson has not worked since 2007, except for taking people to
their appointments one or two hours per month. AR40, 277,
723, 789-90, 1157, 1165, 1167, 1178, 1180.
Larson did not know his family medical history. AR326, 514.
He was born “with eyes pointing out, ” had
surgery and still had a lazy left eye. AR514, 539. He gave
inconsistent dates of surgeries: an undescended left testicle
was repaired in 1978 or 1983 (AR511, 514); in 1992 or 1993 he
had left orchiectomy for testicular cancer. AR511, 514.
Medical Evidence Pre-2009
Larson was seen at the Avera emergency room on November 14,
2007, not feeling well; his initial blood sugar level was
409. AR1669. After he was given insulin, his blood sugar
level dropped “218, adequately controlled.”
Larson was admitted to Avera through the emergency room on
September 19, 2008, for acute poorly controlled diabetes,
hyperglycemia with blood sugars running high the last six
weeks despite his attempts to control the level with insulin
and diet modification. AR1651, 1658. His blood sugar was 424
on the day of admission, and his liver function tests were
elevated. AR1651. The emergency room staff requested a
psychiatric consult, but Mr. Larson asserted he had no
problems with anxiety or depression. AR1651. Mr. Larson also
reported episodic tingling sensations in his fingers and
feet. AR1652. A noninvasive Doppler was obtained of Mr.
Larson's right leg due to pain which revealed
insufficiency right posterior tibial with superficial
varicosities in the right calf, has flow when compressed, low
probability for clotting. AR1660. Mr. Larson was discharged
on September 22, 2008, but the discharge report was not
included in the Avera records. AR1655, 1663-65.
Medical Evidence 2009
Larson received medical care at Falls Community Health
(“Falls Clinic”), where he reported being a
patient since 1992. AR273. On November 27, 2009, he was on
TriCor22, Flonase, Actos, Cozaar, two kinds of insulin
(regular and NPH pork), and Crestor. AR361. On December 29,
2009, he had multiple allergies, home glucose readings that
ran 140-150, and a record of elevated blood pressures. AR358.
Mr. Larson reported he felt “well.” AR358. He had
peripheral vascular disease, varicose veins, diabetes,
“trouble with his knees and back, ” and migraine
headaches “where he loses mental and visual
focus.” AR359. In December 2009, his blood pressure was
146/108, and diabetes was uncontrolled and uncomplicated.
Medical Evidence 2010
January, Mr. Larson treated at Falls Clinic and advised that
he was “going to get back on diet and dailey [sic]
exercise to try to bring sugars down.” AR358. In July,
Judy Jacobsen, Falls Clinic physician assistant, prescribed
Trazodone for Larson's inability to sleep more than one
to four hours at night. AR351-52. She recorded complaints of
radiating low back pain, with little relief from chiropractic
care. AR356-46. She noted difficulty rising from a sitting
position. AR346. The glucometer reported blood sugars from
60-400. Blood pressures were high. Id. Ms. Jacobsen
noted Mr. Larson had run out of and was not taking his blood
pressure medication, and he was not working on exercising.
AR351. In December, triglycerides, Glucose, BUN, Creatinine,
and A1C were elevated. AR362-63.
Medical Evidence 2011
March 2011, Wallace Fritz, M.D., at Falls Clinic noted three
to five blood sugar checks daily and “runs from 70-400.
At waking, 140; fluctuates after meals. … Has trouble
sleeping, insomnia, restless leg syndrome, OSA, has multiple
complaints of neighbors being loud etc that cause him to be
unable to sleep. He does not follow sleep hygiene and has
tried both trazedone and ambien with minimal results.
Resistant to any change suggested.” AR341. He has
dyspnea that Larson said was due to lack of exercise.
Id. Habits were “not exercising regularly,
exercising erratically, and sedentary tries to walk daily, 15
minutes. Goes to Walmart 1-2 weekly for exercise.”
AR342. He felt “tired or poorly.” Id.
Assessment: “Primary diagnosis of type 2 diabetes
uncomplicated, controlled, Hypertension, Hyperlipidemia, and
Type 2 diabetes - uncomplicated, uncontrolled.” AR343.
Dr. Fritz recommended ACE inhibitors and HMGCoA reductase
inhibitors, and he added Hydroclorothiazide30-Lisinopril 12.5
mg-20 mg, and Lisinopril 20 mg to Larson's regimen.
Id. Ambien could be considered for insomnia if
available on the PAP. Id.
April 26, 2011, Mr. Larson sought treatment at Sanford
Medical Center emergency room for chest tightness, mild
shortness of breath and palpitations “after eating a
large lunch with beans.” AR326. Hannah Hall, M.D.,
recorded: “Patient states that normally he develops
some chest discomfort and palpitations described as a fast
and strong heart beat after eating but that they normally
only last a few minutes …. He also complains of
feeling dizzy … similar to when his blood sugar runs
low….” However, he had checked his blood sugar
and it was 119. Id. He said his heart rate was
usually in the upper 90s to 100s but on this day was in the
120s. Upon arrival, chest pain had resolved; dizziness and
nausea persisted. Id. The patient was on two kinds
of insulin plus Pioglitazone, two statins and two
antihypertensive medications. AR327. He had gained 40 pounds
in the last year. Id. He weighed 280 (BMI 41.35).
