United States District Court, M.D. Pennsylvania
WILLIAM J. NEALON UNITED STATES DISTRICT JUDGE.
December 14, 2015, Plaintiff, Rae Ann Yates, filed this
instant appealunder 42 U.S.C. § 405(g) for review of
the decision of the Commissioner of the Social Security
Administration ("SSA") denying her application for
disability insurance benefits ("DIB") under Title
II of the Social Security Act, 42 U.S.C. § 1461. et seq.
(Doc. 1). The parties have fully briefed the appeal. For the
reasons set forth below, the decision of the Commissioner
denying Plaintiffs applications for DIB will be vacated.
protectively filed her application for DIB on October 10,
2012, alleging disability beginning on September 26, 2012,
due to a combination of "seizures, epilepsy, complex
partial seizures, fibromyalgia, manic depression, anxiety,
and migraines." (Tr. 11, 177). These claims were initially
denied by the Bureau of Disability Determination
("BDD") on February 26, 2013. (Tr. 120). On March
27, 2013, Plaintiff filed a written request for a hearing
before an administrative law judge. (Tr. 11). An oral hearing
was held on August 20, 2014, before administrative law judge
Sharon Zanotto, ("ALJ"), at which Plaintiff and
vocational expert Paul Anderson, ("VE"), testified.
(Tr. 11). On August 29, 2014, the ALJ issued a decision
denying Plaintiffs application for DIB. On October 28, 2014,
Plaintiff filed a request for review with the Appeals
Council. (Tr. 7). On December 1, 2015, the Appeals Council
concluded that there was no basis upon which to grant
Plaintiff s request for review. (Tr. 1-6). Thus, the
ALJ's decision stood as the final decision of the
filed the instant complaint on December 14, 2015. (Doc. 1).
On March 9, 2016, Defendant filed an answer and transcript
from the SSA proceedings. (Docs. 9 and 10). Plaintiff filed a
brief in support of her complaint on April 25, 2016. (Doc.
12). Defendant filed a brief in opposition on May 27, 2016.
(Doc. 16). Plaintiff filed a reply brief on June 13, 2016.
was born in the United States on August 28, 1984, and at all
times relevant to this matter was considered a "younger
individual." (Tr. 174). Plaintiff graduated from high
school in 2002, and can communicate in English. (Tr. 176,
178). Her employment records indicate that she previously
worked as a manager, receptionist, salesperson, secretary,
and bank teller. (Tr. 222). The records of the SSA reveal
that Plaintiff had earnings in the years 2000 through 2012.
(Tr. 164). Her annual earnings range from a low of one
thousand five hundred one dollars and twenty-eight cents ($1,
501.28) in 2000 to a high of nineteen thousand five hundred
forty-five dollars and seventy-six cents ($19, 545.76) in
2011. (Tr. 164). Her total earnings during these twelve (12)
years were one hundred seventy-eight thousand three hundred
twenty-seven dollars and thirteen cents ($178, 327.13). (Tr.
document entitled "Function Report - Adult" filed
with the SSA on November 14, 2012, Plaintiff indicated that
she lived in a house with her family. (Tr. 200). From the
time she woke up to the time she went to bed, Plaintiff would
"lay around and sleep most days." (Tr. 201). She
indicated that because of her illnesses, she was no longer
able to work because of daily seizures. (Tr. 201). Her
husband helped her with caring for her two children, three
(3) cats, and dog. (Tr. 201). She had no problems with
personal care tasks such as dressing and bathing, did not
prepare meals, did the laundry, mowed the lawn, and went
grocery shopping, when accompanied, for at least an hour and
a half. (Tr. 201-203). She was unable to drive a car because
she lost her license due to seizures. (Tr. 203). She had no
trouble walking. (Tr. 205). When asked to check items which
her "illnesses, injuries, or conditions affect, "
Plaintiff did not check lifting, bending, standing, reaching,
walking, sitting, kneeling, talking, hearing, stair climbing,
seeing, following instructions, or using hands. (Tr. 205).
concentration and memory, Plaintiff did not need special
reminders to take care of her personal needs, but did need
reminders to take her medicine and to go places. (Tr. 202,
205). She could pay bills, handle a savings account, use a
checkbook, and count change. (Tr. 203). She indicated that
she was not able to pay attention at all due to seizures,
could follow written instructions without a problem
"some days, " could follow spoken instructions
"pretty well, " was not able to finish what she
started, did not handle stress well, and handled changes in
routine well. (Tr. 205-206).
Plaintiff left her house to get her daughter off the bus, and
went to doctor appointments and the grocery store. (Tr.
203-204). Her hobbies included reading. (Tr. 204). She did
spend time with her husband, children, and parents. (Tr.
204). She had problems getting along with others when she was
depressed and wanted to be alone. (Tr. 205). With regards to
authority figures, she got along well with them. (Tr. 206).
completed a Supplemental Function Questionnaire for her
seizures. (Tr. 210). She indicated that she had about five
(5) to six (6) seizures a week, or twenty (20) to twenty-five
(25) a month. (Tr. 210). She noted that her seizures happened
when she was awake. (Tr. 210). She indicated that she had an
aura before her seizure that included numbness in her face,
feeling sick, and a blank stare or unconsciousness. (Tr.
210). Plaintiff stated in this form that, during a seizure,
she would lose consciousness, fall, bruise her body from
falling, sometimes lose bladder control, and sometimes have
body twitching and/or small convulsions. (Tr. 210). Plaintiff
stated that, after her seizure, she experienced headaches,
body aches, and nauseousness. (Tr. 210). Plaintiff was
treated with Lamictal, but she still experienced breakthrough
seizures "just as often. They are still increasing and
may add another drug with this." (Tr. 210). She
indicated that medication caused side effects including
insomnia and sleeping all day. (Tr. 210). Her husband
described her seizure as follows: "Blank stare lack of
motion for a few minutes then leads to total appearance of
unconsciousness. Sometimes muscular twitching, eyes twitch,
sometimes making noise, crying. When coming out of it takes
deep breath and confused." (Tr. 211).
oral hearing on August 20, 2014, Plaintiff testified that she
was disabled due to seizures that began in August of 2012.
