United States District Court, D. Colorado
MICHAEL E. HEGARTY, UNITED STATES MAGISTRATE JUDGE.
James K. Covington, appeals from the Social Security
Administration (“SSA”) Commissioner's final
decision denying his application for disability insurance
benefits (“DIB”), filed pursuant to Title II of
the Social Security Act, 42 U.S.C. §§ 401-33, and
his application for supplemental security income benefits
(“SSI”), filed pursuant to Title XVI of the
Social Security Act, 42 U.S.C. §§ 1381-83c. I hold
the ALJ erred in assigning too little weight to Mr.
Covington's treating physician's opinion. I reverse
the decision of the ALJ and remand this case to the
Commissioner for further proceedings.
Mr. Covington's Conditions
Covington was born on December 21, 1961; he was fifty-four
years old when he filed his application for DIB and SSI. [AR
127]. Mr. Covington claims he became disabled on November 22,
2015 due to physical impairments. [Id.]
December 29, 2014, Mr. Covington saw Dr. David Cohn for a
follow-up and repeat urinary tox screen. [AR 261]. The
medical report stated that Mr. Covington is a
“well-developed male in no apparent distress. He is
alert and conversant.” [Id.] The report noted
that Mr. Covington was diagnosed with HIV in 2001.
[Id.] Dr. Cohn stated that Mr. Covington tolerated
his HIV medications well and reported excellent adherence.
April 20, 2015, Mr. Covington visited Dr. Mark W. Thrun for
an HIV follow-up. [AR 235]. The medical report stated that
Mr. Covington tolerated his medications well and reported
excellent adherence. [Id.] Dr. Thrun also indicated
that Mr. Covington had a history of chronic pain in his knees
and his lower back, and his symptoms have recently worsened.
[Id.] The doctor stated the pain likely resulted
from injuries sustained while Mr. Covington was in military
service. [Id.] Mr. Covington denied any
radiculopathy, weakness, imbalance, or falls. [Id.]
However, he noted that his current job requires heavy lifting
and strenuous activity, which makes it very difficult for him
to perform his duties effectively. [Id.] The report
stated that Mr. Covington had “Cranial nerves II-XII
grossly intact. Strength 5/5 bilaterally. . . . No pronator
drift. Rapid movements intact. Steady gait and balance
observed.” [AR 236].
August 18, 2015, Mr. Covington visited Dr. Margaret McLees
for another HIV follow-up. [AR 224]. Dr. McLees stated that
Mr. Covington had excellent adherence and tolerated his
medications well. [Id.] Mr. Covington was using
medication for chronic ongoing back pain, shoulder pain, and
paresthesia. [Id.] Mr. Covington informed Dr. McLees
that he was working at a retirement community, and it was
going well. [Id.] Dr. McLees concluded that Mr.
Covington was a well-developed male in no apparent distress.
November 4, 2015, Mr. Covington had another appointment with
Dr. McLees. [AR 213]. Mr. Covington said he has had
“right flank pain” for the last three days. He
denied any acute event, and he stated his symptoms were
gradually improving. [Id.]
November 22, 2015, Mr. Covington visited the Lutheran Medical
Center due to wrist and back pain that resulted from
attempting to catch a patient at work. [AR 424]. Dr.
Phillippe Andre Tirman performed an x-ray on Mr. Covington
and found no definite fracture identified in the wrist, but
degenerative changes in the carpus. [Id.]
December 4, 2015, Mr. Covington visited Front Range
Occupational Medicine for his ongoing back and wrist pain.
[AR 288]. Mr. Covington rated his pain at four on a
one-to-ten scale. [Id.] Dr. Matt Miller found Mr.
Covington sprained his lumbar spine ligaments, and he
recommended physical therapy and a twenty pound lifting
restriction. [AR 290]. Dr. Miller anticipated that Mr.
Covington would recover within one to two weeks and should be
back to full duty for work. [Id.]
December 8, 2015, Mr. Covington visited Belmar Physical
Therapy. [AR 292]. The physical therapy records indicate that
Mr. Covington was thirty-six percent disabled because of
lower back pain. [Id.] However, Mr. Covington's
physical therapist anticipated he would return to work in
four weeks. [Id.]
Covington visited Concentra Medical Centers on December 9,
2015. [AR 369]. Mr. Covington complained about central lower
back pain and numbness in his thighs, but he stated that
those issues were improving. [AR 378]. Dr. Chelsea R. Rasis
diagnosed Mr. Covington with a lumbar spine ligament sprain.
[Id.] The report indicated that Mr. Covington could
return to work immediately with the following restrictions:
no bending greater than five times per hour, may lift up to
fifteen pounds frequently up to six hours per day, and may
push/pull up to fifteen pounds frequently up to six hours per
day. [Id.] On the same day, Mr. Covington also
visited Dr. Kathleen E. Voss for a therapy appointment due to
his left wrist sprain. [AR 372]. Dr. Voss recommended Mr.
