Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_04-cv-02907/USCOURTS-azd-2_04-cv-02907-1/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (DIWC)

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WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Robert Robinson, Jr., )

)

 Plaintiff, )

) 

v. ) CV 04-2907 PHX VAM

)

Jo Anne B. Barnhart, ) ORDER

Commissioner, Social Security )

Administration, )

)

 Defendant. )

Pending before the Court is plaintiff's "MOTION TO AMEND

JUDGMENT UNDER RULE 60(b)." (Doc. 27).

Plaintiff asks for relief pursuant to Fed.R.Civ.P. 60(b) on

the basis that the Court's order affirming the ALJ's denial of

benefits is based on "mistake, inadvertance, or excusable

neglect." (Doc. 27 at p. 2). Specifically, plaintiff argues that

the Court denied relief based on the mistaken view that "this

'case turns upon plaintiff's credibility'" and upheld the ALJ's

decision "based entirely upon a finding that the ALJ did not err

in concluding that Plaintiff's testimony about the severity of his

pain was not credible." (Id.). 

Plaintiff contends that although "the Court was correct that

Plaintiff's credibility was key to this case ... the Court erred

in discussing only this issue." (Id.) (emphasis in original). 

Plaintiff states that two other issues were also raised which were

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not considered by the Court, namely, "[1] the ALJ's reliance on

the opinion of nonexamining state agency physicians who did not

testify at the hearing ... and [2] the ALJ's conclusory finding

that Plaintiff's condition did not meet or equal criteria for a

presumptive disability at step three of the sequential evaluation

process." (Id. at p. 3). In addition, plaintiff argues the Court

erred in upholding the ALJ's determination that plaintiff's pain

testimony was not credible because the Court erroneously cited

medical reports relating to pain suffered by plaintiff as a result

of foot surgery and/or treatment, while plaintiff's basis for

disability is predicated solely on injuries causing severe back,

neck and shoulder pain. (Id. at p. 5).

In upholding the ALJ's denial of benefits, the Court noted

that no treating or examining physician "opined that plaintiff

cannot work" and observed that one treating physician, Dr.

Brennan, stated in October, 2001 (after plaintiff's claimed onset

of disability date of March 9, 2001), "that plaintiff was capable

of light work." (Doc. 25 at p. 14). The Court also cited as a

basis for its decision "notes concerning a series of examinations

conducted on plaintiff between May and October, 2003, ... [in

which] plaintiff was specifically asked to indicate ... his level

of pain on a scale of one to ten." (Id. at p. 13). On this

point, the Court noted that: 

On four occasions, plaintiff rated his pain at 0 ("no

pain"). On one occasion plaintiff rated his pain as 1

on a scale of ten. [Citation omitted]. On two other

occasions he characterized his pain as a 3 on a scale

of ten. [Citation omitted]. Once he indicated he

experienced "occasional" pain at 4 on a 10 scale.

[Citation omitted]. Twice he characterized his pain as

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"occasional" and 5 on a scale of ten. [Citation

omitted].

 

(Doc. 25 at pp. 13-14).

Upon re-examination, the Court believes it erred in citing

most of these treatment notes because, with one exception, they

refer to podiatric examinations conducted as follow-ups to

treatment and surgery plaintiff received on his feet. (See Doc.

6A at pp. 257, 264, 267, 271, 274, 277, 287, and 291). It is

clear from his hearing testimony and his summary judgment motion

that plaintiff's claims of disability are predicated on

allegations of severe back, neck and shoulder pain flowing from

injuries to those areas of the body. (See Doc. 6A at pp. 464-72;

Doc. 12). It is also clear that the ALJ's decision focused on

plaintiff's claims of severe back, neck and shoulder pain when she

determined these injuries and pain were not sufficiently credible

to justify awarding disability benefits. (See Doc. 6A at p. 20). 