(Tr. 41). Plaintiff stated that she kept a calendar log of
each seizure she had, which she would then review with Dr.
Khan at each visit. (Tr. 44). She stated that after a
seizure, she would not recall what occurred and would end up
with a headache and exhaustion that would make her lie down
for the remainder of the day. (Tr. 45-46). She stated that,
at best, she was seizure-free for about four (4) weeks once
she started Lamictal, but that then "it just kind of hit
me and it was like a big downfall where I haven't been
able to come back from it yet." (Tr. 47). She testified
that she had only about one (1) seizure a month from April
through June of 2013. (Tr. 47-48). She explained that
"sometimes I will go two or three weeks and not have one
and then I will go weeks and weeks and weeks and continuously
have them." (Tr. 55). She stated that, at the time of
the oral hearing, she was having several a week again. (Tr.
48). She testified that her seizures began to increase again
in January of 2014 when she was hospitalized and saw Dr.
Sollenberger, who increased her Vimpat dosage if approved by
Dr. Khan. (Tr. 49). She stated her insurance would no longer
pay for her visits to Dr. Khan so she could no longer see
him, but that he kept prescribing Lamictal in conjunction
with her primary care physician. (Tr. 49). During her
hearing, Plaintiff seemingly had a seizure, which was on the
record. (Tr. 55-63). After the seizure, Plaintiff testified
that she felt tired and had a headache. (Tr. 76). She stated
that if she were home, she would have been in bed sleeping
after the seizure. (Tr. 80). Plaintiff further testified that
she had difficulty making decisions. (Tr. 79). With regards
to side effects from medications, Plaintiff stated that
Vimpat made her "very, very tired, " but that she
had no other side effects. (Tr. 80). Plaintiff testified that
she was able to do housework, but not on the days she had a
seizure. (Tr. 83).
August 23, 2012, Plaintiff underwent an EEG. (Tr. 332). The
impression was that Plaintiff had "an abnormal EEG which
demonstrated several possibly epileptogenic potentials
arising from the left frontal - anterior temporal region. It
also demonstrated intermittent bilateral temporal slowing of
unclear significance, sometimes indicative of underlying
cortical-subcortical dysfunction. Clinical correlation is
recommended." (Tr. 332).
August 30, 2012, Plaintiff had an appointment with CheunJu
Chen, M.D. of Parkway Neuroscience and Spine Institute. (Tr.
390). Plaintiffs chief symptoms were dizziness and giddiness.
(Tr. 390). Plaintiff described "several spells of
lightheadedness, nausea, numbness int eh face that sometimes
can progress to involve the entire body." (Tr. 390). It
was noted that Plaintiffs "presentation is atypical of
seizures. Her EEG was interpreted as 'possible'
epileptogenic potentials. Although it is possible that these
spells could be complex partial seizures, in this case, would
also consider other possibilities such as complicated
migraine headaches, cardiogenic syncope, or panic
attacks." (Tr. 390). Her physical examination revealed a
normal mood and affect; normal speech and language; intact
naming and repetition; normal muscle bulk and tone; 5/5 neck
flexion and extension; intact sensation to light touch;
normal reflexes; normal gait; and normal toe, heel, and
tandem walk. (Tr. 393). Dr. Chen's recommendation
included starting Plaintiff on "GBP for both seizure and
migraine prophylaxis." (Tr. 390).
September 11, 2012, Plaintiff had a follow-up appointment
with Dr. Chen. (Tr. 395). Dr. Chen stated, "I explained
to the patient that I am still not convinced that these
spells are seizures... She is most concerned about her
abnormal EEG. I explained to the patient that the clinical
picture is the most important factor in her spells. Due to
the varying nature of her spells, I am still not convinced
that these are all seizures." (Tr. 395). Due to
Plaintiffs seizure concerns, Dr. Chen initiated
"LTG." (Tr. 395).
October 2, 2012, Plaintiff had an appointment with Dr. Khan
after she visited the emergency room in August of 2012 after
her body went numb and slid down the wall, with Plaintiff
having no memory of the incident. (Tr. 412). Her physical
examination revealed a normal attention span and
concentration; a normal affect and mood; normal speech;
intact sensation; normal motor function; and normal deep
tendon reflexes. (Tr. 413). Dr. Khan diagnosed Plalintiff
with "C-LOC-REL EPIL&ES SPS w/INTRACT EPIL."
October 10, 2012, at an appointment with Nurse Practitioner
P. Lynn Curley, it was noted that Plaintiffs Medical Problems
included Seizure Disorder. (Tr. 368).
October 11, 2012, Plaintiff had an appointment with Mehrullah
Khan, M.D. at Antietam Neurology Center. (Tr. 409). It was
noted that Plaintiff had been experiencing breakthrough
seizures that caused her to fall and that her seizures were
"still poorly controlled" despite treatment with
Lamictal. (Tr. 409). Her physical examination revealed normal
facial sensations; 5/5 strength in the upper and lower
extremities; normal gait; and a normal sensory exam. (Tr.
409). Dr. Khan increased Plaintiffs Lamictal dose, and
instructed her not to drive. (Tr. 409).
October 29, 2012, Plaintiff underwent EEG Monitoring. (Tr.
420). The impression was the following: "periods of
central sharp transients. Normal video EEG tracing."
(Tr. 420), No events ...