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Chavez v. Berryhill

United States District Court, E.D. California

March 3, 2017

NANCY A. BERRYHILL[1], Acting Commissioner of Social Security, Defendant.



         Juan Miranda Chavez asserts he is entitled to disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act. Plaintiff argues the administrative law judge erred in evaluating the record and seeks judicial review of the decision to deny his application for benefits. Because the ALJ failed to identify legally sufficient reasons for rejecting the opinion of Plaintiff s treating physician and the consultative examiner, the decision is REMANDED pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings.


         Plaintiff filed his applications for benefits on March 20, 2012, alleging disability beginning on January 11, 2011. (Doc. 9-3 at 19) The Social Security Administration denied Plaintiffs application at both the initial level and upon reconsideration. (See generally Doc. 9-4) After requesting a hearing, Plaintiff testified before an ALJ on March 3, 2014. (Doc. 7-3 at 14, 49) The ALJ determined Plaintiff was not disabled and issued an order denying benefits on April 16, 2014. (Id. at 13-25) When the Appeals Council denied Plaintiffs request for review on October 15, 2015 (id. at 4-6), the ALJ's findings became the final decision of the Commissioner of Social Security ("Commissioner").


         District courts have a limited scope of judicial review for disability claims after a decision by the Commissioner to deny benefits under the Social Security Act. When reviewing findings of fact, such as whether a claimant was disabled, the Court must determine whether the Commissioner's decision is supported by substantial evidence or is based on legal error. 42 U.S.C. § 405(g). The ALJ's determination that the claimant is not disabled must be upheld by the Court if the proper legal standards were applied and the findings are supported by substantial evidence. See Sanchez v. Sec 'y of Health & Human Serv., 812 F.2d 509, 510 (9th Cir. 1987).

         Substantial evidence is "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197 (1938)). The record as a whole must be considered, because "[t]he court must consider both evidence that supports and evidence that detracts from the ALJ's conclusion." Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985).


         To qualify for benefits under the Social Security Act, Plaintiff must establish he is unable to engage in substantial gainful activity due to a medically determinable physical or mental impairment that has lasted or can be expected to last for a continuous period of not less than 12 months. 42 U.S.C. § 1382c(a)(3)(A). An individual shall be considered to have a disability only if:

his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work, but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work.

42 U.S.C. § 1382c(a)(3)(B). The burden of proof is on a claimant to establish disability. Terry v. Sullivan, 903 F.2d 1273, 1275 (9th Cir. 1990). If a claimant establishes a prima facie case of disability, the burden shifts to the Commissioner to prove the claimant is able to engage in other substantial gainful employment. Maounois v. Heckler, 738 F.2d 1032, 1034 (9th Cir. 1984).


         To achieve uniform decisions, the Commissioner established a sequential five-step process for evaluating a claimant's alleged disability. 20 C.F.R. §§ 404.1520, 416.920(a)-(f). The process requires the ALJ to determine whether Plaintiff (1) engaged in substantial gainful activity during the period of alleged disability, (2) had medically determinable severe impairments (3) that met or equaled one of the listed impairments set forth in 20 C.F.R. § 404, Subpart P, Appendix 1; and whether Plaintiff (4) had the residual functional capacity ("RFC") to perform to past relevant work or (5) the ability to perform other work existing in significant numbers at the state and national level. Id. The ALJ must consider testimonial and objective medical evidence. 20 C.F.R. §§ 404.1527, 416.927.

         A. Relevant Medical Evidence

         Plaintiff was diagnosed with type II diabetes mellitus and hypertension prior to 2000. (Doc. 9-9 at 26) In addition, Plaintiff was in a car "accident in 1989, which resulted in a back injury" that required "multiple spinal surgeries in Mexico." (Id.)

         In 2000, Plaintiff had "a chronic infection of his left hip, " which was "the result of a prior infection in his lower lumbar spine... after an [operation] in Mexico." (Doc. 9-9 at 55) The infection "tracked down the iliopsoas, creating an iliopsoas abscess, which subsequently went into the hip." (Id.) Plaintiff was diagnosed with chronic septic arthritis, osteomyelitius, and ankylosis in his left hip. (Id. at 54) He had surgery "for resection of his hip and insertion of a methyl methacrylate antibiotic spacer" on May 18, 2000. (Id. at 55) In the fall of 2000, Plaintiff "had significant pain for 2-3 weeks." (Id. at 23) Although "settling" of the articulated spacer was suspected, surgery revealed Plaintiff had "a periprosthetic fracture." (Id.) Therefore, Plaintiff was admitted to the hospital "for reimplantation surgery of his total hip arthroplasty." (Id.)

         In April 2011, Plaintiff visited the Joy Kimpo Medical Center ("Kimpo Center") for a follow-up on his diabetes. (Doc. 9-8 at 17) Marylou Ayon, MA, believed that Plaintiffs diabetes was "well controlled with diet, exercise and weight management and oral medication." (Id.)

