Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_14-cv-02327/USCOURTS-azd-4_14-cv-02327-0/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

Jorge Rafael Miranda, 

Plaintiff, 

vs.

Carolyn W. Colvin, Acting Commissioner

of Social Security,

Defendant. 

 

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No. CIV 14-2327-TUC-LAB

ORDER

The plaintiff filed this action for review of the final decision of the Commissioner for

Social Security pursuant to 42 U.S.C. § 405(g) and 42 U.S.C. § 1383(c)(3). 

The Magistrate Judge presides over this case pursuant to 28 U.S.C. § 636(c) having

received the written consent of both parties. See FED.R.CIV.P. 73; (Doc. 10)

The court finds the final decision of the Commissioner must be reversed. The ALJ’s

finding at step two of the disability analysis that Miranda’s shoulder impairment and back

impairment are not “severe” is not supported by substantial evidence. See Smolen v. Chater,

80 F.3d 1273, 1279 (9th Cir. 1996). The case will be remanded for further proceedings.

PROCEDURAL HISTORY

Miranda filed his application for disability insurance benefits and supplemental security

income on July 6, 2012. (Tr. 19) He alleged disability beginning on April 30, 2012, due to left

shoulder injury, ruptured shoulder tendon, arthritis, osteoporosis, high blood pressure,

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cholesterol, acid reflux, and diabetes. (Tr. 19, 166) His claim was denied initially (Tr. 80-87)

and upon reconsideration (Tr. 88-94). Miranda requested review and appeared with counsel at

a hearing before Administrative Law Judge (ALJ) Norman R. Buls on February 12, 2014. (Tr.

32) In his decision, dated March 7, 2014, the ALJ found Miranda is not disabled because he

has no severe impairments. (Tr. 19-25)

Miranda appealed and submitted additional exhibits, but the Appeals Council denied

review making the decision of the ALJ the final decision of the Commissioner. (Tr. 1-4); see

Bass v. Social Sec. Admin., 872 F.2d 832, 833 (9th Cir. 1989). Miranda subsequently filed this

action appealing the Commissioner’s final decision. (Doc. 1) He argues the ALJ erred in

finding his shoulder impairment, right elbow impairment, and low back impairment are not

“severe.” (Doc. 13) 

Claimant’s Work History and Medical History

At the time of the hearing, Miranda was 60 years old. (Tr. 32-33) He has a sixth grade

education. (Tr. 34) He can understand some English, but he is not fluent. (Tr. 34) 

Miranda worked as a laborer in a plastering company and as a cleaner in a cement plant.

(Tr. 167) In his job as cleaner, he frequently lifted objects weighing 50 pounds or more. (Tr.

189) Miranda was laid off in June of 2008. (Tr. 166) Since that time, he has had surgery on

his left shoulder and a laminectomy in his back. (Tr. 37) Miranda maintains that pain in his

arms, shoulder, and waist prevent him from lifting more that ten pounds at a time. (Tr. 40)

Physical Impairments

Miranda first injured his shoulder in 1999 when he fell at work. (Tr. 262, 388) He

suffered intermittent symptoms until February of 2012 when he aggravated his injury while

trimming trees. (Tr. 388) R. W. Wood, M.D., noted “[t]he MRI study shows a small full

thickness supraspinatus rotator cuff tear.” (Tr. 91) He recommended that Miranda ice and rest

his shoulder. Id. He briefly discussed rotator cuff surgery. Id.

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In April of 2012, the medical record indicates that a corticosteroid injection to Miranda’s

left shoulder was only partially beneficial. (Tr. 384) Wood assessed “rotator cuff tear - smallmoderate, chronic.” (Tr. 386) He referred Miranda to a course of physical therapy. In June of

2012, Wood noted that “injection and therapy have not been helpful,” and Miranda was “taking

Percocet four times a day for pain.” (Tr. 380) 

X-ray studies were performed in June of 2012. (Tr. 378) George R. Bradbury, M.D.,

assessed “rotator cuff tear - large-massive, chronic.” (Tr. 378) In July of 2012, Bradbury

performed a “left shoulder open rotator cuff repair and subacromial decompression.” (Tr. 232)

The medical record documents Miranda’s post operative treatment. (Tr. 364, 368, 371,

373) Miranda reported improvement, but he still had pain and swelling two months after

surgery. (Tr. 368)

