United States District Court, E.D. California
ORDER GRANTING PLAINTIFF'S SOCIAL SECURITY APPEAL AND REMANDING ACTION FOR FURTHER ADMINISTRATIVE PROCEEDINGS
SANDRA M. SNYDER, Magistrate Judge.
Plaintiff Maria Valles, by her attorneys, Law Offices of Lawrence D. Rohlfing, seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for supplemental security income ("SSI") pursuant to Title XVI of the Social Security Act ("the Act"). See 42 U.S.C. § 301 et seq. This action was initially referred to the undersigned pursuant to E.D. Cal. L.R. 302(c)(15), and both parties voluntarily consented to proceed before a United States Magistrate Judge for all purposes pursuant to 28 U.S.C. § 636(c). The matter is before the Court on the parties' cross-briefs, which were submitted without oral argument to the Honorable Sandra M. Snyder, U.S. Magistrate Judge. After a review of the complete record and applicable law, the Court will reverse the Commissioner's decision and remand for further proceedings.
I. Procedural History
On February 4, 2010, Plaintiff applied for supplemental security income. Plaintiff alleges onset of disability on March 15, 2009. The Commissioner initially denied the claims on August 12, 2010, and upon reconsideration again denied the claims on October 18, 2010. Plaintiff filed a timely request for a hearing on November 24, 2010.
On January 5, 2012, represented by counsel, Plaintiff appeared and testified at a video hearing presided over by Betty Roberts Barbeito, Administrative Law Judge ("the ALJ"). See 20 C.F.R. 404.929 et seq. An impartial vocational expert, Judith Najarian, also appeared and testified.
On February 9, 2012, the ALJ denied Plaintiff's application. The Appeals Council denied review on June 10, 2013. Accordingly, the ALJ's decision became the Commissioner's final decision. On August 5, 2013, Plaintiff filed a complaint seeking this Court's review.
II. Administrative Record
A. Plaintiff's Testimony (January 5, 2012)
Plaintiff, born September 15, 1970, lived in a house with her son and niece (ages 18 and 19, respectively, at the time of the hearing). Plaintiff attended high school through 11th grade, had no additional education or training, and was able to communicate in English. Plaintiff testified that she last worked in 2010 as a housekeeper and caretaker and had prior work cleaning houses. Plaintiff testified that she was not currently working and had not worked since 2010. Plaintiff testified she was left handed, five feet tall, and weighed 179 pounds.
At the hearing, Plaintiff amended her alleged onset of disability from March 15, 2009 to February 4, 2010, and testified that she has constant pain in her left leg and lower back. She testified that after back surgery in September 2010, her pain diminished "for maybe a couple of months, " but since then the pain had returned. Plaintiff described experiencing "a lot of pain" and that she was "scared sometimes... to bend [down], " because it felt "like I'm going to paralyze myself."
Plaintiff testified that she cannot hold her grandchildren, and that the most weight that she could lift comfortably was "a gallon of milk." She testified that she could bend down to just below her knees. She stated that she could stand for maybe 40 minutes "at the most, " then would have to sit down to rest. Plaintiff reported pain when sitting, and that she could not sit for more than an hour; for example, she could not drive from Bakersfield to Tulare (about an hour). Plaintiff stated that when home she lays in bed due to the back pain, rather than sitting down. She testified that in an eight hour day she could sit for approximately 1.5 to two hours, cumulatively, if alternating between sitting, standing, and walking.
Plaintiff testified that her duties in 2010 as a part-time caretaker and housekeeper included dispensing medicine, preparing meals, and doing light housekeeping. She testified that she worked four or five hours per day, three days per week. In her prior position as a house cleaner, Plaintiff testified that she worked two to three hours per day, two days per week. Plaintiff testified that she stopped working as a house cleaner because "it was just too hard for my back to keep trying to jeopardize my back, whatever I was trying to do."
Plaintiff described her typical daily activities as follows: "I'm most [sic] laying, like always in bed, because, like, I don't have a - it's just I'm always locked up in my room... maybe half of the day I'm in bed." She testified that she tries to vacuum, mop, dust, and pick up around the house, but "it's not easy." She reported that her niece and son did the "hard work" around the house, such as the laundry, vacuuming, and mopping, but that Plaintiff did still cook "some." She testified that she did not have activities outside the home, did not drink or use illicit drugs, but that she drove, and went to church regularly. Plaintiff testified that she could read "not good at all, or write, " could not read a newspaper, and had attended special education classes while in school.
