United States District Court, N.D. California
ORDER RE: CROSS-MOTIONS FOR SUMMARY JUDGMENT, RE:
DKT. NOS. 16, 17
MARIA-ELENA JAMES United States Magistrate Judge.
Sterling James Hollins (“Plaintiff) brings this action
pursuant to 42 U.S.C. § 405(g), seeking judicial review
of a final decision of Defendant Nancy A. Berryhill
(“Defendant”), the Acting Commissioner of Social
Security, denying Plaintiffs claim for disability benefits.
Compl., Dkt. No. 1. Pending before the Court are the
parties' cross-motions for summary judgment. Pl.'s
Mot., Dkt. No. 16; Def.'s Mot., Dkt. No. 17. Pursuant to
Civil Local Rule 16-5, the motions have been submitted on the
papers without oral argument. Having carefully reviewed the
parties' positions, the Administrative Record
(“AR”), and the relevant legal authority, the
Court hereby GRANTS IN PART Plaintiffs
motion and DENIES Defendant's
cross-motion for the reasons set forth below.
complained of migraines and right knee pain starting in 2011.
AR 264. In May 2012, he contracted Ludwig's angina, a
mouth infection that spread systemically through his brain,
heart, and other vital organs; he spent 15 days as an
inpatient in the Intensive Care Unit of the Alameda County
Medical Center. AR 254, 281, 286, 328, 340, 351, 404.
Plaintiff needs a cane to stand and to walk. AR 17. He has
consistently tested negative for rheumatoid factor and
antinuclear antibodies; he has not exhibited joint
deformities. AR 380, 423, 430, 442-43, 448. He suffers from
cognitive and affective disorders. AR 13.
SECURITY ADMINISTRATION PROCEEDINGS
18, 2012, Plaintiff filed a claim for Disability Insurance
Benefits, alleging disability beginning on May 14, 2012. AR
184. The Social Security Administration (“SSA”)
denied Plaintiffs claim, finding that Plaintiff did not
qualify for disability benefits. AR 59. Plaintiff
subsequently filed a request for reconsideration, which was
denied. AR 69. On March 11, 2014, Plaintiff requested a
hearing before an Administrative Law Judge (“ALJ').
AR 102. Plaintiff also filed a request for good cause for
filing his appeal twenty-two days late, which the SSA
granted. AR 109-11. ALJ Mary Parnow conducted a hearing on
October 11, 2014. AR 30-57. Plaintiff testified in person at
the hearing and was represented by counsel, Katherine
Siegried. AR 11, 30-32. The ALJ also heard testimony from
Vocational Expert (“VE”) Robert Raschke and
medical expert Dr. Gilberto Munoz. Id.
Medical Evidence of Record
was examined by four SSA consultants: Dr. Rana, Dr. Tang, Dr.
Van Gaasbeek, and Dr. Snyder. AR 374-376, 396-99, 400-03,
404-08. His records were reviewed by four SSA Reviewing
Physicians: Dr. Williams, Dr. Blanco, Dr. Fair, and Dr.
Schumacher. AR 64, 66, 69, 77.
Dr. Farah M. Rana, M.D.
Rana performed an internal medicine evaluation of Plaintiff
on behalf of the SSA on January 16, 2013. AR 374-76. Dr. Rana
observed Plaintiff walked with a mild limp and used a cane to
support himself while walking, but all the tests and
examinations she performed were normal. Id. Dr. Rana
noted Plaintiffs history of Ludwig's angina in May 2012,
migraines, and right knee pain with probable
strain/tendinitis. AR 376. In relevant part, Dr. Rana opined
Plaintiff could stand and walk up to six hours with breaks in
an eight-hour work day; had no sitting limitations; could
carry 25 pounds frequently and 50 pounds occasionally; and
did not need any assistive devices. Id.
Dr. Robert Tang, M.D.
Dr. Tang performed a comprehensive internal medicine
evaluation of Plaintiff on September 18, 2013 on behalf of
the SSA. AR 396-99. Dr. Tang observed that Plaintiff walked
with a cane; appeared to have not more than 75 percent
weight-bearing on the right step due to hip discomfort; 3/5
strength in the right hip; and decreased pinprick sensation
on the right forearm, right hand, and lower legs.
