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Vaughn v. Commissioner Social Security

United States District Court, D. Oregon, Portland Division

March 12, 2018

AMANDA R. VAUGHN, Plaintiff,


          Youlee Yim You, United States Magistrate Judge


         Plaintiff, Amanda R. Vaughn (“Vaughn”), seeks judicial review of the final decision by the Commissioner of Social Security (“Commissioner”) denying her applications for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“Act”), 42 U.S.C. §§ 401-433, and Supplemental Security Income (“SSI”) under Title XVI of the Act, 42 USC §§ 1381-1383f. This court has jurisdiction to review the Commissioner's decision pursuant to 42 USC § 405(g) and § 1383(c)(3). All parties have consented to allow a Magistrate Judge to enter final orders and judgment in this case in accordance with FRCP 73 and 28 USC § 636(c) (ECF #6). For the reasons below, the Commissioner's decision is REVERSED and this case is REMANDED for the immediate calculation and payment of benefits.


         In October 2011, Vaughn protectively filed for DIB and SSI alleging a disability onset date of January 24, 2011. Tr. 272-81.[2] She requested a hearing after her application was denied initially and on reconsideration. Tr. 178-97. On July 22, 2013, a hearing was held before Administrative Law Judge (“ALJ”) Elizabeth Watson. Tr. 44-86. ALJ Watson issued a decision on August 21, 2013, finding Vaughn not disabled. Tr. 151-66. Vaughn requested review of the hearing decision, and the Appeals Council remanded the case for further proceedings on November 5, 2014. Tr. 172-75.

         On December 15, 2015, a remand hearing was held before ALJ MaryKay Rauenzahn. Tr. 87-108. ALJ Rauenzahn issued a new decision finding Vaughn not disabled on March 3, 2016. Tr. 14-31. The Appeals Council denied a request for review on August 16, 2016. Tr. 1-3. Therefore, ALJ Rauenzahn's decision is the Commissioner's final decision subject to review by this court. 20 CFR §§ 404.981, 416.1481, 422.210.


         Born February 4, 1989, Vaughn was 21 years old on the alleged disability onset date, and 26 years old at the time of the second administrative hearing. Tr. 272. She graduated from high school and completed some college coursework but did not obtain a degree. Tr. 49, 302. She has no past relevant work that qualifies as substantial gainful activity, although she served as a youth recreational leader for the City of Eugene. Tr. 29, 308-09. Vaughn alleges disability due to fibromyalgia, neck problems, and back problems. Tr. 301.


         The reviewing court must affirm the Commissioner's decision if it is based on proper legal standards and the findings are supported by substantial evidence in the record. 42 USC § 405(g); Lewis v. Astrue, 498 F.3d 909, 911 (9th Cir. 2007). This court must weigh the evidence that supports and detracts from the ALJ's conclusion and “‘may not affirm simply by isolating a specific quantum of supporting evidence.'” Garrison v. Colvin, 759 F.3d 995, 1009-10 (9th Cir. 2014) (quoting Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007)). The reviewing court may not substitute its judgment for that of the Commissioner when the evidence can reasonably support either affirming or reversing the decision. Parra v. Astrue, 481 F.3d 742, 746 (9th Cir. 2007) (citation omitted). Instead, where the evidence is susceptible to more than one rational interpretation, the Commissioner's decision must be upheld if it is “supported by inferences reasonably drawn from the record.” Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008) (citation omitted); see also Lingenfelter, 504 F.3d at 1035.


         Disability is the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 USC § 423(d)(1)(A). The ALJ engages in a five-step sequential inquiry to determine whether a claimant is disabled within the meaning of the Act. This sequential analysis is set forth in Social Security Administration (“Agency”) regulations, 20 CFR §§ 404.1520, 416.920, in Ninth Circuit case law, Lounsburry v. Barnhart, 468 F.3d 1111, 1114 (9th Cir. 2006) (discussing Tackett v. Apfel, 180 F.3d 1094, 1098-99 (9th Cir. 1999)), and in the ALJ's decision, Tr. 18-19.

         At step one, the ALJ concluded Vaughn had not engaged in substantial gainful activity since January 24, 2011, the alleged onset date of disability. Tr. 20.

         At step two, the ALJ determined that Vaughn has the following severe impairments: fibromyalgia, mild degenerative disc disease, post-traumatic stress disorder (“PTSD”), mood disorder, obesity, and asthma. Id.

         At step three, the ALJ concluded Vaughn did not have an impairment or combination of impairments that met or equaled any listed impairment. Id.

         The ALJ then found Vaughn has the residual functional capacity (“RFC”) to perform less than the full range of light work, with the following limitations:

[She] can lift and/or carry 20 pounds occasionally and 10 pounds frequently; she can stand and/or walk for six hours out of an eight-hour workday with regular breaks; she can sit for six hours out of an eight-hour workday with regular breaks; she should be allowed the freedom to perform work either sitting or standing as desired; she can frequently use foot controls bilaterally. . . [she] may occasionally climb stairs and ramps but never climb ladders, ropes and scaffolds. [She] may occasionally stoop, kneel, and crouch, but can never crawl. [She] may occasional[ly] reach overhead bilaterally. [She] must avoid concentrated exposure to extreme cold and atmospheric conditions and is precluded from exposure to workplace hazards such as unprotected heights and dangerous machinery. [She] is able to understand, remember and carry out simple instructions that can be learned in 30 days or less. [She] is unable to engage in conveyor belt paced work. [She] may have occasional public contact, but is precluded from working directly with the public. [She] may have occasional coworker contact, but is unable to perform group tasks.

Tr. 22.

