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Steven Sims v. Michael J. Astrue

May 23, 2012


The opinion of the court was delivered by: Suzanne H. Segal United States Magistrate Judge



Steven Sims ("Plaintiff") brings this action seeking to overturn the decision of the Commissioner of the Social Security Administration (hereinafter the "Commissioner" or the "Agency") denying his application for Disability Insurance Benefits ("DIB"). The parties consented, pursuant to 28 U.S.C. § 636(c), to the jurisdiction of the undersigned United States Magistrate Judge. For the reasons stated below, the decision of the Agency is REVERSED and REMANDED for further proceedings.


Plaintiff filed an application for DIB on October 29, 2007. (Administrative Record ("AR") 91-93). The Agency denied benefits on July 2, 2008. (AR 50-55). Plaintiff requested a hearing by an administrative law judge ("ALJ") on July 22, 2008. (AR 59). The ALJ held a hearing on February 23, 2010, (AR 24-48), and on May 7, 2010, he issued an unfavorable decision. (AR 9-20). Plaintiff sought review of the ALJ's decision on July 12, 2010, (AR 7). The Appeals Counsel denied further review on May 6, 2011. (AR 1). Plaintiff commenced the instant action on June 24, 2011.


A. Plaintiff's Medical History

Plaintiff has sought treatment for several medical problems, including episodes of unconsciousness, (AR 226), dizziness, (AR 146, 181, 207, 209, 221, 226, 233, 345, 391), chest pains, (AR 145, 221), left arm and neck pain, (AR 187, 193, 212, 216, 345), vomiting and nausea, (AR 233, 268, 270, 391, 393, 407), abdominal pain and pancreas problems, (AR 283, 378, 391-94, 394, 408, 410), weight loss (AR 269-70, 378) and anxiety. (AR 166, 185, 345). He has received treatment from Kaiser Permanente's Bellflower Medical Center and West L.A. Medical Center, as well as St. Francis Medical Center and Cedars-Sinai Medical Center. (AR 145, 187, 232, 377).

On August 18, 2006, Plaintiff visited Dr. Ontiveros at West L.A. Medical Center for dizziness and stress following an episode that morning where he "passed out." (AR 226). He said he felt lightheaded, experienced a room-spinning sensation, fell to the ground, hit his back and might have lost consciousness. (Id.). On August 21, 2006, Plaintiff went to the emergency room at Kaiser Permanente's Bellflower Medical Center following a dizzy and fainting episode. (AR 145-46, 148, 181-82).*fn1 The hospital performed a CT scan of Plaintiff's head and the results were negative, indicating no abnormalities. (AR 181).

On August 23, 2006, Plaintiff was admitted to the same hospital for chest pains. (AR 145). Tests performed at the hospital showed Plaintiff had "frequent PVCs", and an echocardiogram and Holter monitor were recommended by the cardiology department. (AR 160, 183). Plaintiff also complained of "vertigo 'spinning' dizziness with movement of his head." (AR 146). On August 24, 2006, Plaintiff was diagnosed with vertigo and discharged. (AR 150).

On August 31, 2006, Plaintiff returned to Dr. Ontiveros at West

L.A. Medical Center for a follow-up appointment, during which he complained of dizziness. (AR 221). In September 2006, Plaintiff saw Dr. Saccone for vertigo dizziness, (AR 207, 209), and was diagnosed with benign paroxysmal positional vertigo ("BPPV"). (AR 207). On October 16, 2006, Plaintiff saw Dr. Tafreshi for pain and tingling in his left hand, wrist, and forearm. (AR 212). Plaintiff had a follow-up appointment with Dr. Saccone on November 2, 2006, during which he again complained of left arm tingling. (AR 216). After this appointment, Plaintiff returned to West L.A. Medical Center several times seeking treatment for his left arm pain and tingling. (AR 187, 193, 199, 202). In January 2007, Plaintiff was prescribed Prednisone. (AR 188, 196).

On October 4, 2007, Plaintiff was admitted to St. Francis Medical Center for "persistent bouts of vomiting, weight loss." (AR 268, 270). A CT scan of the abdomen and pelvis rendered a small stone in Plaintiff's gallbladder, a small irregular density in the right middle lobe, and portions of the bowel showed diverticulosis of the colon. (AR 279-280). A colonoscopy performed on October 8, 2007 revealed an internal hemmorhoid. (AR 282). Plaintiff was subsequently discharged. (AR 274).