Because the Court's reliance in upholding the ALJ's decision

to deny benefits was predicated, in large part, on citation to

treatment notes related foot injuries, the Court's determination

on that basis was erroneous and plaintiff's request for Rule 60(b)

relief will be granted. The Court will re-assess the issue of

whether the ALJ was justified in finding plaintiff's pain

testimony regarding injuries to his back, neck and shoulder not

credible and denying benefits on that basis before considering

plaintiff's other arguments for Rule 60(b) relief.

In its assessment of the credibility of plaintiff's pain

testimony, the ALJ conceded plaintiff "has a history of treatment

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for shoulder, neck and back pain." (Doc. 6A at p. 21). The ALJ

further elaborated that plaintiff "has degenerative disc disease

of the lumbar spine with spondylosis, degenerative disc of the

cervical spine and stenosis, right rotator cuff tear status post

surgery (June 2001), ..., impairments that are 'severe' within the

meaning of the Regulations, ..." (Doc. 6A at p. 21). However,

the ALJ concluded that the impairments were "not 'severe' enough

to meet or medically equal" the requirements necessary for a

finding of presumptively disabled at Step 3. (Id.). As a result,

the Court moved to assess plaintiff's ability to perform his past

relevant work (Step 4) and, if necessary, his ability to perform

any work (Step 5) to determine if he was disabled. 

At the hearing, plaintiff testified his back pain was 9 on a

scale of 10 and that he could stand or sit for no more than 30-40

minutes at any one time. Plaintiff states his pain from standing

or sitting means that in an 8 hour day he must lie down for 4

hours. (Doc. 6A at pp. 465-66). Plaintiff also testified he has

sharp, shooting pain that goes from his neck to his left shoulder. 

He testified he lives with his niece who takes care of him and

that he can't get a drink on his own, can't cook (except to use

the microwave), can't do the dishes and hasn't driven since March,

2001. (Id. at pp. 467-70). 

In discounting plaintiff's pain testimony, the ALJ stated,

inter alia:

... [plaintiff's] allegations concerning his symptoms

and limitations [are] lacking in credibility. Although

[he] testified to a reduced range of activities, as

well as debilitating episodes of pain, the documentary

evidence nevertheless establishes [plaintiff] has

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overstated his limitations. His statements concerning

his impairments and the impact upon his ability to work

are not entirely credible in light of the degree of

medical treatment required, the reports of treating

practitioners, the medical history, findings made on

examination and information reported by [plaintiff].

(Doc. 6A at p. 24). 

The ALJ also noted that relative to plaintiff's claims of

"severe and chronic pain" in his neck, lower back, shoulder and

arm, "[m]agnetic resonance imaging revealed a tear of the

supraspinatus tendon and [plaintiff] underwent a right shoulder

open rotator cuff repair ... with good results" and plaintiff "did

not experience right shoulder problems following surgery." (Id.). 

The ALJ further observed that plaintiff's treating physician

"allowed him to return to light duty work with the right arm with

no lifting of over 20 pounds and no overhead activity with the

right arm." (Id.).

In addition, the ALJ noted plaintiff testified he "had

severely limited his activities of daily living." The ALJ cited

two factors in discounting this claim, namely, (1) that

plaintiff's claims of "limited daily activities cannot be

objectively verified with any reasonable degree of certainty," and

(2) "even if [plaintiff's] daily activities are truly as limited

as alleged, it is difficult to attribute that degree of

limitations to [his] medical condition, ..., in view of the

relatively weak medical evidence ..." (Doc. 6A at p. 26). The

ALJ also opined "even though [plaintiff] reports somewhat limited

daily activities, his activity level is not that of a person

unable to function due to pain" and noted his ability to do "light

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household chores, go[ing] grocery shopping, and car[ing] for his

personal needs" which she found "inconsistent with the presence of

a condition which would preclude all work activity." (Id.).

In addition, the ALJ cited plaintiff's inconsistent

statements on the level of his education as evidence of his

veracity. She noted he testified at a hearing he completed tenth

grade and obtained a high school equivalency diploma but told one

treating physician he completed his high school education. (Doc.

