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Aguilar v. Berryhill

United States District Court, D. New Mexico

September 27, 2017

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.


         THIS MATTER is before the Court on Plaintiff Raymond Aguilar's Motion to Reverse and Remand the Social Security Commissioner's final decision denying Plaintiff disability insurance benefits. Doc. 22. For the reasons discussed below, the Court will GRANT Plaintiff's motion and remand this action to the Commissioner for further proceedings consistent with this opinion.

         I. Background

         Plaintiff is a fifty-five year old male. Plaintiff filed his initial claim for disability on February 28, 2013, alleging disability due to back pain and bone spurs. AR 79. He alleged a disability onset date of March 1, 2011. AR 79. Plaintiff's claim was initially denied on May 22, 2013, and upon reconsideration on July 25, 2013. AR 22. Plaintiff filed a written request for hearing on August 13, 2013. AR 22. The hearing was held before Administrative Law Judge (ALJ) John Morris on November 3, 2014. AR 22. On January 30, 2015, the ALJ issued his decision denying Plaintiff's claim. AR 18. Plaintiff appealed the ALJ's determination to the Appeals Council and it granted his request for review. AR 1. The Appeals Council ultimately found Plaintiff not disabled. AR 5.

         Because the parties are familiar with Plaintiff's medical records, the Court will reserve discussion of the pertinent medical records for its analysis. Nevertheless, in short, Plaintiff was involved in a motor vehicle accident in March 2011. AR 269-70. Plaintiff complained of multiple issues following the accident, including right shoulder, right knee, and back pain. AR 269, 271. In October 2011, Plaintiff received an MRI of his shoulder which showed tendinopathy and a lateral acromial spur. AR 239. Plaintiff presented to Michelle Ruthmann, P.A., who assessed him as having low back pain, right shoulder arthrosis, and right shoulder rotator cuff tendinopathy. AR 288, 295. PA Ruthmann prescribed Plaintiff naproxen. AR 288. A subsequent MRI further showed multilevel degenerative disc disease, facet arthropathy, a moderate disc bulge and facet arthrosis at ¶ 4-L5 resulting in a mild left lateral recess and left neuroforaminal stenosis, and a small disc bulge at ¶ 3-L4. AR 283, 292, 437.

         Plaintiff further presented to various providers over the next few years with complaints of shoulder, back, and knee pain. Consistent with P.A. Ruthmann, these records show assessments of rotator cuff tendinitis and ac joint degenerative joint disease. See e.g., AR 242. Plaintiff was also assessed as suffering a right should impingement and degenerative disease of the radial carpal and ulnar carpal joints. AR 427, 264. Plaintiff decided to forgo surgery but instead opted for corticosteroid injections, which provided some relief. AR 244-45, 427, 440. AR 244.

         On May 13, 2013, Dr. Hui Gong performed a consultative examination of Plaintiff. AR 411. Dr. Gong opined that Plaintiff had subjective tenderness in his right shoulder and lower back. AR 415. Dr. Gong diagnosed Plaintiff with obstructive chronic back pain since the motor vehicle accident, tendonitis in the right wrist, arthritis in the right shoulder, and possible arthritis in the neck. AR 415-16. In his functional assessment of Plaintiff, Dr. Gong opined that Plaintiff did not demonstrate any limitations in the ability to sit, stand, or walk in an 8-hour day and Plaintiff therefore had no restrictions in standing, walking, sitting, or bending. AR 416. Dr.

         Gong further opined that Plaintiff was capable of lifting 25 founds frequently and 50 pounds occasionally. Finally, Dr. Gong found that Plaintiff had no restrictions in “reaching, handling, feeling and grasping” and no other “postural or manipulative limitations.” AR 416.

In his decision, the ALJ found that Plaintiff had the residual functional capacity to perform the full range of medium work as defined in 20 CFR 416.967(c). Specifically, the claimant can lift up to 50 pounds on an occasional basis and up to 25 pounds on an occasional basis; can sit, stand, and/or walk for up to six hours in an eight-hour day; can frequently reach, grasp, and finger as opposed to constant

         AR 26. Because the ALJ found that Plaintiff could perform his past relevant work as a furniture upholsterer, the ALJ found Plaintiff not disabled and denied his claim. AR 29. On review, the Appeals Council adopted the ALJ's statements regarding the governing law, the issues in the case, and the evidentiary facts. The Appeals Council rejected, however, the ALJ's finding that Plaintiff is capable of performing his past relevant work. AR 4. In so concluding, the Appeals Council explained that Plaintiff's work history “does not meet the requisite substantial gainful activity requirement to be deemed past relevant work.” AR 4-5. Thus, “[w]hen an individual demonstrates that he has no past relevant work, the burden shifts to the Commissioner to show that there are other jobs that he can perform.” AR 5. After recognizing the ALJ's error in concluding that Plaintiff could perform his past relevant work, the Appeals Council utilized the grids and concluded that Plaintiff is not disabled. AR 5. This appeal followed.

         II. Applicable Law

         A. Disability Determination Process

         A claimant is considered disabled for purposes of Social Security disability insurance benefits if that individual 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). The Social Security Commissioner has adopted a five-step sequential analysis to determine whether a person satisfies these statutory criteria. See 20 C.F.R. § 404.1520. The steps of the analysis are as follows:

(1) Claimant must establish that she is not currently engaged in “substantial gainful activity.” If claimant is so engaged, she is not disabled and the analysis stops.
(2) Claimant must establish that she has “a severe medically determinable physical or mental impairment . . . or combination of impairments” that has lasted for at least one year. If claimant is not so ...

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