United States District Court, D. Massachusetts
MEMORANDUM & ORDER
WILLIAM G. YOUNG DISTRICT JUDGE
to the Social Security Act, 42 U.S.C. § 405(g), Le Thi
Bui ("Bui") brings this action and moves to reverse
or remand the Acting Commissioner of Social Security's
(the "Commissioner") decision denying her
supplemental security income under the Social Security Act.
The Commissioner cross-moves pursuant to the same Act,
seeking to affirm the decision.
asserts that the hearing officer's decision should be
reversed or remanded because it is legally erroneous and not
based upon substantial evidence. Mem. Law Supp. PL's Mot.
Reverse Or Remand Decision Acting Commissioner
("PL's Mem.") 1, ECF No. 16. The Commissioner
asserts that the decision is supported by substantial
evidence and should be affirmed. Mem. Law Supp. Def.'s
Mot. Affirm Commissioner's Decision ("Def.'s
Mem.") 1, ECF No. 21. For the reasons explained below,
the Court remands the case for further proceedings and denies
the motion to affirm.
24, 2014, Bui applied for disability insurance benefits and
supplemental security income. Administrative Record
("Admin. R.") 22, 180, ECF No. 12. The Social
Security Administration initially denied Bui's request
for both benefits. Id. at 22. Bui only appealed the
supplemental security income denial. Id. On December
17, 2015, a hearing was held upon Bui's request.
Id. at 22, 47, 116, 140. Both Bui and a vocational
expert testified at the hearing. Id. at 47.
March 28, 2016, the hearing officer denied Bui's request
for supplemental security benefits. Id. at 19, 41.
The hearing officer found that Bui's vertigo, depression,
anxiety, and post-traumatic stress disorder
("PTSD") were severe. Id. at 24.
Nevertheless, the hearing officer also found that her
impairments did not equal the severity of the impairments
listed in Appendix 1 of the Social Security Regulations, 20
C.F.R. Part 404, Subpart P. Id. at 26. Finally, he
found that Bui could "perform a full range of
work," with the exception of "climbing ropes,
ladders, and scaffolds; and frequently stooping, kneeling,
crouching, and crawling." Id. at 28. The
hearing officer further recommended that Bui should also
avoid "concentrated exposure to vibration" and
"exposure to unprotected heights." Id. He
concluded that Bui could perform simple tasks and could
maintain her concentration for two-hour periods in an
eight-hour work day. Id. On April 19, 2017, the
Social Security Administration Appeals Council denied review
of the decision. Id. at 1.
16, 2017, Bui filed an action in this Court to reverse or
remand the Commissioner's decision. Compl. 1, ECF No. 1.
Bui also requested attorneys' fees and additional and
alternative equitable relief. Id. at 5. On September
29, 2017, the Commissioner filed an answer, ECF No. 11, and
the Administrative Record. On November 9, 2017, Bui filed a
motion to reverse or remand the Commissioner's decision.
PL's Mem. 1. The Commissioner subsequently filed a
cross-motion seeking to affirm the hearing officer's
decision on January 18, 2018. Def.'s Mem. 1. Bui replied
to the Commissioner's motion on January 30, 2018. Reply
Mem. Opp. Def.'s Mot. Affirm Commissioner's Decision
("Reply Mem.") 1, ECF No. 24. On May 8, 2018, this
Court heard oral argument and took the matter under
advisement. Electronic Clerk's Notes, ECF No. 30.
a 50-year-old woman who was born in Vietnam on June 4, 1968.
Admin. R. 205; Reply Mem. 1. Bui completed the fifth grade in
Vietnam and does not speak or understand English. Admin. R.
53, 211. In 1990, Bui attempted to flee from Vietnam to
Thailand. Id. at 281. While traveling through
Cambodia, Khmer Rouge soldiers sexually assaulted and
tortured Bui. Id.; Reply Mem. 1. In 1998, Bui moved
to the United States and eventually became a naturalized
citizen. Admin. R. 166, 180, 626. From 1999 to 2000, she
worked as a paper assembler and binder in an office.
Id. at 211. In 2012, she worked for a couple of
months as a house cleaner for a maid company. Id.
