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Houston v. Colvin

United States District Court, Ninth Circuit

December 4, 2013

Kim Houston, Plaintiff,
v.
Carolyn W. Colvin, Commissioner of Social Security, Defendant.

ORDER

BRIDGET S. BADE, Magistrate Judge.

Kim Houston (Plaintiff) seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner), denying his application for disability insurance benefits and supplemental security income benefits under the Social Security Act. The parties have consented to proceed before a United States Magistrate Judge pursuant to 28 U.S.C. § 636(b) and have filed briefs in accordance with Local Rule of Civil Procedure 16.1. For the following reasons, the Court affirms the Commissioner's decision.

I. Procedural Background

In June 2009, Plaintiff applied for disability insurance benefits, 42 U.S.C. § 401-34, and supplemental security income, 42 U.S.C. § 1381-83c, under Titles II and XVI of the Social Security Act (the Act). (Tr. 129-39.)[1] Plaintiff alleged that he had been disabled since June 2009, due to lower back pain, diabetes, and a heart attack. (Tr. 144.) After the Social Security Administration (SSA) denied Plaintiff's initial application and his request for reconsideration, he requested a hearing before an administrative law judge (ALJ). (Tr. 63-74, 90-91.) After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 15-25.) This decision became the final decision of the Commissioner when the Social Security Administration Appeals Council denied Plaintiff's request for review. (Tr. 1-3); see 20 C.F.R. § 404.981 (explaining the effect of a disposition by the Appeals Council.) Plaintiff now seeks judicial review of this decision pursuant to 42 U.S.C. § 405(g).

II. Medical Record

The record before the Court establishes the following history of diagnosis and treatment.

A. Enrique Cifuentes, M.D.

Plaintiff received regular treatment from Dr. Cifuentes at Gila Internal Medicine Office (Gila) from January 2009 through 2011. (Tr. 220-38, 287-293, 308-23.) Although the signatures on most of the treatment notes are illegible, the parties do not dispute that Dr. Cifuentes provided the treatment described in the Gila records. The record reflects that Dr. Cifuentes treated Plaintiff for various complaints, including hypertension, lower back pain, and diabetes. (Tr. 221-38, 308-21.) Plaintiff was prescribed various medications including Oxycodone (Tr. 227, 228, 232, 234), Flexeril (Tr. 230), and Percocet. (Tr. 224, 226, 271, 375, 377, 387, 394, 430.) Examinations generally showed that Plaintiff had normal reflexes, normal gait, and no edema, but that he also had some numbness and parethesias. (Tr. 221-38, 308-21.) Dr. Cifuentes consistently recommended "diet" and "exercise." (Tr. 222, 224, 232, 234, 236, 309, 311, 313.)

In January 2010, Dr. Cifuentes completed a physical capacities assessment and a residual functional capacity (RFC) assessment. (Tr. 277-79, 280-81.) He opined that Plaintiff could not perform even sedentary work. (Tr. 277-79.) Dr. Cifuentes opined that Plaintiff could lift less than ten pounds, could stand or walk less than two hours in an eight-hour workday, and could sit two hours in an eight-hour workday. (Tr. 277.) He also opined that Plaintiff could never climb, stoop, kneel, or crouch, and could only occasionally reach. (Tr. 279.)

Dr. Cifuentes explained that these limitations were a result of "lumbalgia [low back pain], lumbosacral neuritis, lumbosacral spondylosis, [and] annular bulges [at] L4-5 and L5-S1." (Tr. 277.) Dr. Cifuentes found that Plaintiff suffered from "chronic back pain [with] radiculopathy, arthralgias, decreased range of motion, [and] vertigal dizziness due to medications." (Tr. 279.) In addition, Dr. Cifuentes assessed severe pain, defined as "[e]xtremely impaired due to pain which precludes ability to function" (Tr. 280), that frequently interfered with attention and concentration, and lead to the failure to complete tasks in a timely manner. (Tr. 281.)

In January 2011, Dr. Cifuentes completed another physical capacities assessment and RFC assessment. (Tr. 372-74, 370-71.) Dr. Cifuntes indicated that Plaintiff had severe pain. (Tr. 370.) He found that Plaintiff could occasionally carry ten pounds, frequently carry less than ten pounds, stand less than two hours in an eight-hour workday, and sit for six hours in an eight-hour work day. (Tr. 372.) He further found that Plaintiff could never climb, balance, stoop, kneel, crouch, or crawl. (Tr. 373.) He opined that Plaintiff could not perform fine manipulation or "feel, " but could occasionally handle and reach. (Tr. 373.)

B. Minesh Zaveri, M.D.

On referral from Dr. Cifuentes, Dr. Zaveri treated Plaintiff at Sonoran Pain Management. (Tr. 224, 253-73, 375-437.) Examinations documented that Plaintiff had some positive straight leg raising tests, tenderness in the lumbar spine, antalgic gait, and normal strength, reflexes, and senses. (Tr. 257, 263, 270, 329, 376, 386, 393, 409, 417, 423, 434.) Plaintiff had several epidural steroid injections beginning in October 2009. (Tr. 254-72, 375-436.) He also had lumbar facet injections (Tr. 272), lumbar medical nerve branch blocks (Tr. 436, 431), and lumbar nerve radiofrequency ablation. (Tr. 381, 419, 425, 438.) He initially reported some resolution of his low back pain. (Tr. 256, 262.) Plaintiff subsequently reported more significant resolution of his pain. (Tr. 375, 385, 416, 422, 428, 433.) Later examinations reflected that Plaintiff no longer had positive straight leg raising tests. (Tr. 376, 378, 386, 393, 400, 409.) On Dr. Zaveri's recommendation, Plaintiff attended physical therapy from January through March 2010. (Tr. 324-63.) At discharge, Plaintiff's therapist opined that his progress had "plateaued" and that his prognosis was fair. (Tr. 324.)