AR328. Mr. Larson stated “his blood sugars are well
controlled and he can easily feel his lows.” AR328. The
ECG was “borderline” with heart rate 126
(tachycardia), probable left atrial abnormality, borderline
T- wave abnormalities in the inferior leads, T-wave
abnormalities involving the lateral leads, and isolated Q
wave in III. AR323. The laboratory reported elevated blood
urea nitrogen (BUN) and D-dimer. AR329-30. Glucose and
Troponin POC were normal. AR332. “[C]ardiac risk
factors include[d] HTN, DM, dyslipidemia and obesity.”
AR330. Computerized tomographic angiography (CTA) of the
chest ruled out pulmonary embolism. AR320. Mr. Larson did not
want a cardiology referral ….” AR330. The plan:
“Discharge to home. Call FCH [Falls Community Health]
for prompt follow-up and to discuss options for further
cardiac evaluation ….” Id.
April 28, 2011, Dr. Fritz noted Mr. Larson “had a
negative cardiac workup and eventually a CTA which was
negative. Feeling better now but continues to have some left
shoulder pain, which he feels is secondary to sleeping on it
wrong and some mild dizziness, although this is
improved.” AR338. Blood sugars ranged from 150-250 and
occasionally went to 400. Id. He could
“somatically feel” sugar changes and manage them
with insulin and rechecking his blood sugar. Id.
Blood pressure was 148/100 and 146/98; he weighed 293. AR339.
His A1C was 8.8. AR339, 367. Dr. Fritz diagnosed
“uncomplicated, controlled” type 2 diabetes and
lower back pain; he offered no new treatment plan. AR339.
29, 2011, Dr. Fritz said glucometer readings ranged from the
60s to 450s. AR368. Mr. Larson had difficulty sleeping even
on Ambien and Trazodone: “Sometimes will sleep for
12-15 hours straight and then other days 2-3 is all he gets
for the day. Is not very active at all.” Id.
He weighed 300 pounds. Id. Dr. Fritz adjusted Mr.
Larson's insulin, recommended Melatonin for sleep,
discussed sleep hygiene, and encouraged Mr. Larson to
increase his activity. AR369.
August 14, 2011, Mr. Larson sought ER treatment for headache,
dizziness, and chest discomfort with shortness of breath. He
thought he got these symptoms with elevated blood pressure;
it was 167/87. AR393-94. He told CNP Augspurger that
“normal BP is 160s.” AR393. He had shortness of
breath, chest discomfort, dizziness and headaches. AR394. He
reported no musculoskeletal problems. AR394. Physical exam
was normal, and the ECG showed “significant rhythm
changes, ” severity “normal.” AR395. He did
not see a physician, and a cardiology referral was completed.
August 19, 2011, Mr. Larson saw Ms. Jacobsen. AR370. She
noted the ER visit for chest pain and dyspnea. AR370. HGMs
were 50-350, and cardiology workup was scheduled.
Id. He was “feeling tired or poorly, ”
had urinary frequency and nocturia. Id. He weighed
285 pounds. Id. He had insomnia. Diabetes was
“uncomplicated, controlled.” AR371. The lab
reported A1C of 9.2. AR367. Ms. Jacobsen wrote a letter
telling Mr. Larson to increase insulin to 60 units in the
morning and 40 in the evening, and “have cardiologist
send us MRs.” AR371.
August 24, 2011, Mr. Larson's nuclear stress test was
negative. AR381. The 2-D echocardiogram revealed mild left
ventricular hypertrophy, mildly enlarged left atrial chamber,
probably enlarged right atrial chamber, trace of tricuspid
regurgitation, mild pulmonary hypertension, and ejection
fraction of 65 percent. AR384.
October 9, 2011, Mr. Larson presented to the emergency room.
AR377. Christopher J. Carlisle, M.D., noted “Pt with
very depressed affect called an ambulance for anterior c/p of
2h duration. He's been w/u through myoview stress test to
date with neg results … [H]e … thinks it might
be stress related and … this is what he was told after
his stress test last month.” Id. Dr. Carlisle
noted Mr. Larson's ECG was unremarkable. AR378.
Assessment: “Ongoing problems with [chest pain],
possibly due to anxiety; no evidence of cardiac [disease].
[Patient] seems resigned to this; almost matter-of-fact in
discussing it.” AR378.
Medical Evidence 2012
April, 2012, Mr. Larson presented at the hospital with
“generalized shakes today after waking up this morning.
Patient states he drank a lot of caffeine last night and this
morning found blood sugar to be markedly elevated.”
AR406. He did not take his insulin but came to the emergency
room. AR406. He denied chest discomfort but felt “a
little sob which is also typical for him with these episodes.
He thinks he just drank too much coffee.” Id.
