Brooks v. Colvin, CIVIL ACTION NO. 15–11872–JGD

217 F.Supp.3d 455

Michael Eamon BROOKS, Plaintiff,

v.Carolyn W. COLVIN, Acting Commissioner of Social Security, Defendant.

CIVIL ACTION NO. 15–11872–JGD

United States District Court, D. Massachusetts.

Signed November 18, 2016

Steven M. Buckley, Lawson & Weitzen, LLP, Boston, MA, for Plaintiff.

Shelbey D. Wright, United States Attorney's Office, Boston, MA, for Defendant.

MEMORANDUM AND ORDER ON CROSS–MOTIONS REGARDING DENIAL OF SOCIAL SECURITY BENEFITS

DEIN, U.S.M.J.

I. INTRODUCTION

Plaintiff, Michael Eamon Brooks ("Brooks"), has brought this action pursuant to Section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), challenging the final decision of the Commissioner of the Social Security Administration (the "Commissioner") denying his claims for Social Security Disability Insurance ("SSDI") and Supplemental Security Income ("SSI") benefits. The matter is presently before the court on Brooks' motion for an order reversing the Commissioner's decision (Docket No. 14), and on the Commissioner's motion for an order affirming the decision. (Docket No. 15). Brooks also moves this court for remand on the grounds of newly discovered evidence. (Docket No. 18).

In support of his appeal, Brooks argues that although the Administrative Law Judge ("ALJ") found that Brooks underwent surgery for a benign brain tumor and has depressive disorder, anxiety disorder and substance abuse in remission (Tr. 270), he failed to consider that Brooks suffers from chronic traumatic encephalopathy ("CTE"), having been concussed "at least" fifteen times and that he failed to consider the interplay between Brooks' traumatic head injuries and his mental impairments.¹ (Docket No. 14 at 1–4).

In support of his motion to remand, Brooks asserts that Boston Medical Center ("BMC") failed to produce a "four inch stack" of his medical records which, inter alia , indicate that Brooks had significant complications after the surgery to remove the tumor and that a second surgery was performed. Brooks asserts further that he was unaware of the existence of these records, in part, because he was in such a dire state and was unaware that he underwent a second brain surgery. (Docket No. 18). These records were provided to counsel on or around January 5, 2016. (Id. at 1.) Counsel filed the motion to remand on behalf of Brooks and alerted this court to the discovery of the new records on January 6, 2016, the same day as this court conducted a hearing on the appeal. (Docket No. 19). Specifically, according to Brooks, the newly produced medical records reflect "two multi-day stays in the surgical intensive care unit," and a second surgery for a "large nonfunctioning pituitary adenoma," as well as a diagnosis not previously known to him of Syndrome of Inappropriate Antidiuretic Hormone Secretion ("SIADH"). (Docket No. 18 at 1; Docket No. 18–1 at 11, 15, 18). The new records also show that Brooks' tumor was not entirely removed even upon a second surgical attempt. (Id. at 1, 11).

For the reasons detailed below, Brooks' motion to remand is ALLOWED. This matter is remanded to the ALJ for consideration of newly produced medical records and a determination as to whether Brooks is disabled in light of the newly produced evidence.

II. STATEMENT OF FACTS²

Brooks was born in 1976. He was 35 years old on his claimed disability onset date of July 1, 2010. (Tr. 284, 320). He attended Boston College High School and Berkshire Preparatory School, where he played hockey. (Tr. 289). He testified at the hearing before the ALJ that he suffered repeated concussions as a result of playing sports in school. (Id. ). The medical records submitted to the ALJ consistently report a history of concussions at a young age from playing sports (see , e.g. , Tr. 552, 606), and that he almost dropped out of high school in his senior year due to significant depressive episodes. (Tr. 526 (report of Dr. Pulas, psychiatrist)). He was, however, able to finish high school and attended four years of college. (Tr. 286).

On December 16, 2010, Brooks was working a construction job when a "steel support beam" struck the left side of his face and head. (Tr. 512). He experienced drowsiness, headache, and vision changes, and went to the BMC emergency room later that day. (Tr. 513–14). Brooks reported to BMC medical staff that he had a history of concussions related to playing sports and that he was taking Klonopin for anxiety. (Tr. 512). The emergency room doctor diagnosed Brooks with head trauma and ordered a CT scan. (Tr. 513–14). The radiology report revealed a "pituitary mass," unrelated to being struck in the head with the beam (an oddly fortuitous event for Brooks), and suggested that additional imaging be conducted. (Tr. 518).

