Reichard v. United of Omaha Life Ins. Co. (331 F. Supp. 3d 435, 2018)

Smith, J.

The Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 - 1461, provides protections for employees participating in their employer's benefits plans. Based upon her diagnoses of Crohn's disease and related gastrointestinal and arthritic conditions, the plaintiff employee received both short-term disability and long-term disability benefits under her employer's respective plans. The claims administrator later terminated her long-term disability benefits after the disability definition under the plan changed from merely requiring an inability to perform her own regular occupation to an inability to perform any gainful occupation. After the claims administrator denied her appeal of the termination of benefits, the plaintiff filed the instant ERISA action against the administrator.

Currently before the court are the parties' cross-motions for summary judgment, as well as the plaintiff's alternative motion pursuant to Federal Rule of Civil Procedure 52, on the issue of whether the termination of long-term disability benefits was arbitrary and capricious. As explained below, the court finds that there are no genuine issues of material fact and that the claims administrator's decision to terminate the plaintiff's long-term disability benefits was not without reason, unsupported by substantial evidence, or erroneous as a matter of law. Accordingly, the court will grant the claims administrator's motion for summary judgment and deny the plaintiff employee's motion for summary judgment, as well as her alternative motion.

I. PROCEDURAL HISTORY

The plaintiff, Giovanna Reichard ("Reichard"), commenced this ERISA action by filing a complaint against the originally-named defendant, Mutual of Omaha Life Insurance Company, on June 27, 2017. Doc. No. 1. Reichard soon filed an amended complaint on July 13, 2017, naming only United of Omaha Life Insurance Company ("United of Omaha") and effectively terminating Mutual of Omaha Life Insurance Company as a defendant. Doc. No. 2. In the amended complaint, Reichard alleges that, pursuant to 29 U.S.C. § 1132(a)(1), United of Omaha's decision to terminate her long-term disability ("LTD") benefits was arbitrary and capricious. Am. Compl. at ¶¶ 1, 27. United of Omaha filed an answer to the amended complaint on August 10, 2018, and the court held an initial pretrial conference with counsel for the parties on October 4, 2017. Doc. Nos. 7, 11.

During discovery, Reichard filed a motion to compel United of Omaha to produce conflict of interest discovery concerning Dr. Thomas Reeder ("Dr. Reeder"), the sole medical reviewer of Reichard's United of Omaha appeal. See Mem. P. & A. Supp. Pl.'s Mot. Compel Disc. at 1-2, Doc. No. 27. Specifically, Reichard sought Dr. Reeder's "batting average"-i.e. the proportion of claims in which Dr. Reeder, as the sole medical reviewer for United of Omaha on appeal, concluded that a claimant had work capacity. See id. ; Def. United of Omaha Life Ins. Co.'s Br. Opp'n Pl.'s Mot. Compel Disc. at 1, Doc. No. 29. United of Omaha filed a response in opposition to the motion to compel on February 9, 2018. Doc. No. 29. Reichard then filed a reply to the response on February 16, 2018. Doc. No. 30. The court heard oral argument and denied the motion to compel on February 20, 2018. Doc. Nos. 31, 32.

After an unsuccessful settlement conference, the parties jointly filed the complete administrative record in this case on April 5, 2018. Doc. Nos. 37, 40. The parties filed cross-motions for summary judgment, accompanied by statements of undisputed material facts and briefs in support of their motions, on May 11, 2018. Doc. Nos. 41, 42. Reichard also alternatively moved for judgment pursuant to Federal Rule of Civil Procedure 52 in her summary judgment motion. Doc. No. 42. The parties then filed responses to the motions on June 1, 2018, and United of Omaha filed a reply to Reichard's response on June 11, 2018. Doc. Nos. 43-46. The court heard oral argument on the cross-motions for summary judgment on June 21, 2018, which are now ripe for disposition.

II. APPLICABLE RECORD

Reichard worked as a registered nurse for Coordinated Health from 2010 to 2014. Pl.'s Statement Undisputed Material Facts Supp. Pl.'s Mot. Summ. J. ("Pl.'s Facts") at ¶ 1, Doc. No. 42-1; Def. United of Omaha Life Ins. Co.'s Resp. Opp'n Pl.'s Mot. Summ. J./Mot. J. and Statement Undisputed Material Facts Related Thereto ("Def.'s Resp.") at ¶ 1, Doc. No. 45; Administrative R. ("Admin. R.") at 511. Coordinated Health maintained a Group Voluntary Long-Term Disability Plan (the "Plan") for its employees. Def. United of Omaha Life Ins. Co.'s Mot. Summ. J. and Statement Undisputed Material Facts Fed. R. Civ. P. 56 ("Def.'s Facts") at ¶¶ 4, 17, Doc. No. 41; Pl.'s Opp'n Def. United of Omaha Life Ins. Co.'s Statement Undisputed Material Facts ("Pl.'s Resp.") at ¶¶ 4, 17, Doc. No. 44; Admin. R. at 173. The Plan included long-term disability ("LTD") benefits provided through an insurance policy issued by United of Omaha (the "Policy"). Def.'s Facts at ¶ 19; Pl.'s Resp. at ¶ 19; Pl.'s Facts at ¶¶ 2-3; Def.'s Resp. at ¶¶ 2-3. Reichard was a participant in the Plan, entitling her to LTD benefits if she met certain criteria. Def.'s Facts at ¶¶ 18-19; Pl's. Resp. at ¶¶ 18-19. Coordinated Health also provided short-term disability ("STD") benefits for its employees under an insurance policy issued by United of Omaha. Def.'s Facts at ¶ 20; Pl.'s Resp. at ¶ 20.

The following factual summary details: (1) the applicable provisions of the Policy; (2) Reichard's applications for STD and LTD benefits; (3) her receipt of benefits and submission of supplementary reports of disability; (4) United of Omaha's medical and vocational examinations and reviews; (5) United of Omaha's termination of Reichard's LTD benefits; (6) her appeal correspondence; (7) Dr. Reeder's medical file review on appeal, including a discussion of Reichard's treatment records dating back to 2014; (8) Dr. Reeder's correspondence with Reichard's doctors; (9) United of Omaha's denial of Reichard's appeal; and (10) her Social Security disability ("SSD") claim.

A. Applicable Provisions Of The Policy

According to the Policy, if a Plan participant becomes "Disabled," United of Omaha agrees to pay a "Monthly Benefit" beginning after an "Elimination Period." Def.'s Facts at ¶ 24; Pl.'s Resp. at ¶ 24; Admin. R. at 188, 200. The amount of the "Monthly Benefit" is the lesser of $5,000 or 60% of monthly earnings. Admin. R. at 178, 180. The "Elimination Period" is the later of 90 calendar days or the end-date of STD benefits. Def.'s Facts at ¶ 25; Pl.'s Resp. at ¶ 25; Admin. R. at 178-79. The term "Disabled" encompasses three separate definitions for "during the Elimination Period," "after the Elimination Period," and "after a Monthly Benefit has been paid for 2 years;" the Policy states that "Disabled" means that

because of an Injury or Sickness, a significant change in Your mental or physical functional capacity has occurred in which:

a) during the Elimination Period, You are prevented from performing at least one of the Material Duties of Your Regular Occupation on a part-time or full-time basis; and

b) after the Elimination Period, You are:

1. prevented from performing at least one of the Material Duties of Your Regular Occupation on a part-time or full-time basis; and

2. unable to generate Current Earnings which exceed 80% of Your Basic Monthly Earnings due to that same Injury or Sickness.

