Hassick v. Commissioner of Social Security

[5] UNITED STATES DISTRICT COURT 6 WESTERN DISTRICT OF WASHINGTON AT SEATTLE [7] FAWN H., [8] Plaintiff, Case No. C20-0231 RSM [9] v. ORDER REVERSING AND 10 REMANDING DENIAL OF COMMISSIONER OF SOCIAL SECURITY, BENEFITS [11] Defendant. [12] 13 Plaintiff seeks review of the denial of her application for disability insurance benefits. 14 Plaintiff contends the Administrative Law Judge (“ALJ”) erred by failing to give adequate 15 reasons for rejecting (1) Plaintiff’s testimony regarding migraine headaches, and (2) the opinions 16 of Gregory Maddox, M.D. Pl. Op. Br. (Dkt. 10), p. 1. As discussed below, the Court 17 REVERSES the Commissioner’s final decision and REMANDS the matter for further 18 administrative proceedings under sentence four of 42 U.S.C. § 405 (g). 19 BACKGROUND 20 Plaintiff is 52 years old, has a GED, and has worked as a service dispatcher, customer 21 service clerk, and store laborer. Admin. Record (“AR”) 25, 61, 215, 249. Plaintiff applied for 22 benefits in 2016, alleging disability as of July 13, 2006, later amended to January 1, 2013. See 23 AR 15, 61–62, 181–84. Plaintiff’s applications were denied initially and on reconsideration. AR 1 61–65, 68–80, 82–94. After conducting a hearing on September 20, 2018, the ALJ issued a 2 decision finding Plaintiff not disabled. AR 15–27, 34–60. In relevant part, the ALJ found 3 Plaintiff had severe impairments of migraine/cluster headaches, and obesity. AR 17. The ALJ 4 found Plaintiff had the residual functional capacity (“RFC”) to perform light work, with 5 additional postural, social, and cognitive restrictions. AR 21. Plaintiff “could be expected to be 6 off task for ten percent of the time but would still meet the minimum production requirements of 7 the position.” Id. She could be expected to miss one day of work per month. Id. 8 The Appeals Council denied Plaintiff’s request for review, making the ALJ’s decision the 9 Commissioner’s final decision. See AR 1–3. 10 DISCUSSION 11 This Court may set aside the Commissioner’s denial of Social Security benefits only if 12 the ALJ’s decision is based on legal error or not supported by substantial evidence in the record 13 as a whole. Trevizo v. Berryhill, 871 F.3d 664, 674 (9th Cir. 2017). The ALJ is responsible for 14 evaluating evidence, resolving conflicts in medical testimony, and resolving any other 15 ambiguities that might exist. Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995). While the 16 Court is required to examine the record as a whole, it may neither reweigh the evidence nor 17 substitute its judgment for that of the ALJ. Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 18 2002). When the evidence is susceptible to more than one interpretation, the ALJ’s 19 interpretation must be upheld if rational. Burch v. Barnhart, 400 F.3d 676 , 680–81 (9th Cir. 20 2005). This Court “may not reverse an ALJ’s decision on account of an error that is harmless.” 21 Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012). 22 1. Plaintiff’s Testimony Regarding Migraine Headaches 23 Plaintiff testified she gets debilitating headaches one to two times a week. See AR 44– 1 45, 233, 235, 257. Plaintiff reported she can usually treat her pain with over-the-counter Tylenol 2 or aspirin, or laying down in the dark. See also AR 43–44, 235. If that does not work, she will 3 use Vicodin. AR 43, 235. She testified the Vicodin usually takes two hours to take effect. See 4 AR 45–46. Plaintiff testified her medication makes her drowsy. AR 44. When she gets 5 extremely bad headaches, they cause eye problems, nausea, vomiting, dizziness, and irritability. 6 See AR 235, 257. If the Vicodin does not work, Plaintiff will go to the emergency room for 7 treatment. See AR 235. 