Opinion ID: 2765947
Heading Depth: 3
Heading Rank: 2

Heading: Conflict with Medical Record

Text: The government argues that Claimant’s testimony that she has, on average, one or two headaches a week conflicts with the medical record. As an initial matter, the ALJ never connected the medical record to Claimant’s testimony about her headaches. Although the ALJ made findings—discussed below—concerning Claimant’s treatment for headaches, he never stated that he rested his adverse credibility determination on those findings. For that reason alone, we reject the government’s argument that the history of treatment for headaches is a specific, clear, and convincing reason to support the credibility finding. Moreover, the ALJ’s findings concerning Claimant’s treatment history are plainly erroneous. The ALJ stated that, BURRELL V. COLVIN 11 “[d]uring the period under review, there is a gap in treatment from September 7, 2007, when the claimant was seen to obtain a work excuse for family medical leave, until September 2, 2008.” As the government concedes, that statement is contrary to the record. Claimant was treated on November 1, 2007, November 8, 2007, November 29, 2007, and May 19, 2008. The ALJ apparently overlooked significant medical records when assessing whether the medical record conflicted with Claimant’s testimony. The ALJ also stated that “[t]here is no record of primary care for headaches, neck, or back pain subsequent to October 2008 other than the medical source statement dated November 9, 2009 and a MRI report dated October 14, 2009.” Yet four different medical records from that period contain reports of headaches or neck pain.4 See Report dated April 21, 2009 (although Claimant’s neck pain was much improved, her migraine headaches continued and were no better than before her surgery); Report dated May 5, 2009 (ongoing headaches without improvement); Report dated August 2, 2009 (head pain); Report dated September 23, 2009 (“neck pain no change”). In sum, the ALJ did not make a specific finding linking a lack of medical records to Claimant’s testimony about the intensity of her back, neck, and head pain and, in any event, the record does not support the ALJ’s findings. 4 Only one of those reports was before the ALJ but, as discussed above, we review all the evidence submitted to the Appeals Council as if it had been before the ALJ. Brewes, 682 F.3d at 1163. 12 BURRELL V. COLVIN