Physical and neurological exams were normal. AR406-07. The
ECG was negative. Chest x-ray showed “mild CM”
(AR407), unchanged from April 2011 AR413. Glucose was 326.
AR407. The patient declined further workup, was anxious to go
home and was discharged. AR408.
October 19, 2012, Mr. Larson was hospitalized for diabetic
ketoacidosis. AR421. He presented with nausea, vomiting and
lightheadedness. AR415. He told Christopher Wong, M.D.:
“he gets like this every couple months … usually
associated [with] high or low sugars.” Id. He
took six units of insulin after finding his sugar was 292; it
helped. He checked his blood pressure (170/112) and pulse
(126). Id. He reported mild chronic shortness of
breath, nausea, lightheadedness, and chronic low back pain.
AR415-16. Darren Manthey, M.D., evaluated Mr. Larson and said
he had intermittent chest pressure, was tremulous, anxious,
and tachycardic. AR419. “My initial assessment …
established that Neil Larson has DKA [diabetic ketoacidosis],
which requires immediate intervention … [H]e is
critically ill.” AR421. An ECG showed sinus tachycardia
and significant rhythm changes. AR417, 419, 445. The lab
reported elevated WBCs (abscessed tooth was diagnosed after
admission) (AR429-30), Glucose (364), BUN (22), and Anion gap
(24). AR417. Chloride and CO2 were decreased. AR419-20. His
eGFR was 77 initially (AR441) and rose to 90. AR440.
Hypertriglyceridemia was present. AR436. Acetone (serum
ketones) was elevated at 1.58. AR440. Thane Gale, M.D.,
recorded a “long history of awakening from sleep with
SOB and tachycardia, easily falls asleep in daytime.”
AR430. The patient used smokeless tobacco and drank about 120
ounces of alcohol a week. AR431. Blood pressure was 151/97,
pulse 102, weight 190, and O2 saturation 92%. AR432. Physical
exam was normal and the patient was alert and oriented.
AR431. Diagnoses: Diabetic ketoacidosis - causing nausea,
vomiting and lightheadedness; hypertension; questionable
sleep apnea; and hypertriglyceridemia with history of
pancreatitis. AR436. The Pulmonary Function Lab found
intermittent sleep desaturations, and recommended
polysomnography if clinically indicated. AR444.
October 23, 2012, Mr. Larson was discharged by Tara Geis,
M.D. AR422. Mr. Larson was provided diabetic information
sheets that explained that being sick could raise blood
sugar. Signs and symptoms of low blood sugar, or
hypoglycemia: shaky, fast heartbeat, sweaty, dizzy, anxious,
hungry, blurry vision, weak or tired, headache, nervous or
upset. Signs and symptoms of high blood sugar, or
hyperglycemia: blurry vision, weak or tired, increased
thirst, increased hunger, and urinary frequency. AR424-25.
Dr. Geis advised that Mr. Larson could “[r]esume normal
activity” upon discharge. AR424.
December 28, 2012, Mr. Larson was hospitalized. AR465. He had
“very vague complaints, mild chest discomfort,
difficulty breathing, rapid heart rate, lightheadedness for 2
days but worsening during his episodes of dyspnea, feeling
very fatigued.” AR469-70. He reported night sweats,
nightmares, and insomnia. AR470. He had slept an hour the
night before, began having vague chest complaints at about 1
pm, “but was fine doing activities around his house
….” AR470. “Patient has poorly controlled
DM, on insulin, A1C is usually around 9.5 …. Has had
multiple bouts of DKA [diabetic ketoacidosis] … and
has been in the ICU for pancreatitis in the past.”
Id. He had “anxiety which he admits could be
playing a role in this.” His O2 saturation was 91
percent with heart rate in the 110s. Id. Review of
systems was positive for fatigue, night sweats, sleep
disturbance, anxiety, shortness of breath and wheezing, chest
pain and palpitations, dizziness. AR470-71. On physical exam,
peripheral pulses were reported as both “normal”
and “diminished.” Varicosities were present.
AR479. Laboratory abnormalities were consistent with his
typical pattern. AR472-73. But D-dimer and troponin I were
elevated. AR487. The ECG showed sinus tachycardia. AR475. The
CTA revealed thyroid abnormality, fatty liver with calcified
lung nodule, and gallbladder calculi. AR490. Mark List, M.D.,
“considered that this is simply anxiety/panic attacks
but with elevation of troponin and risk factors needs further
workup.” AR475. Because of his history of DVT and
elevated D-Dimer, “will check bilateral LE
dopplers.” The patient “does not appear to be in
DKA although wonder about chronicity of acidosis with
compensation.” AR476. During Mr. Larson's first
night in the hospital, Glucose was critically elevated at
439. AR485. At 02:55 hours, Glucose persisted at 415. BUN was
elevated at 29. AR485.
next day, December 29, 2012, Mr. Larson had a cardiology
consult with Tomasz Styz, M.D. AR452. He had a history of
“rest cp suggestive of unstable angina, ECG with subtle
changes, enzymes negative.” Id. He had
Troponin elevation. The patient described chest discomfort
with shortness of breath the day before. He thought it was an
insulin reaction but it wasn't. Id. “He
did have a negative stress test about 1 year ago. He is
sedentary and very limited functionally by back pain. States
he has trouble standing for periods of time due to pain in
back and leg swelling.” Id. Cardiac risk
factors included “DM (since pancreatitis in 2002), HTN
and dyslipidemia.” Id. He drank about 120
ounces of alcohol per week. AR453. On review of systems, Mr.
