United States District Court, D. Arizona
Jesse D. Torres, Plaintiff,
Carolyn W. Colvin, Defendant.
BRIDGET S. BADE, Magistrate Judge.
Plaintiff Jesse D. Torres seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner) denying his application for disability insurance benefits under the Social Security Act (the 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 reverses the Commissioner's decision and remands for an award of benefits.
I. Procedural Background
On November 12, 2009, Plaintiff applied for disability insurance benefits under Title II of the Act, based on disability beginning July 30, 2009. (Tr. 150.) 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). After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 21-32.) This decision became the final decision of the Commissioner when the Social Security Administration Appeals Council denied Plaintiff's request for review. (Tr. 1-7); 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 related to Plaintiff's health. The record also includes an opinion from a lay witness, and opinions from State Agency Physicians who examined Plaintiff and reviewed the records related to Plaintiff's impairments, but who did not provide treatment.
A. Treatment Records
1. Lawrence R. Ryan, D.O.
On July 1, 2008, Plaintiff began treatment with Dr. Ryan for diabetes. (Tr. 291.) Dr. Ryan assessed hypertension, neuropathy in diabetes, disc degeneration, and obesity. ( Id. ) On July 14, 2008, Dr. Ryan noted that Plaintiff had signs of neuropathy in his legs. (Tr. 289-90.) On August 18, 2008, Dr. Ryan noted that Plaintiff had experienced intermittent tingling, stiffness, and numbness in his hands and fingers, particularly when sleeping or driving. (Tr. 287.) Dr. Ryan referred Plaintiff for testing for his bilateral hand deficit. (Tr. 287-88.) Dr. Ryan also noted that Plaintiff had anxiety and prescribed Lexapro. ( Id. ) On October 24, 2008, Dr. Ryan noted that Plaintiff experienced shortness of breath when walking or working in the yard and again assessed Plaintiff with anxiety. (Tr. 284-85.)
On November 17, 2008, Dr. Ryan noted that Plaintiff was having frequent episodes of low blood sugar, anxiety, and decreased energy. He opined that Plaintiff's diabetes was uncontrolled and adjusted his medications. (Tr. 278-79.) Dr. Ryan prescribed Plaintiff medication for hypertension, high cholesterol, and diabetes. (Tr. 270.)
2. Joseph Gottesman, M.D.
In July 2008, Plaintiff began receiving treatment from Dr. Gottesman for his chronic low back pain. (Tr. 268.) In July 2008, Dr. Gottesman noted that on examination Plaintiff had edema upon palpation of his lumbar facets at L4-L5 and L5-S1, and that pressure on the facets produced radiating pain and numbness in Plaintiff's legs. ( Id. ) Dr. Gottesman administered a series of injections for Plaintiff's back pain in July (one shot), September (three shots), November (one shot), and December 2008 (one shot). (Tr. 265-68.) Dr. Gottesman administered another injection in April 2009. (Tr. 264.) Dr. Gottesman's treatment notes consistently record low back pain. (Tr. 264-68.) On May 16, 2009, Plaintiff received an MRI of his lumbar spine, which revealed narrowing of the lumbar spinal canal with degenerative changes, spinal canal stenosis in the lumbar spine, a protruding disc, and "grade I retrolisthesis of L5 on S1." (Tr. 269.)
Plaintiff returned to Dr. Gottesman in December 2009 and reported increasing back pain. (Tr. 387-89.) Plaintiff reported that his medications were not working as well as they had in the past, and although he had discussed back surgery with his doctor, it had been "denied." (Tr. 387.) Dr. Gottesman administered at least six more injections for Plaintiff's lower back pain between December 3, 2009 and May 11, 2010. (Tr. 374, 375, 376, 378, 382, 386.) Dr. Gottesman continued to treat Plaintiff for his low back pain with pain medications, Oxycontin and Percocet, and numerous injections between June 3, 2010 and February 22, 2011. (Tr. 532, 535, 539, 542, 545, 548, 551, 557, 561, 564, 566, 570, 580, 583, 586, 589.) He administered additional injections between June and December 2011. (Tr. 641, 645, 649, 653, 657, 660, 663, 670, 673, 676, 679.)
