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MeDford v. Berryhill

United States District Court, D. Oregon

November 8, 2017

MELANIE J. MEDFORD, Plaintiff,
v.
NANCY A. BERRYHILL, [1] ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.

          OPINION AND ORDER

          Youlee Yim You United States Magistrate Judge.

         INTRODUCTION

         Plaintiff, Melanie Medford (“Medford”), seeks judicial review of the final decision by the Commissioner of Social Security (“Commissioner”) denying her application for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“SSA”), 42 USC §§ 401-33. This court has jurisdiction to review the Commissioner's decision pursuant to 42 USC § 405(g). Both Medford and the Commissioner have consented to allow a Magistrate Judge to enter final orders and judgment in this case. ECF #6; FRCP 73; 28 USC § 636(c). For the reasons set forth below, the Commissioner's decision is REVERSED and this case is REMANDED for further proceedings.

         ADMINISTRATIVE HISTORY

         Medford protectively filed for DIB on December 17, 2012, alleging a disability onset date of November 23, 2012. Tr. 20, 175-80.[2] Her application was denied initially on August 9, 2013 (Tr. 77, 91-92), and on reconsideration on September 18, 2013 (Tr. 93, 108-09). On October 20, 2014, a hearing was held before Administrative Law Judge (“ALJ”) Luke Brennan. Tr. 40-76. The ALJ issued a decision on January 28, 2015, finding Medford not disabled. Tr. 20-33. The Appeals Council denied a request for review on June 8, 2016. Tr. 1-4. Therefore, the ALJ's decision is the Commissioner's final decision subject to review by this court. 20 CFR § 404.981.

         BACKGROUND

         Born in July 1960, Medford was 54 years old at the time of the hearing before the ALJ. Tr. 45. Medford is a high school graduate and previously worked as a house cleaner. However, the ALJ concluded that Medford's past work did not reach the level of “substantial gainful activity, ” and she therefore had no past relevant work for purposes of her DIB application. Tr. 31. Medford alleges she is unable to work due to a history of aneurysmal coiling, anterior communicating artery (brain) aneurysm with intracranial hemorrhage (stroke), hydrocephalus with shunt, hypertension, and depression. Tr. 22, 94.

         MEDICAL BACKGROUND

         On November 23, 2012, Medford was admitted to an emergency room with left leg weakness, was observed to have facial droop, and was diagnosed with an intracranial hemorrhage. Tr. 294-95. Ten years earlier, Medford underwent aneurysmal coiling treatment for a brain aneurysm, which eventually developed a hydrocephalus that required a right parietal shunt. Tr. 294-95, 322. Treating physician Bruce J. Andersen, M.D., felt the hemorrhage was due to Medford's hypertension, and she was discharged after two days. Tr. 294.

         Medford was again admitted to the emergency room less than two weeks later, on December 4, 2012, experiencing disorientation and significant weakness in her left leg. Tr. 302. She was diagnosed with an anterior communicating artery aneurysm, hydrocephalus with shunt placement, hypertension, anxiety, and depression. Id. Medford was advised not to drive or return to work, and the attending physician's assistant felt she might require 24hour supervision when released from the hospital. Tr. 464. After three days in the hospital, Medford was transitioned into acute inpatient rehabilitation. Tr. 459, 461.

         After showing improvement in self-care and mobility over the next two weeks, she was discharged to her home on December 20, 2012. Tr. 457-58. She was advised to attend occupational therapy, physical therapy, speech therapy, and neuropsychological therapy. Tr. 457.

         Jason D. Gage, Ph.D., performed a neuropsychological assessment on January 15, 2013. Tr. 384-85. Medford's memory was improving, though still impaired, and she continued to have difficulty concentrating, organizing, planning, and multitasking. Tr. 384. Dr. Gage diagnosed a cognitive disorder secondary to thalamic bleed, and found Medford to have a lot of difficulty with attention and concentration, as well as processing speed. Tr. 384. She scored in the “borderline range at the 5th percentile” for both attention and processing speed. Tr. 385.

         Two months later, on March 11, 2013, Medford was again admitted to the hospital because she could not open her left hand and had general weakness throughout the left side of her body. Tr. 535, 540. Mary E. River, M.D., evaluated Medford, and indicated it was unclear if she had suffered another seizure/stroke event or if her symptoms were the result of her prior aneurysm. Tr. 533. By the next day, Medford reported feeling that she was “back to her baseline.” Tr. 520. Following an MRI, she was diagnosed with “acute ischemic stroke, ” prescribed Plavix, and discharged on March 13, 2013. Tr. 512.