Larson had “ cough, ” “ shortness of
breath, ” and chest discomfort or mild dyspnea on
exertion. AR454. On physical exam he appeared anxious. He had
diminished peripheral pulses in both feet and varicosities.
Id. The laboratory reported abnormal white cells,
Glucose 232 and BUN 29. AR454-55. Since he could not
“walk on T due to significant back issues, ” he
would have a “lexi stress” test. AR455. Before
Lexiscan injection, he had nonspecific ST-T changes; these
did not change during the injection. Resting left ventricle
ejection fraction was 56 percent; the stress “LV
EF” was 52 percent. AR458, 507. During the injections
he reported “[n]o symptoms suggestive of angina.”
AR507. The study was “equivocal.” Perfusion
images demonstrated a small defect involving the apical
wall(s) that appeared partially reversible. AR458. Venous
Doppler studies revealed an “incompetent 88 ms GSV
Junction, ” diagnosed as superficial venous
insufficiency in the right lower extremity. AR460. Orvar
Jonsson, M.D., ordered lab studies. AR483. Larson's eGFR
was low at 57. BUN and Creatinine were elevated. AR483. Dr.
Jonsson ordered cardiac catheterization with possible
angioplasty. AR481, 482. Cardiac catheterization and
angiogram were accomplished on December 31, 2012. AR494-95.
Thomas Stys, M.D., reported findings: the LAD (left anterior
descending artery) had 30 percent stenosis of the mid LAD and
diffuse, up to 80 percent, stenosis of “small vessel
distal LAD.” There was 30 percent ostial stenosis of
the circumflex and 20 percent distal stenosis of the right
coronary artery. AR495-96. Dr. Stys diagnosed “Small
vessel disease.” AR496. He recommended medical therapy.
AR502. Tracy Davies, M.D., wrote the discharge summary,
noting “multiple risk factors for heart disease
including uncontrolled diabetes, hyperlipidemia, and
obesity.” AR465. “Cath showed stenosis of smaller
lateral vessels and no stenting was performed.” She
noted “multiple bouts of DKA over past couple of years
and has been in the ICU for pancreatitis in the past.”
AR468. She said hypertension was moderately well controlled
on lisinopril and HCTZ, and high cholesterol was “well
controlled on Statin.” Id. In the same note,
Dr. Davies stated “Hyperlipidemia with triglycerides
>600. Mr. Larson is already on the max dosing of Crestor
and Tricor. He states he is compliant … [T]his is a
significant risk factor for cardiac disease and his
medications are optimized, so he needs to change his diet.
Again, this was met with much resistance and many
excuses.” AR466. He was unwilling to stop drinking.
Fish oil would be added to his medications and the primary
care provider could make further changes. AR466. Dr. Davies
talked to Mr. Larson about his cardiac risk factors. His
“excuses” were “mostly related to money and
agoraphobia” as to why he could not change his diet or
exercise. AR465. Discharge diagnoses on December 31, 2012,
were chest pain, right lower lobe pneumonia, diabetes
mellitus, hypertension, hyperlipidemia, and GERD. AR465.
Medical Evidence 2013
January 14, 2013, Ms. Jacobsen recorded ongoing back pain and
the patient's statement that chiropractic treatment
helped for “only a day anymore.” AR462. She noted
muscle spasm. “No money for MRI which we discussed on a
previous visit. Pain radiates down both legs and both legs
will feel numb.” Id. Regarding his recent
hospitalization, she stated “Cardiology work up
good.” Id. His musculoskeletal system was
“normal, ” he was able to twist his torso, and he
had no neurological deficits. AR463. She renewed Naproxen and
said he should exercise more. Id.
Larson was seen at the Physicians Vein Clinic in July, 2013,
for some “significant” symptoms in the veins of
both legs. AR1421. Treatment was delayed due to lack of
October, 2013, James Dickerson, Ph.D., administered a battery
of tests during neuropsychological evaluation, including
Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV)
Wide Range Achievement Test 4 (WRAT 4), Wechsler Memory
Scale-Fourth Edition (WMS-IV) and Halstead-Reitan
Neuropsychological Battery. AR558. The evaluation started at
9:00 a.m. and lasted until 7:00 p.m. and included a one-hour
clinical psychological/psychiatric interview. AR559. He found
much variability in Mr. Larson's scores. AR59-60.
Processing speed was 4th percentile. AR559. “This
extremely low score is attributed to two scores …
involving hand-eye coordination.” Id. He was
an “impaired verbal learner, ” in the second
percentile, which is important because “most learning
on the job is given verbally.” AR560. Mr. Larson's
ability to remember any new verbal learning later or after 30
minutes would be equivalent to an IQ score of 70. AR560. Mr.