Finally, from September 2013 until August 2014, she worked
part-time as a cleaner in a nail salon. Id. In a
function report filed in 2014, Bui describes other short-term
jobs she had from 2004 to 2014. Id. at 225-32. Bui
has not engaged in substantial gainful activity since leaving
her job in 2000 as a paper assembler and binder. Reply Mem. 3
n.9. In 2014, she stopped working completely. Admin R. 24.
to Bui and her doctors, she suffers from various mental and
physical conditions. Id. at 281, 764. Her mental
conditions include PTSD, depression, and anxiety.
Id. at 281, 627. Physically she suffers from chronic
headaches, vertigo, back and knee pain, shoulder pain,
Hepatitis B, and a hand tremor. Id. at 627, 764.
filed two function reports in 2014 in which she described her
daily activities. Id. at 217-24, 248-55. Bui also
gave a similar description of her daily activities in her
testimony at the hearing. Id. at 63-65. Bui lives
with and takes care of her daughter. Id. at 217-19;
248-50. Bui takes her daughter to school every day using
public transportation and does a variety of household chores.
Id. She goes shopping and visits the community park
on a regular basis. Id. at 220-21; 251-52, 252. She
sometimes watches movies. Id. at 217, 248.
Van Nguyen, M.D. ("Dr. Nguyen") has been Bui's
primary psychiatrist. See, e.g., id. at
627. Dr. Nguyen diagnosed Bui with severe PTSD, due to her
repeated abuse by Khmer Rouge soldiers. Id. at 637.
She also suffers from anxiety and depression. Id. at
628. Dr. Nguyen indicated that Bui's PTSD started in
1999, though he first diagnosed her in 2003. Id. at
630. Dr. Nguyen has continuously diagnosed Bui with a Global
Assessment of Functioning ("GAF") score of 60,
which indicates moderate symptoms. See, e.g.,
id. at 578, 581, 638, 690. According to the record,
Dr. Nguyen started treating her with medications (fluoxetine
and klonopin) in 2010. Id. at 750. On July 15, 2014,
Bui told physician Julita Mir ("Dr. Mir") that she
had stopped taking those medications "due to
fatigue" and was feeling better. Id. at 570.
Bui alleges that she has a hand tremor which, according to
Dr. Nguyen, would keep her from doing "fine
manipulation." Id. at 1087. Steve Vogel, N.P.
("Vogel"), Madhusudan Thakur, M.D. ("Dr.
Thakur"), Jeffrey Jampel, Ph.D. ("Dr.
Jampel"), other medical professionals who examined Bui,
and Chau Nguyen ("Ms. Nguyen"), a social worker,
observed the tremor in their examination records.
Id. at 618, 728, 867, 959, 971, 973, 1023.
Additionally, in 2014, neurologist Maria Stefanidous, M.D.
("Dr. Stefanidous"), observed the tremor and
prescribed a beta-blocker to help with the headaches and the
tremor. Id. at 973.
also alleges that she suffers from chronic back, neck, and
shoulder pain. Id. at 703, 750. She has spinal
stenosis at the C5-C6 spinal segment. Id. at 750. A
2008 Social Security decision denying Bui's request for
supplemental security income, mentions two MRIs. Id.
at 82. The first MRI showed a congenitally narrowed spinal
canal at the C4-C5 segment. Id. A second MRI showed
mild tendinopathy. Id. Bui had an epidural in 2010
and was prescribed Cyclobenzaprine in 2015 for her neck and
back pain. Id. at 725, 771. Dr. Nguyen documented
Bui's neck pain in her visits. See, e.g.,
id. at 689, 750, 843, 867, 903. In 2015, Nsa
Henshaw, M.D., a provider at Dorchester House, observed a
tenderness of the left cervical paraspinal muscles and left
trapezius. Id. at 705.
also has a history of chronic knee pain. Id. at 474,
886, 1024. In 2011, Vogel stated that Bui had "long
standing chronic pains of both knees that do not allow her to
bend, squat or climb stairs frequently." Id. at
866. Dr. Mir prescribed tramadol for her knee pain.
Id. at 886. In 2014, Julie Crosson, M.D., diagnosed
Bui with bilateral leg pain and left knee pain. Id.
at 474. In 2015, Dr. Thakur, on behalf of the Disability
Evaluation Services, stated that her difficulties in walking
and climbing were functional limitations. Id. at
1024. In 2015, Hai Dang Truong, N.P. ("Truong"),
stated that Bui "gets dizzy w[ith] bending [and]
twisting" and requires breaks from work every two hours.
