Nelson v. Berryhill
| Decision Date | 07 February 2018 |
| Docket Number | Case No.: 3:17-cv-00614-AJB-KSC |
| Court | U.S. District Court — Southern District of California |
| Parties | AARON THEODORE NELSON, Plaintiff, v. NANCY A. BERRYHILL, Officially as Acting Commissioner of the Social Security Administration, Defendant. |
REPORT AND RECOMMENDATION RE CROSS-MOTIONS FOR SUMMARY JUDGMENT
Pursuant to Title 42, United States Code, Section 405(g), of the Social Security Act ("SSA"), plaintiff filed a Complaint to obtain judicial review of a final decision by the Commissioner of Social Security ("Commissioner") denying his disability insurance benefits.1 Pursuant to Title 28, United States Code, Section 636(b)(1)(B), and Civil LocalRules 72.1(c)(1)(c) and 72.2(a), this matter was assigned to the undersigned Magistrate Judge for a Report and Recommendation.
Presently before the Court are: (1) plaintiff's Motion for Summary Judgment [Doc. No. 13]; (2) defendant's Cross-Motion for Summary Judgment [Doc. No. 14]; (3) defendant's Response in Opposition to plaintiff's Motion [Doc. No. 15]; (4) plaintiff's Reply to defendant's Opposition [Doc. No. 16]; and (5) the Administrative Record [Doc. No. 10]. After careful consideration of the moving and opposing papers, as well as the Administrative Record and the applicable law, this Court RECOMMENDS that the District Court REMAND the case for further consideration by the Commissioner.
On September 4, 2015, plaintiff filed an application for a period of disability and disability insurance benefits ("DIB") alleging disability beginning August 4, 2014. [AR 67]. Plaintiff's application states that he was born on February 13, 1989. [Id.]. He represents in his application that he was unable to work due to (1) chronic back pain; (2) scoliosis; (3) depression; and, (4) arthritis. [AR 67]. On November 10, 2015, the Commissioner denied plaintiff's application for DIB. [AR 92-94].
plaintiff requested reconsideration on December 7, 2015 [AR 77], alleging a change in his medical condition, and listing the following: (1) "recent suicide attempt due to an overdose"; (2) increase in frequency of suicidal thoughts; (3) increase in pain and decreased ability to complete daily physical activities; (4) use of a cane; (5) visual hallucinations; (6) PTSD; and, (7) anxiety. [AR 78]. His request was denied on January 28, 2016. [AR 104].
On March 30, 2016, he requested a hearing before an administrative law judge (hereinafter "ALJ"). [AR 121-122]. He received notice of the hearing on August 3, 2016. [AR 157-161]. A hearing before an ALJ was held on September 8, 2016. [AR 13].
On December 27, 2016, the ALJ issued a written opinion concluding that plaintiff did not qualify for DIB under the SSA. [AR 15]. In reaching this decision, the ALJ found that plaintiff has the severe impairments of "degenerative disc disease of the lumbar spine, scoliosis, a major depressive disorder, and an anxiety disorder with psychosis." [AR 15].However, the ALJ concluded he did not have an impairment or combination of impairments that meet SSA disability criteria, and that he possesses the residual functional capacity to perform unskilled sedentary work with eleven additional limitations. [AR 17-18]. Plaintiff sought review from the Appeals Council, which was denied on February 28, 2017 [AR 1], after which he filed the instant action on March 28, 2017. [Doc. No. 1].
The final decision of the Commissioner must be affirmed if it is supported by substantial evidence and if the Commissioner has applied the correct legal standards. Batson v. Comm'r of the Social Security Admin., 359 F.3d 1190, 1193 (9th Cir. 2004). Under the substantial evidence standard, the Commissioner's findings are upheld if supported by inferences reasonably drawn from the record. Id. If there is evidence in the record to support more than one rational interpretation, the District Court must defer to the Commissioner's decision. Id. Substantial evidence means "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Osenbrock v. Apfel, 240 F.3d 1157, 1162 (9th Cir. 2001). The Court must weigh both the evidence that supports and detracts from the administrative ruling. Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999).
Pursuant to Federal Rule of Civil Procedure 56(a), "[t]he court shall grant summary judgment if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(a). "Summary judgment motions, as defined by Fed.R.Civ.P. 56, contemplate the use of evidentiary material in the form of affidavits, depositions, answers to interrogatories, and admissions. In Social Security appeals, however, the Court may 'look no further than the pleadings and the transcript of the record before the agency,' and may not admit additional evidence. Morton v. Califano, 481 F.Supp. 908, 914 n. 2 (E.D. Tenn. 1978); 42 U.S.C. § 405(g). "[A]lthough summary judgment motions are customarily used [in social security cases], and even requested by the Court, such motions merely serve as vehicles for briefing theparties' positions, and are not a prerequisite to the Court's reaching a decision on the merits." Kenney v. Heckler, 577 F.Supp. 214, 216 (D.C. Ohio 1983).
