United States District Court, N.D. California, San Francisco Division
ORDER GRANTING IN PART AND DENYING IN PART PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT AND DENYING DEFENDANT'S CROSS-MOTION FOR SUMMARY JUDGMENT [Re ECF Nos. 21, 22]
LAUREL BEELER, Magistrate Judge.
Plaintiff Elizabeth Lesley Mesa moves for summary judgment, seeking judicial review of a final decision by defendant Carolyn W. Colvin, the Commissioner of Social Security Administration (the "Commissioner"), denying her Social Security Income ("SSI") disability benefits for her claimed disability allegedly resulting from back pain, neck pain, depression, and carpal tunnel syndrome. (Administrative Record ("AR") 73.) The Administrative Law Judge ("ALJ") determined that Ms. Mesa could not perform her past relevant work but that she was capable of performing other jobs that existed in significant numbers in the national economy and was thus not disabled. (AR 32-33.)
Pursuant to Civil Local Rule 16-5, the matter is deemed submitted for decision by this court without oral argument. All parties have consented to the court's jurisdiction and now move for summary judgment. (ECF Nos. 9, 11, 21, 22.) For the reasons stated below, Ms. Mesa's motion is GRANTED IN PART and DENIED IN PART, the Commissioner's motion is DENIED, and the case is REMANDED for reconsideration.
I. PROCEDURAL HISTORY
Ms. Mesa, now 46 years old, filed a Title II application for a period of disability and disability insurance benefits on January 28, 2009. (AR 62.) She then filed a Title XVI application for supplemental security income on July 14, 2009. (AR 62.) Both applications alleged disability beginning on November 1, 2007, but were denied both initially and on reconsideration. (AR 62.) On November 14, 2010, Ms. Mesa protectively filed both a Title II application for a period of disability and disability insurance benefits and a Title XVI application for supplemental security income. (AR 20.) In both applications, Ms. Mesa again alleged disability beginning on November 1, 2007, but these claims were again denied both initially and on reconsideration. (AR 20.) Ms. Mesa thereafter requested review by an Administrative Law Judge. (AR 106.) An ALJ held a hearing on May 30, 2012. AR 41. Ms. Mesa appeared with her non-attorney representative, Dr. Dan McAskell, and testified at the hearing. (AR 43.) A Vocational Expert ("VE"), Ms. Sandra Trost, also testified. (AR 20, 51.)
The ALJ published a decision on June 8, 2012 and found that Ms. Mesa was not disabled. (AR 20-21.) The ALJ explained that he had determined that Ms. Mesa was capable of performing various jobs which exist in significant numbers in the national economy. (AR 32.)
On June 22, 2012, Ms. Mesa requested that the Social Security Administration ("SSA") Appeals Council review the ALJ's decision. (AR 15-16.) This request was denied, and this denial rendered the ALJ's decision the Commissioner's final decision. AR 1.
Ms. Mesa filed a complaint for judicial review under 42 U.S.C. § 405(g) on April 21, 2014. (ECF No. 1.) Ms. Mesa and the Commissioner both now move for summary judgment. (ECF Nos. 21 and 22.)
II. SUMMARY OF RECORD AND ADMINISTRATIVE FINDINGS
This section summarizes (A) the medical evidence in the administrative record, (B) the vocational expert's testimony, (C) the testimonial evidence provided by Ms. Mesa, and (D) the ALJ's findings.
A. The Medical Evidence
1. Sutter Medical Center of Santa Rosa from 12/6/05 - 6/22/09
On December 6, 2005, Ms. Mesa visited the Emergency Department at the Sutter Medical Center of Santa Rosa ("SMCSR"), seeking a "return to work excuse." (AR 276.) She was seen by Dr. Robert Landman, to whom she reported intermittent back pain. (AR 276-77.) She explained that she had experienced such pain in the past, but that it had gone away on its own. (AR 276.) Dr. Landman found that she had a full range of motion with regard to her back, but that she did have "minimal right paralumbar muscle tenderness." He concluded that she had a "resolved acute low back strain, " but that she was able to return to work. (AR 277.) He wrote her a prescription for ibuprofen and told her to check in again if the pain increased. (AR 277.)
