Quintana v. Commissioner of Social Security Administration

          ORDER

          BRIDGET S. BADE UNITED STATES MAGISTRATE JUDGE

         Plaintiff Elaine Quintana seeks judicial review of the final 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 Rule 16.1 of the Local Rules of Civil Procedure. As discussed below, the Court vacates the Commissioner's decision and remands for further proceedings.

         I. Procedural Background

         In October 2013, Plaintiff applied for Social Security Disability Insurance (“SSDI”) alleging a disability onset date of October 19, 2011.^[1] (Tr. 145-46.)^[2] Plaintiff alleged disability based on neuropathy in her hands and feet, weakness in her wrists, chronic joint pain in her fingers, wrists, elbows, knees and hips, shoulder pain, blurry vision, and teary eyes. (Tr. 211.) Plaintiff alleged that all of these conditions were caused by the medication she took during chemotherapy. (Id.) She also alleged fatigue. (Tr. 27.) After Plaintiff's application was denied on initial review, and on reconsideration, she requested a hearing before an administrative law judge (“ALJ”). (Tr. 22.) Following a hearing the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 22-38.) Plaintiff requested review of the ALJ's decision. (Tr. 1-7.) The Social Security Appeals Council denied Plaintiff's request for review and Plaintiff now seeks judicial review of the Commissioner's decision pursuant to 42 U.S.C. § 405(g).

         II. Administrative Record

         The administrative record includes medical records pertaining to the history of diagnoses and treatment of Plaintiff's alleged impairments. The record also includes several medical opinions. The Court discusses the relevant records and opinions below

         A. Medical Treatment Records

         In December 2011, Plaintiff was diagnosed with breast cancer. (Tr. 366-67.) Oncologist Ian K. Komenka, M.D., prescribed six cycles of intravenous chemotherapy. (Tr. 367.) Plaintiff was also treated with radiation. (Tr. 673.) In February 2012, a liver biopsy revealed that Plaintiff had severe liver disease. (Tr. 401-02.) In April 2012, Plaintiff's treating gastroenterologist, Abdul Nadir, M.D., noted that Plaintiff was currently receiving chemotherapy and had several side effects including fatigue. (Tr. 468.) In May 2012, Colan Kennelly, M.D., noted that Plaintiff had “puffy eyes with excess tearing for 3 weeks, ” which was a symptom of conjunctivitis but was also a side effect of the chemotherapy drug Taxotere. (Tr. 311.) In June 2012, Plaintiff reported that she was exhausted from chemotherapy and wanted to postpone breast surgery for a month. (Tr. 504.)

         In July 2012, Plaintiff had surgery, including a right wire-guided lumpectomy. (Tr. 522.) In February 2013, after Plaintiff completed chemotherapy, Dr. Nadir prescribed hepatitis treatment. (Tr. 607, 661.) After her chemotherapy treatment ended, Plaintiff also continued to receive Herceptin intravenously for one year. (Tr. 458-59, 519.) In March 2013, while Plaintiff was undergoing hepatitis treatment, Charlotte Gurule, M.D., noted that Plaintiff had chronic abdominal pain, lymphedema of the right arm, right shoulder and middle back pain, and ongoing numbness in the hands and feet. (Tr. 304.) Plaintiff reported that she frequently dropped things due to numbness in her hands. (Id.) In May 2013, Plaintiff told Dr. Gurule she felt weak and lightheaded and had severe skin itching and fatigue. (Tr. 300.) That same month, Plaintiff was hospitalized and had a blood transfusion for severe anemia. (Tr. 328-31.) In May 2013, Dr. Nadir decreased Plaintiff's dose of hepatitis medication, Ribavivrin, due to dizziness, shortness of breath, and weakness. (Tr. 686-90.) In August 2013, Dr. Nadir noted Plaintiff had had 21 shots of the hepatitis medication Pegasys, and was “still experiencing nausea, vomiting and headache and fatigue.” (Tr. 724.)

         In October 2013, Sabrina Pojar, D.O., noted that Plaintiff had joint pain “most likely from osteoarthritis, ” but medications used to treat hepatitis “have a side effect of arthritis and arthralgia.” (Tr. 953.) On examination, Dr. Pojar observed Plaintiff had bilateral finger joint swelling and bilateral knee crepitus. (Tr. 956.) In November 2013, Dr. Nadir noted Plaintiff was no longer receiving treatment for hepatitis, but she had abdominal pain and elevated liver function levels on laboratory testing. (Tr. 748-49.)

         In January 2014, rheumatologist Stuart Posner, M.D., noted that Plaintiff had ongoing “generalized joint pain, ” “general fatigue, ” and an x-ray suggested probable degenerative arthritis in the knees. (Tr. 779.) Dr. Posner noted that Plaintiff had mild compression tenderness of the finger joints, mild crepitation in both knees, and a restricted range of motion of the left shoulder. (Id.) In April 2014, Dr. Pojar noted that Plaintiff's pain was “uncontrolled.” (Tr. 976.) Plaintiff reported muscle cramps in her jaw, right foot, arms, and back. (Id.) She reported that muscle cramps were worse with stretching or walking. (Id.) She also had continued polyarthalgias. (Id.) In May 2014, Plaintiff reported to Duane Mitzel, M.D., that she had tearing, eye discharge, burning eyes, and blurred vision. (Tr. 826-27.) In July 2014, Plaintiff reported to Dr. Pojar that she had “diffuse pain, muscle cramping, and occasional numbness and tingling in hands and feet.” (Tr. 966.) Dr. Pojar noted that Plaintiff had undergone chemotherapy and that paraesthesias was a side effect. (Id.) Plaintiff reported decreased activity. (Id.)