After a Monthly Benefit has been paid for 2 years, ... Disabled mean[s] You are unable to perform all of the Material Duties of any Gainful Occupation.

Disability is determined relative to Your ability or inability to work. It is not determined by the availability of a suitable position with the Policyholder.

Def.'s Facts at ¶ 27; Pl.'s Resp. at ¶ 27; Admin. R. at 198-99 (emphasis in original). Thus, the definition of "Disabled" "after the Elimination Period" adds a requirement of an inability to generate more than 80% of monthly earnings; and more stringent still, the definition of "Disabled" "[a]fter a Monthly Benefit has been paid for 2 years" adds the requirement that the participant cannot perform not just her own Regular Occupation, but "any Gainful Occupation." Admin. R. at 198-99 (emphasis added).

The Policy provides instructions for filing a claim for disability benefits and entitles a claimant to notice of and reasons supporting a claim denial, "a reasonable opportunity to appeal a claim review decision," and "a full and fair review of the claim review decision." Pl.'s Facts at ¶ 6; Def.'s Resp. at ¶ 6; Admin. R. at 193-96. Finally, the Policy offers assistance to claimants receiving Monthly Benefits with filing for SSD benefits, including helping them find "appropriate representation." Pl.'s Facts at ¶ 6; Def.'s Resp. at ¶ 6; Admin. R. at 182-83.

B. Reichard's Applications For STD And LTD Benefits

Reichard submitted a STD benefits claim to United of Omaha on April 24, 2014, one day after she contacted her physician to notify him of a "Crohn's attack." Pl.'s Facts at ¶ 7; Def.'s Resp. at ¶ 7; Admin. R. at 116, 146. On the claim form, she listed Crohn's, nausea, depressed appetite, and epigastric pain as illnesses and symptoms; a first treatment date of March 19, 2014; and a disability date of April 24, 2014. Pl.'s Facts at ¶ 7; Def.'s Resp. at ¶ 7; Admin. R. at 116, 146. Dr. Mark Osterman, Reichard's gastroenterologist, submitted an attending physician statement ("APS") dated May 12, 2014, in connection with the STD claim. Admin R. at 119-20. He indicated that Reichard could lift and carry up to ten pounds frequently and 11 to 50 pounds occasionally; could sit, stand, and walk continuously for six to eight hours; and should be able to return to work full-time in six months. Id. In an accompanying Family Medical Leave Act form, he stated that "direct patient care" was the sole job function Reichard was unable to perform. Pl.'s Facts at ¶ 45; Def.'s Resp. at ¶ 45; Admin. R. at 132-33. He explained that Reichard suffered from abdominal and epigastric pain, decreased appetite, fatigue, nausea, multiple trips to the bathroom, joint pain in the hips and knees, and unpredictable and episodic flare-ups that would prevent her from performing her job functions. Pl.'s Facts at ¶ 45; Def.'s Resp. at ¶ 45; Admin. R. at 133-34.

United of Omaha denied Reichard's STD claim on May 27, 2014, as well as her appeal of that denial on August 12, 2014. Pl.'s Facts at ¶¶ 9, 11; Def.'s Resp. at ¶¶ 9, 11; Admin. R. at 49- 52, 145-48. Although United of Omaha had already denied Reichard's STD claim, Dr. Nicole Chiappetta, Reichard's rheumatologist and primary care physician, wrote a letter dated May 29, 2014, on her behalf, stating:

I have been following Giovanna for a history of arthritis of inflammatory bowel disease associated with Crohn's disease. This arthritis is affecting primarily her bilateral knees, and she does also have radiographic evidence of secondary osteoarthritis. I believe this is contributing primarily to her overall pain. Intraarticular cortisone injections have been administered in the past, as well as viscosupplementation injections, all with minimal relief. She unfortunately cannot take NSAIDs due to her bowel disease. Unfortunately, her job requires her to stand for prolonged periods of time and to move from sitting, standing, and squatting positions during the day. Her severe pain due to both arthritis of inflammatory bowel disease and secondary osteoarthritis inhibits this, therefore I do not believe she can perform her trained duties at this time and is disabled.

Pl.'s Facts at ¶ 47; Def.'s Resp. at ¶ 47; Admin. R. at 135.

Reichard next submitted a LTD benefits claim on August 29, 2014. Admin. R. at 38-48. As in her STD claim, she listed a disability date of April 24, 2014. Def.'s Facts at ¶ 36; Pl.'s Resp. at ¶ 36; Admin. R. at 40. She stated she was unable to work because of her Crohn's disease, bilateral knee pain, and right hip pain. Def.'s Facts at ¶ 35; Pl.'s Resp. at ¶ 35; Admin. R. at 40. She identified Dr. Osterman and Dr. Chiappetta as the two doctors for whom she sought treatment for her conditions. Def.'s Facts at ¶ 38; Pl.'s Resp. at ¶ 38; Admin. R. at 41.

Dr. Chiappetta submitted an APS in support of Reichard's LTD claim, listing: knee pain and trochanteric bursitis as primary diagnoses; knee and hip pain as symptoms; "focal tenderness over troch[anteric] bursa and pain with flexion and extension of the knee" as objective findings; Crohn's disease as a "secondary" disabling condition; Humira as a prescribed medication; and viscosupplementation, cortisone injections, and physical therapy as treatment. Def.'s Facts at ¶¶ 42-47; Pl.'s Resp. at ¶¶ 42-47; Admin. R. at 45-47. Concerning Reichard's work ability, Dr. Chiappetta opined that she should not do any heavy lifting or climbing due to severe pain in bilateral knees; could not stand for more than a half hour continually or squat; has chronic arthritis in both knees that will not improve; in an eight-hour workday, could sit for six hours, stand for one hour, and walk for two hours; and was restricted in lifting or carrying more than 20 pounds, squatting for more than 20 minutes continuously, and climbing high heights due to knee pain. Def.'s Facts at ¶¶ 48-49; Pl.'s Resp. at ¶¶ 48-49; Admin. R. at 46. In terms of functions of Reichard's occupation that she could not perform, Dr. Chiappetta wrote that she was unable to stand for more than 20 minutes at a time and would need frequent breaks. Def.'s Facts at ¶ 50; Pl.'s Resp. at ¶ 50; Admin. R. at 47. Dr. Chiappetta also explained that there were "[n]o specific functional restrictions other than what w[ere] mentioned prior" in the claim form. Def.'s Facts at ¶ 51; Pl.'s Resp. at ¶ 51; Admin. R. at 47. Nevertheless, Dr. Chiappetta did not expect Reichard to ever return to her prior level of functioning, never expected fundamental changes in her medical condition, and concluded that she could not work "[d]ue to her professional training." Admin. R. at 46-47.

C. Reichard's Receipt Of Benefits And Submission of Supplementary Reports of Disability

United of Omaha granted LTD benefits on November 4, 2014, effective July 24, 2014, and retroactive STD benefits on February 23, 2015, effective for the 11-week period from May 8, 2014, to July 23, 2014. Def.'s Facts at ¶¶ 53, 56, 57; Pl.'s Resp. at ¶¶ 53, 56, 57; Pl.'s Facts at ¶¶ 13, 14; Def.'s Resp. at ¶¶ 13, 14; Admin. R. at 34-35, 166, 1114-16. United of Omaha's approval letter explained that after 24 months of LTD benefits, on July 24, 2016, the definition of "Disability" under the Policy would change; to continue receiving benefits she would have to be unable to "perform all material duties of any gainful occupation," not just her own regular occupation. Def.'s Facts at ¶ 54; Pl.'s Resp. at ¶ 54; Admin. R. at 1114.

