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Yates v. Berryhill

United States District Court, M.D. Pennsylvania

August 11, 2017

RAE ANN YATES, Plaintiff
v.
NANCY A. BERRYHILL,[1] Acting Commissioner of Social Security, Defendant

          MEMORANDUM

          WILLIAM J. NEALON UNITED STATES DISTRICT JUDGE.

         On December 14, 2015, Plaintiff, Rae Ann Yates, filed this instant appeal[2]under 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.

         BACKGROUND

         Plaintiff protectively filed[3] 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).[4] These claims were initially denied by the Bureau of Disability Determination ("BDD")[5] 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 Commissioner.

         Plaintiff 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. (Tr. 18).

         Plaintiff was born in the United States on August 28, 1984, and at all times relevant to this matter was considered a "younger individual."[6] (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. 164).

         In a 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).

         Regarding 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).

         Socially, 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).

         Plaintiff 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).

         At her 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).

         MEDICAL RECORDS

         On 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).

         On 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).

         On 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).

         On 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." (Tr. 413).

         On October 10, 2012, at an appointment with Nurse Practitioner P. Lynn Curley, it was noted that Plaintiffs Medical Problems included Seizure Disorder. (Tr. 368).

         On 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).

         On 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 ...


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