Bogarin v. Kijakazi
| Docket Number | 1:22-cv-01463-SKO |
| Decision Date | 20 December 2023 |
| Parties | RUBEN SANCHEZ BOGARIN, Plaintiff, v. KILOLO KIJAKAZI, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant. |
| Court | U.S. District Court — Eastern District of California |
ORDER ON PLAINTIFF'S SOCIAL SECURITY COMPLAINT (DOC. 1)
Plaintiff Ruben Sanchez Bogarin (“Plaintiff”) seeks 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”). Doc 1. 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]
Plaintiff was born on June 4, 1978, and he was 42 years old when he filed his claim for DIB on August 5, 2020. (Administrative Record (“AR”) 15, 361). In his application, he alleged a disability onset date of June 20, 2019, based on his “neuropathy, type 2 diabetes, high cholesterol, triglycerides, HBP [high blood pressure], and chiari malformation.” (AR 15, 158, 218). Plaintiff has a high school education, and he previously worked as a tractor-trailer truck driver. (AR 27).
Plaintiff's medical records indicate he suffers from various joint pains, complications from his Diabetes mellitus type two, and a history of headaches.[3] Plaintiff has also complained of ongoing lethargy. (See, e.g., AR 342).
On August 27, 2019, Plaintiff saw Sumeet Bhinder, M.D., and reported pain in his legs and feet, which had been present for roughly nine months and prevented him from working. (AR 314). A joint examination revealed no distinct synovitis, though Dr. Bhinder noted some tenderness over a few joints. (AR 316). Dr. Bhinder referred Plaintiff for x-rays, which later showed heterotopic ossification at the right ischial spine. (AR 289, 316). Dr. Bhinder later referred Plaintiff for an MRI of his pelvis, which showed degenerative change involving the bilateral sacroiliac joints, disc protrusion and facet hypertrophy at ¶ 5-S1, resulting in mild-to-moderate canal and moderate bilateral foraminal stenosis. (AR 297). Dr. Bhinder noted Plaintiff did not meet the criteria for rheumatoid arthritis. (AR 313).
In May 2020, Plaintiff complained of right arm pain, and Dr. Alvarez noted tenderness and a reduced range of motion in Plaintiff's right shoulder. (AR 471). Dr. Alvarez referred Plaintiff for shoulder imaging and instructed him to exercise, diet and keep a log of his blood sugars. (AR 471). Subsequent imaging of Plaintiff's right shoulder showed mild chronic hypertrophic degenerative changes of the AC joint and a small benign bone spur. (AR 334, 359). Felix Trapse, M.D., prescribed Cyclobenzaprine and Hydrocodone for Plaintiff's right shoulder pain and instructed him to exercise. (AR 337). Plaintiff again visited Dr. Alvarez on May 13, 2020, reporting upper extremity pain. (AR 498).
Plaintiff has also reported pain and swelling in his hands. (AR 314). On September 10, 2019, Plaintiff rated his bilateral hand pain as a seven out of ten in severity. (AR 476). Dr. Carlos Alvarez, M.D., noted Plaintiff had a decreased range of motion in his hands but that Plaintiff was already scheduled for neuropathy testing. (AR 476-477). Plaintiff underwent a nerve conduction student and electromyography on his upper extremities in September 2019. (AR 298). The results were “consistent with a severe bilateral Carpal Tunnel Syndrome” and axonal left ulnar neuropathy. (AR 300). Plaintiff returned to Dr. Alvarez on October 3, 2019, for bilateral wrist pain, and Dr. Alvarez noted a decreased range of motion. (AR 474). Dr. Alvarez increased Plaintiff's prescription for Lyrica and referred him to an orthopedic surgeon. (AR 475). Plaintiff followed-up with Dr. Alvarez in January 2020, and while Plaintiff complained of joint pain, Dr. Alvarez noted a full range of motion and no other adverse findings. (AR 472).
The study found Plaintiff underwent a neurological consultation on June 22, 2021. (AR 432). The provider, Sheila Mendoza, N.P., concluded “the degree of polyneuropathy appears mild in the upper extremities” and the “mild chronic neurogenic changes in distal muscles [are] most likely related to polyneuropathy.” (AR 431). At his August 10, 2021, follow-up, Plaintiff complained of weakness in his knees and tingling/pain in his extremities. (AR 429). He rated his pain as an eight out of ten and reported his symptoms worsened at night. (AR 429). Plaintiff stated the pain prevented him from performing his daily activities though he showered and changed on his own. (AR 429). The neurological exams again reflected no neurological deficits. (AR 430). Mendoza referred Plaintiff to physical therapy, a hand specialist and a back specialist. (AR 431).