Reichard submitted two supplementary reports of disability ("SRD") after United of Omaha granted her LTD benefits. In the first SRD, dated June 20, 2015, she explained, "My daily activities have not changed from my last report. My activities are dependent on my pain in my joints and my Crohn's disease." Def.'s Facts at ¶ 58; Pl.'s Resp. at ¶ 58; Admin. R. at 993. That same day, she also submitted a health questionnaire listing the following medications taken since the beginning of 2015: Humira, Methotrexate, Zanaflex, folic acid, Lyrica, Ambien, vitamins D and B12, Dexilant, Ranitidine HCL, Percocet, Zofran, Lomotil, and Levsin SL. Pl.'s Facts at ¶ 16; Def.'s Resp. at ¶ 16; Admin. R. at 995-96.

Dr. Chiappetta also submitted another APS on July 7, 2015, in connection with the June 20, 2015 SRD. Def.'s Facts at ¶ 59; Pl.'s Resp. at ¶ 59; Admin. R. at 994. This APS, Dr. Chiappetta's second, varied in several respects from the APS submitted in support of Reichard's initial LTD claim in August 2014. Dr. Chiappetta now listed Crohn's disease as a primary, not secondary, diagnosis; omitted trochanteric bursitis as a primary diagnosis; added shoulder pain and depression as primary diagnoses and objective findings; opined that in an eight-hour workday Reichard could now stand for two hours, as opposed to one, but only walk for one hour, as opposed to two, and could still sit for six hours; opined that Reichard had no restrictions in lifting or carrying, an improvement over the prior 20-pound restriction; included a new crawling restriction; suggested that Reichard's medical prognosis for recovery was fair; and described Reichard's knee arthritis as "severe." Def.'s Facts at ¶ 59; Pl.'s Resp. at ¶ 59; Admin R. at 45- 46, 994. Both APSs reference knee pain as a primary diagnosis, squatting and climbing limitations, and a conclusion that Reichard had not "achieved maximum medical improvement." Id.

At the request of United of Omaha, Reichard submitted a second SRD and health questionnaire on February 2, 2016. Pl.'s Facts at ¶¶ 18, 19; Def.'s Resp. at ¶¶ 18, 19; Admin. R. at 884, 892. In the Report, she again wrote, "My activities have not changed since my last report. My activities are dependent on my pain in my joints and my Crohn's disease." Pl.'s Facts at ¶ 19; Def.'s Resp. at ¶ 19; Admin. R. at 884. On the accompanying health questionnaire, Reichard listed many of the same medications as she had on the June 20, 2015 health questionnaire: Humira, Methotrexate, Zanaflex, folic acid, Lyrica, Ambien, vitamins D and B12, Percocet, Zofran, and Levsin SL. She omitted Dexilant, Ranitidine HCL, and Lomotil ; she added Prevacid, Naproxen, Keflex, and one other illegible medication. Pl.'s Facts at ¶ 21; Def.'s Resp. at ¶ 21; Admin. R. at 889-90.

Dr. Chiappetta again submitted an APS in connection with the February 2, 2016 SRD. Pl.'s Facts at ¶ 20; Def.'s Resp. at ¶ 20; Admin. R. at 446. Compared to Dr. Chiappetta's prior statement, she added depression, elevated liver function, vitamin D deficiency, and polyarthropathy as primary diagnoses; downgraded Reichard's prognosis for medical recovery to "poor;" opined that, in an eight-hour workday, Reichard could now sit for eight hours (increased from six hours), stand for one hour (decreased from two hours), and walk for one hour (unchanged); and added depression as a psychological restriction. Admin. R. at 446, 994. Rather than check "yes" or "no" for various types of physical restrictions, as she had previously, Dr. Chiappetta simply double underlined "no work" in the section for comments on restrictions. Id.

United of Omaha then sent Reichard a letter on February 16, 2016, that again explained that the Policy's definition of "Disability" would change on July 24, 2016. Def.'s Facts at ¶ 62; Pl.'s Resp. at ¶ 62; Admin. R. at 876-77. The letter explained:

We are currently reviewing your claim to determine if you meet the policy definition of Disability based upon inability to perform all of the Material Duties of any Gainful Occupation beyond July 24, 2016. We may be contacting your doctor(s) for updated medical reports and information regarding your restrictions and limitations.

Admin. R. at 877.

D. United Of Omaha's Medical And Vocational Examinations And Reviews

Following the transition to the "any Gainful Occupation" definition of "Disability" on July 24, 2016, United of Omaha arranged several examinations and reviews relating to Reichard's LTD claim during the latter half of 2016: (1) a nurse referral review by United of Omaha Nurse Julie Grancer ("Nurse Grancer") from June 2016; (2) a transferable skills assessment ("TSA") by vocational rehabilitation consultant Douglas Palmer ("Palmer") from August 2016; (3) a medical peer review by Dr. Thomas Liebermann dated October 3, 2016; and (4) an independent medical examination ("IME") by Dr. Steven Golombek resulting in a report dated November 11, 2016. Pl.'s Facts at ¶¶ 23-26; Def.'s Resp. at ¶¶ 23-26; Def.'s Facts at ¶ 65; Pl.'s Resp. at ¶ 65; Admin. R. at 442-44, 513-19, 557-60, 547-52. The court discusses each report in turn.

1. June 2016 Nurse Referral Review by Nurse Grancer

In conducting her review of Reichard's LTD benefits claim, Nurse Grancer reviewed the records in United of Omaha's claim file, including: (1) a description of Reichard's job; (2) her education, training, and work experience; (3) medical reviews from October 2014; (4) neurology progress notes by Physician Assistant Courtney Bloss from September 2015 and January 2016; (5) progress notes from Reichard's orthopedic surgeon, Dr. Wayne Luchetti, from October 2015 and December 2015; (6) progress notes by Dr. Chiappetta from December 2015 and February 2016; (7) laboratory results from December 2015 and February 2016; (8) an ultrasound of Reichard's abdomen from December 2015; (9) a rehabilitation discharge summary from December 2015; and (10) Dr. Chiappetta's February 2016 Attending Physician's Statement. Def.'s Facts at ¶ 66; Pl.'s Resp. at ¶ 66; Admin. R. at 514.

Nurse Grancer noted the same diagnoses from Dr. Chiappetta's February 2016 APS: "Crohn's disease (chronic bowel inflammation), depression, elevated liver enzymes, vitamin [D] deficiency[,] and polyarthropathy (arthritis that involve[s five] or more joints simultaneously and usually associated with autoimmune conditions)." Def.'s Facts at ¶ 66; Pl.'s Resp. at ¶ 66; Admin. R. at 446, 513. Additionally, she noted a history of "tobacco use, ulcerative colitis, rheumatoid arthritis, fibromyalgia, insomnia, neck pain, migraines[,] and [a] stable lesion of the pituitary gland;" and treatments including a surgical bowel resection in January 2012, cervical fusion in 2009, Synvisc injections in both knees, and a knee replacement in October 2014. Def.'s Facts at ¶ 67; Pl.'s Resp. at ¶ 67; Admin. R. at 514.

