Baldridge-Mayer v. Berryhill

          MEMORANDUM OPINION AND ORDER

         Plaintiff Nellie A. Baldridge-Mayer (“Baldridge-Mayer”) began this case by filing a complaint pursuant to 42 U.S.C. 405(g). In the complaint, she challenged the June 29, 2018, final decision of the Acting Commissioner of the Social Security Administration (“Commissioner”), a decision based upon the February 26, 2018, findings of an Administrative Law Judge (“ALJ”).

         Baldridge-Mayer maintains that the ALJ's findings are not supported by substantial evidence on the record as a whole.^[1] Baldridge-Mayer so maintains for three reasons. Baldridge-Mayer maintains, inter alia, that the ALJ erred when he failed to give controlling weight to the medical opinions of her treating physician. Because it is not clear how the ALJ could weigh the opinions as he did, a remand to more fully develop the record is necessary.

         Baldridge-Mayer alleged in her application for disability insurance benefits that she became disabled beginning on April 1, 2012. She alleged that she became disabled, in part, because of migraine headaches.

         The record contains several hundred pages of evidence that touch in some way on Baldridge-Mayer's impairments and the extent to which they impact her residual functional capacity. She summarized the relevant evidence in her brief, and the Court accepts the summary as a fair summation of the evidence. The summary will not be reproduced in full, except to note several matters germane to the issues raised in the parties' briefs.

         The issue in this case centers upon Baldridge-Mayer's migraine headaches and the extent to which they impact her residual functional capacity. She has complained of them for years and sought repeated medical attention for them. For instance, Baldridge-Mayer saw Dr. William Waldrip, M.D., (“Waldrip”) on April 5, 2012, or four days after the alleged onset date, for complaints of blurred vision. See Transcript at 715-717. She reported a long history of headaches. She was taking Zomig for her headaches and doing so approximately fourteen times a month. She was instructed to take it no more than four times a month. He ordered an MRI of Baldridge-Mayer's brain, the results of which were unremarkable. See Transcript at 724.

         Waldrip saw Baldridge-Mayer again on April 12, 2012. See Transcript at 712-713. They discussed the possibility that her blurred vision was a manifestation of her migraine headaches, but no conclusion was reached. She was continued on Zomig.

         Waldrip saw Baldridge-Mayer next on April 18, 2012. In recording her history of present illness, he noted the following:

... She tells me she is having about 10-15 headaches a month. These are the same type of headache she has always had, accompanied by nausea (and sometimes vomiting), photophobia and phonophobia. No. other neurological symptoms are reported. She has been tried on numerous prophylactic medications in the past without success, including Topamax. She doesn't remember having tried Depakote, however. ...

See Transcript at 709. He prescribed Depakote for her migraine headaches.

         On April 23, 2012, Baldridge-Mayer established care with Dr. Tommy Taylor, M.D., (“Taylor”). See Transcript at 733-735. Although Baldridge-Mayer sought care primarily for blurred vision, she reported that she continued to have migraine headaches. A physical examination was unremarkable, and he continued her on Zomig.

         On July 18, 2013, Dr. Ralph Mann, M.D., (“Mann”) performed a consultative physical examination of Baldridge-Mayer. See Transcript at 767-772. She reported having migraine headaches fifteen to twenty times a month. He diagnosed headaches but made no findings with respect to the work-related limitations they cause. He simply assessed a moderate limitation in carrying, fingering, and handling.

         On August 29, 2013, Baldridge-Mayer saw Dr. Beata Majewski, M.D., (“Majewski”). See Transcript at 784-794. Baldridge-Mayer's history of migraine headaches were noted. As a part of Majewski's notes, he opined the following: “[Baldridge-Mayer] has a cluster of depression, migraine headaches, and sleeplessness and unfortunately is intolerant to medications. ...” See Transcript at 786.

         On September 9, 2013, Baldridge-Mayer was seen by Dr. Garrett Sanford, M.D., (“Sanford”). See Transcript at 802-804. Sanford noted that Baldridge-Mayer had kept a daily log of her symptoms and recorded sixteen migraine headaches in August of 2013. He diagnosed, inter alia, migraine headaches.

         On October 1, 2013, Baldridge-Mayer saw Dr. Thomas Kovaleski, M.D., (“Kovaleski”). See Transcript at 784-794. Baldridge-Mayer reported having approximately twenty migraine headaches a month. Kovaleski made no significant findings but did note that Baldridge-Mayer had multiple drug intolerances.

         Baldridge-Mayer saw Kovaleski again on November 5, 2013. See Transcript at 818-819. Baldridge-Mayer continued to complain of migraine headaches and medication difficulties. Kovaleski observed that Baldridge-Mayer is “going to be a very difficult lady to have any significant impact.” See Transcript at 818.

         On May 6, 2015, Taylor signed a To Whom It May Concern letter on behalf of Baldridge-Mayer. See Transcript at 844. In the letter, Taylor represented that Baldrige-Mayer suffers from debilitating migraines that occur up to twenty times a month. It was his opinion that she also had a “low tolerance for medication.” See Transcript at 844.

         Baldridge-Mayer appears to have seen Taylor on three occasions between May 6, 2015, and November 10, 2015. See Transcript at 859-860 (05/06/2015), 860-862 (10/28/2015), 862-863 (11/10/2015). Baldridge-Mayer continued to complain of migraine headaches, which she reported having in excess of twenty times a ...