(SS) Derek W. Carlon v. Commissioner of Social Security

District Court, E.D. California·Decided September 10, 2019·No. 1:18-cv-01085·Unknown

Opinion

DEREK WADE CARLON, Case No. 1:18-cv-01085-SKO Plaintiff, v. ORDER ON PLAINTIFF’S SOCIAL SECURITY COMPLAINT ANDREW SAUL, Commissioner of Social Security, ORDER DENYING AS MOOT Defendant. PLAINTIFF’S MOTION TO ADMIT NEW EVIDENCE (Docs. 1, 21) _____________________________________/

I. INTRODUCTION On August 13, 2018, Plaintiff Derek Wade Carlon (“Plaintiff”), proceeding pro se, filed a complaint under 42 U.S.C. § 405(g) seeking judicial review of a final decision of the Commissioner of Social Security (the “Commissioner” or “Defendant”) denying his application for disability insurance benefits (“DIB”) under Title II of the Social Security Act (the “Act”). The matter is currently before the Court on the parties’ briefs, which were submitted, without oral argument, to the Honorable Sheila K. Oberto, United States Magistrate Judge.1 ///

1 The parties consented to the jurisdiction of a U.S. Magistrate Judge. (Docs. 6, 7.) On August 28, 2013, Plaintiff protectively filed an application for DIB payments, alleging he became disabled on June 15, 2013 due to back problems, including “herniated discs 14 to s1,” “c4-c6 ddd with reverse lordosis,” L6 (extra lumbar vertebrae) spina bifida occulta, C3-7 degenerative disc disease/foraminal encroachment, cervical reverse lordosis, L4-5 herniated disc, and L5-S1 (L6) herniated disc. (Administrative Record (“AR”) 18, 20–21, 99, 109, 170–76, 198.) Plaintiff was born on May 10, 1972 and was 41 years old as of the alleged onset date. (AR 26, 99, 109, 170, 198.) Plaintiff has a college degree in theater and has past work experience as a mail carrier, salesperson, tank truck driver, stock clerk, heavy truck driver, and truck driver helper, and last worked full-time in 2009. (AR 26, 40–41, 117, 204.) A. Relevant Medical Evidence2 1. Precision Health Imaging On August 7, 2009, Plaintiff underwent magnetic resonance imaging (MRI), which showed that Plaintiff had degenerative disc disease without evidence of herniated discs, and foraminal encroachment and narrowing in his lower back. (AR 373.) On October 23, 2010, Plaintiff underwent an MRI on his lumbar spine, which revealed a minimal degree of disc bulge at L1-L4. (AR 416–17.) On June 25, 2011, an MRI on Plaintiff’s cervical spine showed that Plaintiff’s disc desiccation and disc height loss at C5-6 had increased since the August 2009 MRI, but were unchanged at the C3-4 and C5-6 levels. (AR 374.) On October 3, 2011, a cervical spine myelography showed Plaintiff had degenerative disc disease, mild retrolisthesis, and an extradural bulge, and a separate CT scan showed Plaintiff’s most significantly affected level was at C5-6. (AR 382–84.) 2 Much of the medical evidence in the record either predates Plaintiff’s alleged onset date of disability or postdates Plaintiff’s date last insured. This does not necessarily render the evidence irrelevant. See Carmickle v. Comm’r of Soc. Sec. Admin., 533 F.3d 1155, 1165 (9th Cir. 2008); Tommasetti v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008); Smith v. Bowen, 849 F.2d 1222, 1225 (9th Cir. 1988); Waters v. Gardner, 452 F.2d 855, 858 (9th Cir. 1971). Thus, the Court S1. (AR 375–76.) An MRI on January 10, 2014 showed central disc protrusions at L5-S1 and possible infected fluid collection. (AR 381–82.) On March 3, 2014, an MRI on Plaintiff’s back showed “[m]ild reversal of the normal cervical lordosis,” “mild uncovertebral joint degeneration,” and small disc protrusions at C5-6 and C6-7. (AR 378.) 