Plaintiff testified that lying on her side helped relieve the pain in her leg and back. Describing her left leg, she testified that pain goes "all the way to my toe, " and constantly feels "like little needles poking me." Plaintiff testified that she went to her medical clinic "twice a week." Plaintiff reported using heating pads or ice packs to relive her pain, as well as a kneepad that she wore "every day." To manage her pain, Plaintiff testified that she used prescription medications, including Norcos (four times per day), a muscle relaxer Somas (three times per day), and Prednisone for unexplained reasons. Plaintiff stated that she experienced drowsiness as a side effect of her medications. Plaintiff testified that physical therapy did not help or alleviate her pain.
B. Medical Evidence
The ALJ considered the following medical records and opinions. Treating and examining physicians rendered opinions as to the Plaintiff's abilities. The objective medical evidence confirmed the diagnosis of status post open reduction internal fixation of the right femur, healed, with residual chronic lumbar strain/sprain; obesity; and depressive disorder not otherwise specified. There are substantial treatment records. The ALJ did not consider medical records or opinions dated before Plaintiff's alleged onset date.
Medical records show that Plaintiff had an MRI of her lumbosacral spine on April 9, 2010. The impression was broad based disc bulge with small central protrusion at L4-5 causing mass effect upon the anterior thecal sac and mild to moderate bilateral neural foraminal stenosis. The medical records noted hemilaminectomy at the time. Medical records show that Plaintiff was obese; records show she weighed 218 pounds, was five feet tall with a body mass index of over 41, where a BMI of 30 is considered obese. Plaintiff was not receiving and had no history of mental health treatment or medications. The record contains no evidence of ongoing mental health treatment or counseling.
In June 2010, consultative physician Michael Wlasichuk, M.D., reviewed Plaintiff's medical history and performed a complete orthopedic examination at the request of the state agency. He observed that Plaintiff walked fairly normally and was able to walk on her heels and toes. Although Plaintiff complained of pain and discomfort in her lumbar spine, Dr. Wlasichuk observed no evidence of spasm and no reversal of the lordotic curve. Dr. Wlasichuk noted that Plaintiff was able to flex her trunk with the tips of her fingers six inches from the floor, and reported that her FABER examination was normal. Dr. Wlasichuk noted that Plaintiff had normal motor strength; her knee and ankle joints were normal; and her sensory exam was normal, except Plaintiff's left lower extremity showed sensory input abnormalities below the knee including the toes and great toe. Dr. Wlasichuk opined that Plaintiff may lift and carry 10 pounds occasionally and five pounds frequently; she could stand and/or walk two to four hours per day; she could sit less than six hours per day; and her exertional limitations included climbing, pushing, pulling, crouching, crawling, and balancing. Pending further orthopedic or neurological consultation, Dr. Wlasichuk considered Plaintiff a possible candidate for surgery.
On July 23, 2010, consultative psychiatrist Nadine J. Kravatz, Psy.D., examined Plaintiff at the request of the state agency. Dr. Kravatz indicated that Plaintiff had functional limitations, including a mild restriction of activities of daily living; mild difficulties in maintaining social functioning; and moderate difficulties in maintaining concentration, persistence, or pace. Dr. Kravatz observed that Plaintiff's attention and concentration were fairly intact, and that she was able to do simple cognitive tasks requiring attention or concentration. Dr. Kravatz noted that Plaintiff was not significantly limited in her ability to understand and remember locations and work-like procedures or very short and simple instructions, but she was moderately limited in her ability to understand and remember more detailed instructions. Dr. Kravatz determined that Plaintiff was able to sustain her attention and concentration for extended periods; could perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; was able to sustain an ordinary routine without special supervision; and was able to work in coordination with or proximity to others without being distracted. Dr. Kravatz opined that although Plaintiff may experience difficulty with more complex instructions, she is able to perform significant aspects of her ADLs. Dr. Kravatz observed no significant limitations for Plaintiff's social interactions or ...