Nurse Grancer reached several conclusions in her medical analysis. First, the records suggested that Reichard's Crohn's disease had "remained stable with occasional bouts of diarrhea," and that she had "maintained normal weight and nutritional status." Admin. R. at 516. She also noted elevated white blood counts related to steroids and a recent suggestion that Reichard would start taking Methotrexate. Id. Second, she found "no evidence in the records assessed to indicate a degree of depression that warrants any type of functional impairment." Id. Third, her vitamin D deficiency was not functionally limiting. Id. Fourth, exams did not demonstrate deficits associated with headaches, and they occurred one to three days per month. Id. Fifth, although she complained of right hip pain, her records contained no right hip imaging studies. Id. Sixth, she addressed the status of Reichard's knees:

She's status post left knee unicompartmental knee replacement from 2014. On 10/06/15 x-ray of the left knee demonstrates prosthesis in place in proper anatomical alignment without rotation, loosening[,] or stress shielding. Orthopedic evaluation on 12/22/15 indicated the [claimant] did a lot of shopping the other day[,] and her left knee was sore. Exam of the left knee demonstrates no visible abnormalities and intact [range of motion]. Neurology provides normal exams with intact unaided gait, normal 5/5 strength throughout, normal reflexes and coordination, and intact sensation.

Id. at 516-17. Finally, Nurse Grancer assessed Reichard's restrictions and limitations as follows:

No lifting/carrying > 20 pounds[; u]nlimited sitting with the ability to reposition as needed and stand/walk every 1-2 hours for 5-10 minutes[; n]o prolonged standing/walking > 1-2 hours[,] then would require the ability to reposition or sit down 10 minutes prior to standing/walking again[; n]o running, jumping, full squatting, crawling, climbing ladders, balancing or use of the left lower extremity as in operating forceful foot controls[; m]ay occasionally bend, crouch[,] and kneel[; u]nlimited use of the upper extremities in fine motor activity, pinching gripping, grasping, reaching forward[,] and keyboarding[; n]o constant overhead reaching[; and n]o exposure to large vibratory machinery[.]

Id. at 517.

The following month, on July 5, 2016, Reichard emailed United of Omaha challenging, inter alia , Nurse Grancer's omission of doctors listed on her most recent health questionnaire, including Dr. Osterman; the conclusion that her Crohn's disease was "stable;" and the omission of her most recent medications. Pl.'s Facts at ¶ 22; Def.'s Resp. at ¶ 22; Def.'s Facts at ¶ 72; Pl.'s Resp. at ¶ 72; Admin. R. at 605-08.

2. August 2016 TSA by Palmer

United of Omaha referred Reichard's claim to Palmer in August 2016 for him to evaluate her transferable skills. Def.'s Facts at ¶¶ 73, 74; Pl.'s Resp. at ¶¶ 73, 74; Admin. R. at 442. Based on information provided by United of Omaha, Palmer specifically evaluated whether Reichard's condition permitted her to work within the sedentary and light Dictionary of Occupational Titles ("DOT") levels of activity. Def.'s Facts at ¶ 75; Pl.'s Resp. at ¶ 75; Admin. R. at 442. Specifically, United of Omaha provided Palmer with a referral note detailing functional abilities; an education, training, and work experience form; and Reichard's job description. Admin R. at 442. In his analysis of Reichard's functional abilities, he relays the same diagnoses, restrictions, limitations, and abilities from Nurse Grancer's review. See id. at 442, 446, 513, 517.

Palmer ultimately concluded that Reichard "would currently qualify for employment in other occupations." Id. at 443. He listed examples of viable employment options along with DOT reference numbers, exertional demand levels, and monthly wages. Id. at 444. The list contained five jobs: office nurse, school nurse, medical insurance clerk, hospital-admitting clerk, and administrative clerk. Id. In support of his conclusions, he explained:

According to the Guide for Occupational Explorations..., the Claimant's extensive work experience in nursing patient care ..., laboratory science ..., and business administration support ...would suggest she can apply technical knowledge, common sense, and special medical skills to car[e] for or treat sick or handicapped people; she can adapt to emergency situations; she can instruct, plan[,] or direct the work of others; she can follow technical instructions; she can record data and obtain and safeguard confidential information on individuals; she can speak distinctly when dealing with people in various situations; and she can make decisions involving company policy.

....

... Based upon review of the information provided and research performed by this Consultant, the Claimant currently qualifies for work in other occupations; she resides within a viable labor market where alternate occupations exist; occupations are able to be identified that are comparable with her current work capacity; and she qualifies for work that would be expected to provide a wage meeting or exceeding the gainful threshold ....

Def.'s Facts at ¶ 77; Pl.'s Resp. at ¶ 77; Admin. R. at 443-44.

3. October 2016 Peer Review by Dr. Liebermann

United of Omaha next retained Dr. Liebermann to conduct a peer review of Reichard's records. Def.'s Facts at ¶¶ 79, 80; Pl.'s Resp. at ¶¶ 79, 80; Admin. R. at 230-33, 572-73. In preparing for his report, Dr. Liebermann reviewed: (1) all APSs; (2) medical records, correspondence, and consultations from 2014 through 2016; diagnostics; (3) labs; (4) medications; (5) United of Omaha's internal claim review notes and interviews; (6) occupational information; (7) employee and employer statements; and (8) an authorization. Admin. R. at 231. While noting that Reichard's primary medical issues were Crohn's disease and "multiple rheumatologic issues," Dr. Liebermann, board-certified in gastroenterology and internal medicine, deferred to an appropriate specialist on her rheumatological care. Pl.'s Facts at ¶ 25A; Def.'s Resp. at ¶ 25A; Admin. R. at 230, 232.

Dr. Liebermann summarized Reichard's gastrointestinal medical history as follows:

She has a history of inflammatory bowel disease since the age of 8. Her disease was initially characterized as ulcerative colitis. In 2012 she was seen at the University of Pennsylvania where a diagnosis of Crohn's colitis was made. In January of 2012 the claimant had 18 inches of distal small bowel removed with the right side of the colon. The claimant took Imuran for 20 years. Since 4/24/2014 going forward the claimant has experienced occasional bouts of abdominal pain and diarrhea while maintaining normal weight and nutritional status. She has a history of the arthropathy of inflammatory bowel disease.

On 12/15/2015 she was found to have elevation of liver enzymes which were further evaluated but the results are not part of the documentation. She has undergone several colonoscopies....

Admin. R. at 231. He concluded his summary by stating that he had "no gastrointestinal medical information as of July 2016 going forward." Id.

In addition to summarizing Reichard's gastrointestinal medical history, Dr. Liebermann reaches several conclusions and opinions in his October 3, 2016 report. See id. at 230-33. First, he concludes that Reichard "does not have significant problems with Crohn's disease at this time and has not had significant issues since January 2012 ...;" therefore, her condition was "stable." Pl.'s Facts at ¶ 25B; Def.'s Resp. at ¶ 25B; Admin. R. at 231-32. He supported this conclusion with a purported comment from Dr. Osterman that Reichard was stable on May 15, 2016, and an opinion that "she has done quite well with only occasional bouts of diarrhea and abdominal pain." Admin. R. at 231-32. He continues, "there has been no concrete evidence of recurrence of Crohn's disease," "[Reichard] is doing well as of 7/1/2016 going forward to the present day from a gastrointestinal standpoint," and "I have no reason to think that she had any new symptoms suggesting a flare of the inflammatory bowel disease." Def.'s Facts at ¶ 84; Pl.'s Resp. at ¶ 84; Admin. R. at 230-31.

Second, and relatedly, he explains, "Although a flare is possible I reserve the opportunity to comment if the claimant has additional symptoms from the July to September 2016 time-frame if additional information is provided." Pl.'s Facts at ¶ 25B; Def.'s Resp. at ¶ 25B; Admin. R. at 230. Third, looking forward, he states that "it is likely that she will remain in remission beyond July 2016" because her condition remained stable "for months." Admin. R. at 232. Finally, he concludes that Reichard "has no restrictions or limitations from a gastrointestinal standpoint from 7/1/2016 through 10/1/2016" and is not "functionally impaired." Pl.'s Facts at ¶ 25B; Def.'s Resp. at ¶ 25B; Def.'s Facts at ¶¶ 83, 85; Pl.'s Resp. at ¶¶ 83, 85; Admin. R. at 230, 232.

