United States District Court, D. Colorado
THOMAS A. NAGY, 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 (# 15), the Defendant's Response
(# 16), and the Plaintiff's Reply
(# 19). 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
Thomas
Nagy seeks judicial review of a final decision by the
Commissioner denying his claim for disability insurance
benefits (DIB) and supplemental security income (SSI) under
the Social Security Act. In March 2014, Mr. Nagy filed for
DIB and SSI, claiming he became disabled in May 2011. Tr. at
158-73. His application was denied at all administrative
levels and he 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 Mr. Nagy's functional
capacity. At the time of his alleged onset of disability, Mr.
Nagy was 42 years old. Tr. at 158. He was previously employed
as a pipe fitter, warehouse worker, and wire mesh fabricator.
Tr. at 199. He has a history of musculoskeletal problems in
his back and knees.
In May
2014, Dr. Rebecca Bub conducted a consulting examination of
Mr. Nagy. Tr. at 268-77. Though she conducted a thorough exam
of all of Mr. Nagy's systems, the relevant findings come
from her musculoskeletal exam. Tr. at 273-75. She observed
normal range of motion in his cervical spine, hip joints,
ankle joints, left shoulder joint, elbow joints, wrist
joints, and finger joints. Tr. at 273-74. She also observed
significant discomfort while examining his dorsolumbar spine,
which had a lower range of motion. Tr. at 274. Moving to his
knees, she found discomfort while determining his range of
motion, more so in the right knee than the left. Tr. at 274.
Ms. Nagy had a positive anterior drawer and Lachman test on
the right knee, but a negative McMurray sign bilaterally. Tr.
at 274. Examining his right shoulder, Dr. Bub observed
limited range of motion and significant discomfort; Ms. Nagy
had a positive Neer test and Hawkins test. Tr. at 274.
Finally, though she noted lumbar paraspinal muscle
tenderness, there was no spinous process tenderness to
palpation. Tr. at 275.
Dr. Bub
also reviewed x-ray images of Mr. Nagy's lumbosacral
spine and right knee. Tr. at 276. Her impression was mild to
moderate lumbar spondylosis without evidence of acute
fracture or subluxation and, as to the knee, mild
degenerative changes within the medial and patellofemoral
compartments without evidence for acute fracture or
dislocation. Tr. at 276.
Based
on these observations, she diagnosed Mr. Nagy with back pain,
knee pain, and shoulder pain from a torn rotator cuff. Tr. at
276-77. She recommended physical therapy and exercise for his
back, and an MRI and follow-up with a surgeon for his knee
and shoulder. Tr. at 276- 77. She then opined that Mr. Nagy
(1) could sit between four and six hours per workday; (2) can
stand only two hours per workday; (3) should walk at least
two hours per workday; (4) could lift and carry “25
pounds and 5 pounds, frequently and occasionally,
respectively”;[1] (5) could bend, stoop, squat, crouch, or
crawl occasionally; and (6) could manipulate with his fingers
and arms occasionally. Tr. at 277.
In
March 2014, Dr. Carlos Rodriguez, a conducted a consulting
psychiatric examination of Mr. Nagy. Tr. at 261-62. Dr.
Rodriguez diagnosed Mr. Nagy with a history of post-traumatic
stress disorder (PTSD), major depression, and anxiety
disorder. Tr. at 261-62. In this exam, however, Dr. Rodriguez
largely recounted Mr. Nagy's subjective complaints and
proceeded to draw conclusions and make recommendations. In
June 2016, Dr. Rodriguez again examined Mr. Nagy and, this
time, made a more thorough record of his examination. Tr. at
360-65. Dr. Rodriguez found Mr. Nagy oriented to person,
place, time, and situation, but with deficits in attention,
calculation abilities, working-memory capabilities,
auditory-memory capabilities, and social judgment. Tr. at
361. He exhibited great difficulty in the Serial Seven
Subtraction cognitive task. Tr. at 361. Dr. Rodriguez
observed that Mr. Nagy's responses suggest the presence
of low average to borderline intellectual functioning. Tr. at
361-62. Dr. Rodriguez noted that Mr. Nagy experienced
multiple PTSD symptoms, including nightmares and flashbacks,
as well as intrusive and disturbing thoughts about the death
of his son, the genesis of his PTSD. Tr. at 362-63. Dr.
Rodriguez found that Mr. Nagy presented with evidence of
panic attacks, onset by increased anxiety in the company of
others or in crowds. Tr. at 363. Based on these observations,
Dr. Rodriguez echoed his 2014 conclusions, adding panic
disorder with agoraphobia. Tr. at 364. He then opined that
Mr. Nagy's ability to engage in basic work-related
activities including memory, understanding, sustained
concentration, persistence and pace, social interaction, and
adaption are moderately to significantly impaired. Tr. at
365.
Dr.
Rodriguez also completed a mental residual functional
capacity (RFC) evaluation. Tr. at 366-68. He opined that Mr.
Nagy was moderately impaired in his ability to remember
locations and work-like procedures, understand and remember
very short and simple instructions, carry out very short and
simple instructions, make simple work-related decisions, ask
simple questions or request assistance, and travel in
unfamiliar places or use public transit. Tr. at 366-67. He
opined that Mr. Nagy was at least markedly limited in every
other area of the evaluation: understanding and memory,
sustained concentration and persistence, social interaction,
and adaption. Tr. at 366-67. ...