Larson was a much better visual learner with scores from the
77th to 99th percentile. AR561. On the Halstead-Reitan
Battery, Mr. Larson failed four of seven tests “for an
Impairment Index score of .57 indicating near certain brain
dysfunction.” Id. Dr. Dickerson diagnosed:
Dementia due to Organ Failure and Encephalopathy, as well as
panic disorder with agoraphobia and dysthymia. AR563. Dr.
Dickerson reference a 2013 New England Journal of Medicine
report that “survivors of critical illness often have a
prolonged and disabling form of cognitive impairment that
remains inadequately characterized. Longer duration of
delirium was associated with worse global cognition and
executive function scores.” AR564. Dr. Dickerson also
noted behaviors that “seem ingrained and dysfunctional
but largely unconscious” reported by Mr. Larson's
parents: He was “hyper - but doesn't follow through
and doesn't seem able to get necessary things done, for
example, a re-application for food stamps.” AR554.
“In the most basic social and occupational
responsibilities, like showing up on time for a job,
appointments, he has a great deal of difficulty planning his
time …. He has great difficulty organizing and
planning a day …. He doesn't seem able to set
goals and plan the steps to achieve them. He has trouble
transitioning, shifting gears, and may be come angry when
‘interrupted.' ” AR554-55. The parents
reported, “His sleep pattern is very fitful and
disturbed. He shops at night at Wal-Mart and HyVee around
2:00 a.m. to 5:00 a.m. to avoid crowds.” He wanted to
please, and seemed to be good with children and animals, but
otherwise did not seem to have any special strengths.
Id. He had always had trouble making friends.
Id. He did not date or socialize with females.
Id. He was the product of incest between an
18-year-old brother and 14-year-old-sister. He discovered
this when he was 23. AR556. Mr. Larson himself stated that
“he felt that he did not fit in at home and felt that
way to some extent while in school.” AR556.
Dickerson noted that Mr. Larson's “grip strength
[testing] scores overall were normal for his age.”
Dickerson assessed Mr. Larson's GAF at 46 and opined that
Mr. Larson could not perform the 209.687-026 Mail Clerk Job.
AR570. He explained that on the GATB/SAGE Test a successful
mail clerk is to have general learning ability and verbal
ability equal to the middle third of the working population,
and the reading and sorting of each new piece of mail is a
new unique verbal learning task. The task that best measures
that ability neuropsychologically is on the Weschler Memory
Scale 4 called verbal paired associates 1 and 2, and Mr.
Larson had a scaled score of 5, or bottom 10% on part 1, and
a score of 4 or bottom 2.5% on part 2. AR570. Dr. Dickerson
also noted problems meeting the motor coordination, finger
dexterity and manual dexterity for the job. AR570. Dr.
Dickerson's background included a Masters and PhD in
Rehabilitation Counseling Psychology. AR565. His work
experiences included administering more than 700 VA
Disability Evaluations and 200 Social Security Disability
Evaluations. AR565. Dr. Dickerson also worked as a job
placement interviewer and employment counselor where he
tested job applicants to assess vocational and educational
skills, and provided career counseling and job placement and
requires use of the Dictionary of Occupational
Titles and related vocational materials. AR566.
Larson saw PA Jacobsen for a diabetes check on November 1,
2013. AR1448. The record noted that neuropsych testing had
revealed some organic brain syndrome and Mr. Larson was
applying for SSI. AR1448. Mr. Larson reported chronic back
pain, anxiety, and sleep disturbances. AR1448. Examination
revealed calf muscle cramps, thickening of the toenails, but
the foot exam was otherwise normal. AR1449. He had no
neurological deficits. AR1449. The assessment was Type 2
diabetes, uncomplicated and uncontrolled, and his A1C was
high at 8.7. AR1449, 1451. Mr. Larson was provided insulin
syringes for injections five times per day. AR1449.
Larson saw PA Jacobsen on November 18, 2013, with complaints
of low back and neck pain and numbness down to the left hand.
AR1446. Mr. Larson reported feeling tired, and muscle spasms
in the neck and back. AR1446. Examination revealed a BMI of
39.3, spasms in the left trapezius and rhomboid, with only
the index finger tingling, improved from the prior week.
AR1447. Hydrocodone was prescribed along with stretching
Larson saw PA Jacobsen on December 13, 2013, with ongoing
chronic neck and back pain. AR1444. Mr. Larson had tried
chiropractic treatment and massage with little relief and
wanted to continue hydrocodone for pain. AR1444. Hydrocodone
was continued and gabapentin added for his back pain. AR1445.
Medical Evidence 2014
Larson saw PA Jacobsen on March 24, 2014, for a diabetes
check and reported neuropathy pain, tingling and burning
sensation, and dizziness side affects from gabapentin.
AR1440. Mr. Larson's A1C was high at 9.3, and his
diabetes was assessed as controlled, but later described
under HgbA1c control as not improving. AR1442. His
hydrocodone for pain was continued. AR1440.