3. Ricardo Celaya, M.D.
In March 2009, Plaintiff received injections from Dr. Celaya for his low back pain. (Tr. 335.) Dr. Celaya administered at least five more injections during 2009. (Tr. 366-71.) Dr. Celaya assessed Plaintiff with low back pain and degeneration of the lumbar intervertebral discs. (Tr. 345, 346-38, 353.) He noted that Plaintiff had low back pain that radiated into his lower extremities. (Tr. 365-67.) In November 2009, he noted that Plaintiff had increased low back pain and numbness. (Tr. 371.)
4. James Beauchene, M.D.
On April 21, 2009, Dr. Beauchene examined Plaintiff's hands and wrists. (Tr. 307.) He noted that Plaintiff had pain in his left hand and difficulty flexing his left "long and ring fingers." ( Id. ) Plaintiff reported that using a splint and taking Vicodin had not relived his symptoms. ( Id. ) On examination, Plaintiff had a decreased range of motion in his fingers. (Tr. 309.) During a follow-up examination, on April 28, 2009, Dr. Beauchene noted continued numbness and tingling in Plaintiff's hand, and that Plaintiff was dropping objects. (Tr. 312) Dr. Beauchene found positive Tinel's and Phalen's tests in both carpal and ulnar tunnels. ( Id. ) He also found "locking of the left ring finger in composite flexion with snapping from flexion to extension." ( Id. )
A May 4, 2009 motor nerve conduction test of Plaintiff's left arm revealed findings consistent with left carpal tunnel syndrome. (Tr. 322-23.) On May 12, 2009, Dr. Beauchene noted that Plaintiff continued to experience numbness and tingling in both hands, finger locking, and problems dropping objects. (Tr. 315.) Dr. Beauchene discussed treatment options with Plaintiff, including carpal tunnel release surgery. (Tr. 315-16.) On June 9, 2009, Dr. Beauchene opined that Plaintiff should avoid "lifting or force greater than [five] pounds with either hand, " repetitive use of either hand, climbing to unprotected heights, and exposure of either hand to power tools or open active machinery until he could be reassessed after carpal tunnel surgery. (Tr. 319.)
5. Michael A. Steingart, D.O.
On May 20, 2010, Plaintiff saw Dr. Steingart for right shoulder pain. (Tr. 452.) Dr. Steingart noted tenderness over the top of the shoulder and pain with most motions. ( Id. ) An MRI of Plaintiff's shoulder revealed that his prior surgical repair had not "detach[ed]." (Tr. 452.) Dr. Steingart noted mild weakness of the right scapular muscles and recommended physical therapy. ( Id. )
On October 4, 2010, Dr. Steingart administered an injection for Plaintiff's right shoulder pain. (Tr. 684.) On November 22, 2010, Dr. Steingart examined Plaintiff and noted the he continued to have right shoulder pain and carpal tunnel syndrome in his left wrist. (Tr. 681-82.) Plaintiff told Dr. Steingart that he could not afford physical therapy for his shoulder or surgery for the carpal tunnel syndrome in his wrist. ( Id. )
B. Opinion Evidence
1. Dr. Gottesman
On May 13, 2010, Dr. Gottesman prepared a "Medical Assessment of Ability to do Work-Related Physical Activities" (RFC Assessment). (Tr. 450.) He noted that Plaintiff had been diagnosed with lumbosacral radiculopathy, osteoarthritis, degenerative joint disease, degenerative disc disease, spinal stenosis, lumbosacral facet syndrome, and chronic pain managed with narcotics. ( Id. ) He opined that Plaintiff could sit, stand, or walk less than two hours each in an eight hour day, and lift or carry less than ten pounds. ( Id. ) He also opined that Plaintiff could occasionally bend, stoop, balance, crouch, and kneel, and should avoid crawling, climbing, and repetitive use of his feet. (Tr. 450.) Dr. Gottesman further found that Plaintiff's pain, fatigue, and stress could be expected to result in moderately severe limitations on his ability to sustain work activity. (Tr. 451.) On February 22, 2011, Dr. Gottesman reviewed his 2010 RFC Assessment and concluded that Plaintiff continued to have the same limitations as set forth in that assessment. (Tr. 596-97.)
On November 17, 2011, Dr. Gottesman completed another RFC Assessment. (Tr. 636-37.) He assessed Plaintiff with essentially the same limitations that he assessed in 2010 and affirmed in February 2011. ( Compare Tr. 45-51 with Tr. 636-37.) He concluded that Plaintiff had moderately severe limitations in his ability to perform work due to pain, fatigue, and dizziness. ( Id. ) ...