4. November 2016 IME by Dr. Golombek

Dr. Golombek, a board-certified rheumatologist, conducted an IME of Reichard at the request of United of Omaha on November 1, 2016. Def.'s Facts at ¶ 86; Pl.'s Resp. at ¶ 86; Admin. R. at 234, 561-62.

He then sent a report of his IME to United of Omaha on November 11, 2016. Def.'s Facts at ¶ 87; Pl.'s Resp. at ¶ 87; Admin. R. at 234-39. In addition to physically examining and interviewing Reichard, Dr. Golombek noted in his report that he reviewed various medical records: (1) knee MRIs; progress notes from "Dr. Mark Listerman [sic]," "Dr. Nicole Chiapteta [sic]," and Dr. Mandelker; (2) operative records from Dr. Luchetti; (3) a gynecology evaluation by "Dr. Ravenelle [sic];" (4) physical therapy evaluations by Mario Carranza; and (5) a vocational evaluation by "Ms. Almer [sic]." Pl.'s Facts at ¶¶ 26A-C; Def.'s Resp. at ¶¶ 26A-C; Def.'s Facts at ¶ 88; Pl.'s Resp. at ¶ 88; Admin. R. at 234-35. While no records appear to exist for each of the quoted individuals above, Reichard did receive treatment from Dr. Mark Osterman, Dr. Nicole Chiappetta, and a nurse practitioner named Ravenelle. See Pl.'s Facts at ¶¶ 26A-B; Def.'s Resp. at ¶¶ 26A-B; Pl.'s Resp. at ¶ 88. Additionally, as discussed above, Palmer, not "Ms. Almer," conducted a vocational evaluation. See Pl.'s Facts at ¶ 26C; Def.'s Resp. at ¶ 26C; Pl.'s Resp. at ¶ 88.

Before discussing his conclusions, Dr. Golombek summarized Reichard's individual and medical history, current medical complaints, and the results of his physical examination. Admin. R. at 235-36. Concerning Reichard's medical history, Dr. Golombek noted a history of Crohn's disease and joint pain, as well as fibromyalgia for the previous five years. Id. at 236. He wrote that her Crohn's disease"is manifested by frequent bowel movements and bleeding." Id. at 235. He then listed Reichard's medications and dosages and noted that she recently had started taking Prednisone ; although it helped her joint pain, her gastroenterologist preferred that she not take it. Id. at 236. He considered her fibromyalgia"stable" and noted that she sleeps "on and off for about three hours at a time" and "has daily headaches." Id. Lyrica helped her fibromyalgia symptoms, according to her. Id. at 239.

Concerning Reichard's current medical complaints, Dr. Golombek stated that she complains of "diffuse joint pains, including the fingers, elbows, hips, ankles[,] and knees." Id. at 236. He added, "She also has frequent diarrhea from the Crohn's disease" and described the impact of Crohn's on her work day: "She was unable to eat while she worked because of fear of having to go to the bathroom. She would have about six bowel movements prior to work. As a result of not eating, she felt exhausted with poor energy."Id. at 235-36. As a result of these joint pains, her Crohn's disease, and fatigue, Reichard noted to Dr. Golombek that she could not work. Def.'s Facts at ¶ 89; Pl.'s Resp. at ¶ 89; Admin. R. at 235. Concerning the results of his physical examination, Dr. Golombek explained that a joint examination "revealed no evidence of active synovitis," "[a]ll joints had full range of motion and were non-tender to palpation," grip and motor strength in the extremities was normal, and she could ambulate without a problem and sit and transfer without problems. Admin. R. at 236.

From his review of medical records and physical examination of Reichard, Dr. Golombek found that the records support diagnoses of Crohn's disease, resulting polarthralgias, and fibromyalgia. Id. at 237. He reported few restrictions and limitations from a rheumatological perspective other than her subjective pain as of July 24, 2016:

She does not display any physical restrictions based on her joint exam. She has full mobility and strength of her joints. Her restrictions are limited by her subjective pain. She is able to do all activities that do not cause undue discomfort. She is certainly able to do fine motor activities with her hands. She is able to lift her arms over her shoulders. She is able to grab and carry objects. She is able to walk and sit. I feel that she can sit for six to eight hours daily. She is able to stand one hour continuously without problems. She is able to walk for one hour continuously without problems. She is able to drive. She is able to lift and carry 20 pounds or less. She is able to use her hands repetitively. She is able to use her feet repetitively. She is able to bend. She can do occasional squatting, but not more than 15 minutes continuously. She is able to crawl. She should not be doing climbing. She is able to reach above shoulder level.

....

In reviewing the disability questionnaire of Dr. Chiapteta [sic], I agree that she is able to sit, stand[,] and walk as she notes ....

....

She was able to cooperate fully with the exam and get on the exam table and walk without problems ....

....

The present findings are consistent with the claimant's reports of full mobility and no restriction of motion. The other complaints are more subjective in nature of joint pain, but there is no objective joint swelling or tenderness that is observed.

Pl.'s Facts at ¶ 26D; Def.'s Resp. at ¶ 26D; Def.'s Facts at ¶¶ 91-93; Pl.'s Resp. at ¶¶ 91-93; Admin. R. at 237-38.

E. United Of Omaha's Termination Of Reichard's LTD Benefits

United of Omaha sent Reichard a letter dated December 30, 2016, informing her that it had completed its review of her claim and had decided to deny ongoing LTD benefits. Def.'s Facts at ¶ 94; Pl.'s Resp. at ¶ 94; Admin. R. at 523-31. United of Omaha reached its determination by relying on the same records upon which Nurse Grancer relied in her review, Nurse Grancer's review, prior medical consultant reviews from 2014, Palmer's TSA, Dr. Liebermann's peer review, and Dr. Golombek's IME report. See Admin. R. at 514, 524-25. After summarizing these records, the letter concluded that Reichard "would not be restricted from performing a sedentary or light occupation" with noted restrictions and limitations. Def.'s Facts at ¶ 96; Pl.'s Resp. at ¶ 96; Admin. R. at 528. She also explained that Reichard's Gainful Occupational wage was $3,117.91, sixty percent of her pre-disability wage of $5,196.51. Admin. R. at 529. The letter then reproduced Palmer's "list of sample occupations for which you have the transferable skills to perform and would fall within the gainful earnings:"

?

Def.'s Facts at ¶ 97; Pl.'s Resp. at ¶ 97; Admin. R. at 444, 529.

In summary, United of Omaha explained that

the medical documentation fails to substantiate a condition or conditions that would render you totally disabled from any Gainful Occupation beyond January 4, 2017. We have been able to identify and also document our findings of Gainful Occupations with a physical demand of sedentary and or light. The occupations also meet the necessary gainful wage, sixty percent of your pre-disability wages, and exist in your local economy. Therefore, no benefits are payable beyond January 4, 2017, and your claim will be closed.

Def.'s Facts at ¶ 98; Pl.'s Resp. at ¶ 98; Admin. R. at 529. The letter concluded by explaining how Reichard could appeal United of Omaha's adverse determination. Def.'s Facts at ¶ 100; Pl.'s Resp. at ¶ 100; Admin. R. at 530-31.