C. Elizabeth Ottney, D.O.

In September 2009, the state agency referred Plaintiff to Dr. Ottney for a consultative examination. (Tr. 214-16.) Although Dr. Ottney ordered an x-ray as part of the consultative examination, she conducted the examination without the films because they were not available on the date of Plaintiff's appointment. (Tr. 215 (noting that the lumbosacral spine films [are] unavailable for my review today").)

During that examination, Plaintiff reported that he had low back pain that had started one year earlier with no precipitating injury. (Tr. 214.) Plaintiff stated that an MRI showed that he had two bulging disk in his back. ( Id. ) Plaintiff reported that his back pain was "better" with medication. ( Id. ) During the examination, Plaintiff reported fatigue, dizziness, shortness of breath, and a racing heart. (Tr. 215.) On examination, Dr. Ottney found that Plaintiff had no edema, normal strength in his upper and lower extremities, normal balance, normal coordination, the ability to walk without a cane, and normal straight leg raising tests. (Tr. 215.) Plaintiff could heel and toe walk, tandem walk, and squat. ( Id. ) Plaintiff's range of motion in his joints was normal except his lumbar flexion was limited to thirty degrees. ( Id ). Dr. Ottney opined that Plaintiff was not limited in his ability to "sit, hear, see, speak, finger, grasp or reach." (Tr. 215.) She found that Plaintiff did not appear limited in his ability to stoop or crouch, but "may have difficulty with repetitively climbing ladders and scaffolding as well as crawling secondary to a small knee effusion." (Tr. 216.) She also opined that Plaintiff could lift ten pounds frequently and twenty pounds occasionally. (Tr. 216.)

D. Christopher Maloney, M.D.

On November 4, 2009, Dr. Maloney, a state agency physician, completed a physical RFC assessment based on his review of the medical record. (Tr. 239-46.) Dr. Maloney found that Plaintiff could occasionally lift/carry twenty pounds and could frequently lift/carry ten pounds. (Tr. 240.) He also found that Plaintiff could stand/walk and sit for about six hours in an eight-hour workday. ( Id. ) He further found that Plaintiff could frequently balance, stoop, kneel, and crouch, and could occasionally climb ramps/stairs and crawl. (Tr. 241.) He found that Plaintiff had no "manipulative limitations." (Tr. 242.)

E. James Green, M.D

In March 2010, Dr. Green, a state agency physician, reviewed the medical record, including the opinions of Dr. Ottney and Dr. Cifuentes, and assessed Plaintiff's physical RFC. (Tr. 294-301.) Dr. Green found that Dr. Cifuentes's opinion that Plaintiff had a "less-than-sedentary" RFC and was nearly "bedridden" was not supported by the objective medical evidence or the functional data in the file and was not projected to last twelve months. (Tr. 300.) Dr. Green found that Plaintiff could occasionally lift/carry twenty pounds and could frequently lift/carry ten pounds. (Tr. 295.) He found that Plaintiff could stand/walk and sit six hours in an eight-hour workday. ( Id. ) He further found that Plaintiff could occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl. (Tr. 296.) He found that Plaintiff had no "manipulative limitations." (Tr. 297.) In support of his findings, Dr. Green stated that, although Plaintiff complained of pain, he had "excellent progress" from local injections and was "projected to light work." (Tr. 295.) He also noted that Plaintiff was able to drive, shop, and take his kids to school. (Tr. 299.)

III. Administrative Hearing Testimony

Plaintiff was in his forties at the time of the administrative hearing. (Tr. 23, 37.) He had an eleventh grade education and a general equivalency diploma. (Tr. 39.) Plaintiff's past relevant work included heavy truck driver. (Tr. 51, 145.) Plaintiff testified at the administrative hearing that he was unable to work because of ongoing low back pain due to "three bulging discs." (Tr. 42.) He stated that interventions such as injections and radiofrequency ablation helped relieved his pain for a few days, and "then it's back to where it was." (Tr. 44.) Plaintiff testified that during a typical eight-hour day he spent six hours lying in bed sleeping or watching television. (Tr. 44-45, 49.) Plaintiff testified that he could stand for one hour and sit for forty minutes. (Tr. 44.) He also testified that he experienced numbness and weakness in his hands. (Tr. 47.)

Vocational expert Nathan Dean, M.Ed. also testified at the administrative hearing. He classified Plaintiff's past work as semi-skilled and skilled work performed at the medium exertional level. (Tr. 51.) The vocational expert responded to a hypothetical question from ALJ. The ALJ asked the vocational expert to assume:

[S]o if we had someone... able to do light exertional level work... [a]nd the job would be unskilled. There'd be postural restrictions, so there'd be no crawling or crouching or climbing or squatting or kneeling. And lower extremity limitations, so there'd be no use of[2] the ...

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