Larson saw PA Jacobsen on June 27, 2014, for a diabetes check
and reported home blood sugars running from 90-400, and
continued chronic back pain. AR1437-38. His diabetes was
assessed as uncontrolled, and his A1C was high at 9.6.
Larson saw PA Jacobsen on September 18, 2014, for a diabetes
check and reported that he had seen Dr. L. Hanson at the Vein
clinic for a free consultation and was told he needed surgery
but it would cost him $2000. AR1434. Mr. Larson also reported
having blurry vision at times. AR1434. Mr. Larson's
assessment was Type 1 diabetes - uncontrolled, and his A1C
was high at 8.5. AR1435, 1451. Hydrocodone was continued for
his back pain. AR1434.
Larson saw PA Jacobsen on December 24, 2014, for a diabetes
check and his diabetes was assessed as Type 2 diabetes and
uncontrolled, and his A1C was high at 8.9. AR1469, 1470.
Medical Evidence 2015
Larson saw PA Jacobsen on March 16, 2015, for a diabetes
check and it was assessed at Type 1 diabetes - uncontrolled,
and his A1C was high at 8.8. AR1467-1470.
Larson saw PA Jacobsen on April 13, 2015, and continued
taking hydrocodone for his back pain, and his BMI was 40.7.
AR1464. Mr. Larson's diabetes was assessed as Type 2
diabetes and uncontrolled. AR1465.
Larson saw PA Jacobsen on June 25, 2015, for right hip and
low back pain. AR1481. Mr. Larson reported that he has always
had hip pain, but it was worse the last six weeks, and the
pain in his right hip radiates around to the side and down
the leg. AR1481. He was seeing a chiropractor weekly. AR1481.
Examination revealed obvious muscle spasm on his upper hip
Larson saw PA Jacobsen on July 31, 2015, with complaints of
shortness of breath, and reported his blood sugars had been
190-300, which he attributed to being under a lot of stress.
AR1479. Mr. Larson's diabetes was assessed as Type 1
diabetes - uncontrolled. AR1480.
Larson saw PA Jacobsen on November 17, 2015, and his diabetes
was assessed as Type 1 diabetes with hyperglycemia, long-term
use of insulin. AR1475, 1477. His A1C was high at 9.1.
AR1475, 1477. Mr. Larson also reported chest pain and
shortness of breath for the last three months. AR1476.
Medical Evidence 2016
Larson's hydrocodone was continued in 2016 for his back
Larson saw Krista M. Hoyme, D.O., at Sanford Health for his
diabetes on February 9, 2016, and his A1C was high at 9.9 and
his diabetes was assessed as Type 2 diabetes uncontrolled; he
was referred to the Diabetic Education department. AR1501,
March 1, 2016, Mr. Larson's physical and mental status
exam findings were unremarkable, including “alert,
oriented to person, place and time, overweight, normal mood,
behavior, speech, dress, motor activity, and thought
processes.” AR1504. His assessment included Diabetes
Type 2, uncontrolled. AR1504.
Larson had a Doppler echo study on March 16, 2016, due to
shortness of breath. AR1493. The study revealed normal left
ventricular chamber size, mild left ventricular hypertrophy,
normal LV systolic function, and LV ejection fraction of 60%.
Larson saw Dr. Hoyme on March 25, 2016, for his diabetes and
chronic pain issues. AR1509. Mr. Larson reported struggling
to remember his long-lasting and short-acting insulin on a
regular basis, but did report checking his blood sugars.
AR1509. Mr. Larson reported ongoing back pain and some muscle
spasms and continued to take hydrocodone and naproxen for
pain and weekly chiropractic appointments. AR1509.
Examination revealed limited range of motion in his back due
to pain, antalgic gait, and otherwise normal sensory and
musculoskeletal exam. AR1509. His back was assessed as low
back pain without sciatica and his diabetes continued
uncontrolled. AR1509. His long-lasting diabetic insulin
medication was changed, and his short-acting insulin was
continued but less frequent. AR1509-10. Physical therapy was
ordered for his back pain with a plan to wean him off of
hydrocodone. AR1510. Mr. Larson had normal mental status
findings, “alert, oriented to person, place, and time,
normal mood, behavior, speech, dress, motor activity, and
thought processes.” AR1509.
Larson received 32 physical therapy treatment sessions
between March 31, 2016, and October 18, 2016. AR1568. At his
initial physical therapy evaluation, Mr. Larson was noted as
“cooperative and motivated.” AR1618. He was
discharged with instructions to continue home exercises, join
a fitness center, and to get good shoes. AR1568. At
discharge, Mr. Larson continued to have sacroiliac pain on
the right at least 1/10 at rest and 4/10 with activity.
AR1568. His pain was exacerbated by sitting, standing, and
walking, and helped by relaxation techniques and rest.
