Tadesse v. Social Security Administration, Commissioner

District Court, N.D. California·Decided June 29, 2022·No. 4:18-cv-07643-JST·Unknown

Opinion

DENTA TADESSE, Case No. 18-cv-07643-JST

Plaintiff, ORDER REMANDING FOR FURTHER v. PROCEEDINGS

SOCIAL SECURITY ADMINISTRATION, Re: ECF No. 40 COMMISSIONER, Defendant.

This case is now before the Court on remand from the Ninth Circuit. ECF No. 40. The Court will VACATE its March 31, 2020 order granting the Commissioner’s motion for summary judgment and REMAND the case to the Commissioner for further proceedings. Plaintiff Denta Tadesse alleges that he has been disabled since January 29, 2014, when he visited the emergency room for shoulder pain caused by a motorcycle accident several months earlier. Administrative Record (AR) 69, 342-45.1 He complained the pain “prohibit[ed] him from full range of motion.” Id. at 356-59. Dr. Melissa Clark examined Tadesse and found that he had likely torn his rotator cuff. Id. Dr. Clark gave Tadesse a sling and prescribed a series of exercises. Id. Dr. Clark also recommended that Tadesse follow up with his primary care physician and informed him that he may need an MRI and orthopedic care. Id. Tadesse returned to the emergency room four days later. Id. at 276. His shoulder was worse, and he had a fever. Id. at 345-56. Tadesse was admitted for cellulitis in his left shoulder and prescribed Vicodin, Motrin, vancomycin, and antibiotics. Id. Tadesse did not improve, so doctors took an MRI. Id. It revealed that Tadesse’s left shoulder was inflamed, infected, and covered in an abscess, which limited his use of the shoulder, caused pain, and put him at risk for necrotizing fasciitis – a potentially fatal bacterial infection that could spread quickly through his body. Id. The attending physician noted that Tadesse might need surgery. Id. The doctors performed diagnostic testing, which revealed that Tadesse also had HIV, latent syphilis, Hepatitis C, and a serious infection called MRSA bacteremia. Id. at 328. Tadesse was “very emotional” and “upset” about these findings. Id. at 277. Tadesse remained in the hospital for four days before being transferred to the CPMC Pacific Campus to have the abscess on his shoulder drained. Id. at 276. After the surgery, Tadesse remained in the hospital for a few days, but then left against medical advice because the medication the doctors had given him caused extreme vomiting and nausea. Id. at 336-38. Doctors recommended Tadesse get a primary care physician to treat his HIV infection and prescribe him medicine for syphilis. Id. They then referred him to an HIV clinic at San Francisco General Hospital. Id. After his discharge, however, Tadesse did not seek treatment for HIV or syphilis. Id. He also did not see a primary care doctor until he met with Dr. Joanna Eveland five months later, in July. Id. Nevertheless, Tadesse’s shoulder improved. Id. On August 23, 2014, Tadesse filed for Social Security Disability Insurance Benefits (SSDI). Id. at 76, 98. He completed his application on September 29, 2014. Id. at 209-13. The application listed three impairments: shoulder pain, HIV, and Hepatitis C. Id. It did not list mental disabilities or depression. Id. In January 2015, doctors from the Social Security Administration (SSA) reviewed Tadesse’s SSDI application and found him not disabled because he had not attended the medical examination. Id. at 69-75. The SSA then denied his application and Tadesse filed for reconsideration, claiming that he had not known about the required appointment. Id. at 110. Before Tadesse’s application was reconsidered, he met with Dr. Rose Lewis. Id. at 452- 56. Dr. Lewis conducted an in-person comprehensive medicine evaluation, during which she reviewed Tadesse’s physical symptoms, including those from the motorcycle accident, and his health history. Id. at 452-56. She found that Tadesse could stand and walk for up to six hours; carry 50 pounds occasionally and 25 pounds frequently; climb ladders, scaffolds, and ropes frequently and all other postural activities without limitation; and