Evans v. Commissioner of Social Security

District Court, W.D. Washington·Decided January 9, 2024·No. 3:23-cv-05492·Unknown

Opinion

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5 UNITED STATES DISTRICT COURT 6 WESTERN DISTRICT OF WASHINGTON AT SEATTLE 7 JOSHUA E., 8 Plaintiff, CASE NO. C23-5492-BAT 9 v. ORDER REVERSING AND 10 REMANDING FOR AWARD OF COMMISSIONER OF SOCIAL SECURITY, BENEFITS 11 Defendant. 12

13 Plaintiff appeals the ALJ’s denial of his applications for Supplemental Security Income 14 and Disability Insurance Benefits. He contends the ALJ misevaluated his testimony, the lay 15 witness testimony, and the medical opinion evidence. Dkt. 10 at 1. For the reasons below, the 16 Court REVERSES the Commissioner’s final decision and REMANDS the matter for an 17 immediate calculation of an award of benefits under sentence four of 42 U.S.C. § 405(g). 18 BACKGROUND 19 Plaintiff is currently thirty-eight years-old, has a limited education, and has worked as a 20 restaurant manager and night auditor. Tr. 580, 594-95. On November 27, 2019, Plaintiff applied 21 for benefits, alleging disability as of November 1, 2019. Tr. 270-78. His application was denied 22 initially and on reconsideration. Tr. 69-88, 91-118. On March 11, 2021, the ALJ conducted a 23 hearing, at which Plaintiff, a vocational expert (“VE”), and medical expert (“ME”), neurologist, 1 Dr. James Haynes, testified. Tr. 34-67. On March 31, 2021, the ALJ issued a decision finding 2 Plaintiff not disabled. Tr. 15-26. The Appeals Council denied Plaintiff’s request for review, 3 and, in August 2021, Plaintiff appealed the ALJ’s decision to this Court, and the case, 21-5618- 4 DWC, was assigned to the Honorable David W. Christel. Tr. 1-6, 633-34, 696-99.

5 In March 2022, Judge Christel reversed and remanded, finding the ALJ harmfully erred 6 in evaluating medical opinions from Drs. Robert Hander and Norman Staley. Tr. 643-44. Judge 7 Christel noted the ALJ failed to recognize Drs. Hander and Staley opined Plaintiff would be 8 capable of performing light work only after undergoing surgery to correct a Chiari I 9 malformation.1 Tr. 643. Judge Christel acknowledged Dr. Haynes testified Plaintiff was capable 10 of light work without surgery. Tr. 643. However, Judge Christel found the ALJ erred in failing 11 to make an explicit finding that resolved the discrepancy between Drs. Hander’s and Staley’s 12 opinions that surgery was necessary and Dr. Haynes’ testimony that surgery was unnecessary. 13

14 1 A “Chiari malformation” is “a condition in which brain tissue extends into the spinal canal. It occurs when part of the skull is misshapen or smaller than is typical[,] and [t]he skull presses on 15 the brain and forces it downward.” Chiari Malformation, Mayo Clinic, https://www.mayoclinic. org/diseases-conditions/chiari-malformation/symptoms-causes/syc-20354010 (last visited Jan. 9, 16 2024). Chiari malformations are considered

17 structural defects in the base of the skull and cerebellum, the part of the brain that 18 controls balance. Normally the cerebellum and parts of the brain stem sit above an opening in the skull that allows the spinal cord to pass through it (called the 19 foramen magnum). When part of the cerebellum extends below the foramen magnum and into the upper spinal canal, it is called a Chiari malformation. 20 Chiari Malformation, National Institute of Neurological Disorders & Stroke, Fact Sheet, Nat’l Inst. of Neurological Disorders & Stroke, https://www.ninds.nih.gov/health-information/ 21 disorders/chiari-malformations?search-term=chiari (last visited Jan. 9, 2024). “The most common surgery for Chiari malformation is called posterior fossa decompression,” and the 22 “[s]urgery involves removing a small section of bone in the back of the skull. This relieves pressure by giving the brain more room. During surgery, the covering of the brain called the 23 dura mater may be opened.” Id. 1 Judge Christel additionally found the ALJ failed to provide sufficient reasons for 2 discounting Plaintiff’s testimony based on inconsistencies with the medical record and 3 improvement with treatment. Tr. 645-47. For the same reasons, Judge Christel found the ALJ 4 erred in evaluating the lay witness testimony. Tr. 647.