On July 7, 2011, Brooks was seen by BMC's department of neurosurgery. (Tr. 552). Brooks reported that since the accident, he had "experienced multiple symptoms including drooping right eye, hand shaking, anxiety attacks, loss of appetite, loss of libido and headache." (Id. ). After additional imaging, Brooks was diagnosed with a pituitary macroadenoma ("brain tumor"). (Tr. 702). He underwent surgery to remove the tumor on March 9, 2012. (See , e.g. , Tr. 292 (Brooks' testimony before the ALJ); Tr. 682 (March 28, 2012 notes from a follow-up visit to Dr. Pulas)). At an April 24, 2012 follow-up appointment, Brooks stated that he felt "well," and denied visual symptoms or headaches. (Tr. 690). In September of 2013, Brooks reported no significant changes in vision and no visual field deficits, but did report "occasional" headaches and photophobia. (Tr. 732). He was concerned with his weight and reported significant unintentional weight loss. (Id ).

With respect to his mental impairments, Dr. Pulas, who would become his treating psychiatrist, first saw Brooks on December 16, 2011, and diagnosed him with bipolar disorder II and possible panic disorder and/or PTSD. (Tr. 653). At that time, Brooks' medications included Clonazepam, Suboxone, Doxepin, Proventil, Cabergoline, Seroquel, and Propranolol. (Tr. 654). Dr. Pulas noted that Brooks' medical history included pituitary adenoma, acute stress disorder, smoker, history of concussion, headache, anxiety, insomnia, opioid type dependence in remission, opioid type dependence unspecified abuse, post-traumatic stress disorder, bipolar disorder, substance abuse in remission, and bipolar II disorder. (Tr. 651). As noted by Dr. Pulas, Brooks' trauma history included assaults, physical abuse, as well as abuse at a catholic school in junior high (which is referenced under the sub-heading of sexual abuse). (Tr. 650, 652). Dr. Pulas assessed a Global Assessment of Functioning ("GAF") score of 60. (Tr. 653). In another version of Dr. Pulas' report of Brooks' December 16, 2011 visit, he lists a GAF score of only 50. (Tr. 526, item 1). In February 2012, Dr. Pulas added Fluoxetine and Zyprexa to Brooks' medications. (Tr. 667). A few months later, in May 2012, Dr. Pulas indicated a normal mental status examination other than an "anxious" mood. (Tr. 692). Dr. Pulas assigned a GAF score of 65, and commented, "Patient's mood is improved now. No depression, seems to have had a good response to zyprexa /fluoxetine." (Tr. 692–93).

Additional factual details relevant to this court's analysis are described below where appropriate.

Procedural History

Brooks filed his applications for SSI and SSDI in October 2011, alleging a disability onset date of July 1, 2010. (Tr. 320, 419, 426). After those applications were denied on initial review and on reconsideration, a hearing was held before the ALJ on October 10, 2013. (Tr. 279–319). On November 14, 2013, the ALJ issued a decision finding Brooks was not disabled and therefore not entitled to the requested benefits. (Tr. 267–74). In March 2015, the agency's Appeals Council denied review, making the ALJ's decision the Commissioner's final decision in this case. (Tr. 1).

The ALJ's Decision

When evaluating claims for SSI and SSDI benefits under the Act, the Commissioner employs a five-step sequential evaluation process. Seavey v. Barnhart , 276 F.3d 1, 5 (1st Cir. 2001). The first inquiry in the five-step process is whether the claimant is "engaged in substantial gainful work activity[.]" Id. If so, the claimant is automatically considered not disabled and the application for benefits is denied. See Id. In the instant case, the ALJ found that Brooks had not engaged in substantial gainful activity since the alleged disability onset date of July 1, 2010. (Tr. 269, Finding 2). Thus, he proceeded to the next step in the analysis. (Tr. 270).

The second inquiry is whether Brooks has a "severe impairment," meaning an "impairment or combination of impairments which significantly limits [the claimant's] physical or mental ability to do basic work activities[.]" 20 C.F.R. §§ 404.1520(c), 416.920(c). If not, the claimant is considered not disabled and the application for benefits is denied. See Seavey , 276 F.3d at 5. Here, the ALJ concluded that Brooks "does not have an impairment or combination of impairments that has significantly limited (or is expected to significantly limit) the ability to perform basic work-related activities for 12 consecutive months; therefore, [he] does not have a severe impairment or combination of impairments." (Tr. 270). Therefore, the ALJ found Brooks not disabled at Step Two without proceeding to Steps Three through Five. (Tr. 274, Finding 5). See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4) ("If we can find that you are disabled or not disabled at a step, we make our determination or decision and we do not go to the next step.").

Brooks' Proffer of Additional Evidence

At the opening of the administrative hearing on October 10, 2013, Brooks' counsel informed the ALJ that the medical records submitted were not complete because they did not include records from Brooks' March 9, 2012 brain surgery. (Tr. 283). The ALJ gave counsel one week to submit the additional records from BMC. (Tr. 284). According to counsel, he and...