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Sahagun v. Saul

United States District Court, S.D. California

June 28, 2019

DAVID S. SAHAGUN, Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, Defendant.


          Hon. Cynthia Bashant Judge

         Plaintiff David S. Sahagun seeks judicial review of a final decision by the Commissioner of Social Security[1] denying his application for benefits under Title XVI of the Social Security Act (“the Act”). Presently before the Court are the parties' cross-motions for summary judgment. The Court finds these motions suitable for determination on the papers submitted and without oral argument. See Fed. R. Civ. P. 78(b); Civ. L.R. 7.1(d)(1). For the following reasons, the Court GRANTS Plaintiff's Motion for Summary Judgment, (ECF No. 15), and DENIES the Commissioner's Cross-Motion for Summary Judgment, (ECF No. 16). The Court will remand this matter to the Social Security Administration for further proceedings.


         Plaintiff filed an application for supplemental security income in October 2014, alleging the medical impairments of prostate cancer, depression, high cholesterol, and high blood pressure. (AR 157, 176.) Plaintiff alleged that his disability began in September 2014. (AR 157.) In a function report dated November 8, 2014, Plaintiff reported fatigue, difficulty concentrating, and limited mobility. (AR 193.) In February 2015, after reviewing medical records and ordering a psychological assessment that diagnosed Plaintiff with a major depressive disorder, (AR 321), the Social Security Administration denied Plaintiff's application. (AR 70.)

         In March 2015, Plaintiff underwent a laparoscopic radical prostatectomy to treat prostate cancer. (AR 428.) Subsequent checkups did not indicate any serious complications from the surgery. (AR 435, 443.) In September 2015, Plaintiff requested reconsideration of his application. (AR 108.) Soon after requesting reconsideration, Plaintiff was diagnosed with degenerative disk disease and began physical therapy and pain management treatment. (AR 332.) In February 2016, the Administration upheld its initial decision, denying Plaintiff's application for a second time. (AR 82.) Plaintiff immediately requested a hearing and review by an Administrative Law Judge (“ALJ”). (AR 115.)

         ALJ Donald Cole conducted a hearing in Plaintiff's case on July 6, 2016. (AR 20.) At the hearing, Plaintiff alleged that his daily activities were substantially limited by a combination of depression and back pain. (AR 43-49.) A vocational expert also testified at the hearing, stating that there were jobs available in a significant number in the economy for a hypothetical person of Plaintiff's age, education, and work experience-who was also limited to light work with standard industry breaks and some additional physical, psychological, and social restrictions. (AR 56.) The vocational expert further testified that if, in addition to the abovementioned limitations, the hypothetical person was off-task for more than an hour a day or would typically miss two days of work a month, there would be no work available for a person with those limitations. (AR 57.)

         At the time of the hearing, the Administration had ordered but had not yet received additional medical records from Plaintiff's treating physicians. (AR 240, 243.) These records included brief psychological evaluations by Plaintiff's treating physicians, as well as information about Plaintiff's prostatectomy and degenerative disk disease. (See id.; see also AR 26-29.) After receiving and reviewing these records, the ALJ issued a decision on January 10, 2017, finding Plaintiff was not disabled under the meaning of the Act. (AR 87.)

         In March 2017, Plaintiff filed an appeal request. (AR 146.) Along with the request, Plaintiff submitted two mental impairment questionnaires, one signed by Nurse Practitioner Elizabeth Dewart and the other signed by Doctor Raul Gener. (AR 529-40.) Both N.P. Dewart and Dr. Gener had treated Plaintiff beginning in 2016. (AR 529, 537.) The Appeals Council considered the new evidence-making the evidence part of the record-but ultimately denied review of Plaintiff's case on April 13, 2017. (AR 15-19.)

         On June 12, 2018, stating that it had committed a legal error, the Appeals Council set aside its previous decision and granted review of Plaintiff's case to consider additional information. (AR 152-55.) Plaintiff, who had recently retained an attorney, submitted additional medical records from Paradise Valley Hospital, records from Operation Samahan Health Clinic, and evidence from Dr. Manuel Puig-Llano and Dr. Erick Alayo for the Appeals Council to consider. (AR 541- 640.)

         The Appeals Council issued its final decision on July 23, 2018. (AR 4-7.) In its decision, the Appeals Council evaluated the ALJ's decision and considered the additional evidence that Plaintiff submitted around July 12, 2018. (AR 4.) The Appeals Council found that the new evidence did not have a reasonable probability of changing the outcome of the decision. (Id.) It then adopted the ALJ's findings and conclusions and held that Plaintiff was not disabled under the meaning of the Act. (AR 7.)


