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Saeteurn v. Saul

United States District Court, E.D. California

September 4, 2019

ANDREW M. SAUL[1], Commissioner of Social Security, Defendant.



         Seng Saeteurn asserts she is entitled to a period of disability and disability insurance benefits under Title II of the Social Security Act. Plaintiff argues the administrative law judge erred in evaluating the record and seeks judicial review of the decision to deny her application for benefits. Because the ALJ failed to apply the proper legal standards in evaluating Plaintiff's testimony and the credibility of her subjective complaints, the decision is REMANDED for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g).


         Plaintiff filed an application for benefits on February 3, 2014, alleging disability beginning in May 2008, due to depression, anxiety, migraines, asthma, arthritis, weakness in her arms, pain in her left heel, and treatment for seizure. (Doc. 11-6 at 13; 11-4 at 13) The Social Security Administration denied her application at the initial level and upon reconsideration. (See Doc. 11-3 at 13-42; Doc. 11-5 at 16-26) After requesting a hearing, Plaintiff testified before an ALJ on November 29, 2016. (Doc. 11-3 at 21, 39) The ALJ determined she was not disabled and issued an order denying benefits on December 22, 2016. (Id. at 18-31) When the Appeals Council denied Plaintiff's request for review on February 13, 2018 (id. at 2-4), the ALJ's findings became the final decision of the Commissioner of Social Security.


         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).


         To qualify for benefits under the Social Security Act, Plaintiff must establish she 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).


         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. Medical Background

         Plaintiff reported having left foot pain and was diagnosed with calcaneal spurs in October 2009. (Doc. 11-9 at 25) She was later diagnosed with left plantar fasciotomy and Achilles tendon tear, for which she received surgery on December 22, 2010. (Doc. 11-8 at 3)

         In January 2011, Dr. Eduardo Villarama completed a “Treating Physician General medical Evaluation.” (Doc. 11-8 at 64-66) Dr. Villarama noted Plaintiff had left foot pain with limited range of motion following surgery, and she was in a wheelchair, “unable to bear [weight]” with her left foot. (Id. at 65, 66) He also indicated Plaintiff had right lateral epicondylitis and migraine headaches. (Id. at 65) Dr. Villarama opined Plaintiff had normal reflexes, senses, and normal range of motion in all joints other than her left foot. (Id.) Dr. Villarama noted Plaintiff did not have seizures. (Id.) According to Dr. Villarama, Plaintiff had “mild depression but [it was] controlled by medications.” (Id. at 66)

         Dr. Birgit Siekerkotte performed a consultative evaluation on March 27, 2011. (Doc. 11-8 at 67) Plaintiff reported she was “on various inhalers” for asthma, and had “shortness of breath at night when she [went] to bed” or exercising. (Id.) She told Dr. Siekerkotte that she had pain in her left foot, right arm, and left shoulder pain; headaches “3-4 times a week;” depression; stress; and insomnia. (Id. at 68) Plaintiff told Dr. Siekerkotte that she “use[d] a wheelchair prescribed by her podiatrist, ” and Dr. Siekerkotte noted she used crutches. (Id. at 69) In addition, she told Dr. Siekerkotte she “need[ed] help with everything including washing herself and dressing herself, ” with which her daughter helped. (Id. at 68) Dr. Siekerkotte observed Plaintiff had “tenderness in the lower back area.” (Id. at 70) She also determined Plaintiff had reduced strength in her right hand gripping at 4/5, right bicep at 4, and quadriceps at 4. (Id.) In addition, she found Plaintiff had “decreased sensation along the left leg laterally.” (Id.) Dr. Siekerkotte opined Plaintiff could stand and walk for “[u]p to four hours based on decreased muscular strength” and sit without limitation. (Id. at 71) According to Dr. Siekerkotte, Plaintiff should continue use of her crutches and a wheelchair, “as recommended by the podiatrist … to prevent the claimant from following.” (Id.) She determined Plaintiff should continue using a right elbow brace “for pain control, ” and she did not identify any amount of weight Plaintiff could lift and carry “based on the need to use crutches and to hold onto the crutches.” (Id.) Further, Dr. Siekerkotte concluded Plaintiff could never climb, balance, stoop, kneel, crouch, or crawl “based on [her] decreased grip strength and the need to use crutches with observed balance problems and decreased strength of the upper and lower extremities.” (Id.) Dr. Siekerkotte opined Plaintiff could frequently reach, handle, and finger “when in a seated position, ” but never do so while walking due to her crutches. (Id.)

         In November 2013, Plaintiff went to a clinic where she complained of “[f]acial weakness and numbness, ” along with “left upper extremity weakness and numbness.” (Doc. 11-10 at 12) Plaintiff was transported by ambulance from the clinic to an emergency room, where she was admitted for a “transient ischemic attack and to rule out cerebrovascular accident.” (Id.) Plaintiff had an MRI of her brain and CT scan of her head, which were each normal. (Id. at 22) An EEG test “revealed abnormal sharp waves occurring on the left side, with phase reversal in either of the tip of the left temporal lobe or the posterolateral left frontal lobe, ” which was “consistent with a seizure focus in the same area.” (Id.) Dr. Dinesh Chhagahlal diagnosed Plaintiff with sensory seizures. (Id. at 22-23) Plaintiff was discharged two days later, on November 14, with a prescription for Keppra. (Id. at 23)

         On November 19, 2013, Plaintiff had a follow-up appointment at Golden Valley Heath Center regarding her transient ischemic attack. (Doc. 11-12 at 40) Dr. Sukhdip Kang noted that Plaintiff appeared depressed, and diagnosed her with anxiety and depression. (Id. at 40, 42) Dr. Kang opined Plaintiff's motor strength was 5/5 and her cranial nerves were intact. (Id. at 43) In addition, he determined Plaintiff was “oriented to time, place, person, and situation.” (Id. at 43) Dr. Kang referred Plaintiff to Dr. Vang Leng Mouanoutoua for treatment of her depression. (Id. at 43, 46)

         Dr. Mouanoutoua performed a case consultation on November 20, 2013 and noted Plaintiff reported “depressed feeling, tearfulness, much worries, forgetfulness, frequent anger, poor sleep of about 3-4 hours a night, sadness, and suicidal wishes without a plan 1-2x a day.” (Doc. 11-12 at 46) She also described symptoms of anxiety, including “episodes of nervousness, sweating, heart racing, cold flushes, scary feeling[s], body uptight, and shaking feeling.” (Id.) Dr. Mouanoutoua diagnosed Plaintiff with Panic Disorder and Major Depressive Disorder, recurrent, and severe. (Id.)

         In December 2013, Dr. Mouanoutoua performed an intake evaluation. (Doc. 11-12 at 50) He noted Plaintiff's reported symptoms were severe and “poorly controlled.” (Id.) In addition, Plaintiff stated her “symptoms… prevented her from performing daily chores and relating constructively with people.” (Id.) Dr. Mouanoutoua opined Plaintiff was “oriented to person and place, ” and her “mood [was] anxious and depressed.” (Id. at 51) In addition, he observed Plaintiff's attention was “gained, directed and distracted;” and he determined Plaintiff's memory was intact. (Id.) Dr. Mouanoutoua gave Plaintiff a GAF score of 50.[2] (Id. at 52)

         On July 22, 2014, Dr. Mouanoutoua opined Plaintiff made “[m]inimal progress … [with] her chronic depression.” (Doc. 11-19 at 2) He observed that Plaintiff “remain[ed] hopeless and depressed, but [was] more ...

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