On October 16, 2007, Plaintiff returned to St. Francis Medical Center for "persistent and intractable vomiting." (AR 233). On October 17, 2007, the Department of Imaging Services performed an MRI on Plaintiff's cervical spine. (AR 258-60, 263-65). The MRI showed disc herniation, osteoarthritis, and disc desiccation. (AR 263-64). A radiograph of Plaintiff's upper gastrointestinal tract and small bowel series revealed a small hiatal hernia. (AR 259-60).

In a consultation report also completed on October 17, 2007, Dr. Zevallos, the consulting physician, found mild lymphocytosis. (AR 247). Dr. Zevallos described Plaintiff's symptoms as a "complex clinical picture" and named a number of conditions that could cause Plaintiff's symptoms, including gatroparesis, a tumor or lesion in the inner ear, hyperthrydiosm, prolapse, of the mitral valve or a psychosematic disorder. (Id.). On October 18, 2007, the consulting physician, Dr. Ayoub, diagnosed Plaintiff with labyrinthitis and sent him for audiologic testing. (AR 237). Plaintiff was subsequently discharged. (AR 250).

On October 30, 2007, Plaintiff was admitted to Cedars-Sinai Medical Center, where his operation report reflected his significant problems with vertigo and "probable mild diffuse chronic pancreatitis."*fn2 (AR 407-08). On November 20, 2007, Dr. Ulick diagnosed Plaintiff with "chronic pancreatitis, automimmune." (AR 392). Plaintiff had a CT scan of his abdomen on February 15, 2008, and although radiology report stated there was no abnormality of the pancreas identified, (AR 390), a prescription form dated February 13, 2008 from St. Francis Medical Center, the same medical center that treated Plaintiff in 2007, reads, "Pt is permanty [sic] disable [sic] due to autoimmune pancreati [sic]." (AR 283). On February 29, 2008, Dr. Lo performed an endoscopic ultrasound of Plaintiff's pancreas and biliary tracts. (AR 378). He found a "persistent mild-to-moderate chronic pancreatitis change." (Id.).

On April 4, 2008, Plaintiff underwent a neurological evaluation to "elicit and analyze all clinically significant job or work related injury induced neurological symptoms (primarily radicular neck and back pain, shoulder pain, headaches, dizziness, etc.)." (AR 350). The report listed seven primary diagnoses for Plaintiff: (1) posttraumatic cephalgia, (2) posttraumatic stress disorder, (3) cervical radiculopathy/radiculitis, (4) vertigo, (5) cervical headaches/posterior headaches, (6) probable cervical discopathy and (7) cervical myofascial syndrome. (Id.). The report also listed five additional diagnoses: (1) left shoulder sprain/myofascial syndrome, (2) thoracic myofascial syndrome, (3) lumbo-sacral myofascial syndrome, (4) lumbo-sacral radiculopathy/radiculitis and (5) lumbar discopathy. (AR 353).

Plaintiff had several progress appointments from April 10, 2008 to February 12, 2009. (AR 317-24). The reports from those appointments indicated that he continued to complain of headaches, neck pain, dizziness, and pancreatic problems. (Id.). At his progress appointment on May 8, 2008, Plaintiff still had nausea and vomiting. (AR 323).

B. Plaintiff's Application

Plaintiff received DIB payments since approximately August 23, 2006. (AR 94-99). On November 21, 2007, Plaintiff received a statement notifying him that he had exhausted his DIB. (AR 95). He filed an initial application for DIB to continue payments on October 29, 2007. (AR 91-93). That same day the interviewer who completed the "Disability Report - Field Office - Form SSA - 3367" recorded, "Clmt looked very thin." (AR 103).

On November 7, 2007, Plaintiff completed the "Disability Report -Adult - Form SSA - 3368." (AR 105-115). He wrote that he cannot lift more than fifty pounds at his job, where he was required to lift seventy-five pounds at times. (AR 106). He also cannot stand for more than four hours and his job required eight hours of standing. (Id.). Plaintiff wrote that his vertigo has him "dizzy all the time - there are times [he] just faint[s]." (Id.). Plaintiff listed twelfth grade as the highest grade of school he ...

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