A. Chronological Summary of Medical Records
Medical records submitted in support of plaintiff's claim for disability benefits include medical notes and reports from his treating physicians at emergency rooms and health clinics. The following is a brief summary of the relevant medical records pertaining to plaintiff's physical ailments and mental impairments.
Prior to moving to San Diego in 2014, plaintiff resided in North Carolina where he was a patient at the Mahec Family Health Center. His medical records at the Mahec Center date back to September, 2013. [AR 319-321]. On September 13 and 16, 2013, treating physician, Dr. Samantha Fawcett, recorded that plaintiff stated he struggled with "ongoing back pain" that "look[ed] like [a] compressed disc" for which he occasionally took "5MG APAP, flexeril, +/- skelaxin, [and] naproxen." [AR 319]. Though he was observed to have a "full affect," Dr. Fawcett also observed psychiatric symptoms of fearfulness and anxiety. [AR 320]. During a visit on November 13, 2013, another physician recorded that plaintiff complained of pain in his joints/bones. [AR 318]. Subsequent visits on March 3, April 21, and May 19 of 2014 all dealt with apparent sexual activity problems, which one physician noted was likely "psychosocial." [AR 311-318]. On June 18, 2014, plaintiff's treating physician, Dr. Aaron Vaughn, recorded that plaintiff had a flat affect. [AR 308].
On February 3, 2015, plaintiff was hospitalized at WakeMed Cary Hospital after attempting to commit suicide by ingesting multiple Benadryl pills and alcohol. [AR 327]. During his six-day stay, the psychiatric consulting physician wrote that plaintiff had felt depressed for 1-2 years, was uncooperative during the assessment, and refused to answer questions. [Id.]. The psychiatrist also recorded that plaintiff had previously been treated for depression when he was sixteen. [AR 328]. The discharge evaluation stated that during his hospitalization, he did not "agree[] to tak[e] any medications recommended by psychiatry to treat his depression." [AR 326]. On February 9, 2015, plaintiff was releasedfrom WakeMed hospital to Holly Hill Hospital where he stayed for eleven days. [AR 472]. Dr. Jonathan Ahr conducted an evaluation during his time at Holly Hill and reported that "[t]he test data do suggest a major depressive disorder . . ." and that he "may be expressing paranoid personality traits in these test data as well." [AR 482]. Though safe for discharge with appropriate aftercare, Dr. Ahr concluded that "[o]wing to the severity of his attempt, the patient must be considered with chronic suicide risk." [Id.] Upon discharge, the summary of his stay at Holly Hill Hospital contained, inter alia, the following findings: "major depressive disorder[,] severe and recurrent"; plaintiff "felt much better on [20mg of Paxil]"; and was "improving on these medications"; and he felt much better on the medications and was eager to move forward in a positive manner. [AR 472].
On June 8, 2015, plaintiff went to San Ysidro Health Center where he began treatment for back pain, depression, and scoliosis. [AR 517-520]. The records from his June 8, 2015 visit note symptoms of depression, anxiety, and gait disturbance. [AR 518]. He was prescribed Paxil, Naproxen, and Flexeril. [AR 517].
On June 26, 2015, plaintiff returned to the San Ysidro Health Center seeking a "behavioral health visit." [AR 513]. During that visit, the medical records show plaintiff suffered from anxiety, depression, gait disturbance, insomnia, back pain, and joint pain. [AR 514]. His existing prescriptions from the June 8, 2015 visit did not change, however the treating physician, Dr. Sean Rodriguez, also prescribed 300 milligrams of Gabapentin. [AR 513]. Plaintiff returned to the Health Center on July 2, 2015 for an injection of Toradol to address his chronic back pain. [AR 507]. However, he refused the injection on that date because he could not receive local anesthetic prior to the injection. [Id.]. Instead, Dr. Rodrigquez increased the regular dose of Gabapentin from 300 milligrams to 600 milligrams to be taken at night. [Id.].
Plaintiff was also incarcerated at the San Diego County Jail on July 8, 2015. [AR 485]. Following his initial evaluation, the "encounter notes" stated plaintiff was a risk for violence to himself, to others, and that he showed signs of "[a]lteration in thought process" and "[a]lteration in mood." [AR 488]. For two days, he was placed on suicide watch. [Id.].During that time, he was placed in a safety garment and suicide precaution blanket. [AR 485-87]. No "self-harming gestures" or...
To continue reading
Request your trial