United States District Court, N.D. California
ORDER GRANTING PLAINTIFF'S MOTION IN PART AND
DENYING DEFENDANT'S MOTION RE: DKT. NOS. 15, 18
C. SPERO CHIEF MAGISTRATE JUDGE.
Tamara Hunt seeks review of the final decision of Defendant
Nancy A. Berryhill, Commissioner of the Social Security
Administration (the “Commissioner”), denying her
application for Disability Insurance Benefits under Title II
of the Social Security Act (the “Act”). For the
reasons stated below, the Court GRANTS in part and DENIES in
part Hunt's Motion for Summary Judgment, DENIES the
Commissioner's Cross-Motion for Summary Judgment, and
REMANDS the case to the Commissioner for further
administrative proceedings consistent with this
was born on September 29, 1960. Administrative Record
(“AR, ” dkt. no. 11) at 132. She attended and
graduated from high school. Id. at 75. After
completing high school, she started working for AT&T as a
collections representative in June 1979. See Id . at
156. Hunt continued working in that capacity until August 17,
2011, when AT&T relocated her position to Southern
California. See Id . at 35-36, 58-60, 156, 252. Hunt
has not worked since that day. See id.
relevant medical record for this case begins in October 2010,
when Hunt saw Dr. Gregory Denari for a checkup. See Id
. at 207. Dr. Denari noted that Hunt suffered from
hypertension, but was “[d]oing OK overall” and
losing weight. Id. Dr. Denari also noted that Hunt
was experiencing pre-diabetes and intermittent, but
controlled asthma. Id. at 208. In May 2011, Hunt was
diagnosed with gastro-esophageal reflux disease (referred to
as “GERD” and “reflux” in the record
and in this Order). Id. at 241. She was diagnosed
with obesity the following July. Id. at 250. In
January 2012, Dr. Denari diagnosed Hunt with leg ache.
Id. at 268.
Christine Tsou treated Hunt for shortness of breath and
conducted a treadmill examination in May 2012. Id.
at 289. Among Dr. Tsou's conclusions were that Hunt had a
hypertensive response to exertion, poor-to-fair exercise
tolerance, no chest discomfort, and no significant
arrhythmias. Id. at 290. Michelle Deconge, the nurse
who administered the treadmill examination, noted that the
test had been terminated after Hunt had sobbed and asked to
stop. Id. at 291. Deconge also noted that Hunt had
poor exercise tolerance for her age. Id.
2012, Dr. Denari diagnosed Hunt with diabetes mellitus (type
II) and noted that Hunt was no longer pre-diabetic.
Id. at 304, 306.
completed her application for Disability Insurance Benefits
under Title II of the Act on April 8, 2013, alleging that she
had become disabled on August 17, 2011-the last day that she
worked for AT&T-and had remained disabled since that day.
See Id . at 132-35. The application, which was
submitted in early May, alleged that Hunt suffered from
“muscular atrophy in legs, numbness in lower
extremities, loss of balance causing difficulty walking,
prediabetes, hypertension, hypothyroidism, GERD, asthma,
bulging left eye, [and] vitamin D deficiency.”
Id. at 132 (style altered); see also Id .
also started seeing Dr. Heideh Khalilnejad in April 2013.
Id. at 338. Although Dr. Khalilnejad's treatment
notes are difficult to decipher, the record of Hunt's
April 10, 2013, appointment indicates that Hunt's
“loss of balance” was addressed. Id. A
record of an appointment two weeks later suggests that Hunt
had said that her balance was returning. Id. at 337.
It is unclear from the record whether Hunt addressed her loss
of balance with Dr. Khalilnejad after April 2013. See Id
. at 335-36.
24, 2013, Hunt completed an Exertion Questionnaire and
submitted it to the Administration. Id. at 161-64.
In the questionnaire, she stated that she lived in an
apartment with her family. Id. at 161. In response
to the questionnaire's request that she describe how her
symptoms prevented her from carrying out a normal workday,
I am constantly coughing, I cough all night in my sleep, I
have a very bad balance problem when walking, I am week and
fatigued, I have to hold onto my husband to walk, I rarely
leave the house, the alergans [sic] in the air choke
me constantly, it weakens my whole body.