On September 27, 2006, Ms. Mesa returned to the SMCSR Emergency Department, reporting that she had injured her back while attempting to move a 50-pound air conditioner. (AR 274.) She was seen by Dr. TW Hard, who noted Ms. Mesa's description of "pain in her lower back area radiating down into the posterior legs, predominantly on the right side." (AR 274-75.) Dr. Hard found that Ms. Mesa's neck was supple with a full range of motion, but that she had a "low back strain." (AR 274-75.) Ms. Mesa was given Toradol which provided relief and Dr. Hard prescribed Vicodin, Soma, and Motrin. (AR 274.) Dr. Hard ordered x-rays of Ms. Mesa's lumbosacral spine, which indicated that Ms. Mesa had a "narrowing of the L5-S1 intervertebral disk space with anterior osteophytes" and "[s]maller anterior osteophytes... at the L3-4 level." (AR 275, 347.) Dr. Hard concluded from these x-rays that Ms. Mesa had "moderate degenerative joint disease, but no significant slippage, dislocation, or fracture." (AR 275.) Dr. Hard recommended that Ms. Mesa engage in only light activity for three days and she was given a 72-hour work excuse. (AR 274.)
On December 2, 2006, Ms. Mesa returned to the Emergency Department at SMCSR and was seen by Dr. Richard Reisman, who noted that she was "somewhat distraught." (AR 270.) Ms. Mesa reported experiencing "[s]ome lumbar back issues" and "slight neck problems" in the past. (AR 270.) Ms. Mesa explained that she had been in a car accident five days earlier, after which her neck began to feel sore and she noticed tingling in her right fourth finger. (AR 270.) Dr. Reisman's examination revealed "some tenderness of the posterior musculature" in her neck, but "no obvious spine tenderness." (AR 270.) He ordered x-rays and an MRI which showed "minimal degenerative disk changes" but no fracture. (AR 270, 273.) Dr. Reisman concluded that Ms. Mesa had a cervical strain and a possible peripheral nerve injury. (AR 270.) Ms. Mesa was given morphine while in the Emergency Department, which provided pain relief, and was prescribed Vicodin. (AR 271.) She was released and asked to return if her pain did not improve within the next several days. (AR 271.)
Ms. Mesa did not return to the Emergency Department at SMCSR until June 22, 2009. (AR 267.) She had been having pain in her first, second, and third fingers for about three weeks. (AR 267.) She was seen by Dr. Eric Sterling, who described her as a "well-developed, well nourished female, " but noted that she was in "mild distress." (AR 267.) Dr. Sterling ordered x-rays of her cervical spine, which he described as "unremarkable." (AR 267.) He found the symptoms "consistent with a very mild radial nerve palsy and inflammation" and noted that she was also experiencing neck pain. (AR 267-68.) He started her on an anti-inflammatory medication and pain relievers, but found her in stable condition and discharged her. (AR 267.)
2. Santa Rosa Community Health Centers from 12/19/06 - 10/12/11
From 2006 to 2011, Ms. Mesa regularly visited the Southwest Community Health Center, one of seven facilities that constitute the Santa Rosa Community Health Centers ("SRCHC"). She was seen primarily by Dr. Joel Lewis and Physician Assistant Lupe Pacheco for medical treatment and by Dr. Valerie Smith for psychotherapy treatment, each of whom filled out Progress Notes for each visit. ( See AR 279-85.)
