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Valdez v. Commissioner, Social Security Administration

United States District Court, D. Colorado

July 19, 2018

DANELL A. VALDEZ, Plaintiff,
v.
COMMISSIONER, SOCIAL SECURITY ADMINISTRATION, Defendant.

          OPINION AND ORDER REVERSING THE COMMISSIONER'S DECISION

          MARCIA S. KRIEGER CHIEF UNITED STATES DISTRICT JUDGE

         THIS 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.

         I. JURISDICTION

         The Court has jurisdiction over an appeal from a final decision of the Commissioner under 42 U.S.C. § 405(g).

         II. BACKGROUND

         A. Procedural History

         Danell 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.

         B. Factual Background

         The 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.

         At the 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.

         In 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.

         In 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.

         In 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.

         C. The ALJ's Decision

         In 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 ...


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