Id. She further stated in the questionnaire as
follows. She was not capable of doing much physical activity
without needing to sit or lie down. Id. Her
equilibrium would become unbalanced if she stood too quickly.
Id. Occasionally, she would fall during her coughing
attacks, and had fallen twice recently. Id. The
distance that she could walk was limited to the distance
between her home's parking space and the front door of
her apartment, but she could only walk that far with her
husband's help. Id. She had a problem lifting
pots and pans, and she could not carry anything that weighed
more than three pounds “without feeling dizzy,
fatigued, and off balanced.” Id. at 162
(punctuation altered). She did not climb stairs, do her own
grocery shopping, drive a car, or do yard work. Id.
Before she became disabled, she “had energy, no balance
problem, and no asthma. [She] did all the household chores
and drove a car.” Id. at 163. Since becoming
disabled, she had difficulty finishing her housework because
she could only work in five-minute intervals, and she could
not dust because it would cause her to choke, bring on an
asthma attack, and cause her legs to “give out.”
Id. She slept for eight-to-ten hours each day and
needed 30-minute naps. Id. She used a cane to keep
her balance and to stay upright if she coughed. Id.
She also stated that, “[f]rom lack of being able to
exercise, [she had] lost all the muscle tissue in both of
[her] legs. They barely [held her] torso in a standing
also submitted an Adult Asthma Questionnaire. See Id
. at 166-67. In it, she stated that she experienced
asthma attacks in the early mornings, evenings, and late at
night, and that she used two inhalers to treat her asthma,
one that provided preventative medicine and the other to
relieve asthma attacks when they occurred. Id. at
166. She also stated that she had never visited an emergency
room or otherwise been hospitalized because of her asthma,
but she claimed that her asthma was a constant problem that
had caused other health issues. Id. at 167.
Clark Gable, an internist, examined Hunt on September 3,
2013. See Id . at 331-33. The record of Dr.
Gable's examination of Hunt begins with the following
The claimant is a good historian but the case is complicated.
I think she does a good job of trying to explain what is
wrong. There are follow-up notes from Kaiser. There are
multiple clinic visits for her various problems.
Id. at 331.
problems, Dr. Gable noted, included the following chief
complaints: (1) balance problems since 2011; (2) type 2
diabetes, which was first treated in 2011; (3) asthma, which
started five years earlier; (4) high blood pressure; (5)
hypothyroidism; and (6) reflux. Id. at 331. Dr.
Gable also noted that Hunt was “fairly markedly obese
but stable.” Id. Dr. Gable further observed:
She has had some numbness but no tingling in her feet, which
seems to go back to the time when she was diagnosed. A major
problem, however, has been balance problems. It apparently is
not a postural problem. It doesn't come on with rapid
head changes or turning quickly. It isn't vertigo and she
keeps telling me it's not dizziness. She claims she
can't really explain what it is. Sometimes she will be
looking straight ahead and if she moves her eyes quickly
away, it may cause it. However, she has fallen on several
occasions. She states they wondered if it was due to her
diabetes, but that is the biggest issue that bothers her. It
is the reason she isn't driving apparently.
the results of his examination, Dr. Gable noted that,
although Hunt thought she had experienced atrophy in her
legs, “she had very muscular calves” and there
was no evidence of atrophy in her lower extremities.
Id. In Dr. Gable's notes, he also recorded that
Hunt “seem[ed] overwhelmed by the end of the exam when
we discuss[ed] her various problems. She [got] on and off the
table with relative ease. She demonstrated no apparent
dizziness or imbalance when she was here.” Id.
at 332. Addressing his musculoskeletal examination of Hunt,
Dr. Gable stated that “[t]here [was] no atrophy”
and “[h]er gait and posture were normal.”
Id. Dr. Gable then provided a functional capacity
Based on the history and findings of today's examination,
I think the claimant can sit up to 6 hours a day with usual
breaks. I think she can stand and/or walk up to 6 hours a day
with usual breaks. I think she can lift, push or pull 25 lbs.
frequently and 50 lbs. occasionally. I see no problem with
fine finger and hand movements. Nonetheless, the concerns
about her balance with a history of falling several times
over the past month is disturbing with no definitive
diagnosis at this time. It might be wise for her to carry a
cane or whatever if she were out walking for any distance.