In September of 2012, Miranda was examined by Melvyn Weinberg, M.D., for the state

disability determination service. (Tr. 309) Weinberg diagnosed “rotator cuff derangement of

the left shoulder with recent surgical repair and continued pain and decreased motion plus

regular Oxycodone use; recent muscle injury of the left posterior thigh with possible partial tear

which occurred in the last week; diabetes mellitus; and flexion deformity of the right elbow,

long-standing.” (Doc. 310)

Weinberg completed a Medical Source Statement of Ability to do Work-Related

Activities (Physical). (Tr. 312) He opined Miranda could lift or carry less than 10 pounds

frequently and up to 10 pounds occasionally. Id. He documented no standing, walking, or

sitting limitations. (Tr. 312-13) He opined Miranda should only occasionally climb ladders,

rope, or scaffolds; stoop, kneel; crouch; crawl; reach; handle; finger; or feel. (Tr. 313) He

noted further restrictions on working around heights and around moving machinery. Id. 

In December of 2012, Miranda still had left shoulder pain, which was aggravated by

movement. (Tr. 360) Treatment notes dated February 28, 2013 indicate Miranda still has left

shoulder pain which is aggravated by lifting and movement. (Tr. 352) 

In March of 2013, Allan Jones, P.T., assessed chronic left shoulder pain. (Tr. 424) He

noted Miranda could not lift his hand above his head. Id. Miranda’s short term goal for therapy

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was to decrease shoulder pain to a 6 out of 10. Id. His long term goal was to decrease shoulder

pain to a 3 out of 10. Id.

In July of 2013, Miranda fell in the shower and hurt his back. (Tr. 532) In October of

2013, Miranda was still complaining of severe back pain. (Tr. 532) MRI studies of Miranda’s

back were taken in November of 2013. (Tr. 536) Nicholas Fraley, M.D., noted “moderate to

severe degenerative spinal stenosis at L4-L5 due to disc bulge . . . .” (Tr. 536)

Miranda underwent an L4 and L5 decompressive laminectomy on December 17, 2013.

(Tr. 539, 543) Kurt A. Schroeder, M.D., reported the “surgery went well, the patient did well,

anesthesia went well.” (Tr. 539)

In December of 2013, Miranda reported he was recovering well from his back surgery

(Tr. 542) His gait was stable, but he was still using a cane. (Tr. 542) Treatment notes from

January of 2014 indicate Miranda was still suffering from chronic low back pain. (Tr. 563) In

February of 2014, Miranda still felt pain in the lower back with bending. (Tr. 559)

In February of 2014, Miranda appeared with counsel before the ALJ. (Tr. 30) He

testified through an interpreter. Id. Miranda explained he used to work with jack hammers and

chipping hammers. (Tr. 40) He had to lift objects weighing 60 pounds. (Tr. 40) He explained,

“And it was hard, and my hands used to end up stiff because of the kind of tools that I used to

work with.” (Tr. 40) He explained he can no longer return to work “[b]ecause of the problems

I have in my arms and my shoulder and my waist.” (Tr. 40) “I cannot lift anything overhead;

I get tired; [a]nd I cannot do much movements for more than one hour.” (Tr. 40) 

In March of 2014, Miranda complained of shoulder and back pain after performing two

hours of landscaping work. (Tr. 549)

The record contains third party statements from Luc Alba Quijado de Acosta and Robert

Sandoval. She states she has known Miranda for many years. (Tr. 222) Lately, however, she

has noticed that Miranda has back pain, which limits his movement. Id. When she gave

Miranda a ride in her car, Miranda took a long time to get out. Id. Sandoval also states he has

known Miranda for many years. (Tr. 223) He explains Miranda now has difficulty walking,

which he believes is due to back pain. Id. He states Miranda now walks with a cane. Id.

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1

 Residual functional capacity is defined as that which an individual can still do despite

his or her limitations. 20 C.F.R. §§ 404.1545, 416.945.

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CLAIM EVALUATION

Social Security Administration (SSA) regulations require that disability claims be

evaluated pursuant to a five-step sequential process. 20 C.F.R. §§ 404.1520, 416.920; Baxter

v. Sullivan, 923 F.2d 1391, 1395 (9th Cir. 1991). The first step requires a determination of

whether the claimant is engaged in substantial gainful activity. 20 C.F.R. §§ 404.1520(a)(4),

416.920(a)(4). If so, then the claimant is not disabled, and benefits are denied. Id. 

