Terrell v. Colvin
1:16-cv-02566
D. Colo.Apr 13, 2017Background
- Plaintiff Shurena Terrell applied for Disability Insurance Benefits alleging back injuries (T12 compression fracture), chronic pain/myofascial pain, fibromyalgia, knee and hip problems, and depression; onset claimed February 10, 2013.
- Administrative record includes worker’s compensation treatment (2011–2013), a consultative exam by Dr. Moser (Nov. 2013 diagnosing myofascial pain and finding moderate functional capacity), and a December 2014 primary-care visit where a nurse practitioner recorded fibromyalgia and prescribed Cymbalta and Lyrica.
- ALJ found severe impairments of healed T12 compression fracture and lumbar spine disorder, rejected fibromyalgia as a medically determinable impairment, gave an RFC for the full range of light work with limited bending and no kneeling/squatting or foot/leg controls, and concluded Plaintiff could perform past relevant work.
- Plaintiff appealed, arguing the ALJ failed to develop the record on fibromyalgia, misapplied SSR 12‑2p, omitted consideration of chronic pain/myofascial pain at Step Two, and improperly assessed symptom credibility and functional effects of pain.
- The district court reviewed the record under the substantial-evidence standard and remanded, holding the ALJ properly rejected fibromyalgia but erred by not addressing diagnosed chronic pain syndrome and myofascial pain at Step Two.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| ALJ duty to develop record re: fibromyalgia | Terrell: ALJ should have sought additional records/ordered consultative exam because records were sparse and WC records minimized pain | Berryhill: ALJ ordered a consultative exam; no basis to require fibromyalgia‑specific exam; counsel did not request more development | Denied — no duty to further develop for fibromyalgia given sparse evidence and counsel made no request |
| Proper application of SSR 12‑2p / fibromyalgia diagnosis | Terrell: ALJ misunderstood diagnostic criteria and should have remanded for proper application | Berryhill: Record lacks acceptable‑medical‑source diagnosis; ALJ properly required objective support | Denied — ALJ’s treatment was adequate; record lacks acceptable‑source fibromyalgia diagnosis |
| Consideration of chronic pain syndrome / myofascial pain at Step Two | Terrell: ALJ omitted diagnoses (Dr. Bradley’s chronic pain syndrome; Dr. Moser’s myofascial pain) and thus failed to consider their effects | Berryhill: Pain complaints are attributable to spine disorder already considered; no separate impairment warranted | Granted in part — Court remanded: ALJ failed to determine whether these pain diagnoses are medically determinable impairments and must address them on remand |
| Credibility and RFC regarding pain effects | Terrell: ALJ improperly discounted subjective symptoms and their work‑limiting effects | Berryhill: Objective findings and consultative exam support ALJ’s RFC and credibility findings | Not decided on merits — Court did not reach remaining issues; remand required to reassess after Step Two determinations |
Key Cases Cited
- Bowen v. Yuckert, 482 U.S. 137 (1987) (claimant bears burden to prove disability)
- Wall v. Astrue, 561 F.3d 1048 (10th Cir. 2009) (ALJ’s duty to develop record in nonadversarial hearings)
- Cowan v. Astrue, 552 F.3d 1182 (10th Cir. 2008) (in counseled cases ALJ ordinarily may rely on counsel to present issues needing development)
- Maes v. Astrue, 522 F.3d 1093 (10th Cir. 2008) (ALJ not claimant’s advocate; claimant/counsel must help obtain missing records)
- Salazar v. Barnhart, 468 F.3d 615 (10th Cir. 2006) (ALJ must consider all medically determinable impairments singly and in combination)
- Gatson v. Bowen, 838 F.2d 442 (10th Cir. 1988) (objective medical evidence of disabling pain can include clinical assessments)
- Kepler v. Chater, 68 F.3d 387 (10th Cir. 1995) (remand assures correct legal standards are applied and does not dictate outcome)