a. Dr. Joel Lewis and PA Lupe Pacheco
On December 19, 2006, Dr. Lewis noted back pain and depression and prescribed Ibuprofen and Zoloft. (AR 284.) On January 31, 2007, he noted both back and neck pain. (AR 285.) On February 13, 2007, Dr. Lewis noted a knot Ms. Mesa's back, as well as chronic neck and upper back pain. (AR 285.) On May 2, 2007, someone other than Dr. Lewis (whose name is illegible as written on the Progress Note) noted lower back pain as well as "muscle tension, post neck and upper left back discomfort." (AR 283.) This Progress Note also mentions Zoloft, PT (presumably physical therapy) and chiropractic work. (AR 283.) Ms. Mesa returned to SRCHC on May 21, 2007 and someone other than Dr. Lewis (whose name is also illegible as written on the Progress Note) noted Ms. Mesa's back pain. (AR 282.) On July 26, 2007, Dr. Lewis noted a bump on Ms. Mesa's shoulder blade. (AR 281.) On January 14, 2008, Dr. Lewis noted depression and chronic neck/back pain. (AR 280.) On September 5, 2008, Dr. Lewis again noted Ms. Mesa's neck pain. AR 279. On January 22, 2009, Dr. Lewis again noted depression and chronic neck/back pain. (AR 279.)
Ms. Mesa was seen by Dr. Lewis again on June 17, 2011 and Dr. Lewis noted degenerative disc disease, drug abuse, depression, neck pain, and amenorrhea. (AR 330.) He prescribed her Doxepin for her depression. (AR 330.) On July 17, 2009, Dr. Lewis listed carpal tunnel syndrome in the Progress Notes and gave her a splint to wear for it. (AR 326-27.) On August 17, 2009, Dr. Lewis listed degenerative disc disease, drug abuse and alcohol dependency (both in remission), and neck pain. (AR 324.) He prescribed her Tramadol for her degenerative disc disease and referred her to physical therapy for her chronic neck pain. (AR 324.)
On September 1, 2009, Ms. Mesa was seen by PA Lupe Pacheco, who found her to be suffering from joint stiffness, joint pain, carpal tunnel syndrome, muscle aches, back pain, neck pain, and tingling/numbness. (AR 322.) She also noted "perilumbar [sic] tenderness, trapezius tenderness, multiple paired trigger points, " and that Ms. Mesa was anxious and agitated. (AR 323.) PA Pacheco's assessment included neck pain, carpal tunnel syndrome, and muscle spasms. (AR 323.) PA Pacheco ordered an MRI and a "nerve conduction study/EMG, " gave Ms. Mesa Norflex and prescribed Torodol. (AR 323.) On September 22, 2009, Ms. Mesa reported continued numbness in the first three fingers on her left hand as well as pain in her shoulders. (AR 320.) PA Pacheco also identified muscle aches, joint pain, joint stiffness, and neck pain. (AR 320.) On September 30, 2009, PA Pacheco noted that Ms. Mesa was continuing to experience neck pain. (AR 319.) On October 13, 2009, PA Pacheco and Ms. Mesa discussed the nerve conduction study that had been ordered the previous month as well as the possibility of surgery to improve her carpal tunnel syndrome. (AR 317.) PA Pacheco noted that Ms. Mesa's hand tingling and numbness had dissipated, but that she continued to suffer from muscle aches, joint pain, and joint stiffness in addition to her carpal tunnel syndrome. (AR 317.) PA Pacheco referred Ms. Mesa to Dr. Raymond Severt regarding the carpal tunnel syndrome surgery. (AR 317.)
On November 19, 2009, Ms. Mesa was seen again by Dr. Joel Lewis. (AR 315.) Dr. Lewis noted that she was negative for tingling/numbness and swelling/bruising, but positive for muscle aches, joint paint, and joint stiffness. (AR 315.) His assessment listed depression, carpal tunnel syndrome, and drug abuse. (AR 315.) On April 5, 2010, Ms. Mesa reported continued back pain. (AR 311.) On June 11, 2010, Ms. Mesa returned to SRCHC, but was seen by Nurse Practitioner Marina McIver who noted that Ms. Mesa had pain in her "upper neck, radiating down to mid back, and below scapular." (AR 307-08.) In her assessment, NP McIver concluded that Ms. Mesa was suffering from a whiplash injury to her neck due to a car accident she had been in the month before. (AR 307.) NP McIver referred Ms. Mesa to physical therapy at Santa Rosa Memorial Hospital. (AR 308.) Ms. Mesa returned to SRCHC on June 29, 2010 and was seen again by PA Pacheco who prescribed her medication for the neck pain which had resulted from the car accident. (AR 305.) On July 1, 2010, Ms. Mesa was seen by Dr. Lewis again, who noted her continued neck and back pain and gave her a referral for an MRI. (AR 303.)
