United States District Court, W.D. Washington, Seattle
ORDER REVERSING AND REMANDING FOR AWARD OF
A. TSUCHIDA CHIEF UNITED STATES MAGISTRATE JUDGE
Reding seeks review of the denial of her application for
Disability Insurance Benefits. She contends the ALJ failed to
provide valid reasons for rejecting her treating doctor's
opinion, the Veteran's Affairs disability rating, her
subjective testimony, and her husband's lay witness
evidence. Dkt. 11. The court REVERSES the
Commissioner's final decision and
REMANDS the matter for an immediate award of
Reding is currently 57 years old, has a college education,
and has worked as a marketing manager. Tr. 44, 67, 183. In
November 2015, she applied for benefits, alleging disability
as of January 7, 2015. Tr. 183. After her applications were
denied initially and on reconsideration, the ALJ conducted a
hearing and, on February 21, 2017, issued a decision finding
Ms. Reding not disabled. Tr. 14-29. The Appeals Council
denied Ms. Reding's request for review, making the
ALJ's decision the Commissioner's final decision. Tr.
the five-step disability evaluation process,  the ALJ found
that Ms. Reding had not engaged in substantial gainful
activity since the alleged onset date, she had the following
severe impairments: migraines, lumbar and cervical
degenerative disc disease, and shoulder osteoarthritis; and
these impairments did not meet or equal the requirements of a
listed impairment. Tr. 16-18. The ALJ found that Ms. Reding
had the residual functional capacity to perform light work
that does not require more than frequent balancing, stooping,
kneeling, crouching, crawling, or climbing of ramps and
stairs; that does not require climbing of ladders, ropes, or
scaffolds; that does not involve concentrated exposure to
hazards in the workplace such as dangerous moving machinery
or working at unprotected heights; and that does not require
that she drive. Tr. 19. The ALJ found that Ms. Reding was
capable of performing her past relevant work as a marketing
manager and that she was therefore not disabled. Tr. 28-29.
Dr. Spain's opinion
Reding argues that the ALJ failed to provide sufficient
reasons to reject the opinion of treating neurologist William
Spain, M.D. Dkt. 11 at 4. The ALJ must give specific and
legitimate reasons for rejecting a treating doctor's
opinion that is contradicted by another doctor, and clear and
convincing reasons for rejecting a treating doctor's
uncontradicted opinion. Lester v. Chater, 81 F.3d
821, 830-31 (9th Cir. 1996).
2016, Dr. Spain completed a medical source statement in which
he characterized Ms. Reding's migraines as severe and
reported that she had one to two migraines per week, or five
to six per month. Tr. 737. He opined that she was incapable
of even low stress work, stating that stress at any level
leads to migraines, and that during times she had a headache
she would generally be precluded from performing even basic
work activities and would need a break from the workplace.
Tr. 738. He opined that she would likely be off task 20% of
the time, have good days and bad days, and miss more than
four days of work per month. Tr. 739. He stated she had
right-side numbness and difficulty with concentration, odors,
light, and sound during a headache. Tr. 740.
found that Dr. Spain's opinion was consistent with
disability from migraine, but gave it very little weight. Tr.
26. The ALJ found that Dr. Spain gave full credit to Ms.
Reding's headache logs, which the ALJ found to be simply
a log of subjective complaints that were not consistent with
her treatment history, as shown by the fact that she did not
present to the emergency room or her VA providers during a
migraine episode and was able to attend three physical
therapy sessions when complaining of headache or migraine.
Id. The ALJ found that subjective complaints alone
were insufficient to establish the degree of functioning
restriction Ms. Reding claimed. Id.
does not provide adequate reasons for rejecting a treating
doctor's opinion by questioning the credibility of the
patient's complaints where the doctor does not discredit
those complaints and supports his ultimate opinion with his
own clinical findings. Edlund v. Massanari, 253 F.3d
1152, 1159 (9th Cir. 2001). Here, there is nothing in the
record to indicate that Dr. Spain questioned Ms. Reding's
reports to him, either in his medical source statement or
over the course of three years of treatment. Dr. Spain did
not simply parrot what Ms. Reding told him, but applied his
own independent medical judgment based on his clinical
findings. The ALJ erred in rejecting Dr. Spain's opinion
as based in large part on Ms. Reding's statements.
the ALJ's finding that Ms. Reding's complaints were
inconsistent with her treatment history was not supported by
substantial evidence. The ALJ's reliance on Ms.
Reding's lack of treatment at the emergency department
was based solely on the ALJ's own assumption that
visiting the emergency department during a migraine was a
recommended or appropriate treatment. There is no indication
in the record that Dr. Spain or any other provider directed,
or even suggested, that Ms. Reding should go to the emergency
department during a migraine. The fact that she did not
follow a course of treatment not recommended by her doctors
does not undermine her complaints or Dr. Spain's opinion.
ALJ's finding that Ms. Reding was able to attend three
physical therapy appointments while having migraines is not
supported by the treatment notes. The treatment note from
December 9, 2015, states that Ms. Reding “got a
migraine today with sensations of nausea.” Tr. 591.
This note does not state that she was suffering from a
migraine during the appointment. On January 9, 2016, the
notes states that “today she is having a significant
headache” and that she was having cervicogenic
headaches twice per week. Tr. 716. This note does not
reference migraine headaches. And the note from February 3,
2016, states that “she had a migraine since yesterday
and is more fatigued today.” Tr. 715. This note refers
to the migraine as occurring the past and is ...