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VanLengen v. Saul

United States District Court, N.D. California

July 3, 2019

RENA LANE VANLENGEN, Plaintiff,
v.
ANDREW M. SAUL, COMMISSIONER OF SOCIAL SECURITY, Defendant.

          ORDER GRANTING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT, DENYING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT AND REMANDING FOR AWARD OF BENEFITS RE: DKT. NOS. 21, 24

          JOSEPH C. SPERO, CHIEF MAGISTRATE JUDGE

         I. INTRODUCTION

         Plaintiff Rena VanLengen seeks review of the final decision of Defendant Andrew M. Saul, Commissioner of the Social Security Administration (the “Commissioner”), denying her applications for Supplemental Security Income (“SSI”) benefits under Title XVI of the Social Security Act. For the reasons stated below, the Court GRANTS VanLengen's Motion for Summary Judgment, DENIES the Commissioner's Motion for Summary Judgment, REVERSES the decision of the Commissioner and REMANDS the case to the Social Security Administration for award of benefits.[1]

         II. BACKGROUND

         A. Factual Background

         1. Educational and Employment Background

          VanLengen was born on October 27, 1966. Administrative Record (“AR”) 219. She completed 10th grade. AR 240. She testified that she left school because she was “into drugs.” AR 66. Between January 1999 and December 2002, VanLengen worked as a home care giver, a bartender and a restaurant manager. AR 241, 270. She stopped working in December 2002 and claimed on her initial application for SSI that she became disabled at that time; at the hearing before the ALJ she amended her onset date to the date of her SSI application, December 26, 2013. AR 56.

         2. Medical History

         a. Overview of Alleged Impairments At the hearing before an Administrative Law Judge (“ALJ”), conducted on April 1, 2016, VanLengen's attorney explained that the primary impairment that is the basis of of VanLengen's SSI claim, her chronic abdominal pain, began in March 2013. AR 61. At that time, VanLengen was hospitalized for “[m]ultiple intra-abdominal abscesses, ” “[a]cute sepsis syndrome [and] systemic inflammatory response syndrome secondary to” the abscesses, and “[r]uptured ovarian cyst leading to left salpingo-oophorectomy with extensive lysis of adhesions.” AR 336. A year later she was diagnosed with “pelvic adhesions and adhesive disease, ” among other things, and on May 13, 2014 VanLengen underwent a “total laparoscopic hysterectomy and right salpingo-oophorectomy with extensive lysis of adhesions.” AR 519. Since her hospitalization and surgery in 2013, VanLengen has suffered from chronic abdominal/pelvic pain due to adhesion (scarring). AR 111, 239, 551. In addition to her chronic abdominal pain, VanLengen claims she is impaired by chronic headaches (see, e.g., AR 313, 807-809, 821, 844, 947, 1165); anxiety, depression and memory and cognitive problems (see, e.g., AR 123, 149, 1189); and tarsal tunnel syndrome in her feet (see, e.g., AR 284, 825-826, 833).

         b. Treating Physicians

         The administrative record reflects that since her onset date, the vast majority of VanLengen's medical care has been provided by the Sonoma County Indian Health Project, where she was treated by, among others, Ellen Kruusmagi, M.D. (her primary care physician), Neil Steinberg, Psy. D. (her psychologist) and John Hollander, D.P.M. (her podiatrist). The record reflects that Sonoma County Indian Health Project has its own pharmacy that filled many of the prescriptions written by the doctors who treated VanLengen there. See, e.g., AR 562, 572, 735, 840. During the relevant period, VanLengen also was evaluated by and received treatment at Sutter Medical Center of Santa Rosa and was referred out to other providers for treatment as well, including Marcia Luisi, M.D., who conducted electrodiagnostic testing of VanLengen's lower extremities to evaluate for possible tarsal tunnel syndrome at the request of Dr. Hollander.

