United States District Court, D. Colorado
HECTOR L. GARCIA, JR., Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
T. BABCOCK, JUDGE
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.
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.
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. §
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.
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.
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).
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.
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).
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.
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
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.
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.
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, ...