Id. at 748-49.
also asserts that she has chronic headaches and vertigo.
Id. at 290, 370, 903. In 2012, Bui complained of
dizziness for the first time to Dr. Nguyen. Id. at
903. Vogel suggested that her positive Dix-Hallpike test
could indicate vertigo. Id. at 370. Richard
Grentzenberg, M.D. ("Dr. Grentzenberg"), an
otolaryngologist who evaluated Bui, noted that she felt dizzy
during the Dix-Hallpike test and felt unsteady during the
Romberg test. Id. at 290. Also, an audiology
evaluation showed a "mild to moderate"
sensorineural hearing loss in Bui's left ear.
Id. at 301. After an MRI in 2014, Dr. Grentzenberg
concluded that Bui's dizziness was "more a feeling
of fatigue and faint feeling." Id. at 961. In
2015, Bui started physical therapy to help with her
dizziness. Id. at 1072-76. Alison Hinsberger,
Bui's physical therapist, described Bui experiencing
blurriness and double vision during exams. Id.
Healthcare Professionals' Opinions
Nguyen stated that he has been Bui's psychiatrist since
September 2003. Id. at 1082. Dr. Nguyen concluded
that Bui could not deal with normal work stress and had
difficulty remembering detailed instructions. Id. at
1085, 1087. He indicated that she would have marked
limitations dealing with skilled and semi-skilled work and
that she would get agitated when working under pressure.
Id. at 1086-87. Dr. Nguyen also indicated that he
anticipated Bui's conditions or treatment would lead to
her absence from work about three times per month.
Id. at 1084. Dr. Nguyen indicated that Bui would
additionally have "difficulties in maintaining
concentration, persistence or pace," and that Bui would
need too many breaks and would have a marked limitation in
concentrating for two straight hours. Id. at
1085-87. He also stated that the need to make quick decisions
or dealing with customers could increase the level of her
impairments. Id. at 1087. Dr. Nguyen concluded that
Bui's psychiatric impairments would prevent her from
working an eight-hour work day. Id. at 1085.
Disability Determination Services sent Bui to a psychiatric
consult with Dr. Jampel. Id. at 618. He noted a
"mild tremor" in both hands. Id. He
concluded that Bui had "no evidence of psychosis"
and that she did not seem "markedly depressed or
anxious." Id. at 621. According to Dr. Jampel,
Bui's cognitive capacities would be in the average range,
and she could have some difficulties concentrating.
Id. at 620. He also concluded that Bui could carry
out instructions and could get along with others.
Id. at 621. Finally, he reported that "her
medical condition precludes her from managing the pressure of
a regular work setting." Id.
Evaluation Services sent Bui to a clinical diagnostic
interview with psychologist Linda Manansala ("Dr.
Manansala"). Id. at 1015. Dr. Manansala
reported that during the interview "the client's
mood appeared sad, tearful, but pleasant." Id.
at 1019. According to her, Bui may have difficulty
maintaining "focus and concentration in a work
setting." Id. Dr. Manansala also reported that
Bui's ability to work might depend on her physical status
and that it might be difficult for Bui to initiate social
contact. Id. at 1020.
Evaluation Services also sent Bui to a physical examination
with Dr. Thakur. Id. at 1022. He found that Bui had
a "coarse tremor'' in both hands. Id.
Bui also had difficulties in walking and in climbing stairs.
Id. at 1024.
also examined by psychologist Dr. Nancy Keuthen, Ph.D.
("Dr. Keuthen") of Disability Determination
Services. Id. at 99. Dr. Keuthen ordered an
examination of Bui in October 2014. Id. She
concluded that Bui could never climb ladders and frequently
stoop, kneel or crouch. Id. at 101. She additionally
recommended that Bui avoid concentrated exposure to
vibration. Id. at 102. Dr. Keuthen found that Bui
would be moderately limited in carrying out detailed
instructions and maintaining concentration for extended
periods. Id. at 103. Bui would also have limitations
in working at a consistent pace, without ...