United States District Court, D. Arizona
ORDER
Bridget S. Bade United States Magistrate Judge
Plaintiff
Dorothy Padilla seeks judicial review of the decision of the
Commissioner of Social Security (the
“Commissioner”) denying her application for
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 a determination of benefits.
I.
Procedural Background
On June
24, 2013, Plaintiff applied for social security disability
income (“SSDI”) for a period of disability and
disability insurance benefits under Title II of the Act. (Tr.
29.)[1]
On December 11, 2013, she also applied for supplemental
security income (SSI) under Title XVI of the Act.
(Id.) After the Social Security Administration
(“SSA”) denied Plaintiff's initial
application and her request for reconsideration, she
requested a hearing before an administrative law judge
(“ALJ”). (Id.) After conducting a
hearing, on February 5, 2016 the ALJ issued a decision
finding Plaintiff not disabled under the Act.[2](Tr. 29-41.) On
June 15, 2017, the Social Security Administration Appeals
Council denied Plaintiff's request for review. (Tr. 1-6.)
Plaintiff now seeks judicial review of the ALJ's decision
pursuant to 42 U.S.C. § 405(g).
II.
Administrative Record
The
record before the Court establishes the following history of
diagnoses and treatment related to Plaintiff's physical
impairments.[3] The record also includes medical opinions.
A.
Relevant Treatment History
Plaintiff
received treatment from Steven Sumpter, D.O., at Integrated
Medical Services (“IMS”) beginning in October
2011 and continuing through 2015. (Doc. 16 at 6-7 (citing
(Tr. 399-403 (Oct. 11, 2011); Tr. 702-05 (Dec. 5, 2011); Tr.
396-99 (Dec. 18, 2012); Tr. 504-06 (May 1, 2013); Tr. 500-03
(Aug. 21, 2013); Tr. 496-99 (Nov. 5, 2013); Tr. 493-95 (Dec.
20, 2013); Tr. 552-55 (Jan. 30, 2014); Tr. 673-76 (March 11,
2014; Tr. 669-72 (March 28, 2014); Tr. 664-68 (April 22,
2014); Tr. 569-63 (May 22, 2014); Tr. 655-58 (June 30, 2014);
Tr. 651-54 (July 15, 2014); Tr. 860-64 (Mar. 23, 2015)).)
In
November 2013, Dr. Sumpter referred Plaintiff to the
orthopedic clinic at IMS, where she was evaluated by Navtej
Tung, M.D. (Tr. 518-22.) Plaintiff reported that she had
chronic low back pain that radiated into her legs. (Tr. 518.)
Plaintiff reported that she could sit for about an hour, she
could stand for thirty minutes, and she had difficulty
walking any distance. (Id.) On examination, Dr. Tung
observed that Plaintiff had tenderness at ¶ 4, L5, S1
that was “worse with forward flexion of the lumbar
spine” and with extension. (Tr. 521.) A straight-leg
raising test was positive on the left side. (Id.)
An MRI
of Plaintiff's lumbar spine showed “bilateral pars
defect” at ¶ 5-S1 “resulting in grade 1
anterolisthesis.” (Tr. 522.) The MRI also showed
“some facet degenerative changes . . . a disc bulge,
and foraminal narrowing.” (Id.) Dr. Tung
concluded that Plaintiff was “a good candidate for
interventional procedures.” (Tr. 522.) Therefore,
Plaintiff had lumbar epidural steroid injections on November
21, 2013 (Tr. 536), January 3, 2014 (Tr. 528 (noting chronic
back pain with radiation the legs)), and January 21, 2014
(Tr. 526, 598 (noting chronic back pain with radiation to the
legs)). She had an L4-S1 bilateral medial branch nerve block
on August 7, 2014 for “chronic low back pain.”
(Tr. 590-91.) Plaintiff had lumbar radiofrequency ablation
procedures on June 15 and 24, 2015. (Tr. 756, 749.) The June
2015 treatment notes state that Plaintiff's lumbar sacral
spine exhibited tenderness on palpation, muscle spasms, and
pain on motion. (Tr. 750, 757.) Straight-leg raising tests
were positive. (Id.)
On
referral from IMS, Plaintiff received physical therapy for
her back pain. (Tr. 612-14, 620.) During her initial visit on
March 12, 2014, Plaintiff reported that she had back pain
that “fluctuate[d] but [was] constant.”
(Id.) Plaintiff's pain disturbed her sleep and
was worse with sitting longer than thirty minutes, bending,
lifting or carrying groceries. (Id.) On examination,
Plaintiff had increased pain on forward bending, side
bending, and reported that pain travelled down both legs.
(Tr. 613.) During a March 2014 appointment, Plaintiff
reported that her pain fluctuated and she did not have any
pain at that time. (Tr. 610.) However, on examination,
Plaintiff reported that “STM” to the back was
painful. (Id.) On June 8, 2014, Plaintiff was
discharged from physical therapy for
“non-compliance.” (Tr. 609.)