         i. Dr. Kruusmagi

         Treatment Notes

         VanLengen's primary care physician was Dr. Ellen Kruusmagi, who has treated VanLengen since February 2013. See AR 641. Treatment notes from Plaintiff's visits reflect that Dr. Kruusmagi provided ongoing treatment for Plaintiff's abdominal pain, as well as for anxiety and depression and difficulty sleeping. April 22, 2013 treatment notes reflect that VanLengen was recovering from “extensive hospital stay for septicemia and multiple abdominal abcesses, ” that she “still ha[d] diffuse abdominal pain, ” was on IV antibiotics and was “very weak.” AR-456-457. Dr. Kruusmagi prescribed oxycodone/acetaminophen to be taken “as needed for pain.” Id. June 10, 2013 notes reflect that VanLengen was experiencing “sharp lasting” pelvic pain; Dr. Kruusmagi observed that VanLengen's abdominal pain was “most likely secondary to all of the scarring she developed with her severe abdominal infection.” AR 448-449. Dr. Kruusmagi prescribed 800 mg. ibuprofen tablets. Id. November 6, 2013 treatment notes reflecting “intermittent abdominal pain, ” and occasional migraine headaches. AR 436-440. Dr. Kruusmagi again prescribed 800 mg. ibuprofen tablets and a “small amount of narcotic, ” namely, hydrocodone/acetaminophen, with a caution that “[n]arcotics should not be used on a regular basis for this type of problem and that she expected the prescription to “last.” Id.

         December 4, 2013 notes reflect that VanLengen was experiencing “intermittent abdominal pain that sometimes extends to the sides of her chest” and depression. AR 428. Dr. Kruusmagi ordered a pelvic ultrasound and prescribed Zoloft and Trazodone. Id. January 8, 2014 notes reflect that Plaintiff was reporting continued abdominal pain and pain in her chest when she took deep breaths. AR 422-423. Dr. Kruusmagi increased VanLengen's Zoloft dose. Id. March 5, 2014 notes reflect that Plaintiff had experienced pelvic pain for “months” and that the prescription-strength ibuprofen helped “a bit.” AR 405-407. April 9, 2014 notes reflect that Dr.

         Kruusimagi told VanLengen that removal of her remaining ovary would likely help with pain associated with menses and heavy bleeding but “might not relieve the everyday pelvic pain as this may be related to adhesions from the extensive previous infection.” AR 584-586.

         Treatment notes from a visit to Dr. Kruusmagi on June 13, 2014, after VanLengen had undergone the hysterectomy discussed above, in May 2014, reflect that VanLengen was “anxious” and “tearful, ” had “jumpy” legs due to Trazadone, was experiencing abdominal pain at night and that VanLengen's abdomen was “tender to deep palpitation.” AR 571-572. September 3, 2014 notes reflect that VanLengen's chief complaint was abdominal pain, that she was still experiencing insomnia and that she had gained weight. AR 558-564. Dr. Kruusmagi prescribed 800 mg. ibuprofen tablets for pain and Zolpidem for sleep. Id. On December 31, 2014, Dr. Kruusmagi noted that Plaintiff had experienced “ongoing intermittent abdominal pain worse with bowel movements.” AR 744. Dr. Kruusmagi “asked her to start working on weight loss, ” noting that Plaintiff had gained “about 20-30 pounds since her surgery.” Id. She refilled VanLengen's prescription for Zolpidem. AR 746.

         On January 28, 2015, Dr. Kruusmagi noted that VanLengen experienced “mild daily abdominal pain” and that “frequently throughout the day” it “will flare up and she will have to rest, sit down or lay down.” AR 734. Dr. Kruusmagi noted that the abdominal pain “wakes her up every morning and worsens when she has a bowel movement.” Id. Dr. Kruusmagi also observed that VanLengen was overweight and made a “strong recommendation” to lose weight “as this can help the abdominal pain.” Id. Dr. Kruusmagi noted that VanLengen “look[ed] uncomfortable” but that she was able to ambulate in and out of the clinic. AR 735. Dr. Kruusmagi refilled a prescription for Sumatriptan for VanLengen's migraine headaches during this visit. AR 735.

         Notes from a March 4, 2015 visit reflect that VanLengen “has had constant daily abdominal pain since the severe abdominal infection and septicemia in early 2013.” AR 716. Further, VanLengen continued to report that “the pain wakes her up in the morning and that she has it all day.” Id. The notes reflect that “[b]owel movements make it worse” and that while “[o]ccasionally she can get into a position that will be comfortable for a short period of time” “[s]he is unable to sit in one position for very long.” Id. Dr. Kruusmagi also noted that VanLengen was experiencing “almost daily headaches” with sensitivity to bright lights, and that VanLengen took ibuprofen daily and Sumatriptan occasionally. Id. Dr. Kruusmagi prescribed 800 mg. ibuprofen tablets for pain, sumatriptan for headaches and zolpidem for sleep. AR 718.

