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Valenzuela v. Commissioner of Social Security Administration

United States District Court, D. Arizona

February 27, 2018

Monica Valenzuela, Plaintiff,
v.
Commissioner of Social Security Administration, Defendant.

          ORDER

          Leslie A. Bowman United States 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). (Doc. 1, p. 1); see also 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. 22)

         The court finds that the final decision of the Commissioner at step five of the disability analysis is supported by substantial evidence and free from legal error.

         The ALJ gave specific and legitimate reasons for discounting the opinion of the treating physician. She gave clear and convincing reasons for discounting the claimant's subjective testimony of disability. Her step 2 determination was not reversible error.

         PROCEDURAL HISTORY

         On March 18, 2013, Valenzuela filed for supplemental security income pursuant to Title XVI of the Social Security Act. (Tr. 130) She alleged disability beginning on January 1, 2012, due to fibromyalgia, PTSD, depression/anxiety, chronic migraine, carpal tunnel, chronic spondylosis w/out myelopathy, cervical radiculopathy, and neuralgia neuritis. (Tr. 130, 164).

         Her claims were denied initially (Tr. 92-95) and upon reconsideration (Tr. 96-98). Valenzuela requested review and appeared with counsel at a hearing before Administrative Law Judge (ALJ) Jasmin Elias on December 2, 2015. (Tr. 37) In her decision, dated February 4, 2016, the ALJ found Valenzuela was not disabled. (Tr. 19-29) Valenzuela appealed, and on April 10, 2017, the Appeals Council denied review making the decision of the ALJ the final decision of the Commissioner. (Tr. 1-3) Valenzuela subsequently filed this action appealing that decision. (Doc. 1)

         Claimant's Work History and Medical History

         Valenzuela was born in July of 1963. (Tr. 42) She was 52 years old when the ALJ issued her decision in February of 2016. (Tr. 29, 42).

         Valenzuela graduated from high school and has some college education. (Tr. 43) She worked briefly as a bartender, a concrete form setter, and a grocery stock worker. (Tr. 165) None of her jobs qualifies as “past relevant work.”

         Mental Impairment

         In December of 2013, a psychologist identified as G.R.L., Ph.D., reviewed the medical record for the disability determination service and offered an opinion of Valenzuela's mental limitations. (Tr. 65) G.R.L. diagnosed Valenzuela with affective disorder and anxiety disorder. (Tr. 64) G.R.L. then evaluated Valenzuela's “B” listing criteria, which gauge the severity of her limitations. See 20 C.F.R. § 416.920a(c)(3). G.R.L. found Valenzuela has “mild” restrictions of her daily activities; “moderate” difficulties in maintaining social functioning; “moderate” difficulties in maintaining concentration, persistence, or pace; and no evidence of decompensation. (Tr. 64) G.R.L. further opined that the medical evidence did not establish the presence of the “C” criteria, which are an alternative gauge of the extent of her mental impairment. (Tr. 65)

         G.R.L. found Valenzuela is markedly limited in her ability to understand and remember detailed instructions. (Tr. 69) She is markedly limited in her ability to carry out detailed instructions and moderately limited in her ability to maintain attention and concentration for extended periods. (Tr. 69) She is markedly limited in her ability to interact appropriately with the general public. (Tr. 70) G.R.L. opined that Valenzuela can perform simple tasks with routine supervision. (Tr. 70) She can relate to supervisors and peers but cannot relate to the general public. (Tr. 70)

         In April of 2014, Burnard Pearce, Ph.D., reviewed the medical record for the disability determination service and offered an opinion of Valenzuela's mental limitations. (Tr. 81) He diagnosed Valenzuela with affective disorder, anxiety disorder, and also substance addiction disorder. (Tr. 79) Otherwise, he agreed with G.R.L.'s evaluation of Valenzuela's mental impairments and her functional limitations. (Tr. 83-86)

         In January of 2014, treating physician Donald R. Smith, M.D., completed a Medical Source Statement - Mental. (Tr. 823) He opined that Valenzuela's ability to understand and remember detailed or complex instructions was “poor.” (Tr. 823) Also “poor” was her ability to attend and concentrate; ability to work without supervision; and ability to interact with the public, coworkers, or supervisors. (Tr. 824) Also “poor” was her ability to adapt to changes in the workplace. (Tr. 824) These limitations, he opined, are caused by Valenzuela's chronic pain and medications. (Tr. 824) He noted that her medications “cause mental and physical slowing.” (Tr. 824) Smith's recommendation was made part of the record in January of 2015. (Tr. 823) Apparently, his treatment records were never made part of the case medical record. (Tr. 275)

         In December of 2015, Janet San Nicholas, MC, NCC, LPC, wrote a letter evaluating Valenzuela's mental condition. She stated that Valenzuela “has been diagnosed with Post Traumatic Stress Disorder, the symptoms of which are exacerbated by the severe, constant, physical pain of Fibromyalgia, and resulting physical trauma from years of abuse and a bicycle accident.” (Tr. 1253) “The combination of these mental and physical symptoms results in drastic restrictions to her everyday life functioning in all aspects of her life.” Id. “Ms. Valenzuela is unable to sit through a full hour session as she needs to constantly shift positions ending up lying down as this is the least painful position for her.” Id. “She has no patience for people or things she encounters as she is constantly battling the physical pain and the resulting anger and frustration, anxiety and sadness that results.” Id. San Nicholas completed a Mental Residual Functional Capacity Assessment in which she opined that Valenzuela is “markedly limited” in all areas of mental functioning. (Tr. 1254-55)

         Physical Impairment

         In December 2013, Charles Clayton, M.D., reviewed the medical records for the disability determination service and offered an opinion of Valenzuela's physical limitations. (Tr. 68) Clayton opined that Valenzuela could lift 20 pounds occasionally and 10 pounds frequently. (Tr. 67) She could sit, stand, and/or walk for 6 hours in an 8-hour day. (Tr. 67) She has no other vocational limitations. Clayton's opinion suggests that Valenzuela can perform light work. See 20 C.F.R. § 416.967(b).

         In October of 2015, treating physician Donald R. Smith, M.D., completed an evaluation entitled Medical Work Tolerance Recommendations. (Tr. 273) Smith opined that Valenzuela could stand for 10 minutes at one time and for 2 hours total. (Tr. 273) She could sit for 30 minutes at one time and for 4 hours total. (Tr. 273) She could walk for 10 minutes at one time and for 60 minutes total. (Tr. 273) Smith opined that Valenzuela could not lift 10 pounds occasionally. (Tr. 273) She could not climb ladders or stairs. (Tr. 273) Smith opined that Valenzuela would miss 30 days of work per month. (Tr. 274) He documented further postural limitations, manipulative limitations, and environmental limitations. (Tr. 274) Smith's opinion suggests that Valenzuela cannot perform even sedentary work. See 20 C.F.R. § 416.967. Smith's recommendation was made part of the record in December of 2015. (Tr. 272) Apparently, his treatment records were never made part of the case medical record. (Tr. 275)

         In April of 2014, Herbert Meites, M.D., reviewed the medical record for the disability determination service and considered the severity of Valenzuela's physical impairments. (Tr. 83-84) Meites ...


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