8 Where, as here, an ALJ determines that a claimant has presented objective medical 9 evidence establishing underlying impairments that could cause the symptoms alleged, and there 10 is no affirmative evidence of malingering, the ALJ can only discount the claimant’s testimony as 11 to symptom severity “by offering specific, clear and convincing reasons for doing so. This is not 12 an easy requirement to meet.” Garrison v. Colvin, 759 F.3d 995 , 1014–15 (9th Cir. 2014). The 13 ALJ failed to meet this standard. 14 The ALJ first erred in rejecting Plaintiff’s testimony based on his conclusion that 15 Plaintiff’s medication regimen was unusual, and that she showed evidence of drug-seeking. See 16 AR 22. The ALJ noted Plaintiff’s “migraines were managed with medications such as Vicodin, 17 injections of Dilaudid, steroidal agents, Compazine, Toradol, and Benadryl.” Id. The ALJ 18 pointed out one provider noted this was “not ideal” for headache management, and another noted 19 Plaintiff did not take typical migraine management medications. See AR 22, 380, 606. But 20 Plaintiff cannot be faulted for taking the medications her providers prescribed or administered. 21 Plaintiff’s doctor prescribed her Vicodin, presumably because he felt it was an effective 22 medication. See AR 392. Emergency Department doctors administered Dilaudid and other 23 medications because they determined these would effectively control Plaintiff’s symptoms. See 1 AR 360, 369, 608. 2 As to drug-seeking, the ALJ’s conclusion is not supported by substantial evidence. The 3 ALJ pointed to one note in the record, in which Plaintiff became upset at not getting her 4 hydrocodone prescription a week early. See AR 22, 695–96. Plaintiff exhibited inappropriate 5 behavior at this appointment, but the remainder of the record shows no evidence of drug seeking. 6 Even after this appointment, Plaintiff’s providers regularly noted she showed “[n]o addictive 7 behavior, no red flags,” and was “[n]ot opiate dependent.” AR 659, 662, 665, 668, 670, 674, 8 676, 678, 681, 687. 9 The ALJ further erred in rejecting Plaintiff’s testimony based on her inconsistent reports 10 of headache frequency. The ALJ noted Plaintiff described her headaches as “intermittent” and 11 reported “[n]o recent ER trips.” AR 357, 453. Plaintiff’s temporally vague statements are not 12 inconsistent with her testimony, as she testified even her headaches that do not lead to an ER 13 visit may take several hours to resolve. See AR 45–46; see also AR 494 (“She has been to ED 14 twice because she can’t get rid of headache at 2–3 days of effort”); 611 (“Every few months has 15 headache not controlled with home medications”). 16 The ALJ’s analysis of Plaintiff’s work history is similarly unconvincing as a reason for 17 rejecting Plaintiff’s testimony. The ALJ noted Plaintiff gave reasons for leaving jobs such as not 18 being “the right fit,” reported planning to get a job, and performed work-like activities in caring 19 for a blind man, her husband, and her son during the disability period. See AR 23. Given the 20 ALJ’s errors with respect to his other reasons for rejecting Plaintiff’s testimony, the Court is not 21 confident the ALJ reasonably evaluated this evidence, or that Plaintiff’s work history—standing 22 alone—is a clear and convincing reason for rejecting her testimony. Consequently, the ALJ 23 harmfully erred in rejecting Plaintiff’s subjective symptom testimony. 