United States District Court, D. Arizona
LESLIE A. BOWMAN, Magistrate Judge.
The plaintiff filed this action for review of the final decision of the Commissioner for Social Security pursuant to 42 U.S.C. § 405(g) and 42 U.S.C. § 1383(c)(3).
The Magistrate Judge presides over this case pursuant to 28 U.S.C. § 636(c) having received the written consent of both parties. See FED.R.CIV.P. 73; (Doc. 10)
The court finds the final decision of the Commissioner must be reversed. The ALJ's finding at step two of the disability analysis that Miranda's shoulder impairment and back impairment are not "severe" is not supported by substantial evidence. See Smolen v. Chater, 80 F.3d 1273, 1279 (9th Cir. 1996). The case will be remanded for further proceedings.
Miranda filed his application for disability insurance benefits and supplemental security income on July 6, 2012. (Tr. 19) He alleged disability beginning on April 30, 2012, due to left shoulder injury, ruptured shoulder tendon, arthritis, osteoporosis, high blood pressure, cholesterol, acid reflux, and diabetes. (Tr. 19, 166) His claim was denied initially (Tr. 80-87) and upon reconsideration (Tr. 88-94). Miranda requested review and appeared with counsel at a hearing before Administrative Law Judge (ALJ) Norman R. Buls on February 12, 2014. (Tr. 32) In his decision, dated March 7, 2014, the ALJ found Miranda is not disabled because he has no severe impairments. (Tr. 19-25)
Miranda appealed and submitted additional exhibits, but the Appeals Council denied review making the decision of the ALJ the final decision of the Commissioner. (Tr. 1-4); see Bass v. Social Sec. Admin., 872 F.2d 832, 833 (9th Cir. 1989). Miranda subsequently filed this action appealing the Commissioner's final decision. (Doc. 1) He argues the ALJ erred in finding his shoulder impairment, right elbow impairment, and low back impairment are not "severe." (Doc. 13)
Claimant's Work History and Medical History
At the time of the hearing, Miranda was 60 years old. (Tr. 32-33) He has a sixth grade education. (Tr. 34) He can understand some English, but he is not fluent. (Tr. 34)
Miranda worked as a laborer in a plastering company and as a cleaner in a cement plant. (Tr. 167) In his job as cleaner, he frequently lifted objects weighing 50 pounds or more. (Tr. 189) Miranda was laid off in June of 2008. (Tr. 166) Since that time, he has had surgery on his left shoulder and a laminectomy in his back. (Tr. 37) Miranda maintains that pain in his arms, shoulder, and waist prevent him from lifting more that ten pounds at a time. (Tr. 40)
Miranda first injured his shoulder in 1999 when he fell at work. (Tr. 262, 388) He suffered intermittent symptoms until February of 2012 when he aggravated his injury while trimming trees. (Tr. 388) R. W. Wood, M.D., noted "[t]he MRI study shows a small full thickness supraspinatus rotator cuff tear." (Tr. 91) He recommended that Miranda ice and rest his shoulder. Id. He briefly discussed rotator cuff surgery. Id.
In April of 2012, the medical record indicates that a corticosteroid injection to Miranda's left shoulder was only partially beneficial. (Tr. 384) Wood assessed "rotator cuff tear - small-moderate, chronic." (Tr. 386) He referred Miranda to a course of physical therapy. In June of 2012, Wood noted that "injection and therapy have not been helpful, " and Miranda was "taking Percocet four times a day for pain." (Tr. 380)
X-ray studies were performed in June of 2012. (Tr. 378) George R. Bradbury, M.D., assessed "rotator cuff tear - large-massive, chronic." (Tr. 378) In July of 2012, Bradbury performed a "left shoulder open rotator cuff repair and subacromial decompression." (Tr. 232)
The medical record documents Miranda's post operative treatment. (Tr. 364, 368, 371, 373) Miranda reported improvement, but he still had pain and swelling two months after surgery. (Tr. 368)
In September of 2012, Miranda was examined by Melvyn Weinberg, M.D., for the state disability determination service. (Tr. 309) Weinberg diagnosed "rotator cuff derangement of the left shoulder with recent surgical repair and continued pain and decreased motion plus regular Oxycodone use; recent muscle injury of the left posterior thigh with possible partial tear which occurred in ...