F. Reichard's Appeal Correspondence

Reichard requested an appeal in a January 16, 2017 letter addressed to United of Omaha. Pl.'s Facts at ¶ 28; Def.'s Resp. at ¶ 28; Admin. R. at 345-48. In her letter, she raised several questions and concerns regarding United of Omaha's claim review. Admin. R. at 345-48. First, she did not receive records from Dr. Osterman in the review file, and United of Omaha omitted records from Dr. Luchetti in the review. Pl.'s Facts at ¶¶ 28A, C; Def.'s Resp. at ¶¶ 28A, C; Admin R. at 345. Second, the medical analysis omitted her medication change to ibuprofen from naproxen, which she discontinued due to severe abdominal pain. Pl.'s Facts at ¶ 28C; Def.'s Resp. at ¶ 28C; Admin. R. at 345. Third, in its denial letter, United of Omaha used "inaccurate, outdated" documentation "scattered with several doctors" and "thrown together and unable to be clearly understood." Pl.'s Facts at ¶ 28D; Def.'s Resp. at ¶ 28 D; Admin. R. at 346. Fourth, she challenged Dr. Liebermann's conclusion that her Crohn's Disease had been stable since 2012 with gastrointestinal medical history from 2015 and 2016. Pl.'s Facts at ¶ 28E; Def.'s Resp. at ¶ 28E; Admin. R. at 346. Fifth, she challenged Dr. Golombek's conclusions as to her physical abilities based on a 20-minute visit in which she did not report his noted abilities, as well as his references to "Dr. Mark Listerman" and "Dr. Ravenelle." Pl.'s Facts at ¶ 28G; Def.'s Resp. at ¶ 28G; Admin. R. at 346-47. Sixth, United of Omaha failed to consider her medications and their side effects, which Reichard listed. Pl.'s Facts at ¶ 28H; Def.'s Resp. at ¶ 28H; Admin. R. at 347. Finally, Reichard attached updated records and other records she alleged United of Omaha excluded in their review and concluded by requesting a reexamination of her claim. Pl.'s Facts at ¶ 28I; Def.'s Resp. at ¶ 28I; Admin. R. at 347-48.

During February and March of 2017, Reichard and United of Omaha representative Tim Fidler exchanged correspondence to finalize her medical records for consideration on review. See Pl.'s Facts at ¶¶ 29-32; Def.'s Resp. at ¶¶ 29-32; Def.'s Facts at ¶¶ 104-06; Pl.'s Resp. at ¶¶ 104-06; Admin. R. at 320-40. She explains the outcomes of recent appointments and submits supporting records. Admin. R. at 320-40. In her final email on March 2, 2017, she states, "This is the last of the medical record[s] as of now, so please su[b]mit my appeal. There are two physicians ... that I have appointments for, but no current[ ] medical records for." Pl.'s Facts at ¶ 32; Def.'s Resp. at ¶ 32; Admin. R. at 320.

G. Dr. Reeder's Medical File Review On Appeal

United of Omaha referred Reichard's LTD benefits claim to Dr. Reeder, Senior Vice President and Medical Director of United of Omaha, for a medical file review. Def.'s Facts at ¶ 108; Pl.'s Resp. at ¶ 108. Dr. Reeder, board-certified in internal medicine, issued the Medical File Review on March 21, 2017. Pl.'s Facts at ¶ 33; Def.'s Resp. at ¶ 33; Def.'s Facts at ¶¶ 108- 09; Pl.'s Resp. at ¶¶ 108-09; Admin. R. at 291-302.

In his report, Dr. Reeder states that he reviewed: (1) STD claim procedural documents, including the STD claim form, denial letter, and appeal letter; (2) Reichard's job description; (3) her June 20, 2015 SRD; (4) her July 5, 2015 email in which she challenged omissions and conclusions in Nurse Grancer's review; (5) United of Omaha's December 30, 2016 denial letter; (6) 2017 correspondence from Reichard; (7) United of Omaha's own medical and vocational examinations and reviews, including Nurse Grancer's review, Palmer's TSA, Dr. Liebermann's peer review, and Dr. Golombek's IME report; and (8) Reichard's medical records, including those from Dr. Chiappetta (February 17, 2014, through February 9, 2016), Dr. Osterman (March 19, 2014, through July 27, 2016), Dr. Blanco (October 20, 2016, through February 22, 2017), Dr. Soraya Jiminez (June 28, 2014, through March 2, 2017), and Dr. Luchetti (August 1, 2014, through July 15, 2016). Admin. R. 291-92. He also acknowledges Reichard's LTD appeal letter. Id. at 292. This section summarizes Reichard's medical records, organized by treatment provider, and discusses Dr. Reeder's analysis and conclusions from those records.

1. Treatment Records from Dr. Chiappetta, Rheumatologist and Primary Care Physician

The earliest evidence of treatment from Dr. Chiappetta in the administrative record appears to be from February 17, 2014, when Reichard sought an evaluation of right hip, knee, and right shoulder pain. Admin. R. at 72-75. Dr. Chiappetta summarizes Reichard's recent knee and hip treatment and symptoms: occasional tendinitis in the right hip and right knee, unsuccessful cortisone injections, an MRI and x-ray of the lumbar spine in the normal range, and aggravated symptoms at night. Id. at 74. She also summarizes Reichard's recent history of Crohn's disease, including "18 inches of bowel resection in January 2012." Id. She notes, "Since the surgery and now being maintained on generic, her bowel symptoms have been relatively stable with intermittent bouts of diarrhea." Id. In summary, she stated that Reichard presented with polyarthralgias and Crohn's disease, and her bowels had been "stable." Id. at 75. Reichard next visited on March 25, 2014, when Dr. Chiappetta "injected Synvisc -1 in both of her knees without any complication." Pl.'s Facts. at ¶ 44; Def.'s Resp. at ¶ 44; Admin. R. at 78.

During Reichard's next appointment on June 19, 2014, Dr. Chiappetta discussed with her a recent left knee MRI, the results of which were consistent with osteoarthritis in the medial compartment of the knee. Pl.'s Facts at ¶ 49; Def.'s Resp. at ¶ 49; Admin. R. at 82. She explained that there was

evidence of chondral loss and some subchondral cyst formation but reactive marrow edema. I have tried Visco supplementation without avail as well as recurrent cortisone injections.... To completely exclude an inflammatory cause for this, related to her Crohn's disease, I am increasing her Humira to 40 mg every week from every other week. She will continue with Imuran.

Id. at 82-83.

Prior to Reichard's next appointment on September 25, 2014, Dr. Chiappetta submitted to United of Omaha the August 27, 2014 APS. See Section II.B., supra . At this next appointment, Dr. Chiappetta stated that Reichard was "having an exacerbation other [sic] underlying bowel disease," and gastrointestinal symptoms remained. Id. at 1136.

Following a January 29, 2015 appointment, Dr. Chiappetta's summary primarily discussed shoulder pain and bowel symptoms:

Giovanna is status post injection of her right subacromial bursa today without any difficulty. She is doing well overall since Humira was increased to a weekly dose and methotrexate replace[d] her Imuran. She [is] still having some bowel symptoms however. She will follow up with gastroenterology.

