Padilla v. Commissioner of Social Security Administration

          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 ...