United States District Court, D. Colorado
OPINION AND ORDER REVERSING AND REMANDING DISABILITY
S. Krieger United States District Court.
MATTER comes before the Court as an appeal from the
Commissioner's Final Administrative Decision
(“Decision”) determining that the Plaintiff
Gilbert Medina is not disabled within the meaning of sections
216(i), 223(d), and 1614(a)(3)(A) of the Social Security Act.
Having considered all of the documents filed, including the
record (#17), the Court now finds and
concludes as follows:
Court has jurisdiction over an appeal from a final decision
of the Commissioner under 42 U.S.C. § 405(g). Mr. Medina
sought disability insurance benefits and supplemental
security income under the Social Security Act based on mental
and physical impairments that rendered him unable to work as
of May 14, 2013. The state agency denied his claim. He
requested a hearing before an Administrative Law Judge
(“ALJ”), who issued an unfavorable decision. Mr.
Medina appealed to the Appeals Council, which denied his
request for review, making the ALJ's determination the
final decision of the Commissioner. Mr. Medina timely
appealed to this Court.
Court offers a brief summary of the facts here and elaborates
as necessary in its analysis.
Medina was born on June 25, 1962. He graduated from High
School and has worked as an aircraft mechanic, a utility
worker, a pump mechanic, and a truck driver. He contends that
mental and physical impairments prevent him from working.
Medina suffers from multiple mental and physical impairments.
His mental health impairments include bipolar disorder,
depression, and anxiety. His physical impairments include
chronic low back pain, obesity, joint problems, and diabetes.
and Opinions by Treating Professionals
Ponder, a Clinical Nurse Specialist, began providing
psychiatric treatment to Mr. Medina in November 2013. She
filled out a mental residual functional capacity statement in
support of his disability claim. According to her, Mr.
Medina's abilities to make simple work-related decisions,
ask simple questions or request assistance, accept
instructions and respond appropriately to criticism from
supervisors, and respond appropriately to changes in the work
setting preclude his ability to work for 5% of an eight-hour
workday; his abilities to remember locations and work-like
procedures, understand, remember, and carry out very short
and simple instructions, adapt appropriately with the general
public, get along with coworkers or peers without distracting
them or exhibiting behavioral extremes, maintain socially
appropriate behavior, adhere to basic standards of neatness
and cleanliness, and set realistic goals or make plans
independently of others preclude his ability to work for 10%
of an eight-hour workday; and his abilities to understand,
remember, and carry out detailed instructions, maintain
attention and concentrations for extended periods of time,
perform activities within a schedule, maintain regular
attendance, be punctual and within customary tolerances,
sustain an ordinary routine without special supervision, work
in coordination with or in proximity to others without being
distracted by them, complete a normal workday and workweek
without interruptions from psychologically based symptoms,
perform at a consistent pace without an unreasonable number
and length of rest periods, be aware of normal hazards and
take appropriate precautions, and travel in unfamiliar places
or use public transportation preclude his ability to work for
15% or more of an eight-hour workday. She further opined that
because of his physical and mental impairments, he would be
off-task for more than 30% of an eight-hour workday, would be
absent from work for five or more days each month, would be
unable to complete an eight-hour workday five or more days
each month, and could only be expected to perform a job,
eight hours per day, five days per week, on a sustained basis
for less than 50% of the time.
Medina began receiving treatment from physicians and other
providers at Kaiser Permanente, including Kari M. Kearns,
M.D., Stephen W. Shane, D.O., and Katherine J. Karstens, in
July 2013 for his chronic lower back pain, knee pain, foot
pain, and diabetes. These providers also initially monitored
the medications prescribed to him to treat his bipolar
disorder until he began receiving treatment from Ms. Ponder.
They also performed X-rays which revealed a disc bulge in Mr.
Medina's back in the L5-S1 area and mild arthritis in his
knees and feet. Mr. Medina did not submit a medical source
statement in support of his disability claim from any of
February 12, 2014, Mr. Medina was admitted to Lutheran
Medical Center with suicidal ideation and a plan to overdose
on his sleeping pills. After receiving treatment, he was
discharged to Bridge House, a step down facility and
ultimately returned home. Mr. Medina did not submit a medical
source statement in support of his disability claim from any
of these providers.
Medina also received treatment from several other medical
providers. Dhar Pradeep at Salud Family Health Centers
treated him briefly before he began receiving treatment at
Kaiser Permanente. Ms. Jeanine Tarrant, PA-C, Mr. Brian W.
Drake, PA-C, and Dr. Megan Moon at Practice Fusion treated
Mr. Medina's low-back pain with medication and
soft-tissue therapies between July 2014 and February 2015.
Joseph Michael Morreale, M.D., performed back surgery on Mr.
Medina to address his disc bulge in the L5-S1 area. Mr.
Medina did not submit a medical source statement in support
of his disability claim from any of these providers.
by Non-treating Professionals
Dilger, M.D., a state-agency physician, reviewed Mr.
Medina's file but did not examine him. He opined that Mr.
Medina had the following severe impairments: DDD (disorders
of back-discogenic and degenerative), major joint
dysfunction, diabetes mellitus, and obesity. He further