Lacy v. Berryhill

District Court, N.D. California·Decided October 1, 2019·No. 3:19-cv-00140·Unknown

Opinion

GAYLE AMANDA LACY, Case No. 19-cv-00140-SI

Plaintiff, ORDER RE: CROSS-MOTIONS FOR SUMMARY JUDGMENT v.

ANDREW SAUL1, Re: Dkt. Nos. 15, 16 Defendant.

The parties have filed cross-motions for summary judgment in this Social Security appeal. Dkt. Nos. 15, 16. Based upon the Court’s review of the parties’ papers and the Administrative Record (“AR”), the Court hereby GRANTS plaintiff’s motion and DENIES defendant’s motion. This matter is REMANDED for immediate payment of benefits. On January 9, 2018, the date of the administrative hearing in this case, plaintiff Gayle Amanda Lacy was a fifty-year-old female with some high school education. AR at 106, 1088. Her work history includes packing warehouse shipments and cleaning airplanes. Id. at 134-35. She ceased working in 2006, and in January 2007 she applied for disability insurance benefits (“DIB”) under Title II of the Social Security Act and for Supplemental Security Income (“SSI”) under Title XVI of the Act. Id. at 265-66. After a hearing on February 24, 2009, an Administrative Law Judge (“ALJ”) determined that plaintiff was disabled as of October 17, 2006, due to limitations arising from Post-Traumatic Stress Disorder (“PTSD”) and Borderline Intellectual Functioning. Id. at 76, 134, 148. I. Procedural History On November 6, 2014, the Social Security Administration (“SSA”) initiated a Continuing Disability Review (“CDR”) of plaintiff’s eligibility for benefits. Id. at 288. The SSA concluded that she had medically improved as of March 2015; thus, her disability had ceased. Id. at 197-200. Plaintiff requested a hearing; it was held on January 9, 2018, before ALJ E. Alis. Id. at 56, 105. Plaintiff was represented by counsel at the hearing,2 and Ruth A. Arnush, impartial vocational expert, testified. Id. at 74. No medical expert testified at the hearing. The ALJ issued a decision on March 20, 2018, finding that plaintiff was not disabled as of May 31, 2015. Id. at 71-88. On November 9, 2018, the Appeals Council denied plaintiff’s request to review the ALJ’s decision, making the ALJ’s decision the final decision of the Commissioner. See id. at 1-6. Plaintiff then filed an action for judicial review pursuant to 42 U.S.C. § 405(g). Dkt. No. 1. The parties cross- moved for summary judgment. Dkt. Nos. 15, 16. II. Medical History From 2006 to 2007, prior to her disability determination in 2009, plaintiff underwent treatment for breast cancer. AR at 533, 559. Plaintiff also has a long history of psychological trauma. Id. at 440. Throughout her period of disability, plaintiff’s medical records include numerous primary care, specialist, and emergency room visits. See, e.g., id. at 522, 909, 1022. These records show a history of depression and PTSD as well as knee and foot pain. Id. Plaintiff also has a history of coronary artery disease. Id. at 80. In addition to reviewing treatment records, the ALJ considered the opinions of twelve practitioners—three treating, five examining, and four non-examining consulting. Id. at 82-85.