         Under 42 U.S.C. §§ 405(g) & 1383(c), an applicant for social security disability benefits may seek judicial review of a final decision of the Commissioner in federal district court. “As with other agency decisions, federal court review of social security determinations is limited.” Treichler v. Comm'r of Soc. Sec. Admin., 775 F.3d 1090, 1098 (9th Cir. 2014). A federal court will uphold the Commissioner's disability determination “unless it contains legal error or is not supported by substantial evidence.” Garrison v. Colvin, 759 F.3d 995, 1009 (9th Cir. 2014) (citing Stout v. Comm'r, Soc. Sec. Admin., 454 F.3d 1050, 1052 (9th Cir. 2006)). When reviewing whether the Commissioner's determination is supported by substantial evidence and free of error, the court must consider the record as a whole, “weighing both the evidence that supports and the evidence that detracts from the Commissioner's conclusion.” Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007) (quoting Reddick v. Chater, 157 F.3d 715, 720 (9th Cir 1998)).


         The Act defines “disability” as the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which . . . has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). Under the Act's implementing regulations, the Commissioner applies a five-step sequential evaluation process to determine whether an applicant for benefits qualifies as disabled. See 20 C.F.R. § 404.1520(a)(4). “The burden of proof is on the claimant at steps one through four, but shifts to the Commissioner at step five.” Bray v. Comm'r of Soc. Sec. Admin., 554 F.3d 1219, 1222 (9th Cir. 2009).

         At step one, the Commissioner must determine whether the claimant is engaged in “substantial gainful activity.”[2] 20 C.F.R. § 404.1520(a)(4)(i). If so, the claimant is not disabled. If not, the Commissioner proceeds to step two.

         At step two, the Commissioner must determine whether the claimant has a severe medical impairment, or combination of impairments, that meets the duration requirement in the regulations. 20 C.F.R. § 404.1520(a)(4)(ii). If the claimant's impairment or combination of impairments is not severe, or does not meet the duration requirement, the claimant is not disabled. If the impairment is severe, the analysis proceeds to step three.

         At step three, the Commissioner must determine whether the severity of the claimant's impairment or combination of impairments meets or medically equals the severity of an impairment listed in the Act's implementing regulations. 20 C.F.R. § 404.1520(a)(4)(iii). If so, the claimant is disabled. If not, the analysis proceeds to step four.

         At step four, the Commissioner must determine whether the claimant's residual functional capacity (“RFC”)-that is, the most he can do despite his physical and mental limitations-is sufficient for the claimant to perform his past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). The Commissioner assesses the RFC based on all relevant evidence in the record. Id. § 416.945(a)(1), (a)(3). If the claimant can perform his past relevant work, he is not disabled. If not, the analysis proceeds to the final step.

         At step five, the Commissioner bears the burden of proving that the claimant can perform other work that exists in significant numbers in the national economy, taking into account the claimant's RFC, age, education, and work experience. 20 C.F.R. § 404.1560(c)(1), (c)(2); see also Id. § 404.1520(g)(1). The Commissioner usually meets this burden through the testimony of a vocational expert, who assesses the employment potential of a hypothetical individual with all of the claimant's physical and mental limitations that are supported by the record. Hill v. Astrue, 698 F.3d 1153, 1162 (9th Cir. 2012). If the claimant is able to perform other available work, he is not disabled. If the claimant cannot make an adjustment to other work, he is disabled. 20 C.F.R. § 404.1520(a)(4)(v).


         In Plaintiff's case, the final agency decision on review is that of the Appeals Council. (AR 1.) However, because the Appeals Council adopted the findings and conclusions of the ALJ, (AR 4-5), the Court first examines the ALJ's findings directly.

         At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since the date on which he filed his application for disability benefits. (AR 89.) At step two, the ALJ found that Plaintiff suffered from degenerative disk disease, depression, and anxiety-all severe impairments that more than minimally limited his ability to do basic work activities. (Id.) The ALJ found that Plaintiff had recovered well from his prostatectomy and was not suffering from any lasting effects that would cause a severe impairment. (Id.) At step three, the ALJ found that Plaintiff's combination of impairments did not match the severity of any of the listed impairments in 20 C.F.R. § 404.1520(a)(4)(iii). (AR 90.) At step four, the ALJ determined that Plaintiff had the RFC to perform light work, with standard industry breaks every two hours and some additional physical, psychological, and social restrictions. (AR 91.)

         To reach his step four conclusions, the ALJ considered Plaintiff's physical and psychological limitations. The ALJ supported his conclusions about Plaintiff's physical limitations by relying on Plaintiff's testimony and his 2015-2016 treatment records. (AR 92.) Plaintiff's x-rays from November 2015 reveal mild chronic disk degeneration without acute findings (AR 332), and a CT scan in March 2016 showed evidence of degenerative disc disease, (AR 397). Treatment notes from November 2015 state that Plaintiff was experiencing “mild back pain.” (AR 334.) After several physical therapy sessions, Plaintiff's physical therapist reported overall improvement of his lower quadrant range of motion, good rehabilitation potential, and a ...

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