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Jennifer E. H. v. Berryhill

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

September 18, 2019

Jennifer E. H., Plaintiff,
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, Defendant.

         Consent[1]

          MEMORANDUM OPINION AND ORDER

          IRMA CARRILLO RAMIREZ, UNITED STATES MAGISTRATE JUDGE

         Based on the relevant filings, evidence, and applicable law, the Commissioner’s decision is REVERSED, and the case is REMANDED for further administrative proceedings.

         I. BACKGROUND

         Jennifer E. H. (Plaintiff) seeks judicial review of a final decision by the Commissioner of Social Security (Commissioner) denying her claim for disability insurance benefits (DIB) under Title II of the Social Security Act (Act). (See docs. 1; 13.)

         A. Procedural History

         On September 21, 2015, Plaintiff filed her application for DIB, alleging disability beginning on March 28, 2015. (doc. 10-1 at 62.)[2] Her claim was denied on January 29, 2016, and upon reconsideration on July 12, 2016. (Id. at 71, 79.) On July 26, 2016, she requested a hearing before an Administrative Law Judge (ALJ). (Id. at 82.) She appeared and testified at a hearing on May 10, 2017. (Id. at 30-54.) On July 12, 2017, the ALJ issued a decision finding that she was not disabled and denying her claim for benefits. (Id. at 15-25.)

         Plaintiff timely appealed the ALJ’s decision to the Appeals Council on September 7, 2017. (Id. at 133.) The Appeals Council denied her request for review on May 12, 2018, making the ALJ’s decision the final decision of the Commissioner. (Id. at 4.) Plaintiff timely appealed the Commissioner’s decision under 42 U.S.C. § 405(g). (See doc. 1.)

         B. Factual History

         1. Age, Education, and Work Experience

         Plaintiff was born on October 8, 1987, and was 29 years old at the time of the hearing. (doc. 10-1 at 24, 30-32.) She had at least a high school education and could communicate in English. (Id. at 24.)

         2. Medical Evidence

         On February 5, 2015, Plaintiff met with Linesse Vega, M.D., at the Child and Family Guidance Center for mental health treatment. (Id. at 222.) She had a depressed mood, but it was stable and improved, and she denied suicidal or homicidal ideation. (Id.) She was alert and pleasant, with constricted affect. (Id.) Dr. Vega diagnosed her with bipolar II disorder, and rated her Global Assessment of Functioning (GAF) score at 50-55. (Id.) She prescribed Plaintiff Seroquel, Lamictal, and Cogentin. (Id.)

         On April 30, 2015, Plaintiff saw Jason Medina, M.D., at Lake Pointe Medical Partners for medication refills and treatment of migraine headaches. (Id. at 223-28.) Her migraines had increased recently because of some smells in her house. (Id. at 223.) Propranol was working, but smells would sometimes cause her to have migraines. (Id.) She was oriented to time, place, and situation, and had appropriate mood and affect, normal insight, and normal judgment. (Id. at 226- 27.) She was diagnosed with migraines, unspecified, without mention of intractable migraines or status migrainosus. (Id. at 227.)

         On May 5, 2015, July 4, 2015, and November 20, 2015, Plaintiff again met with Dr. Vega for treatment. (Id. at 219-21.) In May, she reported increased sadness, lability, hopelessness, appetite, and sleep, and she was alert, oriented times three, goal directed, and pleasant but fidgety. (Id. at 221.) Her mood was sad and affect was constricted. (Id.) In July, she was stable and doing well, and she had gained 70 pounds, but no physical health concerns were noted. (Id. at 220.) She was alert and oriented, and her mood was good. (Id.) In May and July, she was diagnosed with bipolar II disorder, and Dr. Vega altered her medications by adding Lexapro in May, and replacing Seroquel with Latuda in July. (Id. at 220-21.) Her GAF score in those months was 55. (Id.) In November, Plaintiff was stable, doing well, alert, oriented, pleasant, future-oriented, and in a good mood, and her speech was goal-directed. (Id. at 219.) She had no suicidal or homicidal ideation, and Dr. Vega assessed her with bipolar disorder and generalized anxiety disorder. (Id.) Her GAF score increased to 58, and she was continued on the same medications. (Id.)

         On December 14, 2015, Plaintiff again saw Dr. Medina for a follow-up on her medications. (Id. at 229.) She had been using Maxalt 2-3 times per month, but felt that Inderal had significantly decreased her migraines. (Id.) She was oriented times four, and had appropriate mood and affect, normal insight, and normal judgment. (Id. at 232.) Her assessments remained the same as during her prior appointment. (Id.)

         On February 13, 2016, Plaintiff saw Dr. Vega for mental health treatment. (Id. at 269.) She reported no more depressive symptoms, no suicidal or homicidal ideation, and her mood and affect were euthymic and better. (Id.) She was stable, and her GAF score was 55. (Id.)