Id. at 332-33.
September 19, 2013, Hunt's application was denied on
initial consideration. Id. at 81. On November 20,
2013, her application was denied on reconsideration.
Id. at 94. Drs. A. Nasrabadi and S. Reddy reviewed
Hunt's medical record for the Administration and both
opined that Hunt was not disabled. See Id . at
71-94. On January 8, 2014, Hunt requested review of her
application's denial by an Administrative Law Judge
(“ALJ”). Id. at 109.
Jerwin Wu, a neurologist, examined Hunt on January 28, 2014.
Id. at 355-57. In a letter written that day, Dr. Wu
listed his impressions of Hunt. Id. at 355. The
impressions included the following medical conditions: (1)
gait ataxia,  which Dr. Wu noted might be due to a
hereditary form of cerebellar ataxia; (2) sensory
neuropathy in her lower extremities of an unknown
cause; and (3) “some leg muscles atrophy, probably due
to disuse atrophy.” Id. at 355. Dr. Wu's
records from January 28 also indicate that Hunt's
54-year-old sister “began to have unsteady walking at
age 51. Her brother might have some problem in
walking.” Id. at 358.
January 31, 2014, Dr. Wu completed an electrodiagnostic
report in which he recorded several impressions regarding
Hunt's health. Id. at 360. Those impressions
included that Hunt had “[s]evere sensory neuropathy or
neuronopathy in the lower extremities bilaterally, ”
“[m]ild right carpal tunnel syndrome, ” and
“[m]ild right ulnar neuropathy across the elbow.”
Id. Dr. Wu further opined, “I think she also
has severe sensory neuropathy or neuronopathy in the upper
extremities bilaterally.” Id.
February 18, 2014, Dr. Wu diagnosed Hunt with gait ataxia due
to sensory neuronopathy. Id. at 347; see also Id
. at 362-63. In his notes from February 18, Dr. Wu
observed that Hunt's “[e]lectrodiagnostic motor
tests were suspicious of sensory neuropathy, ” and that
her “[h]ead MRI did not show cerebellar atrophy or
hydrocephaly.” Id. at 362. He also noted that
Hunt's gait was “moderately unsteady, ” the
results of her pinprick examination were abnormal, and that
“vibration sensation is absent in toes bilaterally[, ]
very reduced in fingers bilaterally.” Id.
Listing his impressions, Dr. Wu further noted that Hunt
“most likely has sensory neuronopathy” in
addition to diabetes and hypothyroidism. Id. Dr. Wu
explained that, “since her symptoms have been over for
about 5 years[, ] sensory neuronopathy due to paraneoplastic
syndrome would be unlikely.” Id. at 363. He
also recommended “physical therapy for gait and balance
March 13, 2014, Dr. Srikanth Muppidi, an Assistant Professor
of Neurology at Stanford University, memorialized an
examination of Hunt that he conducted that day in a letter to
Dr. Wu. Id. at 415-18; see also Id . at
405. In the letter, Dr. Muppidi stated that his impressions
of Hunt consisted of predominant sensory neuropathy and
sensory ataxia. Id. at 415. Dr. Muppidi also
observed that the numbness in Hunt's hands had likely
begun before the numbness in her feet, she had “severe
large fiber sensory loss with preserved pinprick sensation,
” she had “a mildly wide-based gait, ” and
she had undergone a positive Romberg test. Id. Dr.
Muppidi opined that the “[o]verall pattern of symptoms
and sensory loss [was] suggestive of a sensory neuropathy.
Because the balance impairment seems to have preceded
numbness in her feet and hands, one should also consider
additional posterior column disease.” Id. Dr.
Muppidi noted two incidents in which Hunt had fallen, one six
years before his examination of her, the other five years
earlier. Id. at 416. Dr. Muppidi further noted that
Hunt had noticed difficulty with balancing and climbing
stairs four years earlier, and that Hunt's balance had
worsened gradually since then. Id. Dr. Muppidi also
stated that Hunt's sister “was diagnosed with
possible cerebellar ataxia. She apparently has nystagmus, eye
bouncing, severe balance issues and has fallen.”