If the claimant is not engaged in substantial gainful activity, the ALJ proceeds to step

two, which requires a determination of whether the claimant has a “medically severe impairment

or combination of impairments.” 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). In making a

determination at step two, the ALJ uses medical evidence to consider whether the claimant’s

impairment more than minimally limits or restricts his or her “physical or mental ability to do

basic work activities.” Id. If the ALJ concludes the impairment is not severe, the claim is

denied. Id. 

Upon a finding of severity, the ALJ proceeds to step three, which requires a

determination of whether the impairment meets or equals one of several listed impairments that

the Commissioner acknowledges are so severe as to preclude substantial gainful activity. 20

C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); 20 C.F.R. Pt. 404, Subpt. P, App.1. If the claimant’s

impairment meets or equals one of the listed impairments, then the claimant is presumed to be

disabled, and no further inquiry is necessary. Ramirez v Shalala, 8 F.3d 1449, 1452 (9th Cir.

1993). If the claimant’s impairment does not meet or equal a listed impairment, evaluation

proceeds to the next step. 

The fourth step requires the ALJ to consider whether the claimant has sufficient residual

functional capacity (RFC)1

 to perform past work. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).

If yes, then the claim is denied. Id. If the claimant cannot perform any past work, then the ALJ

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must move to the fifth step, which requires consideration of the claimant’s RFC to perform

other substantial gainful work in the national economy in view of claimant’s age, education, and

work experience. 20 C.F.R. §§ 404.1520(a)(4); 416.920(a)(4).

 In determining whether the claimant retains the ability to perform other work, the ALJ

may refer to the Medical Vocational Guidelines (“the grids”) promulgated by the SSA. See 20

C.F.R. Pt. 404, Subpt. P, App.2; Desrosiers v. Secretary of Health and Human Services, 846

F.2d 573, 576-577 (9th Cir. 1988). The grids categorize jobs according to their exertional

requirements such as sedentary work, light work, or medium work. Tackett v. Apfel, 180 F.3d

1094, 1101 (9th Cir. 1999). The grids calculate whether or not the claimant is disabled based

on the claimant’s exertional ability, age, education, and work experience. Id. The grids are a

valid basis for denying claims where they completely and accurately describe the claimant’s

abilities and limitations. Id. at 1101-02. If the claimant has only exertional limitations, the

claim may be resolved based only on the grids. Lounsburry v. Barnhart, 468 F.3d 1111, 1115

(9th Cir. 2006). 

If the claimant has significant non-exertional limitations, the grids do not apply. Penny

v. Sullivan, 2 F.3d 953, 958-959 (9th Cir.1993). “Non-exertional limitations are limitations that

do not directly affect a claimant’s strength.” Burkhart v. Bowen, 856 F.2d 1335, 1340 (9th Cir.

1988). Mental limitations, for example, are non-exertional. Id. at 1340-41. If significant nonexertional limitations prevent the claimant from performing the full range of work in any

exertional category, the ALJ must take the testimony of a vocational expert to deny the claim.

Id. at 1341.

 The ALJ’s Findings

At step one of the disability analysis, the ALJ found Miranda “has not engaged in

substantial gainful activity since April 30, 2012, the alleged onset date . . . .” (Tr. 21). At step

two, he found Miranda “has the following medically determinable impairments: left shoulder

impairment, back impairment, and right arm/elbow impairment . . . .” (Tr. 21) He found,

however, that these impairments are not severe because they do not “significantly limit[] his

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ability to perform basic work activities. . . . (Tr. 22) Accordingly, he found Miranda was not

disabled “from April 30, 2012 through the date of this decision. . . .” (Tr. 24)

STANDARD OF REVIEW

An individual is entitled to disability benefits if he or she demonstrates, through

medically acceptable clinical or laboratory standards, an inability to engage in substantial

gainful activity due to a physical or mental impairment that can be expected to last for a

continuous period of at least twelve months. 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). “[A]

claimant will be found disabled only if the impairment is so severe that, considering age,

education, and work experience, that person cannot engage in any other kind of substantial

gainful work which exists in the national economy.” Penny v. Sullivan, 2 F.3d 953, 956 (9th Cir.

1993).

The findings of the Commissioner are meant to be conclusive. 42 U.S.C. §§ 405(g),

1383(c)(3). The decision to deny benefits “should be upheld unless it contains legal error or is

not supported by substantial evidence.” Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007). 

Substantial evidence is defined as “such relevant evidence as a reasonable mind might accept

as adequate to support a conclusion.” Id. It is “more than a mere scintilla but less than a

preponderance.” Id.

