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Campbell v. Berryhill

United States District Court, E.D. California

June 7, 2017

PHIL CAMPBELL, Plaintiff,
v.
NANCY A. BERRYHILL[1], Acting Commissioner of Social Security, Defendant.

          ORDER REMANDING THE ACTION PURSUANT TO SENTENCE FOUR OF 42 U.S.C. § 405(G) ORDER DIRECTING ENTRY OF JUDGMENT IN FAVOR OF PLAINTIFF PHIL CAMPBELL AND AGAINST DEFENDANT NANCY BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY

          JENNIFER L. THURSTON UNITED STATES MAGISTRATE JUDGE.

         Phil Campbell asserts he is entitled to supplemental security income under Title XVI of the Social Security Act. Plaintiff asserts the administrative law judge (“ALJ”) erred in finding his subjective complaints lacked credibility and in evaluating the opinion of his treating physician. Because the ALJ failed to apply the proper legal standards, as discussed below, the administrative decision is REMANDED for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g).

         PROCEDURAL HISTORY

         In his application for benefits, Plaintiff asserted that he became disabled as of November 20, 2011. (Doc. 14-6 at 2) The Social Security Administration denied Plaintiff's application at both the initial level and upon reconsideration. (See generally Doc. 14-4; Doc. 14-3 at 32) After requesting a hearing, Plaintiff testified before an ALJ on April 8, 2014. (Doc. 14-3 at 32, 48) The ALJ determined Plaintiff was not disabled and issued an order denying benefits on May 2, 2014. (Id. at 32-41) When the Appeals Council denied Plaintiff's request for review of the decision on September 18, 2015 (id. at 2-3), the ALJ's findings became the final decision of the Commissioner of Social Security (“Commissioner”).

         STANDARD OF REVIEW

         District courts have a limited scope of judicial review for disability claims after a decision by the Commissioner to deny benefits under the Social Security Act. When reviewing findings of fact, such as whether a claimant was disabled, the Court must determine whether the Commissioner's decision is supported by substantial evidence or is based on legal error. 42 U.S.C. § 405(g). The ALJ's determination that the claimant is not disabled must be upheld by the Court if the proper legal standards were applied and the findings are supported by substantial evidence. See Sanchez v. Sec'y of Health & Human Serv., 812 F.2d 509, 510 (9th Cir. 1987).

         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 Consol. Edison Co. v. NLRB, 305 U.S. 197 (1938)). The record as a whole must be considered, because “[t]he court must consider both evidence that supports and evidence that detracts from the ALJ's conclusion.” Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985).

         DISABILITY BENEFITS

         To qualify for benefits under the Social Security Act, Plaintiff must establish he is unable to engage in substantial gainful activity due to a medically determinable physical or mental impairment that has lasted or can be expected to last for a continuous period of not less than 12 months. 42 U.S.C. § 1382c(a)(3)(A). An individual shall be considered to have a disability only if:

his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work, but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work.

42 U.S.C. § 1382c(a)(3)(B). The burden of proof is on a claimant to establish disability. Terry v. Sullivan, 903 F.2d 1273, 1275 (9th Cir. 1990). If a claimant establishes a prima facie case of disability, the burden shifts to the Commissioner to prove the claimant is able to engage in other substantial gainful employment. Maounois v. Heckler, 738 F.2d 1032, 1034 (9th Cir. 1984).

         ADMINISTRATIVE DETERMINATION

         To achieve uniform decisions, the Commissioner established a sequential five-step process for evaluating a claimant's alleged disability. 20 C.F.R. §§ 404.1520, 416.920(a)-(f). The process requires the ALJ to determine whether Plaintiff (1) engaged in substantial gainful activity during the period of alleged disability, (2) had medically determinable severe impairments (3) that met or equaled one of the listed impairments set forth in 20 C.F.R. § 404, Subpart P, Appendix 1; and whether Plaintiff (4) had the residual functional capacity (“RFC”) to perform to past relevant work or (5) the ability to perform other work existing in significant numbers at the state and national level. Id. The ALJ must consider testimonial and objective medical evidence. 20 C.F.R. §§ 404.1527, 416.927.

