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Alesa B. v. Saul

United States District Court, N.D. Texas, Dallas Division

August 20, 2019

Alesa B., Plaintiff,
Andrew M. Saul, Commissioner of the Social Security Administration, Defendant.



         Pursuant to 28 U.S.C. § 636 and Special Order 3, Plaintiff's motion for summary judgment and Defendant's responsive brief, which the Court construes as a cross-motion for summary judgment, are now before the Court.[1] Doc. 16; Doc. 17. For the reasons that follow, Plaintiff's Motion for Summary Judgment should be GRANTED, Defendant's construed Motion for Summary Judgment should be DENIED, the Commissioner's decision should be REVERSED, and this case should be REMANDED for further proceedings.

         I. BACKGROUND

         A. Procedural History

         Plaintiff seeks judicial review of a final decision of the Commissioner denying her claim for disability insurance benefits and supplemental security income under Title II of the Social Security Act (“Act”). Plaintiff applied for benefits in 2014, alleging that she had been disabled since March of that year. Doc. 13-1 at 111, 121, 131-33, 143, 153-54, 346-55. Plaintiff's claim was denied at all administrative levels, and she now appeals to this Court pursuant to 42 U.S.C. §405(g). Doc. 13-1 at 3-13; Doc. 13-1 at 14-32; Doc. 13-1 at 155-57.

         B. Factual Background

         Plaintiff was 56 years old on the date of the hearing before the administrative law judge (“ALJ”). Doc. 13-1 at 45. She had a high school diploma and a job training course in banking, with past relevant work experience as a childcare worker, caregiver for the elderly, and accounting clerk. Doc. 13-1 at 45-47, 50; Doc. 13-1 at 88. In terms of Plaintiff's pertinent medical history, she has been diagnosed with uncontrolled diabetes, painful neuropathy, non-proliferative diabetic retinopathy (“NPDR”), retinal edema, and other ailments. Doc. 13-2 at 2; Doc. 13-2 at 125, 137; Doc. 13-2 at 302.

         In January 2015, Plaintiff went to an emergency department for right eye pain, blurred vision, and visual disturbance, where she was diagnosed with diabetic retinopathy and retinal edema. Doc. 13-2 at 112, 125. She reported that her vision had been worsening for months. Doc. 13-2 at 112. In February 2015, Plaintiff was diagnosed with bilateral cataracts. Doc. 13-2 at 140. The same month, she underwent bilateral laser surgery for macular edema.[2] Doc. 13-2 at 152, 154. In October 2015, Plaintiff underwent bilateral eye injections for macular edema and NPDR. Doc. 13-2 at 302. In April 2016, Plaintiff received an injection in her left eye for macular edema. Doc. 13-3 at 97. The following month, Plaintiff presented to the hospital with severe NPDR and macular edema, complaining of visual disturbance. Doc. 13-3 at 127. It was noted that glaucoma was suspected in both eyes, and she received bilateral eye injections. Doc. 13-3 at 127, 130. In August 2017, Plaintiff returned to the hospital with a headache “stemming from [her] eyes” and complained of chronic blurry vision, but she was unable to complete an eye examination because of the vision problems. Doc. 13-3 at 615, 617.

         In terms of her diabetic neuropathy, in February 2015, Plaintiff reported that she could not feel her feet due to numbness, she had problems with balance and walked with a broad base and swayed side to side. Doc. 13-2 at 138, 222. She could not toe or heel walk, and the feeling in both legs from toes to knees was impaired to temperature, pin prick, and vibration. Doc. 13-2 at 141, 222. In February 2015, April 2015 and January 2016, neurologist Dr. Ram N. Narayan, M.D. stated in his progress notes that Plaintiff's “neuropathy has been quite disabling, ” and he issued fall precaution orders on a number of occasions. Doc. 13-2 at 142, 223; Doc. 13-2 at 311; Doc. 13-2 at 312; Doc. 13-2 at 246. During her January 2016 appointment, Plaintiff reported to Dr. Narayan that her neuropathic pain symptoms had worsened, she had “severe burning pain” and numbness in her feet, and her balance continued to worsen. Doc. 13-2 at 310.

         The record is also replete with references to the edema in Plaintiff's lower extremities. Doc. 13-2 at 81; Doc. 13-2 at 81; Doc. 13-2 at 168, 177; Doc. 13-2 at 325; Doc. 13-3 at 254, 419, 515, 524. Plaintiff testified that after taking prescription medication for the edema, she has to urinate two to three times per hour. Doc. 13-1 at 95. Additionally, Plaintiff has osteoarthritis, degenerative joint disease, and pain and decreased range of motion in both shoulders. Doc. 13-1 at 20; Doc. 13-2 at 325, 327; Doc. 13-3 at 420.

         In January 2015, one of Plaintiff's treating physicians, Dr. Arjumand Ghayas, M.D., wrote a “medical statement” asserting that Plaintiff had uncontrolled diabetes complicated by severe neuropathy, severe burning in both feet, and dizzy spells among other conditions. Doc. 13-2 at 98. Dr. Ghayas noted that due to Plaintiff's health, it would be very difficult for her to return to work. Doc. 13-2 at 98. In February 2015, Dr. Narayan wrote a similar statement, indicating that Plaintiff was seeing him for “debilitating neuropathy that is causing her significant gait and balance problems.” Doc. 13-2 at 99.

         C. The ALJ's Findings

         The ALJ initially denied Plaintiff benefits in April 2016. Doc. 13-1 at 161. Upon remand by the Appeals Council in October 2016, the ALJ convened another hearing in November 2017. Doc. 13-1 at 81; Doc. 13-1 at 167. In April 2018, the ALJ issued a new decision, holding that Plaintiff had the severe impairments of osteoarthritis, degenerative joint disease, obesity, Type II diabetes mellitus, neuropathy, kidney disease, diastolic dysfunction, hypertensive heart disease, left ulnar mononeuropathy, carpal tunnel syndrome, and sarcoidosis. Doc. 13-1 at 20. The ALJ stated that there was no evidence that Plaintiff's macular degeneration and NPDR negatively affected her ability to work. Doc. 13-1 at 20. The ALJ concluded that Plaintiff had the residual functional capacity (“RFC”) to perform a range of sedentary work, including her prior work as an accounting clerk, and she was thus not disabled under the Act. Doc. 13-1 at 20-21, 23-24.

         II. ...

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