Pl.'s Facts at ¶ 57; Def.'s Resp. at ¶ 57; Admin. R. at 1031. Prior to Reichard's next appointment, Dr. Chiappetta submitted to United of Omaha the July 7, 2015 APS. See Section II.B., supra . Dr. Chiappetta then evaluated Reichard on July 30, 2015, and wrote: "She continues with Humira, but is having increasing symptomatology and is going to Philadelphia tomorrow for a small bowel follow-through. Her sedimentation rate is mildly elevated at 31. Her main complaint [from] my standpoint is recurrent right shoulder pain." Pl.'s Facts at ¶ 64; Def.'s Resp. at ¶ 64; Admin. R. at 1027. Reichard's final 2015 visit occurred on December 15, 2015, and Dr. Chiappetta analyzed the results of recent blood tests: "From her arthritis standpoint, she is doing very well .... However, my biggest concern is her elevated alkaline phosphatase as well as ALT. With he[r] history of inflammatory bowel disease, she has a higher chance of sclerosing cholangitis." Id. at 463. She also reviewed Reichard's gastrointestinal system, noting "abdominal pain, frequent diarrhea[,] and heartburn," and her mobility, noting that she has "problems with light household tasks and difficulty climbing stairs." Id. at 460.

Reichard's February 9, 2016 visit appears to be the last with Dr. Chiappetta in the administrative record, shortly following the February 3, 2016 APS. See Section II.B., supra . The "Review of Systems" section of the February 9, 2016 office note, containing amendments by Kristyn Wolfer, documents night sweats, weakness or fatigue, immune deficiencies and daytime sleepiness, joint pain and muscle cramps, frequent headaches, numbness, tingling, loss of bowel control, depression and anxiety, abdominal pain, frequent diarrhea, heartburn, and dark or bloody stool. Pl.'s Facts at ¶ 79; Def.'s Resp. at ¶ 79; Admin. R. at 453. Dr. Chiappetta summarized the visit as follows:

[S]he is doing well from my standpoint without any worsening symptoms. She will be started on methotrexate and hopefully this will help some of the bowel issues as well as some of th[e] bladder issues she's been having recently.... I do believe the elevation in her alkaline phosphatase is from her inflammato[ry] bowel disease.

Pl.'s Facts at ¶ 79; Def.'s Resp. at ¶ 79; Admin. R. at 456.

After summarizing Dr. Chiappetta's office notes and APSs, Dr. Reeder analyzed her conclusions and their applicability to Reichard's ability to work:

Dr. Chiap[p]etta's office notes and claims of impairment are internally inconsistent. All of Dr. Chiap[p]etta's Attending Physician Statements up to ... 2/3/16 indicated the insured's restrictions would be compatible with sedentary and light work. It is unclear why on 2/3/16 Dr. Chiap[p]etta stated the insured could sit eight hours, stand and walk one hour each in a work day, and could not work, yet on 2/9/16 Dr. Chiap[p]etta documented pain rating of 0/10, absence of distress, weight of 128 pounds, with normal blood pressure, pulse, respirations, [etc.].... The same essentially normal findings were documented on every encounter in 2014 and 2015. The insured does have some minor laboratory abnormalities that are not relevant to her claim of disability. Liver function tests were transiently elevated. This could be related to her inflammatory bowel disease or her medications, but there is no current evidence of impaired liver function.

....

... [T]he rheumatology examination by Dr. Golombek on 11/11/16 was essentially normal, including the insured's appearance and ability to walk, get on and off the table, general medical exam, range of motion of all joints, palpation of the joints, motor activity, and grip.

See id. at 292-95, 300-01.

2. Treatment Records from Dr. Osterman, Gastroenterologist

The earliest treatment notes in the administrative record from Dr. Osterman appear to be from March 19, 2014, in which he wrote that Reichard was

[f]eeling fair. Some epigastric/[left upper quadrant abdominal] heaviness/[nausea] after eating .... 6 [bowel movements per day], solid-loose, [occasional] blood/mucus .... No more [right upper quadrant] pain, no more lower abdominal pain prior to [bowel movements]; no rectal pain. Still [occasional] rectal prolapse. No [vomiting].... [Occasional fever, chills, and night sweats] .... No dysphagia.

Admin. R. at 157. Reichard called Dr. Osterman twice in the following weeks complaining of continued issues, including irregular bowel movements and abdominal pain. See id. at 98-102. Dr. Osterman ordered an abdominal ultrasound and noted she "will need to stop working for a while." Id. Other than his May 12, 2014 APS and accompanying FMLA form, see Section II.B., supra , no records from Dr. Osterman appear to exist until the following year.

Reichard next visited him for a colonoscopy and esophagogastroduodenoscopy ("EGD") on April 6, 2015. Pl.'s Facts at ¶ 60; Def.'s Resp. at ¶ 60; Admin. R. at 969-72. Dr. Osterman removed a four-millimeter polyp, described the distal colon as tubular, and found the EGD to be "grossly normal except for patchy erythema in the bulb." Admin. R. at 969, 971. Biopsies throughout the stomach and duodenum revealed inflammatory cells. Id. at 964-67, 969, 971.

Around this same time, Dr. Osterman opined that Methotrexate could be causing irregular menses, although the issue seemed to be resolving by June 2015. See Pl.'s Facts at ¶¶ 61-63; Def.'s Resp. at ¶¶ 61-63; Admin. R. at 933, 940, 946. Dr. Osterman next referred Reichard for an upper gastrointestinal series on August 6, 2015, in which the examiner concluded: "1. No Crohn's disease seen in small intestine, with normal side-to-side ileocolonic anastomosis and neoterminal ileum[;] 2. Thick, nodular folds ascending colon suggesting possibility of Crohn's disease in the right colon." Pl.'s Facts at ¶ 65; Def.'s Resp. at ¶ 65; Admin. R. at 369-70.

The final office visit note in the administrative record with Dr. Osterman is from February 8, 2016. See Admin. R. at 426-28. Dr. Osterman noted that Reichard was experiencing ten to twelve bowel movements per day, loose stool with occasional mucus and rare blood, some incontinence, occasional rectal pain, continued occasional rectal prolapse, occasional nausea and vomiting upon waking, continued upper abdominal pain and nausea possibly caused by small bowel obstruction, and irregular menses, although no lower abdominal pain after bowel movements. Id. at 426. Despite increasing muscle strength, biofeedback had not helped Reichard's fecal incontinence. Id. He recommended that Reichard restart taking Methotrexate. Id. at 427. The visit diagnoses were Crohn's disease of both small and large intestine with intestinal obstruction, long-term use of immunosuppressant medication, abdominal pain in the right and left upper quadrants, epigastric abdominal pain, diarrhea, nausea and vomiting, joint pain, dysphagia, gastroesophageal reflux disease without esophagitis, heartburn, inflammatory arthritis, vitamin B12 deficiency, and fecal incontinence. Pl.'s Facts at ¶ 78; Def.'s Resp. at ¶ 78; Admin. R. at 428.

After summarizing Dr. Osterman's office notes, his Attending Physician Statement, and Reichard's colonoscopy and EGD records, Dr. Reeder concluded:

Dr. Osterman was her long[-]term gastroenterologist. When the insured went out of work on 5/12/14, he opined that in an eight[-]hour work day, she could sit six to eight hours, stand and walk, work with others, and had normal finger dexterity. He opined that she [c]ould occasionally lift and carry up to 50 pounds.... While the insured claims that her current disability in part is related to incontinence of rectal prolapse, she had had these symptoms prior to the date of disability.

Id. at 300.

3. Treatment Records from Dr. Blanco, Gastroenterologist

After six years of seeing Dr. Osterman for gastroenterological treatment, Reichard returned to her former gastroenterologist, Dr. Paola Blanco, on October 20, 2016. Id. at 257-59. In her visit summary, Dr. Blanco wrote:

Symptoms include abdominal pain, abdominal cramping, diarrhea[,] and rectal bleeding. Current treatment includes oral corticosteroids, methotrexate... [,] and Humira.... Last colonoscopy was 4 months ago; did not show active disease. Does complain of rectal prolapse ; has tried biofeedback. Last [upper gastrointestinal series ] ... was normal.