AR1568. Mr. Larson's goal had been to decrease his pain
through therapy to a tolerable level and it was
“partially met.” AR1568. Mr. Larson's ranges
of motions were better following therapy, but still limited
by pain. AR1569. Mr. Larson was doing very well walking after
therapy with little to no trunk away and hip rotation, but
still walking slowly. AR1569. Mr. Larson's goal to be
able to perform activities with no sharp increases in pain
that cause him to sit after 1-2 hours of activities was only
partially met. AR1569. Mr. Larson's functional limitation
at the completion of the therapy sessions was described as
“at least 20 percent but less than 40% impaired,
limited, or restricted.” AR1570. The intervention
comments noted that Mr. Larson denied much change in his
symptoms; same back and hip complaints. AR1570.
Larson saw Dr. Hoyme again on April 26, 2016, and his A1C was
8.9 and his diabetes continued controlled and a referral to
an endocrinologist was planned. AR1513, 1548. Mr. Larson also
complained of pain in the finger on his left hand and edema
in his legs with standing. AR1513. Mr. Larson had normal
mental status exam findings, “alert, oriented to
person, place, and time, normal mood, behavior, speech,
dress, motor activity, and thought processes.” AR1513.
10, 2016, Mr. Larson saw Dr. Jonsson for follow up on
uncontrolled hypertension. AR1515. Mr. Larson's
hypertension had been very good lately, but his diabetes was
out of control. AR1518. He had normal musculoskeletal and
neurological exams, including normal range of motion. AR1518.
Larson saw Marcio L. Griebeler, M.D., an endocrinologist, on
May 24, 2016. AR1530. Dr. Griebeler described Mr.
Larson's diabetes as a “combination of type 2
diabetes mellitus due to significant insulin resistance as
well as pancreatic induced hyperglycemia as he had multiple
episodes in the past.” AR1519. Mr. Larson reported
blood sugars greater than 200 most of the time, his diet was
not ideal, and he was using an insulin-to-carb ratio but was
unsure how accurate his calculation was. AR1519. His A1C was
9.2. AR1519. Mr. Larson's insulin was increased and he
was given information on carb counting and needed lifestyle
changes to help better control his diabetes. AR1523. Dr.
Griebeler noted, “[t]he answer for better control of
[Mr. Larson's] diabetes is lifestyle changes.”
Larson saw Dr. Griebeler on June 21, 2016, and his blood
sugars were improved, but still around the 200-300s and not
at goal. AR1525. Mr. Larson's diabetes complications
included positive semiquantitative
microalbuminuria. Mr. Larson's diabetes remained
Larson had a sleep study on September 20, 2016, due to
snoring, insomnia, possible sleep apnea with an Epworth score
of 12. AR1498. The results showed severe obstructive sleep
apnea with an AHI of 90.3 and desaturations to the 83% range,
and a CPAP was refused by Mr. Larson at that time. AR1498.
No. significant cardiac arrhythmias were shown. AR1498.
Larson saw Dr. Hoyme on September 22, 2016, for right sided
low back pain which radiates into the right leg along with
weakness. AR1536. He reported his back pain was the same as
always, but the leg pain and weakness were more intense than
before. AR1536. Mr. Larson was receiving physical therapy and
chiropractic treatments. AR1536. Examination revealed limited
range of motion and extension in the back due to pain, and
“[n]o significant palpable abnormalities, ” and
intact muscle strength and testing in his lower extremities.
AR1536. The assessment was acute bilateral low back pain with
sciatica. AR1536. Hydrocodone and continued PT were
Records Submitted to the Appeals Council
Larson returned to Sanford Medical Center on November 10,
2016, due to his sleep apnea following his initial sleep
study for a CPAP titration study. AR749. A fair titration of
CPAP to pressure of 11 CM was determined to control Mr.
Larson's severe sleep apnea. AR750.
Larson saw Dr. Griebeler on January 9, 2017, for diabetes
follow up. AR590. Mr. Larson's BMI was up to 42.9, and
his last A1C from September was high at 8.7%, and his current
blood sugars averaged 300. AR586, 590. Mr. Larson's
diabetes continued to be uncontrolled with the current A1C
abnormal at 8.6%. AR591. Dr. Griebeler noted that Mr. Larson
had recently started on CPAP. AR591.
Larson saw Dr. Hoyme on January 24, 2017, with worsening neck
pain, and more pain in his hips since ending PT. AR593.
Examination revealed a very distended abdomen and lower chest
which Mr. Larson attributed to bloating from his metformin,
and he declined further recommended workup due to financial
reasons. AR594. Additional physical therapy was recommended
for his neck and hip pain. AR594.
State Agency Assessments
DDS consultant Kevin Whittle, M.D., opined residual
functional capacity (“RFC”) on July 23, 2011.
AR96-98. The claimant could lift and/or carry 20 pounds
occasionally (1/3 or less of an 8-hour day) and 10 pounds
frequently (1/3 to 2/3 of an 8-hour day), stand and/or walk
about 6 hours, and sit a total of about 6 hours in an 8-hour
work day; climb ramps, stairs, ladders, ropes, and scaffolds
frequently; stoop, kneel, and crouch frequently. AR96-98.
