(SS) Mendez v. Commissioner of Social Security

CourtDistrict Court, E.D. California
DecidedFebruary 6, 2024
Docket1:23-cv-00649
StatusUnknown

This text of (SS) Mendez v. Commissioner of Social Security ((SS) Mendez v. Commissioner of Social Security) is published on Counsel Stack Legal Research, covering District Court, E.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
(SS) Mendez v. Commissioner of Social Security, (E.D. Cal. 2024).

Opinion

1 2 3 4 5 UNITED STATES DISTRICT COURT 6 EASTERN DISTRICT OF CALIFORNIA 7 BRENDA MENDEZ, 8 Case No. 1:23-cv-00649-SKO Plaintiff, 9 v. ORDER ON PLAINTIFF’S SOCIAL 10 SECURITY COMPLAINT MARTIN O’MALLEY, 11 Commissioner of Social Security,1 12 Defendant. (Doc. 1) 13 _____________________________________/ 14 I. INTRODUCTION 15 16 On April 27, 2023, Plaintiff Brenda Mendez (“Plaintiff”) filed a complaint under 42 U.S.C. 17 § 405(g) seeking judicial review of a final decision of the Commissioner of Social Security (the 18 “Commissioner” or “Defendant”) denying her application for Supplemental Security Income 19 (“SSI”) under the Social Security Act (the “Act”). (Doc. 1.) The matter is currently before the 20 Court on the parties’ briefs, which were submitted, without oral argument, to the Honorable Sheila 21 K. Oberto, United States Magistrate Judge.2 22 II. BACKGROUND 23 Plaintiff was born on April 11, 1985, and has more than a high school education. 24 (Administrative Record (“AR”) 39–40, 61, 76, 214, 222, 232, 408, 681.) Plaintiff filed a claim for 25

26 1 On December 20, 2023, Martin O’Malley was named Commissioner of the Social Security Administration. See https://www.ssa.gov/history/commissioners.html. He is therefore substituted as the defendant in this action. See 42 27 U.S.C. § 405(g) (referring to the “Commissioner’s Answer”); 20 C.F.R. § 422.210(d) (“the person holding the Office of the Commissioner shall, in [their] official capacity, be the proper defendant.”). 28 2 The parties consented to the jurisdiction of a U.S. Magistrate Judge. (See Doc. 17.) 1 SSI payments on September 22, 2014, alleging she became disabled on February 26, 2014, due to 2 severe congenital thoracic scoliosis causing severe pain. (AR 19, 61, 76, 207, 214.) 3 Following a hearing, an Administrative Law Judge (ALJ) issued a written decision on 4 January 3, 2018, finding Plaintiff not disabled. (AR 19–28.) Plaintiff appealed the decision to the 5 district court, who, on December 23, 2019, remanded the case for further proceedings to consider 6 Plaintiff’s “residual functional capacity [RFC]3 in light of the conclusion that [her] testimony was 7 reliable and consistent and with full consideration of the evidence concerning [Plaintiff’s] ability to 8 sit.” (AR 667. See also AR 790–811.) 9 Upon remand, the Appeals Council directed the assigned ALJ to offer Plaintiff the 10 opportunity for a hearing, take any further action needed to complete the administrative record, and 11 issue a new decision. (AR 667. See also AR 745.) The ALJ held hearings and issued a new written 12 decision once again finding Plaintiff not disabled. (AR 667–82, 690–738.) 13 A. Relevant Evidence of Record4 14 1. Medical Evidence 15 In August 2015, Plaintiff presented to Robert G. Fernandez, M.D., complaining of “severe 16 incapacitating pain” that is “not controlled with fentanyl, Norco and ibuprofen.” (AR 518.) Dr. 17 Fernandez noted it that it is “impossible” for Plaintiff to be titrated off of her pain medications due 18 to her “severe pathology.” (AR 518.) Examination of Plaintiff’s spine showed abnormal gait and 19 posture and decreased range of motion. (AR 519.) 20 An x-ray of Plaintiff’s lumbar spine performed in June 2016 showed degenerative changes, 21 including general demineralization of the vertebral bodies and multilevel degenerative disc disease 22 with multilevel disc space narrowing. (AR 623.) In January 2017, electrodiagnostic testing was 23