Id. at 417.
March 25, 2014, Dr. Wu completed a Residual Functional
Capacity Questionnaire that was submitted to the
Administration. See Id . at 366-70. In it, Dr. Wu
stated that he had diagnosed Hunt with gait ataxia due to
neuronopathy, his prognosis for Hunt was “guarded,
” and she had a “very unsteady gait.”
Id. at 367. Dr. Wu also stated that his clinical
findings that supported his diagnosis were a “[v]ery
abnormal nerve conduction study” and observing
Hunt's “[v]ery unsteady walking.”
Id. Responding to the questionnaire's request
that he describe treatment for Hunt's conditions, Dr. Wu
stated, “I'm not aware of particular treatment for
sensory neuronopathy.” Id. Dr. Wu also opined
that Hunt's impairments had lasted or would likely last
more than 12 months, that Hunt was not a malingerer, that her
symptoms would occasionally interfere with the attention and
concentration that is necessary to sustain a typical
eight-hour workday, and that Hunt could not tolerate
“even ‘low stress'” at work because it
would “increase her unsteadiness.” Id.
at 368. Dr. Wu further opined on Hunt's functional
limitations as follows: (1) she could not sit longer than 20
minutes; (2) she could not stand longer than 10 minutes; (3)
she could sit for less than two hours during an eight-hour
workday; (4) she could stand or walk for less than two hours
during a workday; (5) she would require an unscheduled break
every two hours during a workday; (6) she could lift less
than 10 pounds rarely, and never anything heavier; (7) she
could never twist, stoop, bend, crouch, or climb ladders or
stairs; and (8) she had moderate limitations in doing
repetitive reaching, handling, and fingering. Id. at
underwent an MRI of her thoracic spine on April 10, 2014.
See Id . at 378-79. In the record of that procedure,
Dr. Mark Culton, the interpreting physician, noted clinical
data had shown that Hunt experienced “numbness below
the neck with gait ataxia.” Id. at 378. Dr.
Culton's findings included that Hunt's
“thoracic cord [was] diffusely small in caliber, . . .
this finding could represent a congenital variation in the
size and configuration of the cord without any obvious
indication of myelomalacia.” Id.
underwent another MRI on April 16, 2014, which provided
imaging of her cervical spine and was also interpreted by Dr.
Culton. See Id . at 374-77. In the clinical data
notes, Dr. Culton again observed that Hunt had experienced
numbness below her neck and gait ataxia. Id. at 374.
In his findings, Dr. Culton observed that “imaging of
the posterior fossa and brainstem . . . show[ed] evidence of
mild cerebral atrophy, ” her “cervical cord [was]
diffusely thin in caliber, . . . [which] could represent
normal variation in the size and configuration of the cord
without any obvious indication of myelomalacia.”
1, 2014, Dr. Wu completed a “progress report” in
which he noted that Hunt continued “to have unsteady
walking, ” “[h]er hands ha[d] been clumsy,
difficult to do buttoning, ” and she “had [a]
tendency to lose the balance, especially in the shower
room.” Id. at 373. Dr. Wu observed that an MRI
of Hunt's cervical and thoracic spine “showed
thinning of the cord, but no other condition.”
Id. Dr. Wu also recorded that a “vibration
sensation [was] absent in right toe [and] very reduced in
left toe.” Id. Dr. Wu further observed that
Hunt's abnormal gait was “moderately to very
unsteady.” Id. Results of a pinprick test were
also abnormal: “decreased in right leg” and
“decreased in left leg below the knee.”
Id. Dr. Wu's impressions included sensory
neuronopathy that caused gait ataxia and hand clumsiness, as
well as thinning of Hunt's cervical and thoracic spinal
cord of an unknown cause. Id.
received medical treatment from Dr. Alexander Doan on June 10
and July 8, 2014. Id. at 384-89. In records for
those treatments, Dr. Doan noted several problems, among them
hypertension,  which he found to be “[n]ot well
controlled due to weight gain. Recommend aerobic exercise
with water aerobic of eliptical.” Id. at 384,
387. Also noted to be among those problems were hereditary
sensory neuropathy and primary cerebellar degeneration.