Exertional and postural limitations were “due to back
pain.” AR97. “Claimant appears to overstate
limitations.” AR96. “There is no indication that
there is opinion evidence from any source.” AR98. The
DDS experts in 2011 did not consider mental impairments at
the initial level. AR82-89.
DDS consultant Gregory Erickson, M.D., affirmed Dr.
Whittle's RFC opinion on March 6, 2012. AR108-10.
Exertional and postural limitations were “due to back
pain.” AR109. At the reconsideration level the DDS
psychological consultant found none-severe affective disorder
and personality disorder, so no mental RFC assessment was
DDS consultant Dr. Whittle again reviewed Mr. Larson's
file on April 1, 2015, and found that Mr. Larson had
non-severe impairments of diabetes, other diseases of the
blood and blood-forming organs, sleep related breathing
disorders, and a severe impairment of his spine. AR897. Dr.
Whittle stated that he gave “great weight” to the
opinion of Brian K. Kidman, M.D., the consultative examining
physician. AR899. Dr. Whittle found Mr. Larson could lift
and/or carry 20 pounds occasionally (1/3 or less of an 8-hour
day) and 10 pounds frequently (1/3 to 2/3 of an 8-hour day),
stand and/or walk about 6 hours, and sit a total of about 6
hours in an 8-hour work day; climb ramps, stairs, ladders,
ropes, and scaffolds, stoop, kneel, crawl, and crouch
occasionally. AR900. Exertional and postural limitations were
“due to chronic back and neck pain related to DDD/DJD.
AR900. Dr. Whittle referenced some of Dr. Kidman's
findings from his consultative exam regarding Mr.
Larson's spine impairment, but did not mention that Dr.
Kidman stated Mr. Larson would be unlikely to tolerate work
that required him to be on his feet, or required any
significant amount of bending, stooping, crouching, or
“not be able to do much in the way of lifting because
of back pain….” AR1459, 901.
DDS consultant James Barker, M.D., reviewed Mr. Larson's
file on May 22, 2015. AR914-16. Dr. Barker also stated he
gave Dr. Kidman's opinions from his CE exam “great
weight.” AR914. Dr. Barker found Mr. Larson's spine
impairment to be severe, he also found obesity to be severe,
and he found an RFC identical to the RFC determined by Dr.
Whittle. AR914-15. Dr. Barker also referenced some of Dr.
Kidman's findings from his CE exam regarding Mr.
Larson's spine impairment, but did not mention that Dr.
Kidman stated Mr. Larson would be unlikely to tolerate work
that required him to be on his feet, or required any
significant amount of bending, stooping, crouching, or that
Dr. Kidman stated that Mr. Larson would also “not be
able to do much in the way of lifting because of back
pain….” AR1459, AR915.
DDS consultant Stephanie Fuller, Ph.D., opined on March 8,
2012, that the claimant had non-severe affective and
personality disorders resulting in “mild”
restriction of activities of daily living; “mild”
difficulties maintaining social functioning;
“mild” difficulties maintaining concentration,
persistence or pace; and no episodes of decompensation.
DDS consultant Jerry Buchkoski, Ph.D., opined on March 16,
2015, that Mr. Larson had severe anxiety disorder and severe
affective disorder, resulting in “mild”
restriction of activities of daily living;
“moderate” difficulties maintaining social
functioning; “moderate” difficulties maintaining
concentration, persistence or pace; and no episodes of
decompensation. AR897-98. Dr. Buchkoski found Mr. Larson was
not significantly limited in eleven areas, and he was
moderately limited in five areas including his ability to
understand, remember, and carry out detailed instructions;
maintain attention and concentration for extended periods;
work in coordination with or in proximity to others without
being distracted by them; and interacting appropriately with
the general public. AR901-03. Dr. Buchkoski opined that Mr.
Larson had some cognitive issues, with average overall
intellectual functioning, able to function better if he
learns things hands on rather than being told what to do, and
able to function in settings that are routine and involve
limited contact with the general public. AR903. Dr. Buchkoski
stated that Mr. Larson was not significantly limited in his
ability to get along with co-workers or peers. AR902. Dr.
Buchkoski also stated that “He would likely function
best in settings that involve limited contact with
DDS consultant Doug Soule, Ph.D., opined on May 26, 2015,
that Mr. Larson had severe anxiety disorder and severe
affective disorder, and also found he had a severe organic
mental disorder. AR912. He found these severe impairments
resulted in “mild” restriction of activities of
daily living; “moderate” difficulties maintaining
social functioning; “moderate” difficulties
maintaining concentration, persistence or pace; and no
episodes of decompensation. AR912-13. Based on those
impairments he found Mr. Larson had the identical findings
and mental RFC as determined by Dr. Buchkoski and outlined
above. AR916-18. Dr. Soule also stated that Mr. Larson was
not significantly limited in his ability to get along with
co-workers or peers, and also stated that “He would
likely function best in settings that involve limited contact
with others.” AR917.
Consultative Mental Examination - Shelley ...