Ms. Mesa did not return to SRCHC until January 3, 2011, when she was again seen by Dr. Joel Lewis for her continued back pain. (AR 294.) Ms. Mesa requested a note, for insurance purposes, restricting her activity until she completed physical therapy. (AR 294.) Dr. Lewis assessed her as suffering from low back pain and degenerative disc disease. (AR 294-95.) Ms. Mesa returned to SRCHC on March 11, 2011, reporting to PA Nicole Wilburn that she was "having trouble functioning" due to her pain and that the Vicodin prescribed by Dr. Lewis was ineffective. (AR 458.) PA Wilburn found that she had "chronic neck pain with acute exacerbation." (AR 458.) On November 7, 2011, Ms. Mesa visited SRCHC and was seen again by Dr. Lewis who noted that she had lingering neck pain and advised her to avoid weight lifting. (AR 456.)
On April 3, 2012, Dr. Lewis completed a Residual Functional Capacity ("RFC") Questionnaire regarding Ms. Mesa's manipulative limitations. (AR 590.) He noted that she suffered from tenderness, pain, paresthesia, limitation of motion, and reduced grip strength. (AR 590.) He explained that fingers 1-4 in her left hand were always numb. (AR 590.) He also explained that all fingers in her right hand were numb, with pain after 5 minutes of keyboard use. (AR 590.) He limited her to less than 1 hour of grasping, turning, or twisting objects, fine finger manipulations, and arm reaching per 8-hour work day. (AR 591.)
b. Dr. Valerie Smith
On January 22, 2009, Ms. Mesa was seen by Dr. Valerie Smith, who filled out a Behavior Medicine Referral Form. (AR 278.) Dr. Smith described Ms. Mesa as "near [a] crisis state" and "in sig[nificant] need of therapy." (AR 278.) On August 10, 2009, Dr. Smith noted that Ms. Mesa "presented in a tense, almost hypomanic manner." (AR 511.) Dr. Smith's assessment included moderate recurrent major depression, as well as alcohol and amphetamine dependency, both of which she labeled as in remission. (AR 511.) Ms. Mesa returned two weeks later, on August 24, 2009, and Dr. Smith described her as showing "significant fatigue and pain, " as well as being "very sad and lonely." (AR 507.) On September 8, 2009, Dr. Smith noted that she continued to suffer from moderate recurrent major depression. (AR 504.) On September 22, 2009, Dr. Smith noted that Ms. Mesa had accomplished a "major break-through" and exhibited an "improved sense of self-worth." (AR 499.) On October 6, 2009, Dr. Smith noted that Ms. Mesa showed "confidence and [a] sense of self, " but still assessed her as suffering from moderate recurrent major depression. (AR 496.) On October 20, 2009, Dr. Smith noted her general continued improvement, decreased depressive symptoms, and increased ability to actively deal with her symptoms when they intermittently arise. (AR 492-93.) On November 17, 2009, Ms. Mesa reported feeling "empty, sad and lonely, " and that her prescriptions for pain and depression seemed inadequate. (AR 490.)
