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Valentin Castaneda v. Carolyn W. Colvin

March 22, 2013


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




Valentin Castaneda ("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") and supplemental security income benefits ("SSI"). 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 and SSI on December 15, 2008. (Administrative Record ("AR") 130-36). He alleged a disability onset date of September 10, 2005. (AR 130-33; 134-36). The Agency initially denied Plaintiff's claim on April 3, 2009. (AR 58-62). After Plaintiff requested and received reconsideration of his claim, Plaintiff's claim was denied again on June 29, 2009. (AR 68-73).

On August 4, 2009, Plaintiff filed a written request for hearing. (AR 74-75). On June 1, 2010, with the help of an interpreter, Plaintiff testified at a hearing held before Administrative Law Judge ("ALJ") Jeffrey A. Hatfield. (AR 38-53). On June 14, 2010, the ALJ issued a decision denying benefits. (AR 23-32).

On June 14, 2010, Plaintiff requested that the Appeals Council review the ALJ's decision. (AR 1). The Appeals Council denied Plaintiff's request on January 27, 2012. (Id.). Plaintiff then filed the instant action on March 15, 2012.



Plaintiff, who was forty-two at the time of the hearing, is a Spanish-speaking male with limited English ability and a tenth grade education. (AR 42, 132, 152, 157). Plaintiff worked as a night stocker at a grocery store from 1990 until his alleged disability onset date of September 10, 2005. (AR 152).

During the hearing before the ALJ, Plaintiff stated that he was injured when he was walking backwards at work, tripped over one of the boxes that he was stocking, and fell on his right side. (AR 44, 150). Plaintiff also stated that he worked an additional three months after the incident. (AR 44). Plaintiff testified that lower back pain prevents him from returning to work. (AR 45). Plaintiff further stated that the pain is only slightly reduced by medication and physical therapy, that he uses a cane for stability, and that his back pain has caused him to experience both pain in his left leg and mental problems, including difficulty retaining concepts. (AR 47).

A. Plaintiff's Medical History

A variety of medical professionals have examined Plaintiff between his alleged disability onset date and when he filed for benefits. The Court summarizes Plaintiff's medical history below.

On November 7, 2005, Plaintiff sought treatment from Israel Rottermann, M.D., Plaintiff's primary treating physician. (AR 358). Dr. Rottermann reported that Plaintiff presented as a thirty-seven year-old male who weighed 270 pounds and was alert, well oriented, and cooperative for the examination. (AR 358-59). According to Dr. Rottermann, Plaintiff "sits comfortably for the physical examination, has no difficulty rising from the sitting position, and is able to stand without using the arms of the chair." (AR 359). Dr. Rottermann also noted that Plaintiff "is able to walk without difficulty, but ambulates slowly, having normal ambulation, with no evidence of a limp" and has "normal heel-to-toe gait." (AR 359). Regarding Plaintiff's lower back, Dr. Rottermann reported that Plaintiff presented with "tenderness to palpation in the lumbar spine and muscle spasm" and had limited lumbar range of motion. (AR 359). Plaintiff also had a positive straight-leg test, and "x-rays of the lumbar spine show[ed] spurring and the presence of a compression fracture at T11-12." (AR 360-61). Dr. Rottermann further noted that based on an October 1, 2005 MRI, Plaintiff appeared to have a herniated disc and "a compression fracture with degenerative disc disease." (AR 361). Dr. Rottermann diagnosed Plaintiff with (1) "[l]umbosacral strain, musculoskeletal, with radicular complaints;" (2) "[p]ossible superimposed fracture of T11-12;" and (3) "[h]erniated disc, L4-5 and L5-S1." (AR 361). Dr. Rotternman also reported that Plaintiff was temporarily totally disabled. (AR 362).

