VAL J. WALDON, Plaintiff,
MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION FOR ORDER:
(1) GRANTING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT AND FOR REVERSAL AND OR
REMAND [Doc. No. 16]; and (2) DENYING DEFENDANT'S CROSS MOTION FOR SUMMARY
JUDGMENT [Doc. No. 18].
NITA L. STORMES, Magistrate Judge.
Plaintiff Val Waldon brings this action under the Social Security Act, 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner of the Social Security Administration ("Commissioner" or "Defendant") denying his claim for social security benefits. This case was referred for a report and recommendation on the parties' cross motions for summary judgment. See 28 U.S.C. § 636(b)(1)(B). After considering the moving papers, the administrative record, and the applicable law, the court RECOMMENDS that Plaintiff's motion for summary judgment and for reversal and or remand be GRANTED and the case be remanded for further administrative proceedings, and that Defendant's cross motion for summary judgment be DENIED.
I. FACTUAL BACKGROUND
A. Procedural History.
Waldon filed applications for a period of disability and social security disability insurance benefits (SSD) on August 27, 2008. Administrative Record (AR) 174-184. He did not apply for supplemental security income (SSI). Id. Waldon alleges his condition rendered him unable to work on March 1, 1997. Id. The request was denied initially on December 17, 2008, and on reconsideration on March 4, 2009. AR 21. On March 17, 2009 Waldon filed a written request for a hearing. Id.
An Administrative Law Judge (ALJ) held hearings on April 12 and August 30, 2010. AR 59-67, 34-58. Waldon testified at the first hearing. AR 59-67. Waldon, medical expert Arvin Klein, and vocational expert John Kilcher testified at the second hearing. AR 34-58. Based on the testimony and documentary evidence the ALJ issued a decision denying Waldon's application for benefits. AR 18-33. Waldon then filed an administrative request to review the decision. AR 16-17. The Appeals Council denied the request for review, and the ALJ's decision became final. AR 1-6.
Waldon filed this complaint for judicial review of Defendant's final decision. He argues that the ALJ committed reversible error by giving improper consideration to the treating physician's opinion and to Waldon's testimony. He asks that this court reverse and remand for further administrative proceedings.
B. Documentary Medical Evidence.
1. Examining Physicians.
Waldon has a history of insulin dependent diabetes mellitus, hypertension, depression, post traumatic stress disorder, substance, alcohol and Vicoden abuse, asthma, coronary artery disease, myocardial infarcation, peripheral neuropathy, cerebrovascular accident in 1996 with right lower extremity weakness, gastroesophageal reflux disease, and hypoglycemia. AR 23, 240-286, 380-851, 853-896. Those diagnoses are based on the following reports.
Aparna Kambhampati, M.D., reported Plaintiff was admitted to the hospital on January 25, 1998, for a suicide attempt. AR 23, 869-870. His urine tested positive for benzodiazepines, alcohol, and cocaine. Id. Waldon was discharged on January 31, 1998, with a diagnosis of depression, polysubstance abuse, non-insulin dependent diabetes mellitus, hypertension, and purified protein derivative. Id.
Dennis J. Dicampli, M.D., reported that Waldon was admitted to the hospital on June 20, 1998, for chest pain after being arrested for an outstanding warrant. AR 23, 271. Waldon had a two year history of insulin dependent diabetes mellitus and 18 year history of diabetes. Id. He reported a cerebrovascular accident in 1996 with residual right lower extremity weakness, myocardial infarction in 1986 with angioplasty, tuberculosis status post treatment, increased cholesterol, hypertension for 10 years, gastroesophageal reflux, and ulnar osteotomy secondary to fracture. AR 24. Waldon was admitted and placed on heparin. AR 271. He was scheduled for an angiogram but left the hospital against the advice of doctors, without having had the angiogram. Id. When he left on June 23, 1998, Waldon had a diagnosis of probable coronary artery disease, diabetes mellitus and hypertension. AR 24.
According to Linda Gonzales, Ph.D., on February 27, 2001 Waldon reported that he had been depressed since he returned from Vietnam in 1977. AR 24, 813-817. He was alcohol and cocaine dependent and attempted suicide three times. Id. He had been traumatized by his experiences of being shot and stabbed and was in two serious car accidents. Id. He attended an outpatient rehabilitation center in 1997 for his addictions. Id. Waldon was diagnosed with major depression, posttraumatic stress disorder, and alcohol and cocaine dependence in remission. AR 86.