         In December 2014, Zachary Ortiz, M.D., noted that Plaintiff reported pain in the groin, legs, arms, stomach, and back, that “appears consistent with neuropathy of unclear etiology, chemo side effect, depression.” (Tr. 887.) In May 2015, Dr. Pojar noted Plaintiff had a normal vision screen and eye examination but had “nonspecific color and flashes of light in both eyes.” (Tr. 979.) In August 2015, Dr. Nadir noted that Plaintiff had stopped treatment for hepatitis over one year ago but she continued to report fatigue and joint pain. (Tr. 1002.) In October 2015, an abdominal ultrasound revealed that Plaintiff had hepatic cirrhosis. (Tr. 1092.)

         B. Medical Opinion Evidence

         1. Non-Examining Physicians

         As part of the initial state agency determination, in February 2014, Allen Radkowsky, M.D., opined that Plaintiff retained the physical abilities to perform light work with some restrictions, including occasionally climbing ladders, ropes, and scaffolds, and occasionally crawling. (Tr. 65-67.) As part of the reconsideration determination, in October 2014, Michael Keer, D.O., assessed the same physical abilities and restrictions. (Tr. 82-85.)

         2. Treating Physician Opinion

         In October 2015, Dr. Nadir completed a Medical Assessment of Ability to do Work-Related Physical Activities. (Tr. 984-85.) Dr. Nadir opined that Plaintiff could sit, stand, or walk less than two hours in an eight-hour day. (Tr. 984.) Dr. Nadir opined that Plaintiff needed to change positions and rest every ten to fifteen minutes. Dr. Nadir opined that Plaintiff's “symptoms” caused moderately severe limitations, defined as limitations that would result in being “[o]ff task 16-20% of an 8-hour day.” (Tr. 985.) The form asked Dr. Nadir to identify those symptoms by “(circl[ing] all that apply) pain, fatigue, dizziness, headaches, other.” (Id.) Dr. Nadir did not circle any of the listed symptoms or identify any “other” symptoms. (Id.) Dr. Nadir opined that Plaintiff's “medical condition” would cause her to miss work four to five days per month. (Id.) Dr. Nadir indicated that he had provided or supervised Plaintiff's treatment and that he has considered and reviewed his treatment notes, records from other providers, laboratory reports, and Plaintiff's responses to treatment. (Id.) He indicted “no” in response to whether “the limitations result from objective, clinical, or diagnostic findings which have been documented either by [him], or elsewhere in the patient's medical records.” (Id.)

         III. The Administrative Hearing

         Plaintiff was fifty-five years old at the disability onset date and fifty-nine years old as of the date of the administrative hearing. (Tr. 41, 43.) Plaintiff had a high school education and her past relevant work included work as a “clerk, ” a light, skilled job. (Tr. 30-31.)

         Plaintiff testified at the administrative hearing, but the ALJ did not call a vocational expert to testify. (See tr. 39.) At the administrative hearing Plaintiff testified that while undergoing treatment for breast cancer, she was “constantly sick, very fatigued, ” and “had issues with walking.” (Tr. 45.) Plaintiff also had “problems with [her] legs and [her] hands.” (Id.) Plaintiff stated that a few months after her breast cancer treatment ended, she started treatment for advanced liver fibrosis. (Tr. 46-47.) Plaintiff completed five months of that treatment but could not finish the whole course of treatment. (Tr. 47.) Plaintiff continued to have significant fatigue following her treatment for breast cancer and liver problems. (Tr. 47-48.) Plaintiff testified that the fatigue was “like somebody took all [her] energy. [She couldn't] function [and] need[ed] to just go lay down.” (Tr. 48, 49.) Plaintiff stated that she experienced daily fatigue that required her to nap for two to three hours. (Id.)

         Plaintiff testified that she also had joint pain in her hands, knuckles, shoulders, knees, and feet. (Tr. 50.) Plaintiff stated that the pain in her hands caused her to drop objects. (Tr. 51.) Plaintiff also had ductal tearing as a result of chemotherapy and “it look[ed] like [she was] always crying, ” and made her vision blurry. (Tr. 52.) Plaintiff testified that three or four times a month she got headaches that usually lasted four hours and that made her need to lie down. (Tr. 53-54.)

         IV. The ALJ's Decision

         A claimant is considered disabled under the Social Security Act if she is unable “to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A); see also 42 U.S.C. § 1382c(a)(3)(A) (providing a nearly identical standard for supplemental security income disability insurance benefits). To determine whether a claimant is disabled, the ALJ uses a five-step sequential evaluation process. See 20 C.F.R. §§ 404.1520, 416.920; see, e.g., Garrison v. Colvin, 759 F.3d 995, 1010 (9th Cir. 2014).

         A. The Five-Step Sequential ...