         A. Relevant Medical Opinions

         On November 20, 2011, Plaintiff was picked up by emergency medical services, after reporting “he had been walking when he fell.” (Doc. 14-8 at 4) Plaintiff was transported to a hospital where he “was considered drunk, ” because his blood alcohol level was measured at 0.43. (Id. at 2, 4) However, Plaintiff's “level of consciousness decreased” and he “was near comatose.” (Id. at 2, 49) A CT scan “revealed evidence of an extremely large subdural hematoma” on the right side of his brain, and Plaintiff was transferred to Doctors Medical Center for an emergency right frontotemporoparietal craniotomy. (Id. at 2)

         After the surgery, Plaintiff was placed “in the neuro critical care unit.” (Doc. 14-8 at 2) He demonstrated “[m]arked confusion, agitation and obvious cognitive impairment.” (Id.) Dr. Gregory Helbig noted that Plaintiff “slowly improved, ” and “was transferred to the neuro step-down unit.” (Id.) Dr. Helbig believed Plaintiff was “likely going through an alcohol withdrawal and [had] marked hypertension.” (Id.) As part of his recovery treatment, Plaintiff “was seen by speech therapy with evidence of cognitive problems and probably some preexisting.” (Id.) Once Plaintiff reached the “maximum hospital benefit” and could “perform activities of daily living in general, ” he was discharged on December 12, 2011. (Id. at 3)

         Plaintiff had a follow-up visit with Dr. Helbig on March 6, 2012. (Doc. 14-8 at 49) Plaintiff “complain[ed] of some occasional confusion, ” which Dr. Helbig believed “may be residual post-concussive injury to the brain” that could “take a year or two for [Plaintiff] to fully recover.” (Id.) He found Plaintiff was alert and oriented, had Plaintiff's speech was “clear and fluent.” (Id.) Dr. Helbig observed that Plaintiff had “some mild gait staggering.” (Id.)

         In April 2012, Plaintiff sought to establish care at Tuolumne Health and Wellness Center. (Doc. 14- at 61) Dr. Eric Runte noted observed that Plaintiff had recovered from his injury and was “relatively stable.” (Id.) In addition, Dr. Runte noted Plaintiff had “multiple medical problems including obesity, hypertension, alcoholism, rosacea, and eczema.” (Id.) Plaintiff described symptoms including depression, “forgetfulness, loss of sleep, nervousness, fatigue, headaches…, dizziness, [and] seizures.” (Id.)

         Dr. Gerardine Gauch performed a comprehensive psychiatric evaluation on May 6, 2012. (Doc. 14-8 at 66) She noted Plaintiff “endorsed symptoms of memory loss, head pain, and confusion.” (Id.) Plaintiff told Dr. Gauch that he was “dizzy, disoriented, sleepy, incoherent at times, and in general ‘not the same guy'” since his injury. (Id. at 67) Plaintiff stated he was “not a big drinker but reported drinking 2-8 drinks daily.” (Id.) She tested Plaintiff's memory, and found “[h]e was able to recall 3/3 items immediately and 1/3 items spontaneously after several minutes and a second time after several minutes when offered a clue.” (Id. at 69) Dr. Gauch found Plaintiff “was able to perform a simple three-step command successfully, ” and opined that his “concentration ability was within normal limits.” (Id.) She diagnosed Plaintiff with: “Cognitive disorder, not otherwise specified, secondary to closed head injury” and “Adjustment disorder with depressed mood.” (Id. at 70) Dr. Gauch noted:

Although the claimant appeared to respond to questions in an open and honest manner and appeared to give his best effort to the Mental Status Examination, the claimant repeatedly made statements during the evaluation that he is very depressed and he is crazy. In comparison to available records, the claimant minimized the influence of alcohol in the accident that caused his head injury. The claimant demonstrated mild disinhibition and appeared to be invested in being seen as crazy and in this way toyed with faking bad during this evaluation.

(Id. at 70) Dr. Gauch concluded Plaintiff had a “fair” ability to understand and remember short and simple instructions, complete a workday and workweek, deal with work changes, and interact with coworkers.” (Id. at 71) Further, Dr. Gauch opined that Plaintiff's “ability to maintain attention and concentration” and sustain an ordinary routine was “good.” (Id.)

         Plaintiff had CT scan without contrast on May 11, 2012. (Doc. 14-8 at 74) Dr. G. Schaner determined Plaintiff had “[s]mall subacute to chronic subdural hemorrhages” and “some calcification to the medial margin of the subdural collection consistent with more acute component.” (Id.)

         Dr. Fariba Vesali conducted a comprehensive neurological evaluation on June 1, 2012. (Doc. 14-8 at 75) Dr. Vesali noted that Plaintiff reported he had “dizzy spells and [could not] concentrate” after his subdural hematoma and surgery. (Id.) She noted Plaintiff was able to “answer[] questions and follow[] three-step commands with no difficulties.” (Id. at 76) In addition, Plaintiff did not “have any difficulty getting on or off the examination table, ” taking off his shoes, putting on his shoes, or tying them. (Id.) Dr. Vesali concluded Plaintiff would be able to stand, walk, and sit “with no limitations;” “lift/carry 50 pounds occasionally and 25 pounds frequently;” and did not need an assistive ...


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