(SS) Cisneros v. Commissioner of Social Security

District Court, E.D. California·Decided January 25, 2021·No. 1:19-cv-01307·Unknown

Opinion

NICHOLAS ZAVALA CISNEROS, No. 1:19-cv-01307-GSA Plaintiff, v. ORDER DIRECTING ENTRY OF JUDGMENT IN FAVOR OF PLAINTIFF ANDREW SAUL, Commissioner of Social AND AGAINST DEFENDANT Security, COMMISSIONER OF SOCIAL SECURITY (Doc. 28) Defendant.

I. Introduction Plaintiff Nicholas Zavala Cisneros (“Plaintiff”) seeks judicial review of a final decision of the Commissioner of Social Security (“Commissioner” or “Defendant”) denying his application for disability insurance benefits and supplemental security income pursuant to Titles II and XVI, respectively, of the Social Security Act. The matter is before the Court on the parties’ briefs which were submitted without oral argument to the Honorable Gary S. Austin, United States Magistrate Judge.1 See Docs. 21, 28, 29. After reviewing the record the Court finds that substantial evidence and applicable do not support the ALJ’s decision. Accordingly, Plaintiff’s appeal is granted. II. Procedural Background On July 27, 2015 Plaintiff filed an application for disability insurance benefits and supplemental security income claiming disability beginning April 4, 2015 due to a lower back injury. AR 197–208; 223. The Commissioner denied the application initially on September 25, 2015, and on reconsideration on February 4, 2016. AR 91–94, 97–102. Plaintiff requested a hearing which was held before an Administrative Law Judge (the “ALJ”) on November 15, 2017. AR 36–58. Plaintiff was represented by counsel at the hearing. 1 The parties consented to the jurisdiction of the United States Magistrate Judge. See Docs. 10 and 12. AR 36. On March 7, 2018, the ALJ issued a decision denying Plaintiff’s application. AR 21–30.

The Appeals Council denied review on July 17, 2019. AR 1–8. On September 18, 2019, Plaintiff

filed a complaint in this Court. Doc. 1.

III. Factual Background

A. Plaintiff’s Testimony

Plaintiff lived in a two-story unit with his 19-year old son. AR 43. He attended no school.

AR 43. He worked as a prep cook at a casino for 15 years. AR 43. He lifted containers of poultry

and beef weighing 45–50 pounds. AR 46. He injured his lower back in April 2015 lifting a tray of

chicken. AR 46. He was on workers’ compensation for seven months and returned to work in January 2016. AR 44–45. He was only able to lift minimal weight upon his return, not exceeding 15 pounds. AR 45–46. He used a chair to alternate between sitting and standing while working. AR 50. He was ultimately let go in April 2016. AR 45. He could clean his home for 20 minutes at a time and go for periodic walks. AR 46. He used a cane since his injury. AR 47. His physical therapy helped very little. AR 47. Injections made his back pain worse. AR 47. His pain medication helped for certain periods of time. AR 47. He used a heated girdle twice a day for pain. AR 48. Vacuuming exacerbated his pain. AR 48. He also experienced right leg numbness down to his foot. AR 48. It was numb 40% of the time. AR 49. Without his cane his leg felt as though it would give out. AR 49. He had fallen previously. AR 49. He could walk short distances without his cane and used it periodically around his house. AR 49. Sitting and standing were equally difficult, and he had to alternate between them every 20– 30 minutes. AR 50. He could lift about 8 pounds. AR 51. B. Medical Records On April 4, 2015, Plaintiff visited the emergency room with sudden onset back pain, hip pain, and leg numbness after lifting a heavy object. AR 305, 308. A lumbar spine CT-scan revealed slight central disc bulges at L5-S1 and L4-L5, and minimal neuroforamina narrowing at L5-S1. He was diagnosed with sciatica and given an injection. AR 306, 311. Three days later FNP Narrod examined Plaintiff, noted pain upon palpation, limited range of motion (ROM), diagnosed displaced intervertebral disc, sciatica, skin sensation disturbance and recommended an MRI. AR 363–64. An April 8, 2015 examination by Dr. Madrigal noted similar findings as well as abnormal

motor strength and irregular gait. AR 425. He assessed acute sciatica with bulging discs, prescribed

pain medication and recommended physical therapy. AR 423–25. An April 17, 2015 examination

by Dr. Madrigal revealed similar findings. AR 421. He prescribed additional pain medication,

administered an injection and referred Plaintiff for a spinal surgery evaluation. AR 422. Following

May 1 and May 15, 2015 examinations, Dr. Madrigal noted similar findings, continued medication,

and reiterated his recommendation for neurosurgery evaluation. AR 411–413, 416.

Plaintiff began physical therapy on April 27, 2015 with DPT Rose who noted symptoms of

pain level 9 out of 10, motor deficit at L3 and L4, severe pain with flexion, and that Plaintiff walked with a cane. AR 324–25. DPT Rose diagnosed posterior derangement in the lumbar spine and significant nerve impingement. AR 324–28. At physical therapy on May 7, 2015, he reported no change in pain with treatments. AR 333. Plaintiff attended therapy on May 12, 2015, and experienced increased pain with treatment indicating “significant nerve impingement.” AR 329. DPT Rose discontinued therapy due to myotomal weakness. AR 331. Following a May 22, 2015 orthopedic consultation, Dr. Watson noted Plaintiff’s reported symptoms of increased pain with daily activities, reported inability to lift and carry, inability to sit or stand more than 30 minutes, and inhibited sleep and social life. AR 434. Dr. Watson noted decreased lumbar spine ROM, tenderness, and hyposensitivity at L1-S1. AR 436–37. He ordered a spine MRI. AR 438. The MRI revealed loss of T2 weighted signal of the lower 2 lumbar discs with possible small annular tear at L4-L5, and facet arthropathy at L5-S1. AR 432, 453. Dr. Watson found surgery unnecessary and suggested Plaintiff may improve with time and conservative management. AR 432. Following a June 25, 2015 visit with PA Lemus and Dr. Madrigal, examination was consistent with previous visits, medication was refilled and Plaintiff was referred for pain management. AR 409. Following a July 6, 2015 visit with Dr. Ontiveros, symptoms and findings were consistent with previous records. Plaintiff noted additional side effects of excessive sleep, loss of appetite, described pain as “intolerable,” and underwent a Kenalog injection. AR 400. Dr. Ontiveros also imposed work-restrictions. AR 403. Plaintiff reported dizziness during a July 15, 2015 visit with PA-C Larios, who prescribed medication. AR 361. Following an August 3, 2015

visit, Dr. Ontiveros noted similar symptoms and findings and assessed work restrictions: standing,

sitting, and walking up to 2 hours per day, and no kneeling/squatting, bending/stooping,

pushing/pulling, twisting, climbing, or reaching. AR 392, 395–97.

A September 29, 2015 orthopedic examination with Dr. Nijjar revealed straightening of the

lumbar curvature, tenderness in the midline from L3 to S1, paraspinal muscle spasms, reduced

spine ROM, and decreased thigh sensation. AR 468. Dr. Nijjar diagnosed sprain/strain of the

lumbar spine and degenerative disc disease at L4-L5. AR 468. He concluded Plaintiff suffered an

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