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Hunt v. Berryhill

United States District Court, N.D. California

March 30, 2017





         Plaintiff 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 Order.[1]


         A. Factual Background

         Hunt 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.

         The 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.

         Dr. 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.

         In July 2012, Dr. Denari diagnosed Hunt with diabetes mellitus (type II) and noted that Hunt was no longer pre-diabetic. Id. at 304, 306.

         Hunt 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 . at 133-40.

         Hunt 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.

         On July 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, she stated:

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 position.” Id.

         Hunt 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.

         Dr. 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 overview:

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.

         Those 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.


         Recording 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 assessment:

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.

         On 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.

         Dr. 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, [2] which Dr. Wu noted might be due to a hereditary form of cerebellar ataxia; (2) sensory neuropathy[3] 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.

         On 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.

         On 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 training.” Id.

         On 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.[4] 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.

         On 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 368-69.

         Hunt 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.

         Hunt 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.” Id.

         On May 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.

         Hunt 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, [5] 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.

         On 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.

         Dr. Muppidi also wrote a letter to the Administration on September 19, 2014. Id. at 404- 05. In the letter, he stated:

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.

         On October 30, 2014, the ALJ held a hearing to review Hunt's application for disability benefits. See Id . at 32.

         B. The Hearing

         1. Hunt's Initial Testimony

         At the 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.

         Hunt 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 job.[6] Id. at 35-36.

         2. Dr. Nelp's Testimony

         Dr. Wil 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.

         Dr. 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.

         Transitioning 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 follows:

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 neuropathy.

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.

         Opining 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.” 43-44. Dr. Nelp further opined that Hunt's “general health [was] otherwise very good.” Id. at 44.

         Dr. 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. Id.

         Dr. 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.

         On 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.

         Dr. 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. Id.

         3. Hunt's Examination

         After 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.

         Hunt 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 ...

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