5 On February 7, 2023, the same ALJ held a second hearing on remand. Tr. 590-606. The 6 ALJ acknowledged that following his prior March 2021 hearing, Plaintiff underwent surgery to 7 correct the Chiari malformation on March 18, 2021. Tr. 591-92 (discussing Tr. 816). After 8 recovering from the March 2021 surgery, Plaintiff returned to full-time work on June 29, 2021. 9 Tr. 591-92 (discussing Tr. 816). Accordingly, the ALJ acknowledged that, given his return to 10 work, Plaintiff had amended his application to request benefits for a closed period only: from 11 November 1, 2019 through June 28, 2021. Tr. 816, 866. On March 9, 2023, the ALJ again 12 found Plaintiff not disabled for the closed period, and Plaintiff filed the instant appeal. 13 DISCUSSION 14 A. Plaintiff’s and Lay Witness Testimony

15 In addition to testifying at the March 11, 2021, and February 7, 2023 hearings, Plaintiff 16 attested to the functional limitations and symptoms caused by his headaches in a December 2019 17 Headache Questionnaire and in a May 2020 Function Report. Tr. 355-62 (function report); Tr. 18 319-21 (headache questionnaire). 19 Plaintiff explained he began experiencing headaches in his youth as a result of straining, 20 coughing, sneezing, and/or lifting heavy objects. Tr. 319. He explained the headaches were 21 caused by a Chiari brain malformation whereby his “cerebellar tonsils [were] herniated and 22 23 1 pressing on [his] brain stem.”2 Tr. 355. Plaintiff testified in 2021, before his surgery, that the 2 last time he had been able to work full-time was in November 2019 as a manager of a fast-food 3 restaurant. Tr. 45; see also Tr. 322 (Plaintiff’s work history report). He explained he suffered 4 from headaches every day of varying severity, and they were often so intense he would require a

5 break or would need to leave the jobsite completely. Tr. 57. Plaintiff testified the headaches 6 were often triggered by “literally daily activity stuff,” like “coughing, sneezing, . . . bending 7 over.” Tr. 58. He testified he “tried [his] hardest” to continue with the job, but his employer 8 advised him to “get [his health] situation dealt with and come back when [he could] be [there] 9 every day.” Tr. 54. 10 Plaintiff testified he continued to suffer from the same symptoms and remained unable to 11 work during the closed period in large part because, from day to day, it was unpredictable 12 whether he would be able to complete a full day of work. Tr. 55, 597. He explained he tried not 13 to do anything that would trigger his headaches – including coughing, laughing, straining, 14 bending over, or picking up items. Tr. 50-51. However, that was not always possible, and a trip

15 to the bathroom could cause a severe headache in spite of the fact Plaintiff took stool softeners to 16 prevent bowel movements from interrupting his day. Tr. 55-56. 17 Plaintiff testified in March 2021 that, with his upcoming surgery, he would essentially be 18 “asking [his] doctor to cut [his] brain open for a 50/50 chance of fixing [his malformation] 19 because he literally can’t do it anymore.” Tr. 57. Plaintiff’s Chiari surgery, however, was 20

21 2 The Chiari 1 malformation was first diagnosed in December 2019 following an MRI. Tr. 428- 32 (On December 6, 2019, Physician’s assistant (“PA”) Caoilin Hoctor notes that she “reviewed 22 [Plaintiff’s] MRI results with him and explained the nature of the Chiari Malformation which is very likely . . . causing the majority of his symptoms including his posterior headaches worse 23 with straining”); Tr. 458-59 (Neurosurgeon, Dr. Marc Goldman, notes Plaintiff’s “pain and dizziness” caused by the Chiari malformation and recommends surgery).

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