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Garcia v. Berryhill

United States District Court, D. Colorado

November 7, 2017

HECTOR L. GARCIA, JR., Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Hector Garcia Jr. appeals the final decision of the Acting Commissioner of Social Security (“SSA”) denying his application for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. § 401, et seq. I have considered the parties' briefs (ECF Nos. 17, 19-20) and the administrative record (ECF No. 14) (“AR”). Oral argument would not materially assist me in determining this appeal.

         Mr. Garcia argues the administrative law judge (ALJ) erred when he concluded Mr. Garcia did not meet the requirements of listing 1.04A (disorders of the spine). He also argues the ALJ erred in evaluating Mr. Garcia's residual functional capacity (RFC) by improperly analyzing the opinion of a treating phsycian and improperly weighing Mr. Garcia's obesity and his subjective reports of pain. I agree that the ALJ erred when he determined Mr. Garcia did not meet the requirements of listing 1.04A and in evaluating Mr. Garcia's RFC. Accordingly, I REVERSE SSA's decision and REMAND for proceedings consistent with this opinion.

         I. Background

         A. Procedural History

         Mr. Garcia filed his application for disability insurance benefits and supplemental social security income with SSA in October 2013, alleging disability beginning April 2, 2013. AR 130-38. After SSA initially denied his claim, AR 70, Mr. Garcia requested a hearing, AR 90. The hearing took place on July 8, 2015, before an ALJ. AR 28-58. On August 24, 2015, the ALJ denied Mr. Garcia's claim, concluding he was not disabled within the meaning of the Social Security Act. AR 7-23. Mr. Garcia asked SSA's Appeals Council to review the ALJ's decision. AR 6. On October 21, 2016, the Appeals Council denied review, AR 1-5, making the ALJ's decision the final decision of SSA, see Doyal v. Barnhart, 331 F.3d 758, 759 (10th Cir. 2003). On November 17, 2016, Mr. Garcia timely filed this appeal. (ECF No. 1.) I have jurisdiction pursuant to 42 U.S.C. § 405(g).

         B. Facts

         Mr. Garcia is a 53 year-old man who most recently worked as a taxi driver and dispatcher. He also has worked as a truck driver and a director for an adult baseball association headquartered in Denver, Colorado.

         On April 3, 2013, Mr. Garcia was hit head-on by a drunk driver while he was driving his taxi. AR 258, 338. The airbags deployed, and immediately after the accident, Mr. Garcia complained of neck, back, and abdominal pain. Id. At the emergency room, x-rays and an ultrasound did not show any acute abnormality, and Mr. Garcia was discharged. AR 259-69.

         A few days later, Mr. Garcia went to see Dr. Annu Ramaswamy about a worker's compensation claim because he was experiencing head, back, neck, and right leg pain, as well as some dizziness. AR 338. Mr. Garcia's neck and back were tender on palpitation, and a straight-leg test (a test used to detect whether a patient with low back pain has an underlying herniated disk) was positive on the right leg. AR 340. Dr. Ramaswamy also noted that Mr. Garcia had spasms in his lumbar spine. Id. An MRI of his back showed “[s]evere foraminal stenosis on the right L5 [lumber vertebrae 5]-S1 [sacral vertebrae 1]” level and “a focal compressive deformity of the exiting right L5 nerve root.” AR 349. It also showed “early facet arthritis and shallow minor disc bulge at ¶ 4-5.” Id. In early May and April 2013, Mr. Garcia's straight-leg tests continued to be positive on the right side. AR 328 (positive on May 9, 2013), 334 (positive on April 15, 2013).

         Mr. Garcia then saw a specialist, Dr. Michael Rauzzino, at the Front Range Spine and Neurosurgery center. Dr. Rauzzino found decreased strength in Mr. Garcia's right leg and significant muscle tenderness in his lumbar spine, but a straight-leg test was negative on the right. AR 345. Dr. Rauzzino recommended conservative treatment, including physical therapy, anti-inflammatory medications, and epidural steroid injections, “to try and get him some relief.” AR 345-46. He told Mr. Garcia to follow up with him after the epidural injections. AR 346.

