GRIMES v. COLVIN

Filing 17

SOCIAL SECURITY APPEAL ORDER granting 13 Motion for Summary Judgment; denying 15 Motion for Summary Judgment and remanding the case for further consideration. Signed by Judge Donetta W. Ambrose on 2/27/17. (cha)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA

STEPHANIE ROSALIA GRIMES,

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Plaintiff,
-vsNANCY A. BERRYHILL,1
ACTING COMMISSIONER OF SOCIAL
SECURITY,
Defendant.

Civil Action No. 15-1557

AMBROSE, Senior District Judge.
OPINION AND ORDER
Synopsis
Plaintiff Stephanie Rosalia Grimes (“Grimes”) brings this action seeking judicial
review of the ALJ’s decision denying a claim for supplemental security income (“SSI”)
and disability insurance benefits (“DIB”). Grimes applied for benefits on February 2,
2011 alleging a disability beginning on April 1, 2010. (R. 14) She appeared and testified
at a January 31, 2012 hearing as did a vocational expert. (R. 14) The ALJ denied
Grimes’ claim, finding her capable of medium work with certain restrictions. (R. 19)
Grimes has appealed, challenging the ALJ’s decision in several respects. Pending are
Cross Motions for Summary Judgment. Docket no. 13 and Docket no. 15. After careful
consideration, I find Grimes’ assertions to be persuasive. Consequently, the ALJ’s
decision is reversed and this case is remanded for additional consideration.

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Nancy A. Berryhill because acting Commissioner of Social Security on January 23, 2017, replacing Carolyn W.
Colvin.

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Legal Analysis
1. Standard of Review
The standard of review in social security cases is whether substantial evidence exists in
the record to support the Commissioner=s decision. Allen v. Bowen, 881 F.2d 37, 39 (3d
Cir. 1989). Substantial evidence has been defined as Amore than a mere scintilla. It
means such relevant evidence as a reasonable mind might accept as adequate.@
Ventura v. Shalala, 55 F.3d 900, 901 (3d Cir. 1995), quoting Richardson v. Perales, 402
U.S. 389, 401 (1971). Determining whether substantial evidence exists is “not merely a
quantitative exercise.” Gilliland v. Heckler, 786 F.2d 178, 183 (3d Cir. 1986) (citing Kent
v. Schweiker, 710 F.2d 110, 114 (3d Cir. 1983)). “A single piece of evidence will not
satisfy the substantiality test if the secretary ignores, or fails to resolve, a conflict
created by countervailing evidence. Nor is evidence substantial if it is overwhelmed by
other evidence – particularly certain types of evidence (e.g., that offered by treating
physicians).” Id. The Commissioner=s findings of fact, if supported by substantial
evidence, are conclusive. 42 U.S.C. '405(g); Dobrowolsky v. Califano, 606 F.2d 403,
406 (3d Cir. 1979). A district court cannot conduct a de novo review of the
Commissioner=s decision or re-weigh the evidence of record. Palmer v. Apfel, 995
F.Supp. 549, 552 (E.D. Pa. 1998). Where the ALJ's findings of fact are supported by
substantial evidence, a court is bound by those findings, even if the court would have
decided the factual inquiry differently. Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir.
1999). To determine whether a finding is supported by substantial evidence, however,
the district court must review the record as a whole. See, 5 U.S.C. '706.

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2. The ALJ’s Evaluation of Migraines
Grimes urges that the ALJ’s evaluation of her migraines was erroneous. The
Commissioner counters that the ALJ’s finding with respect to migraines is supported by
substantial evidence of record. After careful review, I agree with Grimes and find that
the ALJ failed to properly assess the medical evidence as it relates to migraines and
failed to incorporate limitations into the RFC relating to migraines.
As a colleague in this District recently observed:
an ALJ must consider all medical evidence contained in the record and provide
adequate explanations for disregarding or rejecting evidence. Weir, 734 F.2d at
961. Courts generally afford significant deference to an ALJ’s credibility
determination. Reefer v. Barnhart, 326 F.3d 376, 380 (3d Cir. 2003). However,
“[a]n ALJ must be particularly diligent in making credibility determinations with
regard to migraines, because laboratory tests cannot prove their existence.”
Thomas v. Colvin, 2015 WL 4067147, at * 5 (W.D. Pa. July 2, 2015) (quoting
Parsley v. Astrue, 2009 WL 1940365, at * 3(W.D. Pa. July 2, 2009)). For this
reason, courts have consistently held that when presented with documented
allegations of symptoms consistent with the claimed disorder, it is not appropriate
for an ALJ to reject a claimant’s testimony solely based on an absence of
objective evidence. Id. at * 5; Abbruzzese v. Astrue, 2010 WL 5140615, at * 7
(W.D. Pa. Dec. 9, 2010) Courts look at a number of factors in determining
whether a claimant’s complaints of migraines are credible, including: whether the
claimant has been diagnosed with migraines; whether the claimant has received
treatment and medication; the length of the history of complaints and treatment
relating to migraines; the alleged severity and frequency; the symptoms the
claimant alleges the migraines cause; and whether the record contains any
statements from doctors questioning the alleged frequency or severity. Thomas,
2015 WL 4067146, at * 5-7 (collecting decisions).