B.
Opinion Evidence
1.
Treating Physician Steven Sumpter, D.O.
Treating
physician Dr. Sumpter completed three assessments of
Plaintiff's ability to perform work-related physical
activities.[4] On December 20, 2013, Dr. Sumpter assessed
Plaintiff and opined that she could not work eight hours a
days, five days a week on a regular basis due to her
“lumbar radiculopathy, facet syndrome, bulging disc,
spondylolisthesis of the lumbar spine, and morbid
obesity.” (Tr. 489.) He opined that, in an eight-hour
day, Plaintiff could sit for two hours, stand or walk for two
hours, and lift or carry less than ten pounds. (Id.)
Dr. Sumpter stated that it was “medically
necessary” for Plaintiff to change position every
twenty-one to forty-five minutes. (Id.) Dr. Sumpter
also opined that due to pain and fatigue, Plaintiff would be
“[o]ff task 16-20% of an 8hour work day.” (Tr.
490.) Dr. Sumpter confirmed that his opinions were based on
treatment notes, medical records, radiographic records, and
Plaintiff's responses to treatment. (Id.)
On
January 19, 2015, Dr. Sumpter completed another assessment of
Plaintiff's ability to perform work-related physical
activities. (Tr. 621.) Dr. Sumpter opined that Plaintiff
could not work on a regular and consistent basis due to
“severe, constant low back pain radiating into
legs.” (Id.) Dr. Sumpter assessed the same
exertional limitations that he assessed in December 2013.
(Compare Tr. 489 with Tr. 621.) Dr. Sumpter
again opined that Plaintiff needed to change positions every
twenty-one to forty-five minutes. (Id.) Dr. Sumpter
also opined that pain would cause severe limitations, defined
as being “[o]ff task greater than 21% of an 8-hour work
day.” (Tr. 622.)
On
August 25, 2015, Dr. Sumpter completed another assessment of
Plaintiff's ability to perform work-related physical
activities. (Tr. 740-41.) He found that Plaintiff's
“chronic back pain, myalgia, headaches, chest pain, and
difficulty breathing” affected her ability to function
and precluded an eight-hour work day. (Tr. 740.) He assessed
the same exertional limitations he had assessed in December
2013 and January 2019. (Compare Tr. 621
with Tr. 740.) He also opined that Plaintiff needed
to change position every twenty-one to forty-five minutes.
(Tr. 740.) Dr. Sumpter opined that Plaintiff's pain,
fatigue, dizziness, and headaches resulted in
“moderately severe” limitations that would cause
Plaintiff to be “[o]ff task 16-20% of an 8-hour work
day.” (Tr. 741.)
2.
State Agency Physician Maria Pons, M.D.
On
March 19, 2014, Dr. Maria Pons, a state agency physician,
reviewed the medical record and completed a residual
functional capacity assessment (“RFC”). (Tr.
160.) Dr. Pons opined that Plaintiff could sit, stand, and
walk about six hours in an eight-hour day. (Tr. 161.) She
opined that Plaintiff could occasionally lift or carry up to
twenty pounds, and could frequently lift or carry up to ten
pounds. (Id.) Dr. Pons found that Plaintiff could
frequently climb ramps and stairs, occasionally climb
ladders, ropes, or scaffolds, frequently stoop, kneel,
crouch, and crawl, and frequently handle. (Tr. 161-62.)
III.
Administrative Hearing Testimony
During
the October 16, 2015 administrative hearing, Plaintiff
testified that she was unable to work due to
“discomfort” caused by “a slipped disc in
[her] back.” (Tr. 86.) She also complained of
fibromyalgia, depression, and anxiety. (Id.)
Plaintiff testified that she had received treatment from her
primary care physician Dr. Sumpter for the previous three
years, and he had referred her to pain management. (Tr.
87.) Plaintiff testified that she was taking
prescribed pain medications, including Percocet and
cyclobenzaprine, which helped but did not eliminate her pain.
(Tr. 87-88, 95-96.) Plaintiff testified that medications
“subdue[d] the throbbing pain, ” but she was
never pain free. (Tr. 90-91, 94-95.) Plaintiff stated that
she had received injections and physical therapy for back
pain, but that she did not experience substantial benefit
from those treatments. (Tr. 91.)
Plaintiff
also testified that she could stand for twenty minutes and
walk for about an hour. (Tr. 90, 92.) Plaintiff testified
that she could sit for about forty-five minutes and then she
either had to “take a pill and ice [her] back” or
“heat [her] back.” (Id.) Plaintiff
testified that “pain management” had instructed
her not to lift anything heavier than a gallon of milk. (Tr.
93.) Plaintiff testified that she napped every day from 11:00
to 2:30, due to pain, fatigue, and depression. (Tr. 99.)
Plaintiff testified that she could take out the trash, do
laundry, and prepare ...