6A at p. 26). The ALJ also noted a discrepancy between

plaintiff's characterization of his pain at the hearing as 9 on a

10 scale, when "he failed to even mention pain during many medical

appointments" and "the record contains a statement from one of

[his] doctors releasing [him] to return to light duty work." 

(Id.). 

The ALJ concluded the credibility assessment by finding

plaintiff's hearing testimony "inconsistent with the record as a

whole," observing that "treating physicians do not note overt

signs of pain during their examinations and there is no evidence

that [plaintiff] has experienced pain or limitations of the

severity he has alleged for a continuous 12 month time period." 

(Doc. 6A at p. 26). The ALJ summed up by stating that

"[o]bjective findings show the ability to perform at least a

significant range of light work with additional limitations." 

(Id.). 

The standard to evaluate the ALJ's assessment of plaintiff's

credibility as to his pain, is laid out in Moisa v. Barnhart, 367

F.3d 882 (9th Cir. 2004). In pertinent part, the Court stated:

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"[O]nce a claimant produces objective medical evidence

of an underlying impairment, an [ALJ] may not reject a

claimant's subjective complaints based solely on lack

of objective medical evidence to fully corroborate the

alleged severity of pain." If the ALJ finds claimant's

pain testimony not to be credible, the ALJ "must

specifically make findings that support this

conclusion," and the findings "must be sufficiently

specific to allow a reviewing court to conclude the

[ALJ] rejected [the] claimant's testimony on

permissible grounds and did not arbitrarily discredit

the claimant's testimony." If there is no affirmative

evidence that claimant is malingering, the ALJ must

provide clear and convincing reasons for rejecting the

claimant's testimony regarding the severity of

symptoms.

Moisa, 367 F.3d at 885 (emphasis added).

As noted, in upholding the ALJ's credibility determination,

the Court cited, prominently, a series of treatment notes which

were not relevant to the maladies plaintiff stated were the cause

of disability (severe pain from chronic injuries to the neck,

shoulder and back). The Court also cited a written statement from

a treating physician, Dr. Michael Brennan, M.D., that plaintiff

could perform "light work." (Doc. 6A at p. 160). The Court

further noted that no treating physician opined specifically that

plaintiff was unable to work. (See Doc. 25 at p. 14).

As stated, the Court's reliance on the treatment notes cited

in its original decision was mistaken. As noted, all these notes,

save one, relate to pain assessments made as follow-up

examinations to foot surgery. They in no way deal, or were meant

to deal with, plaintiff's back, neck and shoulder pain, the pain

he claims renders him disabled. 

Upon re-assessment, the Court believes that given the

objective evidence of an underlying impairment, noted by the ALJ

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in her Step 3 evaluation, the ALJ's determination that plaintiff's

claims of pain were not credible was not supported with sufficient

specificity, nor did she provide the requisite "clear and

convincing reasons" for rejecting his pain testimony.

Closer review of the medical records shows plaintiff did

complain of severe pain with regard to his neck, shoulder and/or

back on several occasions over a substantial period of time. 

Plaintiff had neck surgery in 1995. (Doc. 6A at pp. 137-38). 

For instance, in a disability report filed with the Social

Security Administration in September, 1996, plaintiff complained

of neck, back and shoulder pain. He stated this pain forced him

to leave his job as a nursing assistant and bothered him so much

he got sick "all the time." (Doc. 6A at p. 66). In a "Symptom

Questionnaire to Claimant" filed by plaintiff in October, 1996,

with the Arizona Department of Economic Security, he again cited

pain in his back, neck and shoulder. He described the pain as

"sharp" affecting him when he walks, stands or bends. (Id. at p.

88). Petitioner states this pain is brought on when he has to

stand for more than 10 minutes or when walking more than 4 or 5

steps or when he has to bend over. (Id.). He stated the pain

continues until he lies down. (Id.). Plaintiff chronicled the

same injuries and same pain in later disability reports and

symptom questionnaires filed in 2002. (See id. at pp. 90-99; 109-

10). 