         Mr. Garcia started conservative treatment soon afterward. In addition to physical therapy, medication, and steroid injections, Mr. Garcia was treated with radiofrequency ablation (a minimally invasive procedure designed to decrease pain signals from a nerve). AR 298. Mr. Garcia reported some pain relief from the treatments, e.g., AR 317, even though the relief was sometimes temporary, e.g., AR 310. During this period, Dr. Ramaswamy consistently noted spasms and tenderness in Mr. Garcia's lumbar spine. E.g., AR 283, 288, 318, 323, 328, 334. He also observed that Mr. Garcia walked with antalgic gait (essentially a limp). AR 282, 288, 294, 318, 322, 327, 333. Results of the straight-leg test on the right side were largely negative while Mr. Garcia was periodically receiving the steroid injections and other treatments and for a few months afterward. AR 323 (negative on May 24, 2013), 318 (negative on June 17, 2013); 311 (negative on July 22, 2013), 306 (negative on August 5, 2013), 300 (negative on September 5, 2013), 283 (negative on November 4, 2013), 279 (positive on December 2, 2013), AR 273 (negative on December 17, 2013), 294 (negative on September 26, 2013); 358 (negative on January 2, 2014).

         Mr. Garcia followed up with Dr. Rauzzino in October 2013. Mr. Garcia said his leg pain had decreased since he started treatment in May 2013, but his back pain remained significant. AR 347. Mr. Garcia reported he was able to function and drive, but he complained about some problems with his neck and upper extremity. Id. Because those problems were not part of the worker's compensation claim and Mr. Garcia lacked health insurance, he didn't receive treatment for them. Id. Dr. Rauzzino did not think Mr. Garcia was a good candidate for spinal surgery since he had shown some improvement with conservative care. Id. Dr. Rauzzino referred Mr. Garcia back to Dr. Ramaswamy for further evaluation. Id.

         By January 2014, Mr. Garcia had returned to work on modified duty, working four hours a day. AR 460. However, he was struggling to sit and was still experiencing low back pain. AR 461. In early 2014, Mr. Garcia went to a few sessions with a psychologist to work on strategies for coping with pain. AR 466-75.

         In April 2014, Dr. Anselmo Mamaril, an agency phsycian, reviewed Mr. Garcia's medical records and evaluated his physical impairments. AR 62-67. He assessed limitations that are broadly consistent with the ability to perform light work. Id. He also opined that Mr. Garcia did not meet the requirements of any listing, but he did not elaborate on this conclusion. AR 65.

         Dr. Ramaswamy continued to treat Mr. Garcia after Dr. Mamaril's evaluation. Mr. Garcia consistently complained of pain, and Dr. Ramaswamy consistently found muscle weakness and spasms. AR 405, 399-400, 394, 388. Straight-leg tests were consistently positive on the right. AR 405, 399-400, 394, 388. In late 2014 or early 2015, Mr. Garcia stopped working completely. AR 12, 35-38, 153-54. In March 2015, the most recent treatment record from Dr. Ramaswamy in the file, Mr. Garcia's straight-leg test was positive on the right, and he had an antalgic gait. AR 373. He complained of “constant lower back pain along with right extremity weakness and numbness/tingling.” AR 372. Dr. Ramaswamy concluded Mr. Garcia's back issues were “stable” at that point. AR 374.

         In May 2015, Dr. Ramaswamy opined on Mr. Garcia's limitations. He opined he could occasionally lift and carry up to ten pounds, could sit continuously for an hour for up to five hours in an eight-hour work day, and could stand and walk 15-20 minutes continuously for up to three hours in eight-hour work day. AR 492. He explained that Mr. Garcia “needs to alternate standing/walking with sitting as much as possible. AR 493. He also opined that Mr. Garcia could never climb ladders or scaffolds, crouch, kneel, ...

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