Covington return to modified work. [Id.]
December 11, 2015, Mr. Covington began seeing Dr. Angela J.
Wilt at Concentra Medical Center for physical therapy. [AR
371]. Mr. Covington reported that he was able to walk without
pain after e-stimulation on December 10, 2015. [Id.]
However, Mr. Covington reported that he reinjured his back at
work when trying to catch a resident falling out of her
wheelchair. [Id.] Mr. Covington stated that he
mostly recovered from this, but his back was still sore.
[Id.] Dr. Wilt recommended he return to modified
his next two months of physical therapy, Mr. Covington
reported that his back was close to 100% improved, but he had
a constant pain in his left back. [AR 388]. The pain
increased when lifting heavy objects. [Id.] The
medical report stated that Mr. Covington had increased pain
after siting for five minutes. [AR 389]. During a later visit
with Dr. Wilt, Mr. Covington stated his back felt tight,
especially after work while lifting or transferring
residents. [AR 406]. Mr. Covington had been working at his
regular job, but he took off work from December 7, 2015 to
December 29, 2015, because pain was worsening. [AR 410]. Dr.
Wilt restricted Mr. Covington to lifting up to fifteen pounds
frequently, pushing or pulling up to fifteen pounds
frequently, and bending only five times per hour. [AR 406].
Mr. Covington was able to increase his lifting restriction to
fifty pounds on January 19, 2016. [AR 350].
March 16, 2016, Mr. Covington reported to Dr. Stephen Danahey
that his wrist was healed. [AR 335]. Dr. Danahey reported
that Mr. Covington could return to full work with no
restrictions. [AR 336].
March 24, 2016, Mr. Covington visited the Denver Health
Medical Center complaining about ongoing dizziness that
impaired his work performance. [AR 198]. He also reported
that his chronic neck and back pain was interfering with his
ability to lift and do his job properly. [Id.]
March 31, 2016, Mr. Covington began seeing Dr. Fredric
Zimmerman. [AR 448]. The report indicated that past oral
medications and physical therapy provided some
moderate-to-good relief for his lower back pain.
[Id.] However, his symptoms returned once he began
working. [Id.] He reported constant lower back pain
across the lumbosacral region, and he had sensations of
“pins and needles.” [Id.] Dr. Zimmerman
recorded that Mr. Covington was unable to work without
restrictions at that time. [AR 449].
Zimmerman referred Mr. Covington to Dr. Steve Brown to
perform an MRI. [AR 42]. Although the MRI revealed no acute
intracranial abnormality, it showed a “marked narrowing
of the L5-S1 disc space which may be related to facet joint
arthroplasty.” [AR 196].
April 15, 2016, Mr. Covington saw Dr. Benjamin J. Chambers at
Denver Health Medical Center. [AR 188]. Mr. Covington
reported that his daily episodic dizziness had become more
frequent and consistent. [Id.] He denied having any
major AIDS crises, and he had been adherent to his HIV
medicine regimens. [AR 189]. Dr. Chambers reviewed Mr.
Covington's x-ray and MRI images of the lumbar spine. [AR
191]. He concluded that Mr. Covington had right leg radicular
symptoms. [Id.] Additionally, Mr. Covington's
MRI and x-ray were abnormal at the level of L5-S1. [AR 192].
Dr. Chambers indicated that Mr. Covington had normal bulk and
tone symmetrically in the upper and lower extremities. [AR
190] He had “5/5 strength in upper and lower
extremities throughout.” [Id.]
2, 2016, Mr. Covington returned to the Concentra Medical
Centers for a work activity status report. [AR 329]. His
physician noted the following additional work restrictions:
may lift up to five pounds occasionally up to three hours per
day; may push/pull up to five pounds occasionally up to three
hours per day; may bend occasionally up to three hours per
5, 2016, Mr. Covington revisited Dr. Zimmerman. [AR 327]. Dr.
Zimmerman indicated that Mr. Covington's symptoms did not
improve and might be mildly worse. [Id.] Further,
his lower back symptoms began to interfere with activities of
daily living. [Id.] Dr. Zimmerman's physical
examination revealed that Mr. Covington was uncomfortable in
the seated position and struggled to go from a seated to
standing position. [Id.]
15, 2016, Mr. Covington reported a pain score at rest of five
out of ten to Dr. Zimmerman. [AR 446]. His lumber range of
motion showed he was able to reach down just above his
kneecaps. [Id.] Although his pain increased to six
to seven out of ten when extending, his pain decreased
significantly after Dr. Zimmerman performed bilateral L5-S1
transformational epidural steroid injections. [AR 446-47].
7, 2016, Mr. Covington revisited Dr. Zimmerman and reported
seventy percent relief immediately after the steroid
injection, but the relief had diminished. [AR 441]. Dr.
Zimmerman determined that Mr. Covington could not work, in
part because he was stiff and slow when transitioning from
sitting to standing. [Id.] Dr. Zimmerman ...