2. Dr. Carol Sprague-Treating Physician.
Dr. Sprague from the Veterans Affairs Medical Center treated Plaintiff from December 2000 through March 2009. AR 289-348; 380-852. She diagnosed him as suffering from diabetes with significant peripheral neuropathy in his feet, significant numbness in his thighs with severe pain (meralgia paresthetica), distant history of a stroke with chronic right lower extremity numbness and mild weakness, high blood pressure, high cholesterol, obstructive sleep apnea, obesity, depression and PTSD symptoms. AR 852. She noted he takes the following medications: metformin, insulin, simvastatin, metoprolol, losartan, doxazosin, pantoprazole, testosterone, duloxetine, amitriptyline, trazodone and methadone. Id.
On April 8, 2010, Dr. Sprague described Waldon's functional impairments as follows:
Over the time that I treated Mr. Waldon he had significant functional impairment. This worsened over the time that I treated him. He was disabled when I first evaluated him in 2000, and became increasingly disabled over time. His symptoms include significant depression and anhedonia, severe neuropathy and pain which limit his endurance and ability to do many activities. Mr. Waldon has marked limitation in his concentration due to pain and fatigue and marked impairment in his social functioning. He would not be able to work in even a sedentary job and it is very likely his medical and mental functioning would likely worsen if he was in a competitive work environment. Although he is able to perform his activities of daily living, he would be unable to work in any capacity due to his medical and medication side effects. In my opinion he was unable to work since at least 6/30/02 and likely before that. His condition is not reversible and is likely to be progressive and I consider him fully and permanently disabled.
C. Relevant Testimony from the Hearing.
1. Dr. Arvin Klein-Medical Expert.
Dr. Klein, who is Board Certified in internal medicine, reviewed Waldon's medical file and found he had a history of diabetes mellitus, hypertension and substance abuse with a history of noncompliance. AR 27-28, 38-41. He noted that in June 1999 Waldon had a physical examination at the University of California, San Diego, with all normal results. Id. While Waldon refused the angiogram his basic cardiac tests were all normal. Id. Dr. Klein explained that even though Waldon did not comply with taking all his medications his blood sugar and blood pressure were reasonably well-controlled. Id. Finally, Dr. Klein opined that Waldon did not meet or equal the criteria of any listing, had no exertional limitations or postural limitations, and can sit for six hours, stand for six hours and walk for six hours in an eight hour work day, and should avoid hazards. Id.
Waldon testified that various impairments prevented him from working since at least 1997. AR 26, 43-51. He testified that he broke his right wrist and had three operations on it. AR 26. While recovering from his wrist injuries he had a stroke followed by right sided weakness. AR 26, 43. He has used a cane since the late 1990s due to weakness on his right side. AR 41, 45. While he was treated at UCSD for the stroke, those records are no longer available. AR 43, 65-66.
Waldon was insulin-dependent due to his 1993 diagnosis of diabetes. AR 26. Diet and medicine helped his diabetes. Id. He stopped using cocaine in 1999, after he was incarcerated. Id. Waldon said that he could not sustain an eight hour workday and 40 hour workweek due to his energy level and medication levels. Id.
3. Vocational Expert.
The ALJ explained to the vocational expert Waldon's age, education, work experience and residual functional capacity, and asked if any jobs existed in the national economy through June 30, 2002 that would accommodate these parameters. AR 28. The vocational expert stated that jobs were available as an assembler, packager and garment sorter, which all required a light exertional level. AR 28-29.
D. ALJ's Written Decision.
The ALJ found that Waldon last met the insured status requirements of the Social Security Act on June 30, 2002. AR 23. He did not engage in substantial gainful activity from the alleged date of the onset of his disability, March 1, 1997, through the date last insured of June 30, 2002. Id.
1. Rejection of Treating Physician's Opinion.
The ALJ considered and rejected Dr. Sprague's testimony that Waldon was disabled as unsupported. AR 27. Specifically, he found that Dr. Sprague failed to establish any timeline for when Waldon's alleged mental impairment and stroke began. AR 26. He found no objective evidence to support a finding of severe residuals of a stroke, and there was no evidence of testing and examination of his extremities. Id. While Waldon has an extensive history of severe alcohol and cocaine abuse during the insured period, there is no evidence this prevented him from ...