Vaughn v. Berryhill

242 F. Supp. 3d 998, 2017 U.S. Dist. LEXIS 38967, 2017 WL 1349292
CourtDistrict Court, E.D. California
DecidedMarch 17, 2017
Docket1:15-cv-01247-GSA
StatusPublished
Cited by21 cases

This text of 242 F. Supp. 3d 998 (Vaughn v. Berryhill) 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
Vaughn v. Berryhill, 242 F. Supp. 3d 998, 2017 U.S. Dist. LEXIS 38967, 2017 WL 1349292 (E.D. Cal. 2017).

Opinion

ORDER REGARDING PLAINTIFF’S SOCIAL SECURITY COMPLAINT

. Gary S. Austin, UNITED STATES MAGISTRATE JUDGE

I. INTRODUCTION

Plaintiff Perry Howard Vaughn (“Plaintiff’) seeks judicial review of the final decision of the Commissioner of Social Security (“Commissioner” or “Defendant”) denying his application for Disability Insurance Benefits (“DIB”) benefits pursuant to Title II of the Social Security Act. (Docs. 1 and 14). The Commissioner filed an opposition and a cross-motion .for summary judgment, (Doc. 17). Plaintiff filed a reply. (Doc. 20). The matter is currently before the Court on the parties’ briefs which were submitted without oral argument to the Honorable Gary S. Austin, United States Magistrate Judge. After reviewing the administrative record and the pleadings, the Court finds the ALJ’s decision is' not supported by substantial [1000]*1000evidence, grants Plaintiffs appeal in part, and denies the Defendant’s cross-motion for summary judgment. The case is remanded for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g).

II. BACKGROUND AND PRIOR PROCEEDINGS 2

Plaintiff filed an application for DIB on May 1, 2012, alleging a disability beginning April 18, 2012. AR 12; 146-152. His application was denied initially on August 16, 2012, and on reconsideration on March 4, 2013. AR 12; 95-99; 102-104; 146-152. Plaintiff requested a hearing before an administrative law judge (“ALJ”). AR 8. ALJ G. Ross Wheatley conducted a hearing on September 30, 2013 (AR 27-70), and published an unfavorable decision on November 4, 2013. AR 12-21. Plaintiff filed an appeal on May 16, 2014. AR 7-11. The Appeals Council denied the request for review on November 20, 2015, rendering the order the final decision of the Commissioner. AR 1-6.

III. ISSUES FOR JUDICIAL REVIEW

Plaintiff filed for disability due to degenerative disc disease in his lumbar spine, a cardiac impairment including shortness of breath, sleep apnea, obesity, and degenerative joint disease in his bilateral feet, knees, sacroiliac joints, and right elbow. AR 174. He alleges that the ALJ improperly assessed the evidence when reviewing his case. Specifically, he argues that: (1) the ALJ failed to give specific and legitimate reasons for rejecting the opinions of Plaintiffs treating orthopaedist and cardiologist, as well as a chiropractor who performed a consultative exam. Instead, the ALJ improperly relied on two non-examining physicians’ opinions when formulating the residual functional capacity (“RFC”);3 (2) the ALJ erred in finding that Plaintiffs cardiac impairment was nonsevere; (3) the ALJ did not provide clear and convincing reasons for finding Plaintiff not credible;, and (4) the ALJ improperly rejected Plaintiffs wife’s testimony. (Doc. 14, pgs. 16-29; Doc. 20, pgs. 1-5). Based on these errors, Plaintiff requests that the ease be remanded for an award of benefits, or alternatively, that the case be remanded for further proceedings. (Doc. 14, 29-30; Doc. 20, pg. 5). The Commissioner opposes each of these arguments and contends that the ALJ’s evaluation of the medical evidence and his credibility determinations were proper and are supported by substantial evidence. (Doc. 17, pgs. 6-16).

