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Weeks v. Berryhill

United States District Court, E.D. Oklahoma

September 25, 2017

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, [1] Defendant.



         The claimant Megan Brooke Weeks requests judicial review of a denial of benefits by the Commissioner of the Social Security Administration pursuant to 42 U.S.C. § 405(g). She appeals the Commissioner's decision and asserts the Administrative Law Judge (“ALJ”) erred in determining she was not disabled. For the reasons set forth below, the Commissioner's decision is hereby REVERSED and the case REMANDED to the ALJ for further proceedings.

         Social Security Law and Standard of Review

         Disability under the Social Security Act is defined as the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment[.]” 42 U.S.C. § 423(d)(1)(A). A claimant is disabled under the Social Security Act “only if h[er] physical or mental impairment or impairments are of such severity that [s]he is not only unable to do h[er] previous work but cannot, considering h[er] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy[.]” Id. § 423 (d)(2)(A). Social security regulations implement a five-step sequential process to evaluate a disability claim. See 20 C.F.R. §§ 404.1520, 416.920.[2]

         Section 405(g) limits the scope of judicial review of the Commissioner's decision to two inquiries: whether the decision was supported by substantial evidence and whether correct legal standards were applied. See Hawkins v. Chater, 113 F.3d 1162, 1164 (10th Cir. 1997). Substantial evidence is “‘more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'” Richardson v. Perales, 402 U.S. 389, 401 (1971), quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938); see also Clifton v. Chater, 79 F.3d 1007, 1009 (10th Cir. 1996). The Court may not reweigh the evidence or substitute its discretion for the Commissioner's. See Casias v. Secretary of Health & Human Services, 933 F.2d 799, 800 (10th Cir. 1991). But the Court must review the record as a whole, and “[t]he substantiality of evidence must take into account whatever in the record fairly detracts from its weight.” Universal Camera Corp. v. NLRB, 340 U.S. 474, 488 (1951); see also Casias, 933 F.2d at 800-01.

         Claimant's Background

         The claimant was born on July 10, 1995, and was nineteen years old at the time of the administrative hearing (Tr. 177, 181). She has a high school education, some college, and no past relevant work (Tr. 25, 38-39). The claimant alleges that she has been unable to work since April 8, 2013, due to a blood clotting disorder, blood clots in her brain, migraine headaches, seizures, and mini-strokes (Tr. 218).

         Procedural History

         On May 14, 2013, the claimant applied for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401-434, and for supplemental security insurance payments under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-85 (Tr. 177-86). Her applications were denied. ALJ James Bentley conducted an administrative hearing and determined that the claimant was not disabled in a written opinion dated January 7, 2015 (Tr. 10-27). The Appeals Council denied review, so the ALJ's written opinion is the Commissioner's final decision for purposes of this appeal. See 20 C.F.R. §§ 404.981, 416.1481.

         Decision of the Administrative Law Judge

         The ALJ made his decision at step five of the sequential evaluation. He found that the claimant retained the residual functional capacity (“RFC”) perform work at all exertional levels, but must avoid working at unprotected heights or around dangerous moving machinery, and was unable to climb ropes, ladders, or scaffolds (Tr. 23). The ALJ concluded that the claimant was not disabled because there was work that she could perform in the national economy, e. g., office helper, sales attendant, and furniture rental clerk (Tr. 26-27).


         The claimant contends that the ALJ erred by failing to properly: (i) evaluate the opinion of treating physician Dr. David Lee Gordon, and (ii) discuss the vocational expert's testimony regarding accommodation requirements for individuals who have suffered a seizure at work. The Court agrees with the claimant's first contention, and the decision of the Commissioner must therefore be reversed.

         The ALJ found that the claimant had the severe impairments of seizure disorder and migraine headaches (Tr. 15, 22). The record reveals that the claimant began experiencing headaches shortly after giving birth to her daughter in April 2013 (Tr. 365, 667-718). She presented to the McAlester Regional Health Center Emergency Room (“MRHC”) on April 8, 2013, and was diagnosed with a post-epidural headache (Tr. 667-79). The claimant returned two days later and reported headache, neck pain, bilateral shoulder pain, twitching in her left eye, bilateral leg numbness, and a change in vision (Tr. 683-96). A nurse noted that the claimant would follow commands, but could not speak, and had a blank stare upon admission (Tr. 683). A CT scan of the claimant's brain revealed venous thrombosis (Tr. 691). Thereafter, the claimant was transferred to OU Medical Center where she received inpatient care for five days (Tr. 329-68). In a discharge summary on April 15, 2013, Dr. Gordon diagnosed the claimant with, inter alia, cerebral vein thrombosis (“CVT”) due to postpartum state and likely underlying primary hypercoagulable state; complex partial seizures secondary to CVT; migraine headache with aura-visual, sensory, and vertigo; and abdominal and precordial migraine (Tr. 365-68). At a follow-up appointment with Dr. Gordon on July 11, 2013, he noted the claimant had a seizure shortly after her April 2013 discharge, but had not experienced any additional seizures since then, and that her headaches were much improved (Tr. 822). Dr. Gordon's treatment notes dated October 8, 2013, reflect that the claimant experienced seizures in August and September 2013 (Tr. 808). Dr. Gordon also noted that an MRI of her brain dated September 16, 2013, showed definite improvement, but that a small residual lesion remained that may explain her persistent seizures, and that the claimant had not had any migraines since her July 2013 visit (Tr. 809). At a follow-up appointment on November 3, 2014, Dr. Gordon noted the claimant had a seizure on January 13, 2014; he released the claimant to drive on July 15, 2014, because she had been seizure free for six months; she remained seizure free through the date of his exam; and that her seizures were well controlled with medication (Tr. 849-50). As to her migraines, Dr. Gordon noted the claimant experienced them every one or two weeks, which was an improvement from three times per week, and that they were well controlled (Tr. 850). The same day, Dr. Gordon completed a Medical Source Statement (“MSS”) wherein he ...

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