         On March 25, 2016, Dr. Vega completed a mental medical source statement for Plaintiff. (Id. at 237-42.) Plaintiff was doing well, but she had difficulties with concentration and staying on task. (Id. at 237.) She had decreased energy, generalized persistent anxiety, difficulty thinking or concentrating, sleep disturbance, and recurrent severe panic attacks, and she was easily distracted. (Id. at 238.) Dr. Vega opined that Plaintiff was seriously limited or unable to meet competitive standards for remembering work-like procedures; understanding, remembering, and carrying out short and simple instructions; working in coordination with others; completing a normal workday and workweek without interruptions from psychologically based symptoms; performing at a reasonable pace; dealing with work stress; responding appropriately to changes in a routine work setting; and getting along with others. (Id. at 239-40.) She found that Plaintiff was seriously limited in interacting appropriately with the general public and maintaining socially appropriate behavior. (Id. at 240.) She further opined that Plaintiff was unable to understand, remember, and carry out detailed instructions, and that she could be expected to miss more than four days of work per month due to her impairments. (Id. at 240-41.) Dr. Vega noted that Plaintiff’s highest GAF score in the prior year and at the time of the statement was between 50 and 55, and her prognosis was fair to guarded. (Id. at 237.) Dr. Vega concluded that Plaintiff impairments were reasonably consistent with the symptoms and functional limitations described in her evaluation. (Id. at 241.)

         From June 4, 2016 to March 22, 2017, Plaintiff saw Dr. Vega almost monthly for mental health treatment. (Id. at 261-68.) In June, her behavior was engaged, her speech was goal-oriented and soft, and her mood and affect were sad. (Id. at 268.) In July, Plaintiff reported mood issues, sleep frustration, being overwhelmed at times, and headaches. (Id. at 266.) In August, she was stable on her medications, and her behavior was pleasant, her speech was goal-oriented, and her mood and affect were anxious. (Id. at 265.) In October, she reported difficulty with her high school reunion, her mood and affect were dysphoric, and her speech was goal-oriented. (Id. at 264.) In November, her mood was improved, her behavior was calm, her speech was goal-oriented, and she denied having manic or depressive symptoms. (Id. at 263.) In January, Plaintiff reported no depression and good results on her medication regimen, and she was calm with euthymic mood and affect. (Id. at 262.) In March, she reported that her depression was controlled, her mood was stable, and she had been sleeping well. (Id. at 261.) She was cooperative, euthymic, and had good rapport, logical thought process, and good insight. (Id.) Throughout her appointments, she had no suicidal or homicidal ideation, and her GAF scores were between 50 and 55. (Id. at 261-68.)

         On June 5, 2016, in her Function Report - Adult, Plaintiff reported that she lived with her family. (Id. at 177.) Her migraines kept her from attending or completing shifts, and working caused an increase in her anxiety and panic attacks and flare-ups in her bipolar disorder. (Id.) Her daily activities consisted of waking up, feeding her dog and taking her outside, eating breakfast, and going back to bed to either sleep or watch YouTube. (Id. at 178.) She would also possibly eat lunch, run errands, eat dinner, and then go back to sleep. (Id.) She took care of her dog, but her mother helped her pay for all of the dog’s things. (Id.) Her conditions caused her to either sleep all day or not sleep at all. (Id.) She changed her clothes about three times per week, bathed and cared for her hair about 1-2 times per week, and fed herself 1-3 times per day. (Id.) She needed reminders to eat, dress, and take medication, but she could prepare her own meals. (Id. at 179.) She could sweep, vacuum, and dust with encouragement and reminders, and she did those things about twice every two weeks. (Id.) She went outside a few times per day to take the dog out, and she could drive and ride in a car for travel. (Id. at 180.) She could go out alone most of the time, but sometimes she would get panicky about other people and crowds. (Id.) She was also able to shop in stores and online, and she could count change and use a checkbook, but could not pay bills or handle a savings account because she did not have money to do those things. (Id.) She talked to others and occasionally went out with others for food; she also went to Kroger and Walgreens on the regular basis to pick up medications. (Id. at 181.) She reported some issues in getting along with her extended family because they did not know how to handle her bipolar disorder. (Id. at 182.) She felt that her conditions affected her abilities to memorize, complete tasks, concentrate, understand, follow instructions, and get along with others. (Id.) She could follow written instructions pretty well, but she could not follow spoken instructions as well. (Id.) She got along well with authority figures if they were patient with her, but she did not handle stress very well and did not do well with changes in routine. (Id. at 183.)

         On December 28, 2016, Plaintiff returned to see Dr. Medina for medication refills, and she reported doing well with her migraines; there were no issues with her medication. (Id. at 255.) She was stable on her medication, and her diagnoses remained the same as during her prior appointments with him. (Id. at 259.)

         On May 10, 2017, Plaintiff’s mother submitted a statement to the A L J . (Id. at 217.) It stated that Plaintiff had been unable to work since April 2015, due to bipolar disease, migraines, and anxiety. (Id.) Since diagnosed, Plaintiff had become progressively worse. (Id.) Plaintiff was unable to handle finances, and she had decreased social ability, decreased energy, and distractability. (Id.) Plaintiff spent 90% of her time in her room and mostly had social contact only through Facebook; she was easily fatigued, had trouble sleeping, and suffered migraines that incapacitated her for 2-3 days at a time; and she had to read aloud to understand, would forget what she was saying mid-sentence, and had trouble formulating words. (Id.)

         3. Hearing Testimony

         On May 10, 2017, Plaintiff and a vocational expert (VE) testified at a hearing before the ALJ. (Id. at 30-54.) Plaintiff ...


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