         In treatment notes from a visit on April 22, 2014, Dr. Kruusmagi opined that VanLengen “has two types of pain[:] . . . a general mid abdominal pain worse with BM and an epigastric pain that feels like she is hungry.” AR 861. Dr. Kruusmagi assessed the second type of pain to be gastritis, while the first she described as “adhesion pain, ” that is, pain associated with the scarring in VanLengen's abdomen. Id. On August 5, 2015, Dr. Kruusmagi noted that VanLengen has “chronic abdominal pain, ” that she takes Motrin and Tylenol for the pain and that she “has been trying to lose weight as this may help.” AR 833. Although VanLengen was “down to 194” pounds, Dr. Kruusmagi noted that Plaintiff was still overweight. Id. Dr. Kruusmagi also noted that VanLengen had “corns and calluses” on her feet and had recently seen Dr. Holland, a podiatrist. Id.

         September 23, 2015 treatment notes reflect that VanLengen continued to experience abdominal pain and complain of headaches. AR 820. Dr. Kruusmagi noted that VanLengen “does take Propranolol” for her headaches but that she was “out of Sumatriptan.” Id.; see also AR 1029 (May 6, 2013 prescription for Propranolol for “cardiovascular therapy”). Dr. Kruusmagi refilled VanLengen's prescription for Sumatriptan and Zolpidem. AR 821. In notes from a November 18, 2015 visit, Dr. Kruusmagi noted that the purpose of VanLengen's visit was to manage abdominal pain with bowel movements that VanLengen had experienced for “months” and migraines. AR 927. She noted that VanLengen was experiencing increased abdominal pain and insomnia. Id. Dr. Kruusmagi wrote that VanLengen had seen Dr. Hollander for bilateral Tarsal Tunnel Syndrome and that he had started her on Neurontin. Id. She also noted that Dr. Holland had recommended compression stockings and topical NSAIDs but that VanLengen was unable to get them because they were not covered by insurance. Id.

         On January 6, 2016, Dr. Kruusmagi saw VanLengen again for abdominal pain, nausea and vomiting. AR 916. Dr. Kruusmagi referred VanLengen to the Emergency Room due to the severity of her symptoms. AR 917; see also AR 939 (reflecting that VanLengen went to the Emergency Room that day and that a CT scan showed a kidney stone that had also be observed in earlier CT scan in 2013, which was removed using uteroscopy with laser lithotripsy).

         RFC Questionnaires

         Dr. Kruusmagi completed four questionnaires in connection with VanLengen's SSI application: 1) a Residual Functional Capacity Questionnaire dated March 12, 2014, AR 1005-1007; 2) a Residual Functional Capacity Questionnaire dated January 28, 2015, AR 641-642; 3) a Headache Residual Functional Capacity Questionnaire, dated March 4, 2015, AR 807-809; and 4) a Physical Assessment, dated February 24, 2016, AR 996-998.

         In the RFC questionnaire dated March 12, 2014, Dr. Kruusmagi described VanLengen's diagnosis as “chronic abdominal pain due to adhesions and previous surgery.” AR 402. She opined that VanLengen's symptoms (lower abdominal pain “much worse with urination and Bowel movements”) are “constantly” severe enough to interfere with the attention and concentration required to perform simple work-related tasks. Id. In response to questions addressing VanLengen's ability to sit, Dr. Kruusmagi opined that VanLengen can sit for thirty minutes at a time for a total of four hours in an eight-hour day and stand/walk for thirty minutes at a time for three of eight hours. Id. She checked “no” in response to the question “Does your patient need a job which permits shifting positions at will from sitting, standing or walking” with the following a handwritten explanation: “(in pain all day) shifting won't help.” Id. Dr. Kruusmagi indicated that VanLengen would need to take unscheduled breaks every thirty minutes and that the required breaks would need to be 30 minutes long. Id. The next question addressed limitations on lifting and carrying. Id. at 403. Dr. Kruusmagi opined that VanLengen can occasionally lift up to ten pounds and never lift more than ten pounds. Id. Dr. Kruusmagi answered “no” in response to the question that followed, which asked whether VanLengen had trouble with “reaching handling or fingering.” Id. She wrote in the margin next to this question, “no probs with hands - just can't sit.” Id. In response to a question asking how often Plaintiff would be “likely to be absent from work” as a result of her impairments, Dr. Kruusmagi checked the option for “More than four times a month” and wrote under the option she had checked “much more.” Id. Finally, she answered “no” in response to the question of whether VanLengen was “physically capable of working an 8 hour day, 5 days a week employment on a sustained basis.” Id.

