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Reding v. Berryhill

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

July 17, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Deborah 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 benefits.


         Ms. 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. 1.


         Using the five-step disability evaluation process, [1] 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.[2] 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.


         A. Dr. Spain's opinion

         Ms. 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).

         In June 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.

         The ALJ 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.

         An ALJ 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.

         Moreover, 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.

         And the 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 ...

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