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Leehans v. Saul

United States District Court, E.D. Louisiana

July 19, 2019

LISA LEEHANS
v.
ANDREW SAUL, ACTING COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION

         SECTION: “J” (1)

          CARL J. BARBIER, JUDGE

          REPORT AND RECOMMENDATION

          JANIS VAN MEERVELD, UNITED STATES MAGISTRATE JUDGE

         The plaintiff, Lisa Leehans, seeks judicial review, pursuant to Section 405(g) of the Social Security Act (the “Act”), of the final decision of the Commissioner of the Social Security Administration (the “Commissioner”) denying her claim for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI[1] of the Act, 42 U.S.C. §§ 423, 1381. The matter has been fully briefed on cross-motions for summary judgment. For the following reasons, IT IS RECOMMENDED that the Motion for Summary Judgment filed by the plaintiff (Rec. Doc.14) be GRANTED in part and DENIED in part; and the Motion for Summary Judgment filed by the Commissioner (Rec. Doc. 19) be DENIED. The matter should be remanded to the ALJ for further proceedings as recommended herein.

         Procedural Background

         Ms. Leehans applied for DIB on July 7, 2015, and for SSI on August 1, 2015, [2] asserting in both applications a disability onset date of January 15, 2011. She alleged the following illnesses, injuries, or conditions: bipolar. On December 10, 2015, her claims were denied by the state agency. The Disability Determination Explanations on her DIB application concluded that “The medical evidence shows you had a history of mental problems. The evidence was not sufficient to show your condition was totally disabling prior to 03 / 31 / 15, when you were last insured for these benefits.” R. at 115. The Disability Determination Explanations on her SSI application concluded that “[t]he medical evidence shows your overall condition restricts the types of jobs you can perform, but is not totally disabling. You can perform most normal activities. You can get along with others and follow simple directions.” R. at 106.

         Ms. Leehans obtained counsel and requested a hearing before an Administrative Law Judge (“ALJ”), which was held on March 15, 2017. At the hearing, Ms. Leehans noted that there was a prior final ALJ decision dated January 13, 2014 and requested that the alleged disability onset date be amended to March 12, 2014, the date on which Ms. Leehans was hospitalized at the Greenbriar hospital. The motion to amend the alleged onset date was granted. On June 9, 2017, the ALJ issued an adverse decision. Ms. Leehans timely appealed to the Appeals Council, which denied review on April 12, 2018.

         On June 16, 2018, Ms. Leehans filed a Complaint in federal court to review the Commissioner's decision. (Rec. Doc. 1). The Commissioner answered and filed the administrative record. (Rec. Docs. 10, 11). The parties filed cross-motions for summary judgment. (Rec. Docs. 14, ) 19. Ms. Leehans is represented by counsel.

         Evidence in the Record

          At the hearing before the ALJ in March 2017, Ms. Leehans testified that her most recent psychiatric hospitalization was in March 2014. R. at 43. She testified that since that time she had been on medication and had been receiving treatment through the St. Tammany Community Health Center. R. at 43-44. She testified that she had no side effects from her medication. R. at 45, 47. However, she later testified that the medicine makes her “real zombified.” R. at 47. She testified that even with the medication she still hears voices about every other day. R. at 45. She testified that she felt her condition was getting worse. R. at 48. She testified that she did not think she could work because the medication does not always work and she was afraid she would not be able to multitask. R. at 50. When asked if she thought she could work if she did not have to multitask, she said “no” because her medication makes her feel like she is in another world. R. at 60. Upon further questioning, she explained that it made her feel sleepy and she thinks about being somewhere else. R. at 61. She said that about once a week, for 15-20 minutes, she wishes to be in Mexico. Id.