         The ALJ determined at step four that Vaughn had no past relevant work. Tr. 29. At step five, the ALJ found that considering Vaughn's age, education, and RFC, she was capable of performing jobs as an electronics worker, information router, and assembler of electronics accessories. Tr. 29-30. Accordingly, the ALJ determined that Vaughn was not disabled at any time through the date of her decision. Tr. 30.


         In January 2011, Vaughn was seen at a hospital emergency department complaining of sudden neck pain caused by no particular injury. Tr. 401. A CT-scan showed a “congenital fusion of C7-T1, ” and she was prescribed Oxycodone and Flexeril. Id. On examination several weeks later, Donna Givens, M.D., noted near full rotation and flexion of the spine, tenderness to palpation over the trapezius muscles bilaterally and paraspinous soft tissues on the right side of the neck, but no point tenderness over the cervical spinous processes. Id. Dr. Givens assessed myofascial neck strain without concern for neurological compromise. Id. She referred Vaughn to physical therapy, approved her for light duty work, renewed her prescription for Flexeril, discontinued Oxycodone, and recommended she gradually resume normal activities. Id.

         In March 2011, Vaughn reported no improvement with her neck pain and increasing low back pain. Tr. 399. On examination, Dr. Givens noted a negative straight leg test, normal strength and sensation, an “entirely normal” lumbar x-ray, and “essentially no tenderness over the lumbosacral spine, ” although Vaughn was noted as visibly crying by the end of the examination. Id. Based on Vaughn's presentation, Dr. Givens described that “her clinical picture has become more complex.” Id. Dr. Givens prescribed Naproxen for daily pain management, Skelaxin for more severe pain, and continued to endorse physical therapy. Id.

         In May 2011, Vaughn was seen by Christopher Noonan, M.D., for continued treatment of her back pain. Tr. 361-66. She reported a “burning pain” in her lower back with stiffness in her hips, pain levels ranging from three to ten out of ten, and the ability to stand for 15 minutes and walk a half-block at a time. Tr. 364-66. With the exception of some hyperreflexia, the physical examination was largely unremarkable. Tr. 362. Dr. Noonan recommended an MRI, noting that Vaughn's pain “seem[ed] to be out of proportion to any findings.” Id. A cervical MRI confirmed the congenital fusion at ¶ 7-T1, and revealed mild disc desiccation and slight degenerative change at ¶ 5-6. Tr. 359. Other than some mild disc desiccation at ¶ 5-S1, Vaughn's lumber MRI was also normal. Id. Dr. Noonan saw no need for surgical intervention, recommended Vaughn continue conservative treatment and exercise, and advised Vaughn to see a physiatrist if her pain continued. Tr. 359.

         Dr. Noonan referred Vaughn to physiatrist Lisa Albanese, M.D., for assessment. Tr. 387-88. At an examination on June 27, 2011, Vaughn reported an average pain level of eight out of ten and difficulty concentrating, but no issues with memory. Tr. 387. Dr. Albanese noted significant tenderness to light palpation over the paraspinal musculature, tenderness in 13 of 18 tender points and all four quadrants of her body, difficulty with lumbar flexion and extension, and a positive Hoffman's test on the left. Tr. 388. Dr. Albanese diagnosed fibromyalgia, prescribed Cymbalta, and referred Vaughn to a pain psychologist. Id; see also Tr. 384.

         At a follow-up appointment with Dr. Albanese on July 25, 2011, Vaughn reported that Cymbalta was helping with her pain, mood, and drive. Tr. 385. Her pain was slightly reduced, ranging from a three to eight out of ten. Id. Vaughn also inquired about joining Weight Watchers and swimming to help with her weight loss goals. Id. Dr. Albanese encouraged her to join Weight Watchers and to gradually ease into swimming, using her pain levels as a guide. Id.

         A few days later, Vaughn underwent a comprehensive psychological evaluation with Terri Lechnyr, Ph.D. Tr. 422-28. She endorsed severe anxiety, moderate depression, and low-level coping strategies. Tr. 422. She further reported past suicide attempts and a history of physical and sexual abuse. Id. Vaughn rated her pain level as an eight out of ten, and reported difficulty sleeping due to pain and recurring nightmares. Tr. 423. Vaughn described watching television for seven to eight hours a day, sitting for nine to ten hours a day, and practicing yoga at home for exercise. Id. On a typical morning, she would wake up late, take her medications, and visit with a neighbor. Id. In the afternoon, she would prepare lunch, watch television, clean her home in small portions, play with her kitten, and do some yoga. Id. In the evening, she would watch more television, eat dinner, and wait for her fiancé to get home from work before going to bed. Id.

         Dr. Lechnyr found no indication of malingering or secondary gain, and opined that Vaughn's “psychiatric state is aggravating her organic pain issues.” Tr. 424. Although Vaughn was able to sit through the entire interview, she appeared physically uncomfortable at times and occasionally lost her train of thought. Tr. 425. On testing, Vaughn demonstrated a severe level of anxiety on the Burns Anxiety Inventory, and moderate depression on the Burns Depression Inventory. Id. Dr. Lechnyr diagnosed PTSD and mood disorder, not otherwise specified, and assigned a Global Assessment of Functioning (“GAF”) score of 54. Tr. 427. Dr. Lechnyr recommended Vaughn undergo mental health counseling to learn cognitive strategies for managing her fibromyalgia. Tr. 428.

         In mid-August 2011, Vaughn returned to Dr. Albanese, reporting recently experiencing a “significant flare up” where she could hardly walk. Tr. 383. Vaughn reported continuing pain radiating “up and down her back and in her arms and legs.” Id. She also described that her pain levels worsened with increased physical activity, but improved with rest, massage therapy, and stretching. Id. Dr. Albanese counseled Vaughn on pain ...

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