A. Mental Health Treatment and Evaluation Plaintiff’s records first include a diagnosis for depression in 2010. Id. at 581. In 2009, an ALJ determined she was disabled due in part to the effects of PTSD. Id. at 76. She has also reported anxiety and panic attacks. Id. at 1007. 1. Dr. Acenas, MD (Examining Psychiatrist) On February 11, 2015, plaintiff met with Dr. Anoinette Acenas, who conducted a comprehensive psychiatric evaluation as part of the SSA’s CDR process. Id. at 440. Dr. Acenas noted that plaintiff was depressed and suffered from PTSD, and that her stressors included multiple medical conditions. Id. at 442. Dr. Acenas observed that plaintiff was able to remember two out of three objects in three minutes and concluded that plaintiff was able to understand and follow complex and detailed instructions. Id. Dr. Acenas opined that plaintiff was not impaired in any functional area. Id. at 442-43. 2. Dr. Smith, MD, and Dr. Olaya, MD (Non-Examining Consultants) In March 2015, SSA psychological consultants Drs. Smith and Olaya found plaintiff’s impairments to be non-severe and concluded that she had no functional limitations. Id. at 84. Neither doctor examined plaintiff or accessed her longitudinal records. Id. 3. Dr. Hipolito, MD (Treating Psychiatrist) On April 20, 2016, plaintiff sought psychiatric treatment at the Schuman-Liles Clinic. She reported suffering from depression, low appetite, and panic attacks. Id. at 1006-09. Dr. Hipolito diagnosed her with major depressive disorder, recurrent severe; and he prescribed Mirzapine for depression, anxiety, insomnia, and low appetite. Id. at 1009. 4. Dr. Weber, MD (Treating Psychiatrist) Slightly less than a year later, on March 9, 2017, plaintiff again sought treatment at Schuman-Liles. Id. at 1002. Dr. Armeen Weber examined her and diagnosed her with major depressive disorder and PTSD. Id. at 1004. At subsequent appointments in June, August, and November of 2017 Dr. Weber continued to remark that plaintiff was tearful and depressed. Id. at that he would expect her symptoms to be increased by the demands of work. She would likely need to take breaks during the day due to her difficulty staying focused. Due to her mood instability and irritability, I expect she would have difficulty sustaining appropriate and consistent social functioning, and would likely need to limit her contact with the general public and peers in the workplace. I expect her attendance at work to fluctuate given her symptoms of mood instability and anxiety, causing her to be absent from work 3 days per month or more. Id. at 1072. 5. Dr. Miller, PsyD (Examining Psychologist) At the SSA’s request, Dr. Keiko Miller conducted a second psychological evaluation of plaintiff on August 30, 2017. Id. at 1012. Dr. Miller noted that plaintiff had an unspecified depressive disorder and was functional but teary. Id. at 1012-15. Based on cognitive and psychological assessments, Dr. Miller concluded that plaintiff had limitations in various areas of functioning. Id. at 1015-16. These ranged from no limitation in the ability to accept instructions, to significant limitations in the ability to handle normal work-related stress. Id. at 1016. 6. Dr. Pearce, PsyD, and Ms. Molla, MA, trainee (Treating Psychotherapists) At the request of her treating psychiatrist, Dr. Weber, plaintiff began psychotherapy sessions at the Hume Center on September 8, 2017. Her treatment team included Suada Molla, M.A., trainee, supervised by Elizabeth Pearce, Psy.D. Id. at 1078, 1085. Plaintiff attended four scheduled sessions through November 5, 2017. Id. at 1082-1103. She also called Ms. Molla on November 15, 2017. Id. at 1092. Throughout their sessions Ms. Molla and Dr. Pearce observed that plaintiff exhibited a sad and depressed mood and had frequent crying spells. Id. at 1098-1100. They noted both in initial treatment records, and in a Mental Impairment Questionnaire, that plaintiff’s depression impacted her “daily life, parenting responsibilities, self-care, housework, and dynamics with her family members.” Id. at 1131. They went on to state “[i]n employment settings, Ms. Lacy would likely have marked/severe challenges with attendance, dealing with other people . . . responding to work demands and meeting expectations, concentrating, [and] maintaining stable mood (i.e. inability to more days per month. Id. at 1135. B. Physical Health Treatment and Evaluation Plaintiff has also reported a variety of physical impairments, including persistent foot and knee pain as well as recurring nausea, vomiting, headaches, and clogged arteries in her heart. Id. at 76, 80, 429, 445, 520. 1. Dr. Karon, MD (Examining Physician) Dr. Jeffrey Karon examined plaintiff on January 18, 2015, as part of the CDR process. Id. at 426. He also reviewed her Disability Report and one emergency room record from Decem

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