Kulbacki v. Colvin, Civ. No. 15-297, 2016 WL 2609984 at * 6 (W.D. Pa. May 6, 2016).
Here, a review of the record reveals that the ALJ ran afoul of this admonition. In fact, the
ALJ repeatedly made reference to the lack of objective evidence supporting Grimes’
claims. For instance, he states that “the claimant’s lack of candor calls into question her
overall veracity as a witness and renders her laundry list of asserted symptoms suspect,

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with very few symptoms having any clinical confirmation despite the claimant’s
assertions that they are debilitating.” (R. 641) (emphasis added). With respect to
migraines in particular, the ALJ commented that “despite the lack of clinical
confirmation, Dr. Rice wrote a letter on May 8, 2015, indicating that she had seen the
claimant three years earlier for chronic migraines and bipolar / depression.” (R. 644)
(emphasis added). He later added that “[c]laimant’s allegations of pain and related
subjective complaints are credited only when objective medical signs and findings show
the existence of a medical impairment which could reasonably be expected to produce
such complaints.” (R. 645) (emphasis added). The ALJ summarizes his findings by
stating that “while it is reasonable to expect that claimant has experienced intermittent
episodes of discomfort, particularly with significant exertion, the record fails to delineate
objective evidence establishing that the claimant is unable to perform sustained work
activity due to mental or physical impairment or a combination thereof.” (R. 649)
(emphasis added). He later states that “[t]here is … simply no convincing evidence
which corroborates or substantiates the claimant’s asserted inability to engage in any
substantial gainful activity on a regular and continuing basis since the residual functional
capacity outlined above provides accommodation for all medically documented
impairments, associated symptoms, and concomitant limitations reasonably supported
by this record.” (R. 649) (emphasis added).

See also (R. 647) (stating that “[t]he

undersigned notes that no treating source has assessed the claimant with respect to
strength limitations and finds that a limitation to medium work is reasonable given the
lack of any clinical findings despite complaints of generalized pain.”)(emphasis added)

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Moreover, the ALJ made these repeated references despite a record replete with
documentation of Grimes’ complaints of symptoms consistent with migraine headaches.
During the hearing, Grimes confirmed that her headaches and moods constituted her
most significant health conditions and that she had been experiencing the migraines for
approximately 3-4 years. (R. 656, 661-662). She stated that she experiences
headaches two to three times a day and that they each last approximately one hour. (R.
668) She takes Topomax for the headaches. (R. 668) Occasionally there are days when
she does not experience a headache, but the headaches are stronger and more
frequent when she is around loud noises. (R. 668-669) She testified that when she has
a headache she has to call her sister to come over to help her with her children. Grimes
explained that her sister usually comes over for a couple of hours or the whole day. (R.
670) According to Grimes, her sister takes care of the kids, makes them dinner, bathes
them and puts them to bed while Grimes rests and tries to rid herself of the headache.
(R. 670) Thus, Grimes’ testimony certainly establishes the history of, symptomology,
severity and frequency of the migraines as well as the medication she has been
prescribed for them.
Further, the record does in fact contain documentation from medical experts
confirming Grimes’ diagnosis of migraines. That evidence is uncontradicted. Not a
single medical provider questioned whether or not Grimes suffered from migraines or
whether the migraines were as debilitating as she claimed them to be. Grimes treated
with a neurologist, Dr. Rice, who both diagnosed her with migraines and prescribed
medication. (R. 304-305, 306, 842, 843, 847, 850, and 852) Significantly, Dr. Rice filled
out a “Medical statement regarding headaches for Social Security disability claim” dated