1 2. Dr. Maddox’s Opinions 2 Dr. Maddox was Plaintiff’s treating provider. See AR 392–458, 505–07, 511–12, 515– 3 18, 545–47, 549–50, 552–54, 658–708. He completed a questionnaire from Plaintiff’s counsel in 4 June 2018. See AR 650–51. Dr. Maddox agreed counsel accurately summarized several 5 findings and reports from treatment notes. Id. Dr. Maddox agreed treatment notes describing 6 Plaintiff’s migraines as “not intractable” meant the migraines were susceptible to control with 7 medication or treatment, but did not address the severity or impact of the migraines prior to 8 being brought under control through medication or treatment. Id. Dr. Maddox opined Plaintiff 9 would probably miss three or more days of work per month due to her migraine headaches. Id. 10 The ALJ gave Dr. Maddox’s opinions little weight. AR 24. The ALJ reasoned Dr. 11 Maddox’s opinions were unsupported by objective medical evidence because “[i]n almost every 12 instance, Dr. Maddox circled his answer or checked a box.” Id. The ALJ further reasoned Dr. 13 Maddox’s opinions were inconsistent with the overall medical evidence and Plaintiff’s work 14 history. Id. 15 An ALJ may only reject the uncontradicted opinions of a treating doctor by providing 16 “‘clear and convincing’ reasons.” Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1996) (quoting 17 Baxter v. Sullivan, 923 F.2d 1391, 1396 (9th Cir. 1991)). If the treating doctor’s opinions are 18 contradicted, the ALJ must provide “‘specific and legitimate reasons’ supported by substantial 19 evidence in the record for so doing.” Lester, 81 F.3d at 830 (quoting Murray v. Heckler, 722 20 F.2d 499, 502 (9th Cir. 1983)). The ALJ’s reasons here fail under either standard. 21 The ALJ erred in rejecting Dr. Maddox’s opinions as unsupported and inconsistent with 22 the medical evidence. An ALJ errs when he rejects a treating doctor’s opinions as 23 unsupported—even when they are given in an otherwise unexplained check-box form—while 1 ignoring the doctor’s treatment records. See Garrison, 759 F.3d at 1013 . An ALJ further errs 2 when he rejects a medical opinion “with boilerplate language that fails to offer a substantive 3 basis for” the ALJ’s conclusion. Id. at 1012–13 (citing Nguyen v. Chater, 100 F.3d 1462 , 1464 4 (9th Cir. 1996). The ALJ failed to adequately address Dr. Maddox’s treatment records, and 5 failed to explain how the overall medical evidence was inconsistent with Dr. Maddox’s opinions. 6 See AR 24. To the extent the ALJ intended to rely on his analysis of the medical evidence in 7 relation to Plaintiff’s testimony, that analysis was in error, as explained above. It thus cannot 8 support rejecting Dr. Maddox’s opinions any more than it could support rejecting Plaintiff’s 9 testimony. 10 The ALJ also erred in rejecting Dr. Maddox’s opinions based on Plaintiff’s work history. 11 The ALJ’s analysis here was the same as his analysis with respect to Plaintiff’s testimony. See 12 AR 23–24. That analysis fails here for the same reasons it failed with respect to Plaintiff’s 13 testimony. The ALJ thus failed to provide valid reasons for rejecting Dr. Maddox’s opinions, 14 and harmfully erred. 15 3. Scope of Remand 16 Plaintiff asks the Court to remand this matter for an award of benefits, but does not make 17 any substantive argument in support of this request. See Pl. Op. Br., p. 5. Plaintiff has not 18 shown “rare circumstances” exist that justify departing from the ordinary rule of remand for 19 further proceedings. See Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1099 (9th Cir. 20 2014). The Court therefore remands this matter for further administrative proceedings. 21 On remand, the ALJ shall reevaluate Plaintiff’s testimony, and Dr. Maddox’s opinions. 22 The ALJ shall reevaluate all relevant steps of the disability evaluation process, and conduct 23 further proceedings necessary to reevaluate the disability determination in light of this opinion. 1 CONCLUSION 2 For the foregoing reasons, the Commissioner’s final decision is REVERSED and this 3 case is REMANDED for further administrative proceedings under sentence four of 42 U.S.C. § 4 405(g). 5 DATED this 31st day of August, 2020. [7] 8 RICARDO S. MARTINEZ CHIEF UNITED STATES DISTRICT JUDGE