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Oyler v. Berryhill

United States District Court, W.D. Washington, Tacoma

April 16, 2018

NANCY A BERRYHILL, Deputy Commissioner of Social Security for Operations, Defendant.


          David W. Christel, United States Magistrate Judge

         Plaintiff Tracy Edwin Oyler filed this action, pursuant to 42 U.S.C. § 405(g), for judicial review of Defendant's denial of Plaintiff's application for disability insurance benefits (“DIB”). Pursuant to 28 U.S.C. § 636(c), Federal Rule of Civil Procedure 73, and Local Rule MJR 13, the parties have consented to have this matter heard by the undersigned Magistrate Judge. See Dkt. 5.

         After considering the record, the Court concludes the Administrative Law Judge (“ALJ”) erred by failing to adequately address medical opinion evidence from Dr. Patricia Sylwester, M.D. Had the ALJ properly considered Dr. Sylwester's opinion, the residual functional capacity (“RFC”) may have included additional limitations. The ALJ's error is therefore not harmless, and this matter is reversed and remanded pursuant to sentence four of 42 U.S.C. § 405(g) to the Acting Commissioner of Social Security (“Commissioner”) for further proceedings consistent with this Order.


         On August 4, 2014, Plaintiff filed an application for DIB, alleging disability as of September 9, 2013. See Dkt. 8, Administrative Record (“AR”) 25. The application was denied upon initial administrative review and on reconsideration. See AR 25. ALJ David Johnson held a hearing on May 10, 2016. AR 42-90. In a decision dated June 10, 2016, the ALJ determined Plaintiff to be not disabled. AR 22-41. The Appeals Council denied Plaintiff's request for review of the ALJ's decision, making the ALJ's decision the final decision of the Commissioner. See AR 1-6; 20 C.F.R. § 404.981, § 416.1481.

         In Plaintiff's Opening Brief, Plaintiff maintains the ALJ erred by: (1) failing to properly consider medical opinion evidence from Dr. Sylwester; and (2) failing to respond to Plaintiff's post-hearing objections. See Dkt. 10. As a result of these errors, Plaintiff requests the Court remand his claim for further administrative proceedings. Id. at 17.


         Pursuant to 42 U.S.C. § 405(g), this Court may set aside the Commissioner's denial of social security benefits if the ALJ's findings are based on legal error or not supported by substantial evidence in the record as a whole. Bayliss v. Barnhart, 427 F.3d 1211, 1214 n.1 (9th Cir. 2005) (citing Tidwell v. Apfel, 161 F.3d 599, 601 (9th Cir. 1999)).


         I. Whether the ALJ properly considered the medical opinion evidence.

         Plaintiff asserts the ALJ erred by failing to give adequate reasons to reject medical opinion evidence from examining physician Dr. Sylwester. Dkt. 10, pp. 10-17.

         On March 27, 2016, Dr. Sylwester conducted a physical examination of Plaintiff. See AR 596-600. Dr. Sylwester's examination included a record review, a discussion with Plaintiff regarding his complaints and medical history, and a physical examination. See AR 595-600. Based on her physical examination, Dr. Sylwester noted Plaintiff could “change position with difficulty.” AR 598. Dr. Sylwester further determined Plaintiff had an unsteady, wide-based gait in the absence of his brace and cane. AR 598. Similarly, Dr. Sylwester found Plaintiff “very unbalanced, ” with an unsteady walk, unable to perform a toe walk, unsteady on a heel walk, and unable to stand or hop on either leg independently. AR 598. Dr. Sylwester diagnosed Plaintiff with right knee arthritis, and noted he was “tender to palpation over the medial joint line of his right knee.” AR 599.

         Regarding Plaintiff's heart conditions, Dr. Sylwester noted Plaintiff had existing diagnoses of atrial fibrillation, congestive heart failure, and dilated cardiomyopathy. AR 596-97, 599. Dr. Sylwester's examination revealed Plaintiff's heart had irregular rhythm with normal ventricular response, and Plaintiff displayed “shortness of breath with minimal exertion.” AR 599. In all, Dr. Sylwester wrote she did not expect any of Plaintiff's conditions - his right knee arthritis, heart conditions, or unsteady gait - to improve over time. AR 599.

         After her examination, Dr. Sylwester provided a functional assessment of Plaintiff's abilities. See AR 599-600. She opined Plaintiff had a maximum ability to stand or walk with normal breaks for less than two hours due to his arthritis, heart condition, and unsteady gait. AR 599. Furthermore, she determined that although Plaintiff was not limited in his ability to sit with normal breaks, he “may need to change positions as needed.” AR 600. Dr. Sylwester opined it was “medically necessary” for Plaintiff to use his right knee brace and cane “for all distances and all terrain.” AR 600. She also wrote Plaintiff had a maximum lifting and carrying capacity of less than ten pounds occasionally and frequently in light of his heart condition and unsteady gait. AR 600. In addition, she opined Plaintiff “should never climb, balance, stoop, kneel, crouch or crawl due to his heart condition, arthritis, and unsteady gait.” AR 600. Dr. Sylwester determined Plaintiff was not limited in his ability to reach, ...

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