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May 15, 2015. (R. 988-990) As part of that report, Dr. Rice stated that Grimes suffered
from migraine headaches occurring several times a week lasting one to two hours
each, and which caused associated symptoms of irritability, photophobia and increased
sensitivity to noise. (R. 988-990) Dr. Rice expressed the belief that Grimes would not be
able to work while she was suffering from a headache. (R. 990)
The ALJ stated that he “has not given great weight” to Dr. Rice’s opinion because
of the lapse in time between the last day of treatment and the authoring of the report
and because Grimes saw her primary care physician “on many occasions for a wide
variety of complaints including urinary tract infections, abdominal pain, asthma
exacerbation, menstrual cramps, pregnancy tests, fractured finger, etc … [but] failed,
however, to mention any concerns about headache pain….” (R. 648) However, the fact
that a claimant “did not always mention, or her physicians did not always take the time
to note, migraines during visits to treat other ailments does not necessarily mean her
complaints were insincere.” Kulbacki, 2016 WL 26009984 at * 8. Further, given Grimes’
diagnosis of borderline intellectual functioning, it is not surprising that when Grimes
went to see her primary care physician for a particular ailment (i.e., urinary tract
infection), she would not discuss with him any issues related to migraines. Additionally,
the records unquestionably confirm that Dr. Firoiu was well aware of Grimes’ history of
migraines and that he repeatedly noted the same in the records. (R. 872, 875, 879, 882,
884, 889, 895, 898, 901, 904, 905, 907, 913, 915, 917, 921, 925, 927, 931, 933, 935,
938, 949, 961,971, 973) Further, it is clear that her primary care physician was in
contact with Dr. Rice regarding Grimes’ neurologic needs and that he found Dr. Rice’s
conclusions to be reliable and persuasive.

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In a submission to the Pennsylvania

Department of Public Welfare, Dr. Firoiu noted that Grimes was temporarily
incapacitated and unable to work until June 30, 2015. (R. 969) As an explanation for
such a finding, Dr. Firoiu referenced both psychiatric conditions and the corresponding
treating physician and “neurology” and Dr. Rice. (R. 969)
In sum, I have done an exhaustive review of the record and I “cannot find a
single statement from any medical professional questioning the existence, severity, or
frequency of [Grimes’] migraines.” Kulbacki, 2016 WL 2609984 at * 7. “In short, most if
not all of the factors courts look at are present in this case.” Id., citing, Thomas, 2015
WL 4067147 at * 5-7 (collecting cases). Given

the

absence

of

contrary

medical

opinions; the presence in the record of many of the factors relating to migraines; a
report from her treating neurologist diagnosing Grimes with migraines and opining that
they prevent her from working while she is suffering from one; and the ALJ’s erroneous
reliance upon the lack of clinical, objective evidence as a reason to reject Grimes’ claim
of disabling migraines, I find that the ALJ’s assessment of Grimes’ credibility regarding
migraines and the failure to account for migraines in the formulation of the RFC was
erroneous. The error is particularly troubling here where the vocational expert testified
that an individual who had to miss work two to three times per week for one to two
hours a day because of headaches would not be able to perform any of the jobs
identified in the record. (R. 677)
For the foregoing reasons, Grimes’ Motion for Summary Judgment will be
granted. The ALJ’s decision will be vacated and remanded for further consideration
consistent with this Opinion.2

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In light of this decision I need not address Grimes’ contention that the ALJ showed bias.

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IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA

STEPHANIE ROSALIA GRIMES,

)
)
)
)
)
)
)
)
)
)
)

Plaintiff,
-vsNANCY A. BERRYHILL,3
ACTING COMMISSIONER OF
SOCIAL SECURITY,
Defendant.

Civil Action No. 15-1558

AMBROSE, Senior District Judge.

ORDER OF COURT
Therefore, this 27th day of February, 2017, it is hereby ORDERED that the
decision of the ALJ is vacated. It is further ORDERED that Plaintiff’s Motion for
Summary Judgment (Docket no. 13) is granted and Defendant’s Motion for Summary
Judgment (Docket no. 15) is denied. This action is REMANDED for further
consideration consistent with the accompanying Opinion.
BY THE COURT:
/s/ Donetta W. Ambrose
Donetta W. Ambrose
United States Senior District Judge

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Nancy A. Berryhill became acting Commissioner of Social Security on January 23, 2017.

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