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Lydon v. Berryhill

United States District Court, D. Utah, Central Division

September 15, 2017

ANGELA LYDON, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Dustin B. Pead United States Magistrate Judge.

         All parties in this case have consented to the jurisdiction of a United States Magistrate Judge, including entry of final judgment, with appeal to the United States Court of Appeals for the Tenth Circuit. See 28 U.S.C. § 636 (c); F.R.C.P. 73; (ECF No. 14). Plaintiff, Angela Lydon, (“Ms. Lydon”) appeals the Commissioner of Social Security's decision denying her claim for Disability Insurance Benefits and Supplemental Security Income under Titles II and XVI of the Social Security Act, 42 U.S.C.§§401-433. (ECF No. 3). Having considered the parties' briefs, the Administrative Record (“A.R.”), the arguments of counsel, and the relevant law, the Court REVERSES and REMANDS the Commissioner's decision for further consideration.


         Ms. Lydon filed an application for Disability Insurance Benefits, as well as, Supplemental Security Income on April 5, 2012, alleging disability beginning January 1, 2010. (A.R. 487-488; 489-500). Ms. Lydon's claims were initially denied on July 16, 2012, and upon reconsideration on December 12, 2012. (A.R. 388-398, 399-408, 412-422, 423-433). Ms. Lydon timely requested a hearing before an Administrative Law Judge (“ALJ”) on February 28, 2013. (A.R. 447-448).

         The ALJ held a hearing on March 18, 2014, in St. George, Utah. (A.R. 362-385). On June 10, 2014, the ALJ issued a decision finding Ms. Lydon not disabled. (A.R. 339-361). On November 2, 2015, the Appeals Council denied Ms. Lydon's request for review. (A.R. 1-7). This Appeals Council denial was the final administrative decision of the Commissioner of Social Security in this case.

         Yet neither Ms. Lydon, nor her attorney received notice of this decision. (A.R. 12-16). Consequently, on May 9, 2016, the Appeals Council granted a request for the extension of time to file a civil action. (A.R. 1-11). Ms. Lydon then brought this action to appeal the Commissioner's decision pursuant to 24 U.S.C. § 405(g), which provides for judicial review of the Commissioner's final decision.

         A. Factual History

         Ms. Lydon was thirty-two-years old on her alleged onset date of January 1, 2010. (A.R. 487). Ms. Lydon completed high school in 1996. (A.R. 542). Ms. Lydon previously worked as a store laborer. (A.R. 542). Ms. Lydon alleges disability due to multiple sclerosis, high blood pressure, high cholesterol, chronic back pain, depression, and anxiety. (A.R. 541, 566, 577).

         Ms. Lydon was diagnosed with multiple sclerosis (“MS”) in 2004. (A.R. 656). In 2007, an MRI of Ms. Lydon's brain showed detrimental changes. (A.R. 665). In 2011 Ms. Lydon reported chronic muscle pain and cramping. A May 2013 brain MRI continued to show moderately extensive multifocal white matter disease in the brain compatible with MS. (A.R. 737). A spinal MRI showed straightening of the normal cervical lordotic curvature and possibly a small MS plaque on the spine. (A.R. 739). During exams, Ms. Lydon's physician noted that she had a mildly wide-based gait and had fallen. (A.R. 742, 820, 825). By 2014, she was walking with a wide-based stance. (A.R. 826).

         Ms. Lydon received treatment from neurologist, Dr. Laura Schlagel, multiple times from at least 2011 through 2014. (A.R. 735, 742, 763, 767, 773, 827-28). Ms. Lydon has tried multiple medications to treat her MS, including infusion treatments and injections several times a week. (A.R. 787, 805, 828). The Commissioner notes that Ms. Lydon was not always compliant with certain medication. (ECF No. 23 at 3) (citing A.R. 704). Ms. Lydon points out that at least some noncompliance with medication can be explained by financial hardship. (ECF No. 18 at 3) (citing A.R. 700).

         Ms. Lydon also has issues with her blood pressure. Even with medication, she has had readings so high that she has been instructed to go to the emergency room to ensure she does not have a stroke or heart attack. (A.R. 794). The medication she received for her MS has resulted in increased blood pressure. (A.R. 835).

         In 2014, Dr. Laura Schlagel referred Ms. Lydon to physical therapist Brady Englestead for a residual functional capacity assessment. Mr. Englestead opined that Ms. Lydon must use a single point cane for walking, can only stand for ten minutes before she would need to rest, and is unable to lift and carry in a competitive environment. (A.R. 849). He also opined that Ms. Lydon could not walk one city block without rest or severe pain, walk one block on rough or uneven ground, or climb steps without the use of a handrail. (A.R. 849).

         Ms. Lydon's treating physician, Dr. Philip Smith, M.D., filled out a residual functional capacity assessment noting that Ms. Lydon had been diagnosed with multiple sclerosis, hypertension, hyperlipidemia, depression, and anxiety. (A.R. 854). He opined that Ms. Lydon's pain was severe enough to interfere with the attention and concentration needed to perform simple work tasks occasionally. Her stress was severe enough to interfere with concentration frequently. (A.R. 854). He opined that she could not walk one city block without rest or severe pain, could not walk one block or more on rough or uneven ground, cannot climb steps without the use of a handrail, and would have problems with balance when ambulating. (A.R. 855). He opined that Ms. Lydon could sit for about forty-five minutes at a time and stand/walk for fifteen minutes at a time. (A.R. 855). He opined that Ms. Lydon would be off task more than thirty percent of an eight-hour workday, would likely be absent four days a month, and would be unable to complete an eight-hour workday five or more days a week. (A.R. 857). The ALJ afforded Dr. Smith's opinions “very little weight.” (A.R. 353).

         B. Hearing Testimony

         At the administrative hearing, Ms. Lydon testified that she is always sore and in pain. (A.R. 366). Ms. Lydon also testified that she had three children, ages ten, eight, and seven, who helped her with all her household chores. (A.R. 367). She has side-effects from her medications, such as dizziness, fatigue, and nausea. (A.R. 367). Ms. Lydon testified that she drove, but had been doing so less because of numbness in her legs. (A.R. 367). Ms. Lydon worked part time as a health aid at a school until 2012. (A.R. 367-68).

         Ms. Lydon testified that her MS has made her left side weaker than her right side. (A.R. 370). Her legs and hands cramp up. She has been having problems with her eyes. (A.R. 370). She uses a cane. (A.R. 371). Ms. Lydon testified she could walk only half of a block before she needed to stop and rest. (A.R. 371). Ms. Lydon also testified that in 2011 she had to walk “a few miles” after he car became stuck. (A.R. 377-78). She can stand for only about five minutes. (A.R. 371). Ms. Lydon has depression and anxiety that make it difficult for her to leave the house. (A.R. 373). Her mother and a friend come over to help with chores. (A.R. 373-374).


         The Social Security Administration follows a five step sequential evaluation to determine whether a claimant is disabled. The five steps are summarized in Social Security Ruling (SSR) 00-4p as follows:

To determine whether an individual applying for disability benefits (except for a child applying for Supplement Security Income) is disabled, we follow a 5-step ...

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