IV.THE MEDICAL RECORD

On July 9, 2011, chiropractor Douglas W. Roberts, D.C., performed an independent medical assessment to evaluate pain in Plaintiffs lower back, hips and neck. AR 270. Plaintiff informed Dr. Roberts he had experienced these symptoms for many years but they had worsened. AR 271. Dr. Roberts observed that Plaintiff was in distress and weighed 285 pounds. A Minor’s sign test was performed and was indicative of sciatica, and his gait was antalgic, favoring the right side. AR 272. Dr. Roberts’ examination revealed severely limited flex-ion and extension in Plaintiffs lumbar spine and positive straight-leg raises. AR 272-274. There was significant loss of strength in both hands and all results of [1001]*1001cervical testing were positive. AR 273. Dr. Roberts’ examination also revealed severe pain to palpation and hypertonicity (excessive muscle tone or tension) throughout Plaintiffs paraspinal muscles and active tender points throughout Plaintiffs scapular muscles, his trapezius, rhomboid and gluteal muscle groups. AR 275. Dr. Roberts determined Plaintiffs present condition was caused by his excess weight and years of injuries. He diagnosed chronic lumosacral sprain/strain, chronic lumbar sprain/strain and degeneration of the lumbar or lumbosacral disc. AR 271, 275. He opined Plaintiff would experience episodes of pain and weakness and was unable to perform any work duties that would lead to gainful employment. AR 275.

On July 26, 2011, Plaintiff was examined by Mark Cook, M.D., his primary care physician, who detected an irregular heartbeat. AR 379. Dr. Cook ordered x-rays of Plaintiffs right elbow which revealed marked degenerative changes involving the elbow joint with osteophyte formation along the olecranon and coronoid process and multiple small bone fragments that suggested the possibility of loose bodies in the joint capsule. Joint spaces appeared to be fairly well maintained. AR 377. X-rays of Plaintiffs knees revealed osteoarthritic changes and narrowing joint spaces with osteophyte formations (bony growths) in both knees and chondrocalcinosis (calcification of cartilage) in his right knee. AR 375. Dr. Cook referred Plaintiff to an orthopae-dist. AR 331.

On August 29, 2011, Plaintiff presented to Robert M. Cash, M.D., an orthpaedist, for an evaluation of his bilateral knees and right elbow. AR 278. Dr. Cash reviewed Plaintiffs x-rays and his examination revealed crepitus (grinding or crackling in the joint) and pain with motion in both knees with the left worse than right, and crepitus in Plaintiffs right elbow. AR 278. Dr. Cash diagnosed bilateral knee arthro-sis and right elbow arthosis with loose bodies and injected corticosteroids and li-docaine in Plaintiffs left knee. AR 279. Dr. Cash indicated Plaintiff may be a candidate for hyaluronic acid injections in his knee and was a candidate for right elbow arthroscopy with removal of loose bodies. AR 279.

On November 11, 2011, Plaintiff reported to Jeffrey Mark, M.D., his gastroenter-ologist, that his mobility and weight-loss goals had been affected by his left knee. AR 388. Dr. Mark observed slightly increased tone at Plaintiffs anastomotic site, and noted he had a hiatal hernia. AR 388.

Dr. Cook referred Plaintiff to a cardiologist and was seen by Charles C. Tsai, M.D., on December 3, 2011. AR 309-311. Dr. Tsai could hear an irregular rate and rhythm with normal SI and S2. He diagnosed atrial fibrillation but indicated Plaintiff was stable at that time. AR 311-312. Dr. Tsai also noted that Plaintiff had a history of duodenal ulcer with perforation. AR 309; 311.

On April 23, 2012, Plaintiff returned to Dr. Tsai for a follow-up of his atrial fibrillation, at which time Dr. Tsai recommended Plaintiff undergo a transthoracic echo with doppler. AR 304. Dr. Tsai reported Plaintiff had gradually and steadily been regaining the weight he lost after his bariatric surgery and currently weighed 295 pounds. AR 302. Dr. Tsai noted that Plaintiff wanted to quit work and apply for disability so that he could stay at home with his eight year old adopted daughter. AR 302.

On April 24, 2012, Plaintiff complained to Dr.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
242 F. Supp. 3d 998, 2017 U.S. Dist. LEXIS 38967, 2017 WL 1349292, Counsel Stack Legal Research, https://law.counselstack.com/opinion/vaughn-v-berryhill-caed-2017.