United States District Court, N.D. California
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,
C. SPERO, CHIEF MAGISTRATE JUDGE
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
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.
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,
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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
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.”
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.
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.
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
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 ...