....

... Spent more than 30 min[utes] discussing w[ith] patient. I am not sure if her [symptoms] are from Crohn's[,] short gut[,] or pelvic floor dysfunction.... I do not have [Dr. Osterman's] records. Will discuss with him. Suggested trial of Questran. Order MRE and blood work. May need refer[r]al to colorectal for stool incontinence.

Pl.'s Facts at ¶ 81; Def.'s Resp. at ¶ 81; Admin. R. at 257, 259. Following a MR enterography on January 20, 2017, resulting in findings "suggestive of chronic rectosigmoid inflammatory changes" and "[n]o acute findings ... in the small or large bowel," Reichard revisited Dr. Blanco on February 21, 2017. Pl.'s Facts at ¶ 84; Def.'s Resp. at ¶ 84; Admin. R. at 254-56, 260-61. Dr. Blanco wrote that starting Reichard on iron had improved her stool quality. Admin. R. at 254. Reichard was now experiencing approximately five bowel movements daily, paroxysms of severe diarrhea (but also periods of constipation), and bloody stool when she strained to move her bowels. Pl.'s Facts at ¶ 86; Def.'s Facts at ¶ 86; Admin. R. at 254. Dr. Blanco switched Reichard to Remicade because her last colonoscopy showed active Crohn's disease and suggested that she may benefit from a rectal stimulator. Pl.'s Facts at ¶ 86; Def.'s Facts at ¶ 86; Admin. R. at 256.

After summarizing Dr. Blanco's treatment notes, Dr. Reeder concluded:

The insured is now seeing another gastroenterologist, Dr. Blanco. The records supplied from Dr. Blanco did not include a history of physical exam.... Apparently, MR enterography revealed rectosigmoid inflammation, but according to the 2/21/17 note, she was having about five bowel movements a day. Again, there was no examination. Dr. Blanco prescribed Questran primarily for [the] side effect of constipation.

According to the claims analyst, the insured is seeing [a] rectal surgeon and is going to have surgical treatment of the rectal prolapse. However, there is nothing in the records to indicate that this is a constant issue and would not impact her ability to do seated work.

The Gastroenterology Peer Review by Dr. Liebermann did not support any GI restrictions or limitations ....

Id. at 301.

4. Treatment Records from Dr. Jiminez, Neurologist

Reichard received neurology treatment for headaches from Dr. Jimenez and associated physician assistants, Krista Remmel ("Remmel") and Courtney Bloss ("Bloss"). In the earliest neurology note in the administrative record, Reichard visited Remmel as a "follow[-]up for headaches" on June 28, 2014, her first visit in two years. Pl.'s Facts at ¶ 46; Def.'s Resp. at ¶ 46; Admin. R. at 59. Reichard reported a few episodes of dizziness at work and indicated that she had to hang onto the wall because she felt like the room was spinning. Pl.'s Facts at ¶ 46; Def.'s Resp. at ¶ 46; Admin. R. at 59. Remmel noted that Reichard's Crohn's disease had been flaring up resulting in her not eating while working, which in turn possibly caused vertigo, hypovolemia, or hypoglycemia. Admin R. at 59, 63. She discontinued Topamax after developing blurred vision on the medication. Pl.'s Facts at ¶ 46; Def.'s Resp. at ¶ 46; Admin. R. at 59. Additionally, "[D]aily tension headaches in [Reichard's] neck and posterior scalp" persisted, including "more severe headache[s] during her period," although they were less severe than in the past. Pl.'s Facts at ¶ 46; Def.'s Resp. at ¶ 46; Admin. R. at 59.

Reichard next visited Kimmel on September 2, 2015, reporting daily headaches of four-out-of-ten pain, menstrual headaches at eight-out-of-ten-pain, and muscle spasms in the neck. Pl.'s Facts at ¶ 66; Def.'s Resp. at ¶ 66; Admin. R. at 689, 692. Kimmel repeated trigger point injections that Reichard had previously found helpful, concluded that there was no need for an MRI given the normal exam, and instructed Reichard to use Maxalt as needed and increase her Zanaflex dosage. Pl.'s Facts at ¶ 66; Def.'s Resp. at ¶ 66; Admin. R. at 692. Kimmel advised Reichard to take the Zanaflex at bedtime due to sedation. Pl.'s Facts at ¶ 66; Def.'s Resp. at ¶ 66; Admin. R. at 689, 692.

Bloss saw Reichard for her next appointment on January 14, 2016. Pl.'s Facts at ¶ 77; Def.'s Resp. at ¶ 77; Admin. R. at 695-700. Reichard reported tension headaches lasting one to three days and occurring once per month, limiting her use of Zanaflex because she gets tired on it, avoiding Maxalt for non-migraine headaches, and that taking both Zanaflex and ibuprofen was not effective in treating headaches. Pl.'s Facts at ¶ 77; Def.'s Resp. at ¶ 77; Admin. R. at 695. Bloss instructed her to try naproxen in addition to Zanaflex for the monthly tension headaches, opining that this limited use of NSAIDs should "be fine" with her Crohn's disease. Pl.'s Facts at ¶ 77; Def.'s Resp. at ¶ 77; Admin. R. at 698.

Reichard returned on November 16, 2016, visiting with Dr. Jiminez, who indicated that ibuprofen was now helping the menstrual headaches, although left arm numbness now accompanied headaches. Pl.'s Facts at ¶ 82; Def.'s Resp. at ¶ 82; Admin R. at 359. The left arm numbness prompted Dr. Jiminez to order an MRI of the cervical spine, which revealed evidence of osseous fusion and slightly increased spondylosis on December 6, 2016. Pl.'s Facts at ¶ 83; Def.'s Resp. at ¶ 83; Admin. R. at 380-81. Dr. Jiminez last saw Reichard on February 8, 2017, for a follow-up, at which she listed left arm numbness, neck muscle spasms, and menstrual migraines as active problems. Pl.'s Facts at ¶ 85; Def.'s Resp. at ¶ 85; Admin. R. at 321-24.

After summarizing Reichard's neurology treatment, including the noted Topamax and Zanaflex side effects, Dr. Reeder concluded that the "neurological records from Dr. Jiminez never documented focal neurological deficits, only tenderness to palpation of the cervical muscles," and the MRI demonstrated "no evidence of spinal cord or nerve root contact." Admin. R. at 296, 301-02.

5. Treatment Records from Dr. Luchetti, Orthopedist

Dr. Luchetti treated problems with Reichard's knees and shoulder. On August 1, 2014, Reichard visited Dr. Luchetti complaining of bilateral knee pain. Pl.'s Facts at ¶ 50; Def.'s Resp. at ¶ 50; Admin. R. at 1148-50. His assessment was osteoarthritis, and he concluded, "When the pain becomes intolerable she is a candidate for a unicompartmental knee replacement." Pl.'s Facts at ¶ 50; Def.'s Resp. at ¶ 50; Admin. R. at 1149-50. Reichard saw Dr. Luchetti three weeks later on August 21, 2014, complaining of shoulder pain after slipping on black ice the prior winter. Admin. R. at 1145-47. An x-ray revealed no acute fracture or dislocation, but mild degenerative joint disease and type 1 acromial morphology. Id. at 1147. Dr. Luchetti ordered an MRI to determine whether a rotator cuff tear was causing her supraspinatus weakness, which was negative. Pl.'s Facts at ¶¶ 51-53; Def.'s Resp.