After examinations on January 9, 2006, June 5, 2006, and July 19, 2006, Dr. Rottermann diagnosed Plaintiff with the same three conditions and reported that Plaintiff remained temporarily disabled. (AR 346, 351, 354). Additionally, on March 19, 2007, Dr. Rottermann reported findings "consistent with an L5-S1 radoculopathy." (AR 339). At various points during Plaintiff's treatment, Dr. Rottermann prescribed pain medication, including Darvocet, Soma, Lodine, Naprosyn, Hydrocodone, Naproxen Sodium, Orphenadrine, and Ranitidine. (AR 340, 343, 357, 362, 367, 370, 374, 376).

B. Consultative Evaluations

1. Orthopedic Examinations

On February 17, 2006, at the request of Dr. Rottermann, Dr. Lawrence Miller, M.D., saw Plaintiff for an initial pain management consultative examination. (AR 216). Dr. Miller reported that Plaintiff complained of lower back pain with radiation down both legs. (AR 217). Dr. Miller diagnosed Plaintiff with lumbar disc herniation with bilateral lumbar radiculitis and signs of sciatic nerve root tension, and Dr. Miller recommended treating Plaintiff with epidural steroids. (AR 218-20). Dr. Miller also reported positive straight leg raise and diminished lumbar range of motion. (AR 218). On April 24, 2006, Dr. Miller treated Plaintiff with epidural steroids. (AR 228). However, on May 1, 2006, Dr. Miller reported that, according to Plaintiff, the steroid injection only helped for two days. (AR 224). That same day, Dr. Miller again diagnosed Plaintiff with lumbosacral intervertebral disc disease with radiculopathy and observed that Plaintiff's "[l]umbar flexion is limited to 40 degrees with pain" and that his "[s]traight leg raise is positive bilaterally." (Id.).

On August 25, 2006, Plaintiff saw Dr. Seymour Alban, M.D., for an agreed medical examination. (AR 244). Plaintiff was diagnosed with (1) lower lumbar spine degenerative disease with stenosis at L4-5 and L5-S1, (2) a slight compression fracture at T12, and (3) obesity. (AR 258). Dr. Alban also noted that Plaintiff, who "appeared to give full and consistent effort during measurement," had twenty-five degrees of lumbar flexion, which is "42% of normal lumbar spinal flexion." (AR 255). Later, on April 5, 2007, Dr. Alban noted that Plaintiff was a candidate for decompression and spine fusion surgery. (AR 239). However, Dr. Alban observed that Plaintiff was a poor candidate due to his weight and "tendency to magnify his weakness." (Id.). Dr. Alban also noted that Plaintiff had stenosis of L4-5 and L5-S1 and that electrodiagnostic studies corroborated nerve root irritation. (Id.).

On September 1, 2009, Dr. Kamran Hakimian, M.D., saw Plaintiff at the request of Dr. Alban. (AR 469). Dr. Hakimian reported that Plaintiff's "[r]ange of motion in the lumbar spine was painful." (Id.). Dr. Hakimian also reported that an electrodiagnostic study of Plaintiff's lower extremities was abnormal and that the results of his examination "could indicate lumbar radiculopathy." (AR 472).

2. Psychiatric Evaluations

On June 17, 2008, Plaintiff saw Dr. Nelson Flores, Ph.D., for a psychological consultation. (AR 474). According to Dr. Flores, Plaintiff reported that the pain and physical limitations Plaintiff experienced following the September 10, 2005 incident left him unable to carry out his ususal daily activities and that Plaintiff began to feel sad and anxious about his inability to cope with the pain. (AR 477). Dr. Flores diagnosed Plaintiff with (1) major depressive disorder, single episode, mild; (2) generalized anxiety disorder; (3) psychological factors affecting mental condition, diabetes; (4) pain disorder associated with both psychological factors and general medical condition; (5) sleep disorder due to chronic pain, general medical condition; (6) and male hypoactive sexual desire disorder to due chronic pain. (Id.). Dr. Flores reported that Plaintiff's psychological disorders were directly related to the ...

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