United States District Court, D. Massachusetts
MEMORANDUM AND ORDER ON CROSS-MOTIONS REGARDING
DENIAL OF SOCIAL SECURITY BENEFITS
Gail Dein, United States Magistrate Judge
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 Commis-sioner'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).
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. (Docket No. 14 at 1-4).
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).
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
STATEMENT OF FACTS
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).
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).
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.
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).
factual details relevant to this court's analysis are
described below where appropriate.
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 ...