The Court has re-examined the medical records in detail,

particularly those relating to treatment for back, neck and

shoulder pain. Since at least 1995, plaintiff has visited

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physicians complaining of substantial lower back pain and/or neck

and shoulder pain. These complaints are documented in separate

examinations conducted in 1996 by Drs. Paul Geimer, D.O. and Dr.

Kirk Williams, M.D., respectively. (See Doc. 6A at pp. 147-48 and

149-52). Both noted plaintiff complained of severe back pain but

neither opined about whether plaintiff could work or not because

of it. 

Since March 9, 2001 (the disability onset date), plaintiff

has been examined by several physicians concerning his back, neck

and/or shoulder pain. From April-September, 2001, petitioner was

examined on several occasions by Dr. Michael Brennan, M.D. Dr.

Brennan's observations and analysis appear confined to the effects

of surgery on plaintiff's right shoulder. (See Doc. 6A at pp.

159-69). During this period, Dr. Brennan noted steady improvement

in his shoulder and in notes dated August 16, 2001, stated he

believed plaintiff could return "to light-duty with the right

arm." (Id. at p. 160). It is clear that Dr. Brennan confined his

assessment of plaintiff's ability to work to the limitations

imposed as a result of the right shoulder surgery.

Records from a treating physical therapist with NovaCare

from April 17, 2001, show plaintiff made three visits for

treatment of low back pain/neck pain/right shoulder pain. (Doc.

6A at pp. 156-58). The physical therapist noted plaintiff

complained of "an onset of complaints gradually from the end of

February through the beginning of March 2001" as a result of his

most recent job as a truck driver. (Id. at p. 157). The

therapist noted complaints of "shoulder pain, neck pain,

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bilateral/central low back pain and intermitted LE pain" and he

stated an x-ray revealed a compression fracture of the first

lumbar vertebrae. (Id.). The therapist also noted plaintiff

claimed "a limited ability to stand or walk for periods longer

than 5-10 minutes secondary to severe complaints of pain." (Id.). 

 Plaintiff was also examined on several occasions between 1995

and 2001 by Dr. Lewis J. Brown, M.D. In particular, Dr. Brown

examined plaintiff in April, 2001 and again in September, 2001

(after the alleged onset of disability date of March 9, 2001). In

the April 30, 2001 "progress notes," Dr. Brown wrote about

plaintiff's back and shoulder pain. He noted plaintiff was last

seen in January, 2000 for low back problems. He further noted

"plaintiff continues to have low back pain aggravated by sitting

or standing" and had not worked since March, 2001 (the alleged

time of onset of disability). Dr. Brown also recounted that in

addition to the back pain plaintiff's most pronounced pain was in

his right shoulder which "is very painful with active and passive

movement." (Doc. 6A at p. 172). Dr. Brown stated that plaintiff

was informed that x-rays were taken but they were normal. (Id.).

Dr. Brown did conclude, however, that plaintiff's intense shoulder

pain was causing "frozen shoulder syndrome" to develop. (Id. at

p. 173).

In his September 13, 2001, "progress notes," Dr. Brown again

noted plaintiff suffered great pain from his right shoulder and

had an "intention tremor" which caused him to have to use his left

hand to do "most things" like handling liquids and driving. (Doc.

6A at p. 170). Dr. Brown also noted plaintiff's continuing back

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pain which had been worsened by a truck driving job which he began

in November, 2000. (Id.). 

Plaintiff also was examined in 2002 by doctors with MedPro

Orthopedics. (Doc. 6A at pp. 190-93). They noted plaintiff's

complaints of back and shoulder pain and prescribed a plan of

treatment, including epidurals. (Id.). These doctors did not

opine on plaintiff's ability to work or not work but noted he had

received steady treatment for these problems since 1995 and had

not worked since March, 2001. (Id. at p. 191). 

Finally, medical records from the Phoenix Indian Medical

Center from late-2002 to March, 2004, show plaintiff was seen on

several occasions. Examinations relating specifically to claims

of back/shoulder/neck pain during this period document that

plaintiff characterized his pain as substantial in each instance. 

(Doc. 6A at pp. 316, 319, 333-35, 386, 399-400).

