United States District Court, D. Colorado
DANELL A. VALDEZ, Plaintiff,
COMMISSIONER, SOCIAL SECURITY ADMINISTRATION, Defendant.
OPINION AND ORDER REVERSING THE COMMISSIONER'S
S. KRIEGER CHIEF UNITED STATES DISTRICT JUDGE
MATTER comes before the Court on the Plaintiff's
Complaint (# 1), the Plaintiff's Opening
Brief (# 14), the Defendant's Response
(# 15), and the Plaintiff's Reply
(# 16). For the following reasons, the
Commissioner's decision is reversed and the matter is
remanded for further proceedings.
Court has jurisdiction over an appeal from a final decision
of the Commissioner under 42 U.S.C. § 405(g).
Valdez seeks judicial review of a final decision by the
Commissioner denying her claim for disability insurance
benefits (DIB) and supplemental security income (SSI) under
the Social Security Act. In August 2013, Ms. Valdez filed for
DIB and SSI, claiming she became disabled in January 2011,
later amended to September 2013. Tr. at 40, 171-79. Her
application was denied at all administrative levels and she
now appeals to this Court.
Court summarizes only the medical evidence relevant to its
decision. Here, the dispositive issue concerns the weight
given to the medical opinions as to her functional capacity.
At the time of her alleged onset of disability, Ms. Valdez
was 46 years old. Tr. at 66. She was previously employed as a
waitress, cook, bartender, and office manager. Tr. at 240.
She has a history and findings of cervical and lumbar spine
musculoskeletal disorders, with chronic pain and limited
motion, vertigo, and headaches.
direction of the Commissioner, in January 2014, Dr. Jaime
Easchief evaluated Ms. Valdez. Tr. at 360-74. Dr. Easchief
observed that Ms. Valdez did not appear to have any
difficulty maneuvering in the examination room. Tr. at 363.
Dr. Easchief noted normal ranges of cervical range of motion,
but moderate discomfort with more limited dorsolumbar range
of motion. Tr. at 364. Dr. Easchief also observed mild
discomfort while Ms. Valdez was supine and performing
straight leg raises. Tr. at 364. Ms. Valdez had normal range
of motion without discomfort in her knee, ankle, shoulder,
elbow, wrist, and finger joints. Tr. at 364-65. Though Dr.
Easchief did not find any tenderness on the cervical,
thoracic, or sacral spine, she did note pain on palpitation
at ¶ 2 to L4. Tr. at 365. Based on her examination, Dr.
Easchief diagnosed Ms. Valdez with lumbalgia with likely
spondylolithesis. Tr. at 365. She then opined Ms. Valdez
could sit between four and six hours; stand and walk
occasionally; and bend, stoop, squat, crouch, and crawl
occasionally; all in an eight-hour workday. Tr. at 365. Dr.
Easchief did not recommend any limitations for weight bearing
or fingering, or for environmental concerns. Tr. at 365.
February 2014, Dr. Morris Susman, a state-agency
non-examining physician, reviewed the compiled medical
records and completed a residual functional capacity (RFC)
assessment. Tr. at 73-76. He found Ms. Valdez could
occasionally lift or carry 20 pounds and frequently lift or
carry 10 pounds; stand, walk, or sit six hours with periodic
alternation to relieve discomfort; and climb ramps/stairs
occasionally, never climb ladders, balance frequently, stoop
occasionally, kneel occasionally, crouch occasionally, and
crawl occasionally. Tr. at 73-74.
January 2016, Dr. Velma Campbell, a consulting examiner,
examined Ms. Valdez. Tr. at 528-39. Dr. Campbell also
conducted a review of Ms. Valdez's medical records. Tr.
at 529- 33. Dr. Campbell observed no muscle spasms in Ms.
Valdez's neck, but noted tenderness in her paravertebral
muscles and at ¶ 7 to T1. Tr. at 533. Dr. Campbell found
no tenderness or pain in the upper extremities, lower
extremities, and thoracic spine, though she did observe
tenderness between L3 and L5. Tr. at 533. Dr. Campbell also
observed pain on straight leg raises. Tr. at 533. Based on
this examination, Dr. Campbell diagnosed Ms. Valdez with,
among other things, cervical spine degenerative disc disease,
spondylosis, and moderate-to-servere foraminal stenosis with
muscle tension and limited motion; vertigo without any
indication of Meniere's disease; occipital neuralgia with
headaches, consistent with occipital origin; and lumbar spine
degenerative disc disease with right sciatica, subjective
left weakness. Tr. at 534. Based on these diagnoses, Dr.
Campbell opined that, among other things, that Ms. Valdez
could lift and carry 20 pounds less than 30 minutes a day and
10 pounds for three hours a day; walk and stand three hours a
day; sit six-to-eight hours a day; bend, stoop, squat, and
kneel two hours a day; and reach or work above shoulder
height less than two hours a day with no more than five
pounds, all based on an eight-hour workday. Tr. at 534-38.
February 2016, Dr. Gary Cohen completed a headaches
questionnaire. Tr. at 526-27. He stated that it was unclear
what type of headaches Ms. Valdez has or how long they last,
but also that they occur “continuously, now less
often”. Tr. at 526. He observed that, despite treatment
with medication, the headaches still occur. Tr. at 526. He
stated that Ms. Valdez typically experiences more than
moderate pain, exhaustion, and photosensitivity during
headaches, and that there are no particular triggers for the
headaches. Tr. at 526-27. He opined that bright lights and
noise make the headaches worse, and that lying down in quiet
makes them better. Tr. at 527. He noted that other causes of
the headaches have been ruled out and concluded that Ms.
Valdez would not be able to function on the job during a
headache spell. Tr. at 527.
The ALJ's Decision
April 2016, the ALJ issued a decision unfavorable to Ms.
Valdez. At step one, the ALJ found that she had not engaged
in substantial gainful activity since September 2013. Tr. at
20. At step two, the ALJ found that Ms. Valdez had the
following severe impairments: lumbar degenerative disc
disease, cervical degenerative disc disease, and right carpal
tunnel syndrome. Tr. at 20. At step three, the ALJ found that
Ms. Valdez did not have an impairment that met or medically
equaled the presumptively disabling conditions listed in 20
C.F.R. Part 404, Appendix 1. Tr. at 23. The ALJ further found
that Ms. Valdez had the residual functional capacity (RFC) to
perform light work with the following limitations: she cannot
bend, squat, kneel, or perform overhead work more than
occasionally; she cannot work on ladders or scaffolds; and
she cannot handle or finger objects more than frequently. Tr.
at 24. At step four, the ALJ found that Ms. Valdez was unable
to perform any of her past relevant ...