reach overhead frequently. Id. at 471. She found that his only workplace limitation was “around heavy machinery because of the decreased range of motion” in his shoulder. Id. at 471. The following month, Dr. J. Berry of the SSA reviewed Tadesse’s medical records to determine whether Tadesse was disabled. Id. at 69, 78-97. Based on his review, Dr. Berry concluded that Tadesse’s symptoms were “partially credible” because the symptoms were consistent with the medical evidence in his file, but the severity of the symptoms was “not supported.” Id. at 83. Dr. Berry determined that Tadesse was not disabled because he could sit, stand, kneel, crouch, and only experienced limits in reaching in climbing. Id. at 86, 94-95. Dr. Berry did not evaluate or review Tadesse’s mental limitations. The day after Dr. Berry’s review, the SSA denied Tadesse’s application for benefits. Id. at 110. Following the denial of benefits, Tadesse attended a number of appointments with his primary care doctor, Dr. Joanna Eveland, and his therapist, Juan Cabrera. Id. at 130, 459-513. During the earliest of these appointments, Dr. Eveland diagnosed Tadesse with HIV and Hepatitis C and gave him a letter to allow him to receive resources from the AIDS emergency fund. Id. at 130-31, 462, 488-501. Around this time, though, Tadesse first began struggling with homelessness. Id. at 130, 462. He was reluctant to begin HIV treatment until his housing situation stabilized. Id. He was also skeptical of Western medicine, possibly because of his experience with side effects after his shoulder surgery. Id. Around the end of 2015, Tadesse’s housing situation continued to be unstable, and in January 2016, he was arrested for trespassing. Id. at 126-28. A few days after that arrest, Tadesse met with Cabrera. Id. at 483. The therapy sessions with Cabrera focused primarily on Tadesse’s homelessness. Id. Cabrera noted that Tadesse had become “increasingly angry and somewhat mistrusting of the agencies and people” that are “supposed to help him” since becoming homeless. Id. In particular, following Tadesse’s arrest, because he was ashamed of his condition and could not concentrate well because he was “worried about basic things like getting food.” Id. Since his HIV diagnosis and becoming homeless, Tadesse lost much of his enjoyment in life and was “less hopeful and motivated” than ever. Id. Tadesse struggled with “everyday issues of discrimination that seemed to bring out past wounds related to personal mistreatment.” Id. While he met with Cabrera, Tadesse continued to meet with Dr. Eveland – indeed, throughout February and March 2016, Tadesse attended appointments with either Dr. Eveland or Cabrera more than twice per week every week. Id. at 473, 476-83, 511-13. Dr. Eveland continued to press Tadesse on HIV treatment, but he continued to resist because his housing was unstable. Id. at 479. Both Dr. Eveland and Cabrera noted that Tadesse was friendly, cooperative, forthcoming, well-groomed, and articulate. Id. at 468, 483. But he regularly arrived late to or missed appointments entirely. Id. at 468. Dr. John Brim examined Tadesse on May 23, 2016, focusing on Tadesse’s mental limitations. Id. at 503. Dr. Brim found that Tadesse did “not met the criteria for major affective disorder or generalized anxiety disorder” because his depression and anxiety seemed to be “byproducts” of “angry outbursts.” Id. Dr. Brim further noted that Tadesse blamed conflicts on others’ bad behaviors because Tadesse was “rigid[ly] egocentric[]” and had difficulties “understanding other people’s motivations.” Id. at 504. Dr. Brim diagnosed Tadesse with narcissistic personality, intermittent explosive disorder, and an adjustment disorder with a depressed and anxious mood. Id. He based these diagnoses on Tadesse’s statement that he would not care if his refusal to get HIV treatment put other sexual partners at risk and his “extreme and disproportionate anger when others don’t behave as he feels they should.” Id. Dr. Brim informed Tadesse that he s

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