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High v. Berryhill

United States District Court, D. Hawaii

April 30, 2019

LATOYA S. HIGH Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          ORDER REVERSING DECISION OF ACTING COMMISSIONER OF SOCIAL SECURITY AND REMANDING FOR FURTHER ADMINISTRATIVE PROCEEDINGS

          Derrick K. Watson, United States District Judge.

         On June 11, 2018, Plaintiff Latoya High appealed the Acting Commissioner of Social Security's denial of her application for disability insurance benefits. High asks this Court to review whether the Administrative Law Judge's (ALJ's) failure to discuss several of her acknowledged medical ailments constitutes reversible error and whether the ALJ improperly dismissed medical evidence and symptom testimony, such that his decision was not based on substantial evidence. After carefully reviewing the record and the arguments of counsel, the Court concludes that this case must be remanded for further administrative proceedings, as set forth below.

         BACKGROUND

         I. Procedural History

         On July 15, 2016, High applied for benefits under Title II, alleging an onset date of March 22, 2016. Opening Brief, September 26, 2018, Dkt. No. 20, at 1; Administrative Record (“AR”), Dkt. No. 8, at 150.[1] The ALJ denied the application on December 5, 2017. AR at 12-31. The Appeals Council denied High's request for review on April 26, 2018. AR 1-6. High filed her appeal in this Court on June 11, 2018. Dkt. No. 1.

         II. Summary of the Relevant Evidence

         High alleges that she suffers from the following impairments: lymphocytic colitis irritable bowel syndrome; anemia; submucosal lesion of the stomach; degenerative arthritis/meniscal tear in the right knee; uterine fibroids; depressive disorder; anxiety disorder; posttraumatic stress disorder (PTSD); memory issues; low hemoglobin; premenstrual dysphoric disorder (PMDD); lumbar spine disorder and cervicalgia. Opening Brief at 8. The ALJ determined that High's uterine fibroids, depressive disorder, anxiety disorder, PTSD, and PMDD were all severe. AR at 17.

         A. High's Identification of Lumbar Spine Disorder and Cervicalgia as Impairments

         High's August 30, 2017 pre-hearing brief listed her various disabling impairments, including “low back pain, ” and provided narrative descriptions of those impairments identified as “more severe.” AR at 301. The narrative descriptions, which included the diagnostic history and impact of those “more severe” ailments, focused on High's emotional and psychological disorders, knee pain, and PMDD. Id. However, High's brief also specified that the medical record was extensive and noted, in particular, High's 6 to 10 visits per month with health care providers in a variety of fields. Id. High's August 2016 SSA “Disability Report” (SSA-3368), for instance, also listed a “lower back” condition.[2] AR at 175. And during her ALJ hearing, High testified regarding her symptoms, stating that she suffered from chronic neck and back pain. AR at 41, 49, 50.

         B. Medical Evidence of Lumbar Spine Disorder and Cervicalgia

         In February 2016, High underwent physical therapy for lower back pain, which she stated had been worsening since May 2015. AR at 976. In June 2016, an MRI of High's lumbar spine revealed abnormalities, including a degenerative disc. AR 503. The following year, in May 2017, High visited the Tripler Pain Management Center, complaining of chronic neck and back pain, and was seen by Dr. Cuong. AR at 2982. That Tripler report identified, among other things, a “Lumbar MRI 2016: Degenerate disc and facet changes within the lower lumbar spine contribut[ing] to mild bilateral neuroforaminal narrowing.” Id. Reports from these visits note that sitting for long periods causes pain; that, at its worst, the pain is a six on a ten-point scale; and that High should limit the amount of time she spends sitting. Id. at 976, 2982. Dr. Cuong labeled High's neck pain, “cervicalgia, ” recommended various treatments to manage it, and administered Botulinum TPI injections to relieve it. Id. at 2858.

         By June 2017, High's physical therapist noted ongoing back pain that appeared to be worsening, despite 13 sessions of physical therapy. AR at 2836. A car accident on June 13, 2017 resulted in another treatment report identifying neck and back pain as an ailment. AR at 2834. As of July 2017, High continued physical therapy and chiropractic adjustments to alleviate her complaints of lower back and neck pain. AR at 2733, 2748.

         III. Summary of Relevant ALJ Findings

         ALJ's employ a five-step process to determine whether a person is disabled under the Social Security ...


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