Fowler v. Berryhill, 3:16-cv-05631

Brian Fowler applied for Disability Insurance Benefits and SSI on Feb 27, 2015, alleging disability from July 16, 2012; ALJ Cynthia Rosa denied benefits on Feb 16, 2016; Appeals Council denied review.
Medical records show a longstanding diagnosis of headaches/migraines since 2012, escalating in 2015 with treatments including Imitrex, Fiorcet, Propranolol, and Imitrex injections.
Fowler reports migraines 2–4 times per week, lasting hours to days; during attacks he lies in a dark room and sleeps 3–5 hours after taking medication and experiences photophobia, nausea, vomiting, and severe pain.
A state agency reviewer (Dr. Robinson) and the VA (30% disability rating) recognized migraines as a severe impairment; treating records document missed appointments and functional incapacitation during attacks.
The ALJ found migraines were not a severe impairment at Step Two, citing purported inconsistencies and limited findings in older treatment notes, and did not meaningfully incorporate migraine-related limitations into the RFC or Step Three analysis.
The magistrate judge reversed and remanded under sentence four of 42 U.S.C. § 405(g), finding the Step Two error harmful because migraines were a severe impairment that may affect Step Three (listings) and the RFC/VE analysis.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether ALJ erred by finding migraines not severe at Step Two	Fowler: ALJ ignored/significantly failed to discuss medical evidence and treating/VA findings showing migraines cause more than minimal work limitations	Commissioner: Any Step Two error harmless because ALJ accounted for limitations elsewhere and record showed non-acute findings earlier	Court: ALJ erred — migraines are a severe impairment; failure to consider records and Dr. Robinson’s opinion was harmful
Whether Step Two error was harmless	Fowler: Error prejudiced sequential evaluation — could change Step Three listing analysis and RFC/VE hypotheticals	Commissioner: Error not prejudicial; ALJ’s other findings compensate	Court: Not harmless — error may have affected listing determination and RFC/VE outcomes; remand required
Whether ALJ properly weighed VA disability rating	Fowler: VA rating supports severe impairment and should be given weight	Commissioner: ALJ may give less weight with valid reasons	Court: Did not decide on merits; instructed ALJ on remand to ordinarily give great weight to VA rating or explain reductions with persuasive reasons
Scope of remand remedy	Fowler: Remand for further proceedings to reevaluate migraines through Steps Two–Five	Commissioner: (implicit) no remand needed if error harmless	Court: Reverse and remand for full reconsideration of migraines at Step Two and their effect at Steps Three–Five; reevaluate VA rating weight

Bayliss v. Barnhart, 427 F.3d 1211 (9th Cir.) (standard of review re: ALJ findings and substantial evidence)
Smolen v. Chater, 80 F.3d 1273 (9th Cir.) (Step Two severity standard; basic work activities)
Yuckert v. Bowen, 841 F.2d 303 (9th Cir.) (impairment ‘‘not severe’’ requires only minimal effect)
Flores v. Shalala, 49 F.3d 562 (9th Cir.) (ALJ may not reject significant probative evidence without explanation)
Lingenfelter v. Astrue, 504 F.3d 1028 (9th Cir.) (ALJ must provide clear and convincing reasons to reject claimant testimony)
Molina v. Astrue, 674 F.3d 1104 (9th Cir.) (harmless error principles in social security cases)
Stout v. Commissioner, 454 F.3d 1050 (9th Cir.) (error harmless only if inconsequential to ultimate nondisability determination)
McCartey v. Massanari, 298 F.3d 1072 (9th Cir.) (ALJ ordinarily should give great weight to VA disability determinations)