The record demonstrates Plaintiff's Diabetes is generally uncontrolled. At a May 14, 2020, appointment with Dr. Trapse, Plaintiff admitted he had been out of his prescription insulin since December 2019. (AR 339). In December 2020, Sharon Vejvoda, N.P., performed Plaintiff's annual physical and noted high glucose leels. (AR 468). On April 28, 2021, Plaintiff's A1c reached 13 percent. (AR 518). Plaintiff reports headaches related to his diabetes. (AR 345).
On July 9, 2021, Raynado Garcia, M.D., completed a medical source statement related to Plaintiff's conditions. (AR 441-45). Dr. Garcia opined that Plaintiff could sit for 20 minutes at a time and stand for 30 minutes at a time. (AR 443). Dr. Garcia also noted Plaintiff would need a 20-minute break every two hours because of his muscle weakness, chronic fatigue, pain/paresthesias, numbness and the adverse effects of his medication. (AR 443). He also stated Plaintiff would be off-task 25 percent or more of the day, and he would be absent more than four days per month. (AR 444). He concluded Plaintiff was incapable of even “low stress” work. (AR 444).
Roger Wagner, M.D., performed a consultative examination in November 2020. (AR 361365). Plaintiff's chief complaints included Diabetes mellitus type 2, a Chiari malformation and low back pain. (AR 361). Plaintiff reported he could walk half a mile and sit for between 60 to 75 minutes at a time, though bending and lifting exacerbated his back pain. (AR 361-362). Dr. Wagner noted that Plaintiff could drive, shop and perform his own activities of daily living without assistance. (AR 362). Plaintiff suffered from some early neuropathy connected to his diabetes. (AR 364). Dr. Wagner concluded that Plaintiff had no limitations related to standing and walking with normal breaks. (AR 365). He also found Plaintiff could occasionally lift and carry 50 pounds, and he could frequently lift and carry 25 pounds. (AR 365). Dr. Wagner also concluded Plaintiff could climb, stoop, crouch and reach overhead with his right arm frequently. (AR 365). Dr. Wagner assigned no other workplace limitations. (AR 365).
In November 2020, state agency consultant S. Lee, M.D., assessed Plaintiff's claim at the initial level. (AR 54-66). After reviewing the evidence, Dr. Lee found Plaintiff could perform medium work (AR 64) with some limitations. Dr. Lee found Plaintiff could occasionally lift or carry 50 pounds and frequently lift or carry 25 pounds. (AR 62). They also found Plaintiff could stand or walk with normal breaks for six out of eight hours per workday, and he could sit with normal breaks for roughly six out of eight hours per workday. (AR 62). In February 2021, state agency consultant G. Lee, M.D., found Plaintiff was limited to light work with various postural limitations while reviewing the record on reconsideration. (AR 70-79). Dr. G. Lee found Plaintiff could occasionally lift or carry 25 pounds and could frequently lift or carry 10 pounds. (AR 77).
Plaintiff testified to lifting 50 pounds while working in his previous position, though he reported occasionally struggling with it. (AR 41). Plaintiff reported leaving his previous position because his legs often felt tired, though now he struggles with pain in his hands. (AR 42). He stated he suffers from two to three headaches a week, which date back to his childhood. (AR 43). He reported that he is in pain “all day” and has no strength. (AR 45).
The Commissioner denied Plaintiff's application for benefits initially on November 19, 2020, and again on reconsideration on March 1, 2021. (AR 62, 87). Plaintiff requested a telephonic hearing before an Administrative Law Jaw (an “ALJ”), and the parties attended a hearing on September 9, 2021. (AR 43).
In a decision dated September 77, 2021, the ALJ found that Plaintiff was not disabled as defined by the Act after conducting the five-step disability analysis set forth in 20 C.F.R. § 404.1520. (AR 15-28). At step one, the ALJ found Plaintiff had not engaged in substantial gainful activity since June 20, 2019 (step one). (AR 17). At step two, the ALJ found that Plaintiff suffers from the following severe impairments: degenerative disc disease of the lumbar spine, degenerative joint disease of the sacroiliac (SI) joint, diabetes mellitus, bilateral carpal tunnel syndrome, and Chiari malformation. (AR 17). Plaintiff did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (“the Listings”) (step three). (AR 18).
The ALJ then assessed Plaintiff's residual functional capacity (RFC)[4] and applied the assessment at steps four and five. See 20 C.F.R. § 404.1520(a)(4) (...
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