         Just under a year later, on January 28, 2015, Dr. Kruusmagi completed the same Residual Functional Capacity Questionnaire a second time. Her answers were the same or similar to the previous RFC questionnaire. She again answered the questions about sitting limitations by stating that VanLengen could sit no more than thirty minutes at one time and no more than four hours in an eight-hour work day. AR 641. Likewise, she again answered “no” in the response to the question asking whether VanLengen needed a job that would allow her to shift positions, with a handwritten note next to the question saying that “this will not help.” Id. She opined that VanLengen would need to take unscheduled breaks “at least hourly” (previously she said every thirty minutes) and the breaks would last thirty minutes (the same as in the previous RFC questionnaire). Id. As in the previous questionnaire, Dr. Kruusmagi stated that VanLengen could lift ten pounds occasionally and could never lift more than ten pounds. AR 642. She again checked the “no” box in response to the question about repetitive reaching, handling or fingering, with a handwritten notation stating “hands - fingers and arms work[.] It is the abdominal pain that is the limiting factor.” Id. Although the follow-on question (asking the doctor to provide the percentage of the work day the claimant could perform certain activities using her hands, fingers and arms) was to be answered only if the answer to the previous question was “yes, ” Dr. Kruusmagi filled in the blanks for the specified activities, indicating that VanLengen's ability to use her hands, fingers and arms to perform them could not exceed 50% of the work day. Id. Dr. Kruusmagi again checked the box indicating VanLengen would miss more than four days a month of work and checked “no” in response to the question as to whether VanLengent was capable of “working an 8 hour day, 5 days a week employment on a sustained basis.” Id.

         On March 4, 2015, Dr. Kruusmagi completed a Headache Residual Functional Capacity Questionnaire. The first half of the questionnaire posed questions specifically related to VanLengen's headache symptoms and limitations that were not included on the RFC questionnaires discussed above. In response to these questions, Dr. Kruusmagi stated that VanLengen suffered from headaches six days a week that were “severe so that [they] interfere with activity.” AR 807. She stated that VanLengen's headaches were triggered by bright light and that to make them better she needed to lie in a dark room, and that ibuprofen and Sumatriptan help. Id.; see also AR 808 (stating that ibuprofen and Sumatriptan provide “moderate relief”). She stated that VanLengen's headaches caused impaired sleep. AR 807. Dr. Kruusimagi attributed VanLengen's headaches to “migraine” and “abdominal pain, ” and also opined that “emotional factors” contribute “somewhat” to VanLengen's headaches. AR 808. She stated that the medications used to treat VanLengen's headaches (ibuprofen 800 mg. and Sumatriptan) cause “some fatigue.” Id. Dr. Kruusmagi states that VanLengen would not be able to work when she had headaches, that she would need to take unscheduled breaks five times a week due to headaches and would need these breaks to last at least two hours. Id.

         The Headache RFC questionnaire went on to ask a series of questions about VanLengen's physical limitations. AR 808-809. In this section, Dr. Kruusmagi again stated that VanLengen could lift ten pounds occasionally and could never lift more than ten pounds. AR 808. The next question asked how long VanLengen could sit at one time and Dr. Kruusmagi gave the same response she had given in the two RFC questionnaires discussed above, namely, that VanLengen could not sit for more than 30 minutes at a time. AR 809. She opined that VanLengen would need to sit or lie down for a total of four hours of an eight-hour day. Id. She further stated that VanLengen's ability to sit or stand was less than two hours a day. Id. As in the previous questionnaires, Dr. Kruusmagi stated that VanLengen was likely to miss more than four days of work a month due to her impairments. Id Finally, on February 24, 2016, Dr. Kruusmagi completed a Physical Assessment. AR 996-998. In that questionnaire, Dr. Kruusmagi stated that VanLengen's diagnosis was “chronic abdominal pain due to previous severe abdominal internal infections and subsequent bowel adhesion and scar[r]ing.” AR 997. She listed constipation and diarrhea as side-effects VanLengen experienced due to medications. Id. Dr. Kruusmagi opined that VanLengen could sit no more than a total of three hours of an eight-hour work day and stand or walk no more than two hours a day. Id. She again stated that VanLengen would need to take breaks every 30 minutes; she estimated these breaks would last 15-20 minutes. Id. Dr. Kruusmagi found the same restrictions as to lifting and carrying that she had found in the forms discussed above. Id. In response to the question whether VanLengen had limitations as to repetitive reaching, handling or fingering, Dr.

         Kruusmagi for the first time checked the “yes” box. She went on to provide percentages for various activities, opining that Plaintiff's limitations with respect to reaching, handling and fingering would limit her to performing these activities no more than 25% of the work day. Again, a handwritten notation next to this question made clear that Dr. Kruusmagi did not see these limitations as primary; she wrote, “It is more sitting in place greater than 30 min. that is the ...


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