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Morales v. Commissioner, Social Security Administration

United States District Court, D. Colorado

November 2, 2018




         THIS MATTER comes before the Court on the Plaintiff's Complaint (# 1), the Plaintiff's Opening Brief (# 15), the Defendant's Response (# 17), and the Plaintiff's Reply (# 20). For the following reasons, the Commissioner's decision is reversed and the matter is remanded for further proceedings.


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


         A. Procedural History

         Ramona Morales seeks judicial review of a final decision by the Commissioner denying her claim for disability insurance benefits (DIB) under the Social Security Act. In December 2014, Ms. Morales filed for DIB, claiming she became disabled in September 2013, later amended to August 2014. Tr. at 39, 169-70. 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. Morales was 54 years old. Tr. at 169. She was previously employed as a receptionist and a fast-food services manager. Tr. at 218. She has a history of musculoskeletal problems that were exacerbated by injuries that she suffered in a vehicular accident in July 2016.

         In March 2015, consultant Dr. Matthew Simpson examined Ms. Morales. Tr. at 649-60. Although he conducted a thorough exam of all of Ms. Morales' systems, the relevant findings come from his musculoskeletal exam. Tr. at 657-58. He observed normal range of motion in her cervical and dorsolumbar spine, knee joints, ankle joints, elbow joints, wrist joints, and finger joints. Tr. at 657-58. He also observed mild discomfort while examining her hip joints, though her straight-leg tests were negative, as well as her shoulder joints. Tr. at 657. Moving her to spine, he found there was no cervical, thoracic, lumbar, or sacral spinous process - only mild tenderness to palpitation in paraspinal areas on the left. Tr. at 658. He noted postoperative changes in hardware installed in Ms. Morales' lumbar spine during a prior surgery, but that there was no evidence of hardware failure. Tr. at 659. Based on these observations, he diagnosed her with chronic lumbar back pain but no “red flag signs on examination”. Tr. at 659. He then opined that Ms. Morales could (1) sit without limitation during a workday; (2) stand three to five hours and walk between two and four hours in a workday; (3) frequently lift and carry 20 pounds and occasionally lift and carry 35 pounds; (4) occasionally bend, stoop, squat, or crouch; (5) manipulate with her fingers and arms without limitation; and should (6) use a cane for intermediate distances, longer distances, and uneven terrain. Tr. at 660.

         Ms. Morales has a treatment relationship with Dr. Munni Setty. In November 2016, Dr. Setty completed a physical residual functional capacity (RFC) questionnaire. Tr. at 899-903. Dr. Setty observed that Ms. Morales has chronic lower back pain, depression, fatigue, numbness / severe neuropathy, neck pain, and balance / instability. Tr. at 899. Based on her treatment relationship with Ms. Morales, Dr. Setty opined that: (1) Ms. Morales' pain was such that it would constantly interfere with her attention and concentration needed to perform simple work tasks; (2) Ms. Morales was incapable of handling even low-stress jobs; (3) Ms. Morales could not walk more than one block without severe pain; (4) she could not sit for more than 10 minutes at a time or stand for more than five minutes at a time; (5) Ms. Morales must walk every 90 minutes for five minutes; (6) Ms. Morales needed a job that permits the volitional shifting of positions and unscheduled breaks; (7) Ms. Morales only used a cane as needed for balance; (8) Ms. Morales could not lift or carry anything more than 10 pounds, look down, turn her head right or left, look up twist, stoop, or climb; (9) Ms. Morales could rarely crouch and climb stairs; and that (10) Ms. Morales could manipulate and twist objects with her hands and fingers less than half of a workday, and reach overhead less than 5% of a workday. Tr. at 901-03.

         C. The ALJ's Decision

         In May 2017, the ALJ issued a decision unfavorable to Ms. Morales. At step one, the ALJ found that she had not engaged in substantial gainful activity since August 2014. Tr. at 19. At step two, the ALJ found that Ms. Morales had the following severe impairments: history of right knee, status-post total knee replacement; mild right knee arthritis; obesity; lumbar fusion with left L3-4 radiculopathy; peripheral neuropathy; diabetes; osteoarthritis and history of C2 fracture; and depression and anxiety. Tr. at 19. At step three, the ALJ found that Ms. Morales 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 19. The ALJ further found that Ms. Morales had the residual functional capacity (RFC) to perform light work with the following characteristics: she can lift, carry, push, or pull 20 pounds occasionally and ten pounds frequently; she can sit for six hours in an eight-hour workday with normal breaks; she can stand or walk two hours in an eight-hour workday with normal breaks; if she walks more than two blocks, she must have the opportunity to use a cane; she can climb ramps and stairs, stoop, kneel, crouch, crawl, and balance occasionally; she cannot climb ladders, ropes, or scaffolds; she can drive for work occasionally; she cannot work at heights; she can understand, remember, and carry out tasks learned in two years or less; and she can tolerate frequent interaction with the public. Tr. at 22. At step four, the ALJ found that Ms. Morales was capable of performing her past relevant work as a receptionist. Tr. at 26. The ALJ did not make alternative findings at step five.

         At the hearing, the ALJ heard testimony about Ms. Morales' mental impairments from Dr. Mary Buban, the medical expert. Tr. 42-46. In crafting Ms. Morales' RFC, the ALJ gave minimal weight to Dr. Setty's opinion, great weight to Dr. Simpson's opinion, little weight to an opinion from Dr. Mary Ann Wharry ...

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