         Ms. Leehans testified that about 3 or 4 days a week she just wants to stay in bed. R. at 51. She later testified she feels that way every day. R. at 52. Ms. Leehans testified that she had not had homicidal thoughts since her March 2014 hospitalization. R. at 56. She testified that she lives with her husband and daughter and that she gets along well with her daughter and “pretty good” with her husband. R. at 56. She testified that she takes a shower and gets dressed on her own every day. R. at 58.

         At the hearing, Ms. Leehans amended her disability onset date to March 12, 2014, and the court begins its summary of the medical records on that date.[3] Ms. Leehans was hospitalized at Greenbriar Behavioral Hospital from March 12, 2014, through March 20, 2014 on referral from Slidell Memorial Hospital “on a [physician's emergency commitment] secondary to suicidal ideations with a plan.” R. at 503. Ms. Leehans reported that she had recently started having auditory hallucinations, that she was feeling paranoid, was experiencing low energy, and was having intermittent crying and suicidal ideations. Id. She reported spending money impulsively, worrying excessively with tension and irritability, and that she had been charged with theft of more than $500. Id. Ms. Leehans was placed on Prozac, Haldol, and Vistril. Id. At discharge she was tolerating her medication well, denied suicidal or homicidal ideations, reported an improvement in her depression and anxiety, and reported no auditory of visual hallucinations. Id. She was diagnosed with schizoaffective disorder, depressed with a Global Assessment of Functioning (“GAF”) score of 50. Id. She had been assessed with a GAF of 27 upon admission. R. at 508.

         On July 18, 2014, Ms. Leehans presented at the NMCH Emergency Department reporting hearing voices telling her to rob a store and hurt herself. R. at 336. She noted a recent medication change to Risperdal on July 10, 2014. R. at 336-37. She was noted to be negative for suicidal ideas, confusion, sleep disturbance, and self-injury. R. at 337. Dr. John B. Seymour noted that Ms. Leehans did not appear to be responding to internal stimuli and did not appear to be delusional. R. at. 383. She was discharged later that day. R. at 336.

         Ms. Leehans again presented at the NMCH Emergency Department on August 27, 2014 reporting suicidal thoughts. R. at 348. She reported multiple recent stressors. R. at 349. She reported that she had not seen her psychiatrist since discharge (presumably from her July 18, 2014, emergency department encounter) and that she was compliant with her medication. Id. Upon examination, Dr. Michael Knisley noted Ms. Leehans had a restricted affect, depressed mood, but fair insight. R. at 351. She was diagnosed with bipolar disorder. R. at 352. When she spoke with registered nurse Kenitra Payne, Ms. Leehans reported being under a lot of stress and that she was going to a psychiatric facility that would help her. Id. Nurse Payne noted that Ms. Leehans had a pleasant mood and was calm and cooperative. Id. A psychiatric placement was sought, and on August 28, 2014, the NMCH records indicate that Ms. Leehans was transferred to Northlake Behavioral Hospital for psychiatric evaluation and treatment. R. at 353-55. Although neither party has addressed their absence, it appears there are no records of treatment at the Northlake Behavioral Hospital. There may not have been an inpatient hospitalization at that time. Ms. Leehans testified at the hearing before the ALJ in March 2017 that the last time she had been hospitalized was in March 2014. R. at 43.

         There do not appear to be any medical records from September 2014 through December 2014.

         Ms. Leehans presented at the Slidell Memorial Hospital on January 1, 2015 complaining of left ear pain. R. at 436. A physical examination was performed, but no notes regarding her psychiatric condition were made.

         On January 15, 2015, she visited the St. Tammany Community Health Center and reported hearing voices and having thoughts that people are out to get her for no reason. R. at 530. She reported chest pain, anxiety and worry, impulsivity, and irritability. Id. Her attitude was noted to be guarded, her mood was noted to be dysthymic. Id. She was nervous and fidgety. Id. But Ms. Leehans was also noted to be non-psychotic. R. at 531. Her thought flow was coherent and rational and her attention demonstrated no abnormalities. Id. She had no suicidal or homicidal ideation. Id. Invega and lithium were continued and she was prescribed Risperdal. Id.