2. Dr. Gabriel Garcia-Diaz, M.D. On June 20, 2013, Plaintiff established care with orthopedic surgeon Dr. Gabriel Garcia- Diaz, M.D., at Ortho Spine Advance Health Inc. in Merced, California. (AR 326–71.) At his initial appointment with Dr. Garcia-Diaz, Plaintiff reported he had pain in his upper posterior neck, upper extremities, and both sides of his lower back. (AR 327.) Plaintiff reported his back problems began 27 years earlier and had worsened since Spring 2009. (AR 327.) On examination, Dr. Garcia-Diaz noted that Plaintiff’s cervical spine and thoracic spine were “unremarkable with normal inspection, normal alignment, full pain-free range of motion, no muscle spasms, no tenderness . . . and no other significant findings[.]” (AR 330–31.) Dr. Garcia-Diaz noted that a lumbosacral spine x-ray showed a congenital abnormality in the sixth lumbar vertebrate and diagnosed Plaintiff with spina bifida occulta. (AR 332.) Dr. Garcia-Diaz recommended home exercise and provided free samples of muscle relaxants. (AR 332.) Plaintiff next saw Dr. Garcia-Diaz for an evaluation on July 18, 2013. (AR 336–43.) Dr. Garcia-Diaz observed that Plaintiff’s pain was generally unchanged, but review of an MRI taken earlier in July 2013 showed Plaintiff had more conditions affecting his back. (See AR 336–37, 340– 42.) Dr. Garcia-Diaz diagnosed Plaintiff with spina bifida occulta; idiopathic low back pain; herniated nucleus pulposus; L4-5 herniation; degenerative disc disease; central spinal stenosis; lateral recess spinal stenosis; and radiculitis. (AR 342.) Dr. Garcia-Diaz recommended epidural corticosteroid injections at L4-5 and prescribed a muscle relaxant. (AR 342.) 344–52.) Dr. Garcia-Diaz noted that Plaintiff’s pain and physical condition were generally unchanged, he had normal gait, normal heel and toe walking, no evident pain, and normal general strength. (AR 344–48.) Dr. Garcia-Diaz recommended home exercise, ice packs, “patient directed self care,” and lumbar spine surgery. (AR 350.) Dr. Garcia-Diaz noted that Plaintiff had considered all available treatment options and indicated he wanted to proceed with the lumbar spine surgery as recommended. (AR 350–51.) Dr. Garcia-Diaz saw Plaintiff for a pre-operative visit on September 16, 2013 and performed a laminectomy and decompression surgery on September 18, 2013. (AR 353–60, 369–71.) The surgery was successful, and Dr. Garcia-Diaz saw Plaintiff for a post-operative evaluation on October 1, 2013. (See AR 370–71, 361–68.) Dr. Garcia-Diaz noted that “[t]he previously described symptoms have gotten much better since the last office visit” except for some numbness in the left leg. (AR 361.) Plaintiff’s post-operative status was described as “excellent” and Dr. Garcia-Diaz noted that the surgery provided “a great deal of relief of current symptoms.” (AR 361–62.) Dr. Garcia-Diaz recommended home exercise and patient-directed self-care. (AR 367.) Dr. Garcia-Diaz’s treatment notes from September 16, 2013 indicate that Plaintiff was scheduled for a follow-up appointment four weeks later, but no treatment notes from that appointment or other appointments with Dr. Garcia-Diaz are included in the record. (See AR 367.) The record similarly does not contain medical opinion evidence from Dr. Garcia-Diaz. 3. Dr. Diana J. Hylton, M.D. On February 4, 2014, Plaintiff first saw neurologist Dr. Diana Hylton, M.D. (AR 387–88.) Dr. Hylton diagnosed Plaintiff with severe left L5-S1 radiculopathy and noted that Plaintiff had “a moderate right L5 denervation pattern.” (AR 387–88.) On March 19, 2014, Dr. Hylton performed motor nerve conduction and sensory nerve conduction studies on Plaintiff, and concluded that returned to Dr. Hylton on July 15, 2016, and she prescribed Lyrica for shoulder pain. (AR 488.) 4. Stanford Neurology Clinic In June 2014, Plaintiff established care with the General Neurology Clinic at Stanford Healthcare. (See AR 434–49.) On June 5, 2014, neurosurgeon Dr. Jongsoo Park, M.D., noted that Plaintiff reported that after the September 2013 surgery, pain and numbness in his left leg increased and he did not experience any relief from his pre-operative symptoms. (AR 438.) Dr.

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