Based on the ALJ's finding that plaintiff's suffers from

"severe" maladies capable of causing pain in his back, neck and

shoulder, as well as plaintiff's well-documented complaints of

intense pain in these areas of the body and a lack of any finding

of malingering by the ALJ, plaintiff's pain complaints should be

credited unless the ALJ presents "clear and convincing" evidence

for not doing so. See Moisa, 367 F.3d 885. The Court believes

that the ALJ has failed to meet this standard.

The ALJ cited inconsistencies about plaintiff's

characterization of his level of education as an example of why he

is not credible. The Court is not convinced. The discrepancy is

between a claim of being a high school graduate and a high school

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equivalency graduate. This difference is negligible and is not

persuasive evidence of a lack of credibility.

In addition, the ALJ cited the opinion of Dr. Brennan in

April, 2001, that plaintiff could perform "light work." A close

look at this statement reveals Dr. Brennan was assessing only

plaintiff's shoulder injury. Dr. Brennan did not speak to

plaintiff's back and neck pain. Thus, this conclusion is not

conclusive and, without more, is not "clear and convincing"

evidence supporting a conclusion that plaintiff lacks credibility

as to his level of pain.

Next, the ALJ merely asserts that plaintiff's claimed level

of pain "is so severe as to appear implausible." (Doc 6A at p.

26). She follows this by again reiterating her belief that his

level of claimed pain is "inconsistent with the record as a

whole." (Id.). Perhaps the ALJ also mistakenly relied on

podiatric medical records. No examining doctor has specifically

concluded plaintiff cannot work due to pain from his neck, back

and shoulder. But no examining doctor has concluded he can work,

save for Dr. Brennan's statement in April, 2001, that his shoulder

impairment did not prevent his return to "light work."

Conversely, the only professionals to opine plaintiff can

work are non-examining agency professionals. (See Doc. 6A at pp.

194-201, 238-45). This alone, is insufficient to discount

plaintiff's claims of pain testimony. Indeed, the Court believes

the medical record shows consistent claims by plaintiff of

debilitating back, neck and shoulder pain over several years up

through and beyond the date of onset of disability (March 9,

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2001). These records are consistent with his hearing testimony. 

The reasons cited for discounting this pain testimony do not rise

to the "clear and convincing" standard required by Moisa, in light

of the ALJ's finding that plaintiff suffers from severe

impairments and has no history of malingering. For these reasons,

the ALJ erred in discounting plaintiff's pain testimony. Both

parties and the ALJ concede that if plaintiff's pain testimony is

credited he is disabled and entitled to benefits. (See Doc. 6A at

p. 479). For this reason, no purpose will be served by remanding

to the Agency for anything other than an award of benefits. See

Benecke v. Barnhart, 379 F.3 587, 594-96 (9th Cir. 2004).

Because the Court believes it erred in assessing evidence in

support of the ALJ's finding that plaintiff's pain testimony was

not credible and now finds that plaintiff's pain testimony should

be credited and benefits awarded on that basis, the Court will not

address the issues of whether it erred in not considering

plaintiff's additional claims related to the ALJ's reliance on

nonexamining professionals and the claim that the ALJ erred in

making only a conclusory assessment of whether plaintiff's

impairments met or exceeded the requirements for a finding of

presumptively disabled at Step 3 of the sequential evaluation

process. (See Doc. 27 at p. 4).

IT IS THEREFORE ORDERED that plaintiff's "MOTION TO AMEND

JUDGMENT UNDER RULE 60(b)" based on mistake and/or inadvertence

(Doc. 27) is granted.

IT IS FURTHER ORDERED that the Court's prior Order granting

defendant's Cross-motion for Summary Judgment (Doc. 25) is

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vacated.

IT IS FURTHER ORDERED that plaintiff's Motion for Summary

Judgment (Docs. 10,11 and 12) is granted. This matter shall be

remanded to the Social Security Administration for an award of

benefits. 

IT IS FURTHER ORDERED that the Clerk of Court shall enter

judgment in this matter accordingly.

 DATED this 10th day of March, 2006.

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