         Rodde Cox, M.D., examined Medford on March 18, 2013. Tr. 456. Dr. Cox felt Medford had suffered a recurrent stroke the week before, and noted continuing symptoms in her left arm and right leg. Id. At a follow-up appointment on April 8, 2013, Dr. Gage noted “significant improvement with regard to processing speed.” Tr. 476. Although Medford still showed “significant deficits regarding visuospatial skills and attention, ” she was doing well enough to attempt a driving test. Id. The following month, Dr. Cox noted that Medford was driving again and was doing “reasonably well.” Tr. 566. Dr. Cox observed continuing “discoordination” in Medford's left upper extremity, gave Medford some exercises, and encouraged her to begin using her hand more for “fine motor hobbies such as jigsaw puzzles.” Id. Also in May 2013, Medford's speech pathologist indicated that Medford had met all of her long-term treatment goals and she was therefore discharged. Tr. 592.

         In July 2013, Dr. Gage noted that Medford was “driving during the day . . . without any problems.” Tr. 570. Although she had made improvements in some areas, she continued to have difficulty with visual attention and memory. Id. Dr. Gage explained that Medford should be able to resume nighttime driving once she had shown some mild improvement in visuospatial skills. Id.

         On July 27, 2013, Ralph D. Heckard, M.D., performed a consultative neurological examination. Tr. 620-23. At that exam, Medford displayed “[e]vident memory and executive function impairments” and “asymmetrical sustained dyscoordination of dexterity.” Tr. 621. Although Medford had mild left-sided weakness, she had normal range of motion and strength, and no other deficits of motor, sensory, or reflex functions of any extremity. Tr. 623. With regard to her mental condition, Dr. Heckard concluded that Medford presented with “mental status features which could significantly impair her ability to make reasonable workplace decisions and occupational adjustments, ” was “easily confused at time, ” and displayed “alterations of affect and cognition.” Id.

         At a follow-up appointment in mid-August 2013, Dr. River noted a slight loss of motor strength on the left side and that Medford had one more week of Plavix before switching to aspirin once daily. Tr. 626-27. The doctor noted that Medford asked her to complete some disability paperwork, stating, “this may or may not get her disability, [s]he may need to undergo neuropsychological testing . . . [, ] actual physical and neurologic difficulties are not profound.” Tr. 627.

         Within a day of the initial and reconsideration denials of Medford's application, two state agency doctors reviewed Medford's record, including Martin Seidenfield, Ph.D. (Tr. 87-90, Aug. 9, 2013) (followed by initial denial the same day) and Mack Stephenson, Ph.D. (Tr. 104-07, Sept. 17, 2013) (followed by reconsideration denial the following day). Dr. Seidenfield found Medford to have “some confusion and difficulty with stress, ” as well as moderate limitations in her ability to: (1) understand and remember detailed instructions; (2) carry out detailed instructions; (3) maintain attention and concentration for extended periods; and (4) respond appropriately to changes in the work setting. Tr. 88-89. Dr. Stephenson found these same limitations. Tr. 105-06. With regard to the paragraph B criteria, the opinions of Drs. Seidenfield and Stephenson differ: Dr. Seidenfeld assessed moderate limitations in both ADLs and social functioning, while Dr. Stephenson assessed merely mild limitations in ADLs and moderate limitation in social functioning. Tr. 83-84, 100. However, in the separate section for assessing Medford's mental RFC, Drs. Seidenfeld and Stephenson both declined to assess any social limitations. Tr. 89, 106.

         Medford had another follow-up appointment with Dr. River on January 22, 2014. Tr. 706-07. At that appointment, Medford reported an abrupt onset of bilateral hand numbness, which Dr. River found “concerning for paraneoplastic neuropathy.” Tr. 706. Dr. River ordered a nerve conduction study, to look for peripheral neuropathy, followed by an MRI of the cervical spine to rule out spinal stenosis if the nerve conduction study proved negative. Tr. 707.

         On February 27, 2014, Medford again saw Dr. River, who noted that the nerve conduction study was normal in both the upper and lower extremities. Tr. 711. Dr. River opined that Medford's reported neuropathy might be musculoskeletal rather than neurological, and suggested Medford wear an elbow sleeve. Id.

         A month later, on March 20, 2014, Dr. Andersen reviewed a catheter angiogram of Medford's aneurysm site, which revealed no unprotected aneurysmal wall. Tr. 704. He indicated he would continue the annual surveillance of the issue as scheduled in a few months. Id.

         On May 7, 2014, at a follow-up appointment with Dr. River, Medford reported no new complaints and that her peripheral numbness had improved with avoidance of prolonged positioning and the use of elbow ...


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