Id. Dr. Doan observed that his June 10 neurological
examination of Hunt showed a “normal gait and stance,
” and his July 8 examination showed that Hunt had
“no tremor; balance [was] not impaired.”
Id. at 385, 388. In a section of his June 10
treatment record entitled Assessment and Plan, Dr.
Doan noted the following in regard to Hunt's primary
cerebellar degeneration: “follow by Dr. Jerwin Wu and
Stanford neurology.” Id. at 385-86. There was
no notation in Dr. Doan's Assessment and Plan
section for cerebellar degeneration in the record of the July
8 treatment. See Id . at 389.
August 27, 2014, Hunt underwent EMG and nerve conduction
studies at Dr. Muppidi's direction “to better
characterize her sensory neuropathy.” See Id .
at 473-76. Dr. Muppidi concluded that “[t]hese
electrodiagnostic studies demonstrate sensory
neuropathy/neuronopathy, without evidence of motor nerve
involvement.” Id. at 475.
Muppidi also wrote a letter to the Administration on
September 19, 2014. Id. at 404- 05. In the letter,
Tamara Hunt is followed by the neuromuscular team here at
Stanford for evaluation of progressive gait imbalance
(Ataxia) and sensory neuropathy. Her condition makes it very
difficult to ambulate safely and perform routine work related
activities safely and I believe she is significantly disabled
and like [sic] will remain so in near future.
Id. at 405.
October 30, 2014, the ALJ held a hearing to review Hunt's
application for disability benefits. See Id . at 32.
Hunt's Initial Testimony
start of the hearing, Hunt testified that she was 54 years
old, 5′7″ tall, and weighed 227 pounds. AR at 34.
A year earlier, she had weighed 260 pounds. Id. Hunt
had been married for 34 years and her husband was retired.
Id. at 34-35. She graduated from high school, but
had no other vocational training. Id. at 35.
had last worked in August 2011. Id. at 35-36. At
that time, she was a collections representative for AT&T,
a company for which she had worked for 27 years. Id.
at 35. Hunt retired from AT&T when her office was moved
to Southern California, and she could not move there for her
Id. at 35-36.
Dr. Nelp's Testimony
Nelp, Professor of Medicine and Radiology at the University
of Washington, and board certified in internal medicine and
nuclear medicine, testified as a medical expert after
reviewing Hunt's medical records. AR at 33, 38-40,
see also Id . at 406.
Nelp's testimony began with a summary of Hunt's
health in which he stated that Hunt suffered from
“several persistent issues, ” including obesity,
minor diabetes for which she took oral medication, low
thyroid function that was treatable by medication, modest
hypertension with no recorded complication,
normal-to-slightly-high blood pressure, intermittent
shortness of breath or asthma that was treated with an
inhaler, and minor esophageal discomfort that was treated by
oral medication. Id. at 40-41. Dr. Nelp also noted
that examinations had indicated that Hunt's lungs were
clear and EKGs yielded normal results. Id. at 41.
to Hunt's major medical issues, Dr. Nelp stated that Hunt
suffered from “a feeling of unsteadiness when
walking.” Id. He described Hunt's sensory
neuropathy and other conditions from which she suffered as
This sense of imbalance is due to a condition called sensory
neuropathy. This is not a diabetic neuropathy, but probably a
hereditary neuropathy. [Hunt's] sister apparently has
some similar issues. This problem has been fully evaluated at
the Stanford Clinic. . . . Major issues[: a] loss of full
sensation in the hands and feet, such that [Hunt] shows
unsteady while walking or climbing or changing positions.