Ms. Mesa visited Dr. Smith again on December 1, 2009 and reported "feeling very sad recently due to increased pain in neck and back, " but also feeling grateful for having had carpal tunnel surgery on her left hand. (AR 486.) Ms. Mesa was again seen by Dr. Smith on January 5, 2010. (AR 484.) Dr. Smith noted that her depression symptoms had increased and that she was still experiencing neck and back pain. (AR 484.) On January 26, 2010, Dr. Smith wrote a letter, addressed To Whom it May Concern, explaining that she had been treating Ms. Mesa "for mental disabilities covered under the ADA" and described her as "an exemplary psychotherapy patient." (AR 291.) Dr. Smith commented that Ms. Mesa's progress had been "steady and remarkable." (AR 291.)
On October 12, 2011, Ms. Mesa returned to SRCHC for mental health services, but was seen by Dr. Stephanie Disney. (AR 449.) Ms. Mesa reported feeling stressed and depressed and Dr. Disney assessed her as having a depressive disorder. (AR 449.)
3. Palm Drive Hospital on 6/1/09 and 6/2/09
On June 1, 2009, Ms. Mesa visited Palm Drive Hospital, where she was seen by Dr. Jorge Gonzalez. (AR 255.) Ms. Mesa reported left arm numbness, and Dr. Gonzalez ordered a CT scan, which was conducted by Dr. Ingo Rencken. (AR 258.) Dr. Rencken found everything to be normal and unremarkable. (AR 258.) Ms. Mesa returned the next day, again reporting left hand numbness, and was seen by Dr. Lawrence Gettler, who noted that Ms. Mesa was "quite agitated" and that she was "thrashing in bed." (AR 253-54.) He found that there was "slight tenderness over the palmar webspace between the left thumb and left index finger" and that movement of Ms. Mesa's left arm increased her arm and hand pain. (AR 253.) He diagnosed her as suffering from neuropathy of the left arm/hand and anxiety with hyperventilation. (AR 254.) He prescribed her Motrin for her pain and recommended that she participate in drug treatment for her drug abuse problem. (AR 253.)
4. Santa Rosa Imaging Medical Center on 09/9/09
On September 9, 2009, Ms. Mesa visited the Santa Rosa Imaging Medical Center for an MRI of her cervical spine. (AR 340.) Dr. Norman Silverman noted a "major protrusion" and "asymmetric compression of the ventral surface of the cervical spine cord extending toward the right neural foramen." (AR 340.) He also noted the narrowing of various disc spaces. (AR 340.) He concluded that she had "multilevel discogenic disease with osteoarthritis" and "slightly increased disc prominence at C2-3 and C5-6." (AR 341.)
5. Dr. Jonathan Gonick-Hallows on 10/5/09
On September 17, 2009, the Department of Social Services authorized a consultative psychological evaluation which was performed by Dr. Jonathan Gonick-Hallows on October 5, 2009. (AR 608-09.) Dr. Gonick-Hallows concluded that Ms. Mesa had post-traumatic stress disorder, depressive disorder, polysubstance dependence, mixed personality disorder, and multiple physical problems. (AR 611.) He noted that her conditions could cause her to have "difficulty in terms of her ability to sustain adequate interpersonal interactions." (AR 611.) He explained that Ms. Mesa "is able to understand and carry out simple one- and two-part instructions" and would "have marked difficulty managing the usual work-related stresses." (AR 611.)
6. Dr. Kevin Satow on 10/12/09
On October 12, 2009, Ms. Mesa visited Dr. Kevin Satow for an electrodiagnostic evaluation. (AR 557.) He concluded that Ms. Mesa had moderate carpal tunnel in her right arm and severe carpal tunnel in her left arm. (AR 560.)
7. Dr. Carl Fieser on 10/15/09
On September 17, 2009, the Department of Social Services authorized a consultative neurologic examination which was performed by Dr. Carl Fieser at MDSI Physician Services on October 15, 2009. (AR 614, 618.) Dr. Fieser noted that Ms. Mesa had a "[h]istory of chronic neck pain with limitations to the cervical range of motion and the presence of cervical paraspinal spasms" as well as "findings consistent with left carpal tunnel syndrome" and subjective right carpal tunnel syndrome. (AR 618.) He ...