         Plaintiff returned to the Kimpo Center in May 2011, describing "generalized hip pain, " which he said was a constant, "mild to moderate" pain and rated "as a six on a 1 to 10 scale." (Doc. 9-8 at 21) Dr. Paramjit Panesar determined Plaintiff had "mild tenderness" in his left hip. (Id.) Dr. Panesar also found Plaintiff had limited internal rotation, external rotation, and flexion. (Id.)

         In October 2011, Plaintiff continued to report hip pain at the Kimpo Center, stating he could not "bend to do chores." (Doc. 9-8 at 33) He told Dr. Juan Cabrera that he had an appointment with an orthopedist at Kern Medical Center set "next year." (Id.) Dr. Cabrera did not see any bruising, rash, or eruptions on Plaintiffs skin. (Id.)

         In November 2011, Dr. Panesar determined that Plaintiffs diabetes was "well controlled with diet, exercise and weight management and oral medication." (Doc. 9-8 at 35) He did not find any "[o]ther manifestations of his diabetes, " such as pedal edema or ulcerations. (Id. at 35-36)

         On January 25, 2012, Plaintiff went to Kern Medical Center, and described "stiffness and discomfort and pain that extend[ed] from his left hip to his left thigh." (Doc. 9-8 at 6) Plaintiff said he did not have night pain, fevers, chills, or recent trauma. (Id.) Dr. Arturo Gomez observed that Plaintiff walked with a "[s]tiff limping gait." (Id. at 7) Upon examination, Plaintiff had "full range of motion" with his right leg, but the motion with his left hip was "significantly limited." (Id.) Dr. Gomez opined Plaintiff did "not appear to have any range of motion at the hip joint." (Id.) After reviewing x-ray findings, Dr. Gomez informed Plaintiff they did not have anyone at Kern Medical Center with "the skill set to manage this kind of condition, " and he recommended that Plaintiff "see... somebody who is fellowship trained in total joints to help." (Id.)

         In April 2012, Plaintiff "continue[d] to have low back pain and [was] unable to bend and lift things." (Doc. 9-8 at 86, emphasis omitted) In addition, Dr. Cabrera observed that Plaintiff continued to walk with a limp. (Id.) Dr. Cabrera completed a supplementary certificate for the Employment Development Department, in which he indicated Plaintiff had been diagnosed with "pelvic joint pain" and was "unable to lift things [secondary] to pain." (Id. at 88, 98) In addition, Dr. Cabrera indicated Plaintiff was expected to remain disabled until May 31, 2012. (Id. at 86, 88, 98)

         Dr. Juliane Tran performed a comprehensive orthopedic evaluation on June 22, 2012. (Doc. 9-8 at 48) Plaintiff reported his hip surgery provided "75% of pain relief, " but the pain returned and "got worse by 2010." (Id.) He said it was "a shooting, throbbing pain" that was a "5" to 8" out of 10. (Id.) In addition, Plaintiff described "occasional symptoms of paraesthesia in the left foot and left ankle." (Id.) Dr. Tran observed that Plaintiff was able to "ambulate[] to the exam room without an assistive device, " though he walked with a slow pace and "mild moderately antalgic" gait. (Id. at 49) Dr. Tran found Plaintiffs left hip flexion and internal rotation were limited. (Id.) Plaintiff had a "very positive" FABER test result in the left hip, and "mildly positive" test in the right hip. (Id. at 50) Dr. Tran found Plaintiffs grasping strength was "5/5" and motor strength was "5/5... throughout the deltoids, biceps, triceps, wrist extensors, first dorsal interosseous muscles, abductor pollicis brevis, and abductor digiti minimi." (Id.) She also determined Plaintiff had "some abnormal sensation in the distal feet, " and opined Plaintiff had "[p]ossible peripheral neuropathy." (Id. at 51) Dr. Tran concluded Plaintiff would "need to have an assistive device to ambulate in the community, " and "even with an assistive device he probably should not ambulate more than four hours a day." (Id.) Further, she believed Plaintiff had "restriction with all climbing, balancing and working with heights;" was limited to "frequent negotiating of steps, stairs and uneven terrain;" and should do no more than "frequent bending, stooping, kneeling, and crouching." (Id.) Dr. Tran opined Plaintiff did not have restrictions with fingering or grasping, but should be limited to lifting "no more than 10 pounds." (Id.)

         Dr. J. Frankel reviewed the record and completed a physical residual functional capacity assessment on July 6, 2012. (Doc. 9-4 at 7-12) Dr. Frankel observed that Plaintiff had a total hip arthroplasty, diabetes, and hypertension. (Id. at 8) According to Dr. Frankel, Plaintiff was limited to lifting and carrying 10 pounds frequently and 20 pounds occasionally; and was limited with pushing and pulling with his left leg. (Id. at 8-9) Dr. Frankel believed Plaintiff could occasionally climb ramps and stairs, kneel, stoop, crouch, and crawl; but never climb ladders, ropes and scaffolds. (Id.) Further, Dr. Frankel opined Plaintiff could stand or walk for "2 hours" in an 8-hour day and sit "about 6 hours in an 8-hour day." (Id.) Dr. Frankel believed Plaintiff needed to ...

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