Fajardo v. Commissioner of Social Security
Filing
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FINAL JUDGMENT and ORDER Regarding Plaintiff's Social Security Complaint signed by Magistrate Judge Erica P. Grosjean on 11/9/2017. (Sant Agata, S)
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UNITED STATES DISTRICT COURT
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EASTERN DISTRICT OF CALIFORNIA
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BELEN MARY FAJARDO,
Plaintiff,
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v.
Case No. 1:16-cv-01784-EPG
FINAL JUDGMENT AND ORDER
REGARDING PLAINTIFF’S SOCIAL
SECURITY COMPLAINT
COMMISSIONER OF SOCIAL
SECURITY,
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Defendant.
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This matter is before the Court on Plaintiff’s complaint for judicial review of an
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unfavorable decision of the Commissioner of the Social Security Administration regarding his
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applications for supplemental security income and disability insurance benefits. The parties have
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consented to entry of final judgment by the United States Magistrate Judge under the provisions
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of 28 U.S.C. § 636(c) with any appeal to the Court of Appeals for the Ninth Circuit.
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At the hearing on October 31, 2017, the Court heard from the parties and, having
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reviewed the record, administrative transcript, the briefs of the parties, and the applicable law,
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finds as follows:
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For the reasons announced by the Court on the record at the conclusion of the parties’ oral
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argument on October 31, 2017, the Court finds that the decision of the Commissioner of Social
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Security should be reversed and the case should be remanded for further proceedings.
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Plaintiff applied for disability, disability insurance benefits, and supplemental security
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income on May 10, 2012, alleging a disability onset date of May 15, 2011. The disability onset
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date was later amended to January 1, 2013.
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On August 21, 2012, Emmanuel Fabella, M.D., administered a consultative internal
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medicine examination of Plaintiff. AR 380-385. Dr. Fabella observed that Plaintiff had low back
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pain with evidence of paralumbar strain and right paralumbar tenderness, as well as apparent
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history of lumbosacral spine x-ray in 2011 showing “some arthritis.” AR 384. Dr. Fabella also
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observed right lateral thigh pain. Id. Based on these impressions, Dr. Fabella opined as to
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Plaintiff’s physical limitations. Id.
Doctors E. Wong, M.D. and A. Nasrabadi, M.D. served as the Commissioner’s non-
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examining physicians with respect to Plaintiff’s disability application. On October 4, 2012, Dr.
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Wong opined as to Plaintiff’s physical residual functioning capacity (“RFC”). AR 80-82. On
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March 19, 2013, Dr. Nasrabadi also opined as to Plaintiff’s physical RFC. AR 124-126. Drs.
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Wong and Nasrabadi’s medical opinions concerning Plaintiff’s physical limitations were based
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upon Plaintiff’s spine disorder.
In the summer of 2013, Plaintiff sustained a right foot injury diagnosed as fracture
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dislocation of right Lisfranc joint, which required surgical repair with pins and other hardware.
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AR 640, 646. A February 5, 2014 x-ray revealed a Lisfranc fracture-dislocation, and orthopedic
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consultation was recommended. AR 548-49. On February 28, 2014, Plaintiff reported pain with
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weight-bearing and ambulation problems to Dr. Shah, who recommended a revision surgery on
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the right foot. AR 486-87. Plaintiff again reported problems to Dr. Shah with weight-bearing and
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ambulation persisting as of March 21, 2014. AR 563. Plaintiff reported 10 out of 10 pain in her
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foot and low back again on June 13, 2014. AR 492.
On November 5, 2014, Plaintiff testified before the ALJ. She testified that her back, right
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foot pain and anemia conditions were disabling. AR 45-46. Plaintiff stated that she believed her
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right foot would heal after surgery, but it did not. AR 51. She consistently has pain in the right
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foot and swells up to the point where she cannot wear shoes. AR 51-52. Standing on the foot
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makes the pain excruciating, and the injury prevents her “from doing a whole bunch of things.”
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AR 53. She testified that she could only stand on the foot for 5-10 minutes at a time and cannot
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walk for 15 minutes without experiencing the pain. AR 57.
At step two, the ALJ found severe impairments significantly limiting Plaintiff’s ability to
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work in the form of cervical and lumbosacral degenerative disc disease and right foot disorder.
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AR 17. Based on these impairments, the ALJ formulated an RFC finding that Plaintiff has ability
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to:
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perform sedentary work as defined in 20 CFR § 404.1567(a) and 416.967(a)
except the claimant can occasionally stoop, crawl, and climb ramps and stairs, but
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she cannot climb ropes, ladders or scaffolds; she can frequently balance; and she
must avoid working around unprotected heights and moving mechanical parts, and
she cannot perform commercial driving.
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AR 20, 22 (stating that Plaintiff “is limited to sedentary work with postural and environmental
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limitations due to back pain and foot pain secondary to a history of mild degenerative disc disease
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and Lisfranc fracture of the right foot.”)
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In discussing his RFC formulation, the ALJ gave limited weight to the medical opinion of
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Dr. Fabella (summarized above) because “the recent evidence of claimant’s foot fracture and
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cervical spinal degenerative disc disease support further limitations in the claimant’s ability to lift
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and stand/walk.” AR 22. The ALJ further applied reduced weight to Drs. Wong and Nasrabadi’s
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medical opinions concerning Plaintiff’s physical limitations inter alia due to Plaintiff’s recent and
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non-healing right foot injury. AR 24.
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The Court recognizes that “Residual functional capacity is an administrative finding
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reserved to the Commissioner.” Lynch Guzman v. Astrue, 365 F. App'x 869, 870 (9th Cir. 2010)
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(citing 20 C.F.R. § 404.1527(e)(2)). The ALJ’s RFC determination should be affirmed “if the
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ALJ applied the proper legal standard and his decision is supported by substantial evidence.”
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Bayliss v. Barnhart, 427 F.3d 1211, 1217 (9th Cir. 2005).
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The Court also recognizes that the ALJ did attempt to take into account the right foot
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injury by imposing the sedentary limitation. While this could possibly be an accurate functioning
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limitation to impose, the limitations caused by the right foot injury could also demand greater
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than a sedentary limitation. Prior to the right foot injury, Plaintiff’s disability application had
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been based entirely on her spine disorder and associated back pain. As discussed above, every
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doctor that issued a medical opinion regarding Plaintiff’s work-related limitations did so prior to
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the right foot injury. Thus, there was insufficient evidence in the record discussing the actual
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physical limitations resulting from the right foot injury.
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Accordingly, the Court finds that, in the absence of a medical opinion(s) describing actual
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work-related limitations concerning the right foot injury, the ALJ’s RFC determination was not
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based on substantial evidence. The Court remands the case for additional development regarding
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work-related limitations resulting from the right foot injury.
Accordingly, the Court GRANTS Plaintiff’s appeal from the administrative decision of
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the Commissioner of Social Security and the case is remanded to the Social Security
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Administration. The Clerk of the Court is DIRECTED to enter judgment in favor of Plaintiff and
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against Defendant Nancy A. Berryhill, Acting Commissioner of Social Security.
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IT IS SO ORDERED.
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Dated:
November 9, 2017
/s/
UNITED STATES MAGISTRATE JUDGE
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