Id. He diagnosed Plaintiff with severe gum infection
resulting in sepsis and lower extremity swelling; residual
neuropathy in the right forearm and both lower legs; right
step decreased weight-bearing due to hip pain; and neuropathy
due to main-end organ. AR 398-99. His findings were otherwise
normal. AR 396-99. In relevant part, Dr. Tang opined that
Plaintiff could walk up to six hours with a cane, had no
limitation in sitting, had medical necessity for a cane,
could carry 20 pounds occasionally and 10 pounds frequently,
and had no postural, manipulative, or height limitations. AR
Dr. Kyle Van Gaasbeek, Psy. D.
Gaasbeek, conducted a comprehensive psychiatric evaluation of
Plaintiff on September 21, 2013 at the request of the SSA. AR
400-403. In relevant part, Dr. Van Gaasbeek found Plaintiff
had “quite slow” movements, “concentration,
persistence and pace” were “a bit slow, ”
his thoughts were “a bit slow to organize, ” his
speech “a bit pedantic”; blunted affect and
self-described bad mood; average intellectual functioning;
was able to recall three out of three objects for immediate
memory; could recall one out of three words after several
minutes, but could remember a second one on cue; had adequate
past memory. Id. He further found Plaintiff had a
fair fund of knowledge, reduced calculation ability, fair
concentration, adequate abstract thinking, could distinguish
similarities and differences, and had adequate judgment and
insight. Id. He described Plaintiff as “open
and cooperative.” AR 401.
Gaasbeek diagnosed Plaintiff with cognitive and depressive
disorders, and assessed Plaintiff as having a
score of 45. AR 402-03. While Dr. Van Gaasbeek opined
Plaintiffs depression was treatable and was “a reaction
to his health decline, ” he believed Plaintiffs
cognitive problems “may potentially be chronic”
and found “indications that they developed after his
infection and emergency surgery.” AR 403. Dr. Van
Gaasbeek opined Plaintiff was “moderately
impaired” in his ability to perform detailed and
complex tasks, interact with coworkers and the public,
perform work activities on a consistent basis without special
or additional instruction, ability to maintain regular
attendance, and dealing with the usual stress encountered in
a competitive work environment. AR 403. He also found
Plaintiff was substantially impaired in completing a normal
workday and workweek without interruptions from his
psychiatric condition. Id.
Dr. Jodi Snyder, Psy. D.
Snyder, performed a psychological evaluation of Plaintiff on
December 3, 2013 at the SSA's request. AR 404-408. Dr.
Snyder observed Plaintiff put forth “good effort during
testing” but that his gross motor skills appeared
abnormal, he walked with a cane and moved “very slowly,
” he had difficulty with cognitive sequencing and
shifting sets of information; psychomotor retardation was
noted. AR 404. The mental status exam Dr. Snyder administered
was mostly normal, except for speech (spoke slowly and had
difficulty with annunciation), attention
(“poor”), memory (recalled 0/3 words after brief
delay), mood (depressed/anxious), and affect (sad). AR 406.
Plaintiff tested borderline in verbal comprehension,
perceptual reasoning, working memory and full scale IQ
(“FSIQ”); he tested “extremely low”
in processing speed. AR 406. He tested “low
average” in auditory memory index and borderline in
visual working memory index. AR 407. He took 1:37 to complete
a Trail A test, and 4:38 to complete a Trail B test; these
results placed him below the first percentile of the
population and exhibited a “severe deficit” in
both trails. Id Dr. Snyder opined Plaintiff s
borderline to extremely low range performance was “most
likely secondary to his residual cognitive deficits from
Ludwig's angina.” AR 407.
Snyder's prognosis was guarded: Plaintiff
“continues to have significant residual cognitive
difficulties secondary to his medical issue of Ludwig's
angina.” AR 407. She suggested he “may benefit
from an acquired brain injury support group to address the
cognitive changes as well as support and mental health
treatment to address his mood symptoms.” AR 407-08.
Based on the results of her tests, a clinical interview, and
Plaintiffs personal history and documentation, she opined
that from a psychological standpoint alone, Plaintiff was
“moderately impaired” in his ability to follow
complex/detailed instructions; maintain adequate pace or
persistence to perform complex tasks; maintain adequate
attention/concentration; adapt to changes in job routine;
withstand stress of a routine workday; ...