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Fernandez v. Colvin

United States District Court, D. Colorado

February 5, 2016

CAROLYN W. COLVIN[1], Acting Commissioner of the Social Security Administration, Defendant.


RAYMOND P. MOORE United States District Judge

This matter is before the Court on Plaintiff Gregory A. Fernandez’s (“Plaintiff”) request for judicial review pursuant to 42 U.S.C. § 405(g). (ECF No. 1.) Plaintiff challenges the final decision of Defendant Carolyn W. Colvin, Acting Commissioner of the Social Security Administration, by which she denied Plaintiff’s applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) respectively under Titles II and XVI of the Social Security Act (“Act”). An Administrative Law Judge (“ALJ”) ruled Plaintiff was not disabled within the meaning of the Act and therefore not entitled to DIB or SSI.

Defendant provided the Court with the administrative record. (ECF Nos. 11; 11-1; 11-2; 11-3; 11-4; 11-5; 11-6; 11-7.) The parties have fully briefed the matter and it is ripe for adjudication. (ECF Nos. 14; 21; 22.)

For the reasons set forth below, the Court vacates Defendant’s denial of Plaintiff’s DIB and SSI applications and remands for further proceedings consistent with this Order.


Plaintiff applied for DIB and SSI in June 2010, alleging he was disabled as of May 25, 2010, due to the following conditions that limit his ability to work: torn rotator cuff right shoulder, mental issues, upper back, and migraines. (Admin. R. (“Tr.”) 84, 92, 95, 163-70.) After Plaintiff’s applications were initially denied, Plaintiff requested a hearing before an ALJ. (Tr. 98-99.) The ALJ denied Plaintiff’s applications. (Tr. 7-28.) Plaintiff requested review of the ALJ’s decision and, in January 2013, the Appeals Council denied such request. (Tr. 1-6.) Plaintiff timely requested judicial review before the Court.

A. Background and Relevant Medical Evidence

Plaintiff was born in 1967. (Tr. 38.) Plaintiff completed high school. (Tr. 40, 53-54.) Plaintiff’s past relevant work, as referenced in the Dictionary of Occupational Titles, includes: lubrication tech and asbestos removal worker. (Tr. 58, 232.)

Plaintiff claims he became disabled on May 25, 2010 due to a combination of physical and mental health impairments. (Tr. 84, 92, 95, 163-70.)

1. Physical Issues

From 2009 through 2011, Plaintiff obtained treatment from the Pueblo Community Health Center. (Tr. 246-54, 325-41.)

On October 7, 2010, Lindsay Lilly, M.D., examined Plaintiff and assessed that Plaintiff a herniated nucleus pulposus: right C55-6 and Left C6-7; radiculitis. (Tr. 264.) Dr. Lilly recommended a cervical decompression and fusion surgery. (Tr. 264.)

On October 29, 2010, Dowin H. Boatright, M.D., examined Plaintiff and completed a consultative examination. (Tr. 273-77.) Dr. Boatright opined that Plaintiff has certain physical limitations including not lifting more than fifteen pounds; not engaging in fine motor movements with the right hand; not bending (neck); environment limitations which would require high visual acuity. (Tr. 277.)

On December 28, 2010, Dr. Lilly performed cervical surgery on Plaintiff. (Tr. 308-09.) On February 10, 2011, Plaintiff reported he had a decreased range of motion and was in pain. (Tr. 337.) On March 10, 2011, Plaintiff had another MRI which revealed the central canal stenosis had improved to a moderate degree (Tr. 297) but “hypertrophic changes in the lateral recesses and neural foramina are resulting in severe bilateral foraminal narrowing at C5-C6 and C6-C7.” (Tr. 298.) Subsequent to the surgery, Plaintiff received conservative treatment. (See Tr. 325-38.)

Alan Ketelhohn, M.D., a non-examining state-agency consultant, completed a residual functional capacity assessment of Plaintiff. (Tr. 75-79.) Dr. Ketelhohn opined that Plaintiff retained the residual functional capacity consistent with the following: occasionally lifting and/or carrying 10 pounds; frequently lifting and/or carrying 10 pounds; standing and/or walking 4 hours; sitting for about 6 hours; occasionally climbing ladders/ropes/scaffolds; occasionally crawling; limited right fine manipulation; and avoiding exposure to hazards. (Tr. 75-79.)

Plaintiff testified that he can sit for forty-five minutes to an hour; stand for an hour while leaning on something; walk for eleven minutes and lift fifteen to twenty pounds. (Tr. 47.) Plaintiff has problems with strength on his right side. (Tr. 48.) Plaintiff has headaches twice a day which last about an hour. (Tr. 48.) Plaintiff’s medication causes sleepiness, drowsiness, dizziness, dry mouth, and an upset stomach. (Tr. 49.) Plaintiff uses a cane to ambulate. (Tr. 54-55.)

2. Mental Issues

In 2009, Pueblo Community Health Center treated plaintiff for ...

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