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Medina v. Berryhill

United States District Court, D. Colorado

March 23, 2018

GILBERT MEDINA, Plaintiff,
v.
NANCY BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.

          OPINION AND ORDER REVERSING AND REMANDING DISABILITY DETERMINATION

          Marcia S. Krieger United States District Court.

         THIS 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:

         JURISDICTION

         The 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.

         STATEMENT OF FACTS

         The Court offers a brief summary of the facts here and elaborates as necessary in its analysis.

         Mr. 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.

         Mr. 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.

         Treatment and Opinions by Treating Professionals

         Susan 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.

         Mr. 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 these providers.

         On 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.

         Mr. 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.

         Opinions by Non-treating Professionals

         Mark 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 ...


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