24 3 RFC is an assessment of an individual’s ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis of 8 hours a day, for 5 days a week, or an equivalent work schedule. TITLES 25 II & XVI: ASSESSING RESIDUAL FUNCTIONAL CAPACITY IN INITIAL CLAIMS, Social Security Ruling (“SSR”) 96-8P (S.S.A. July 2, 1996). The RFC assessment considers only functional limitations and restrictions that 26 result from an individual’s medically determinable impairment or combination of impairments. Id. “In determining a claimant’s RFC, an ALJ must consider all relevant evidence in the record including, inter alia, medical records, lay 27 evidence, and ‘the effects of symptoms, including pain, that are reasonably attributed to a medically determinable impairment.’” Robbins v. Soc. Sec. Admin., 466 F.3d 880, 883 (9th Cir. 2006). 28 4 Because the parties are familiar with the medical evidence, it is summarized here only to the extent relevant to the 1 normal with no evidence of polyneuropathy or lumbar radiculopathy. (AR 617.) Plaintiff received 2 bilateral lumbar transforaminal epidural injections in February 2017. (AR 586.) 3 In December 2017, Plaintiff presented to Dr. Fernandez to re-establish care for chronic back 4 pain due to severe scoliosis. (AR 1158–60.) She rated her pain at 5/10 but reported that it 5 intermittently increases to 7/10 secondary to the cold weather. (AR 1158.) She reported “good 6 control of her pain” on Naproxen and Butrans weekly. (AR 1158.) A physical examination of 7 Plaintiff showed no acute distress; clear lungs; abnormal gait and posture; severe spinal deformity 8 and asymmetry of spinal muscles with diffuse tenderness; severe decreased range of motion; 9 muscular spasm; and uneven hip heights. (AR 1159.) Dr. Fernandez continued Plaintiff on Butrans, 10 Gabapentin, Naproxen, and Baclofen for pain relief and referred her to physical therapy. (AR 1159.) 11 At a medication refill appointment in February 2018, Plaintiff continued to complain of 12 chronic back pain, described as a constant aching pain that increases to a higher level of pain with 13 certain types of movements. (AR 1161.) In May 2018, at a follow up appointment with Dr. 14 Fernandez, Plaintiff rated her pain at 3/10, but said it increased intermittently from a 3 to an 8 out 15 of 10. (AR 1165–67.) Plaintiff also reported that her right thigh pain above her knee inhibited her 16 walking, although she had been told by her other provider that her knee was normal. (AR 1165.) 17 According to Plaintiff, epidural steroid injections improved her condition. (AR 1165.) 18 Plaintiff presented for another follow up appointment with Dr. Fernandez in July 2018. (AR 19 1168–70.) She rated her pain at a 7 to 8 out of 10 (with some escalations to a level 8 or 9) and 20 reported being very depressed and fatigued all the time with crying spells and problems sleeping. 21 (AR 1168.) Examination findings documented a bony deformity, uneven hips, full range of motion 22 of major joints except spine, and tearful affect. (AR 1169.) Dr. Fernandez noted that Plaintiff’s 23 severe pain was “well controlled on Baclofen, Butrans, Gabapentin, and Ibuprofen,” and he 24 administered a Ketorolac injection. (AR 1169.) Plaintiff was prescribed Venlafaxine for her 25 depression and given a B12 injection for fatigue. (AR 1169.) 26 In October 2018, Plaintiff reported at a follow-up appointment with Dr. Fernandez that she 27 felt better and rated her pain at a 3/10. (AR 1171–73.) She noted “some control of her back pain” 28 with Naproxen and Butrans. (AR 1171.) Plaintiff requested another set of epidural injections, and 1 reported that the “slightest movements made her back pain worse.” (AR 1171). She was referred 2 back to pain management for epidural injections and another B12 injection for fatigue was 3 administered. (AR 1172.) 4 Plaintiff presented for another follow-up appointment with Dr. Fernandez in January 2019. 5 (AR 1174–76.) She rated her pain at a 3/10, but reported that it had gone up to a level 9 that week. 6 (AR 1174.) Dr. Fernandez noted that Plaintiff’s pain was “fairly well controlled” on her current 7 pain regimen.

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(SS) Mendez v. Commissioner of Social Security, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ss-mendez-v-commissioner-of-social-security-caed-2024.