         Ms. Leehans again presented at the Slidell Memorial Hospital on February 11, 2015 with ear pain. R. at 454. Her behavior, mood, and affect were noted to be within normal limits. R. at 456. She was awake and alert with orientation to person, place and time. Id.

         On April 21, 2015, she visited the St. Tammany Community Health Center and reported that she was hearing voices again. R. at 523. She denied a suicidal plan. Id. Her thinking was vague at times and tangential, her mood was worrisome and her thought content was of helplessness. Id.

         Ms. Leehans presented at the Slidell Memorial Hospital on May 2, 2015 with a sore throat. R. at 493. Her behavior, mood, and affect were noted to be within normal limits. Id. She was awake and alert with orientation to person, place and time. Id.

         In August 2015, Ms. Leehans filled out a Function Report and reported feeling “the shakes” because of her medication and feeling like “everybody is watching everything I do.” R. at 211. She reported that her daily activities included watching TV, doing housework, washing clothes, and taking walks to calm her nerves. R. at 212. She reported going shopping for groceries or clothing every week for about two hours. R. at 214. She reported that she cannot talk intimately with others, cannot remember everything she is supposed to, cannot concentrate enough to complete, understand, and follow instructions. R. at 215.

         In November 2015, the consultative examiner Dr. Shah conducted a medical status examination and found Ms. Leehans' affect restricted and mostly euthymic, her speech normal, and her thought process concrete. R. at 498. For memory and understanding, she was able to recall three objects out of three at the end of five minutes and was able to repeat seven digits forward and five digits backward correctly. Id. For concentration and attention, she was able to do serial 3s subtractions from 20. Id. She was able to interpret the proverb “spilled milk, ” her insight was fair, and her judgment was normal (if she found a stamped envelope in the street she would put it in a mailbox). Id. Dr. Shah concluded that Ms. Leehans “did well with cognitive tests on mental status examination today.” R. at 499. Dr. Shah noted that Ms. Leehans could manage personal hygiene daily on her own and manage some cooking, cleaning, and doing laundry and that she gets help from her spouse with shopping. Id. Dr. Shah noted that Ms. Leehans reported avoiding socialization and crowds in general. Id. Dr. Shah diagnosed Ms. Leehans with Bipolar 1 Disorder MRE [Most Recent Episode] Mixed with Psychosis in Partial Remission. Id.

         Decision of the Administrative Law Judge

          The ALJ found that Ms. Leehans meets the insured status requirements of the Act through March 31, 2015. The ALJ found that Ms. Leehans has not engaged in substantial gainful activity since March 12, 2014, the amended alleged onset date. The ALJ determined that Ms. Leehans has the following severe impairments: bipolar disorder, schizoaffective disorder with psychosis and depression, and anxiety disorder. However, the ALJ determined that Ms. Leehans does not have an impairment or combination of impairments that meet or medically equals the severity of one of the listed impairments in 20 C.F.R. § 404, Subpart P, Appendix 1. The ALJ considered the criteria in listings 12.03, 12.04, and 12.06. The ALJ then found that Ms. Leehans has the residual functional capacity to perform a full range of work at all exertional levels but with the following non-exertional limitations: performance of tasks commensurate with an SVP level of two or less, only occasional interactions with co-workers and supervisors, no interaction with the public, and only work not requiring fast-paced production quotas such as those quotas present in moving assembly work or lunchtime work in a fast food establishment. The ALJ determined that Ms. Leehans was unable to perform any of her past relevant work. The ALJ found that Ms. Leehans was 38 years old, which is defined as a “younger individual, ” on the alleged disability onset date. The ALJ determined that Ms. Leehans has at least a high school education and is able to communicate in English. The ALJ found that transferability of job skills was not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that Ms. Leehans is “not disabled” whether or ...


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