This is referred to as a sense of imbalance. All objective
examinations such as MRI of the spinal cord show no cord
compression, and a relatively small spinal cord, but no major
disc or bony changes. . . . Feels wobbly when walking; worse
when it's dark and can't see the surroundings. MRI of
the brain showed mild changes in the cerebellum, posterior
area of the brain; no pain associated with this. The full
neurological exam . . . notes good muscle strength . . .
normal gait; slightly broad-based. [She] cannot stand with
legs closed together without wobbling. . . . Coordination was
intact. . . . When you tweak or touch the skin lightly, she
had some sensory loss. And this is referred to as sensory
Id. at 41-42. Dr. Nelp also addressed the physical
examinations performed and evaluations completed by agency
examiners and experts, calling them “[g]ood” and
“[e]xcellent” reviews of Hunt's health
issues. Id. at 43.
on the Commissioner's Medical Listings, Dr. Nelp stated
that Hunt would not meet or equal Listing 2.07 for special
senses, explaining that Hunt “has an unusual loss of
sensory function, with good preservation of other
neurological capability.” Id.at 43-44. Dr.
Nelp further opined that Hunt's “general health
[was] otherwise very good.” Id. at 44.
Nelp then addressed Hunt's residual functional capacity
(“RFC”), opining that she could work in an
environment that did not require climbing or complex walking;
she could lift at least 20 pounds occasionally and 10 pounds
frequently; she could stand and walk on smooth surfaces for
up to six hours; she could sit at least six hours; and she
could use a cane if she desired more stability when she
walked. Id. Hunt's postural limitations included
occasional use of ramps or stairs, no use of ladders or
ropes, and no balancing. Id. Hunt should also avoid
all hazards and heights, moderate exposure to fumes and dust,
and concentrated exposure to other environmental issues.
Nelp testified that his assessment of Hunt's impairments
applied from the time of her alleged disability onset date to
the date of the hearing. Id. at 45. Dr. Nelp further
testified that Hunt did not meet or equal any of the Medical
Listings, including Listing 2.07. Id.
cross-examination, Dr. Nelp testified that pinprick sensation
tests of Hunt's legs would not have an effect on her
ability to manipulate objects. Id. at 46. Dr. Nelp
further explained, “That is a loss of very fine
sensation for needle prick, and that's part of the
sensory neuropathy. There's been no description of loss,
inability to move fingers, or touch, or pick up light objects
in the medical records. . . . Sensory neuropathy is a very
unusual condition.” Id.
Nelp also testified that Hunt “should be able to walk
at least a block or more” with a walker. Id.
at 47-48. Upon further questioning about Hunt's use of a
walker, Dr. Nelp explained, “It's not a matter of
strength or energy; it's a matter of her sensation of
instability. And balancing with a cane or a walker would be
helpful.” Id. at 48. Dr. Nelp further opined
that it was not medically necessary for Hunt to use a walker.
Dr. Nelp's testimony concluded, Hunt was questioned by
her representative. See AR at 48-49. In response to
being asked what prevented her from working, Hunt testified,
“Loss of balance, coordination, the wobbly, the turning
from motion to motion from one direction to another.”
Id. at 49. She explained that she could not shower
alone, could not stand in darkness without feeling like she
would fall, and could not ascend stairs. Id. Hunt
further explained that she moved around her home by using the
walls for support. Id. at 49-50. She had been using
a walker prescribed by Dr. Wu for more than a month.
Id. at 50. She did not feel sufficiently secure when
she had attempted to use a cane in the past. Id.
testified that she did not go outside because it required
walking, and she always felt like she would fall.
Id. at 51. She could walk from her front door to her
mailbox and back while holding onto her husband's hand,
but could no longer go outside and exercise as she had in the
past. Id. Hunt explained, “It just-my
everything's thrown off. Like right now, you know, I feel
this all the time. It's constant.” Id.
Hunt also testified that her hands had stiffened and were
“not coordinating.” Id. She could no
longer tie her shoes or put on lipstick or earrings.
Id. at 52. Hunt concluded:
[T]his condition has-I don't mean to get emotional, but
it's taken over my life. And it's, like, part of me.
It's just part of my whole self. It's gotten worse
and worse . . . . Little things I'm noticing. Just, like,
you know, I'm sitting more at my house. I'm sitting
there. Because if I get up, you know, I'll walk to the
kitchen. And I used to cook a lot . . . . But when I go from
the sink to the stove, that movement, that's what ...