“Where evidence is susceptible to more than one rational interpretation, the ALJ’s

decision should be upheld.” Orn, 495 F.3d at 630. “However, a reviewing court must consider

the entire record as a whole and may not affirm simply by isolating a specific quantum of

supporting evidence.” Id.

In evaluating evidence to determine whether a claimant is disabled, the opinion of a

treating physician is entitled to great weight. Ramirez v. Shalala, 8 F.3d 1449, 1453-54 (9th Cir.

1993). The ALJ may reject a treating physician’s uncontradicted opinion only if she sets forth

clear and convincing reasons for doing so. Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995).

If the treating physician’s opinion is contradicted by another doctor, the ALJ may reject that

opinion only if she provides specific and legitimate reasons supported by substantial evidence

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in the record. Lester, 81 F.3d at 830. No distinction is drawn “between a medical opinion as

to a physical condition and a medical opinion on the ultimate issue of disability.” Rodriguez

v. Bowen, 876 F.2d 759, 761 n.7 (9th Cir. 1989). 

“The opinion of an examining physician is, in turn, entitled to greater weight than the

opinion of a non[-]examining physician.” Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1996).

“[T]he Commissioner must provide ‘clear and convincing’ reasons for rejecting the

uncontradicted opinion of an examining physician.” Id. “[T]he opinion of an examining doctor,

even if contradicted by another doctor, can only be rejected for specific and legitimate reasons

that are supported by substantial evidence in the record.” Id. at 830-31.

“Where medical reports are inconclusive, questions of credibility and resolution of

conflicts in the testimony are functions solely of the [Commissioner].” Magallanes, 881 F.2d

747, 751 (9th Cir. 1989) (punctuation omitted). The Commissioner’s finding that a claimant is

less than credible, however, must have some support in the record. See Light v. Social Security

Administration, 119 F.3d 789 (9th Cir. 1997).

The ALJ need not accept the claimant’s subjective testimony of disability, but if he

decides to reject it, “[]he must provide specific, cogent reasons for the disbelief.” Lester, 81

F.3d at 834. “Unless there is affirmative evidence showing that the claimant is malingering, the

Commissioner’s reasons for rejecting the claimant’s testimony must be clear and convincing.”

Id. “General findings are insufficient; rather, the ALJ must identify what testimony is not

credible and what evidence undermines the claimant’s complaints.” Id.

DISCUSSION

In this case, the ALJ rejected Miranda’s application at step two of the disability analysis.

The step two inquiry, however, is only “a de minimis screening device to dispose of groundless

claims.” Smolen v. Chater, 80 F.3d 1273, 1290 (9th Cir. 1996). “An impairment or

combination of impairments can be found ‘not severe’ only if the evidence establishes a slight

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abnormality that has no more than a minimal effect on an individual’s ability to work. Id.

(punctuation modified).

Here, the ALJ acknowledged that Miranda suffered from shoulder and back impairment

serious enough to warrant surgery. He concluded, however, that these impairments were no

longer “severe” subsequent to his surgeries. Substantial evidence, however, does not support

his optimistic assessment of Miranda’s post-surgical condition.

The ALJ’s explanation of his reasoning is relatively brief. His analysis of Miranda’s

shoulder impairment reads as follows:

The claimant was doing well after surgery. An x-ray taken in September 2012

after the claimant’s surgery showed no evidence of acute intraosseus injury. This

indicates that the claimant’s left shoulder impairment is non-severe.

(Doc. 23)

The reasons advanced by the ALJ do not constitute substantial evidence. The fact that

Miranda was doing well after surgery indicates that his condition would likely be improved by

the surgery. Without more, however, there is no way of knowing just how much improvement

Miranda would ultimately see. There is simply no evidence in the record that after surgery,

Miranda’s shoulder impairment was no longer severe and he could return to his previous work

where he had to lift objects weighing 50 to 60 pounds. (Tr. 40, 189) In fact, the medical record

indicates to the contrary that Miranda continues to experience shoulder pain that is exacerbated

by lifting and movement. See (Tr. 352, 360, 424)

The fact that an x-ray revealed “no evidence of acute intraosseus injury” also is not

substantial evidence supporting the ALJ’s decision. There is nothing in the record to support

the ALJ’s assertion that a lack of “acute intraosseus injury” is evidence that Miranda no longer

suffered from a severe shoulder impairment. The ALJ is not qualified as a medical expert and

may not substitute his own lay judgment in place of an informed medical opinion. See Day v.

Weinberger, 522, F. 2d 1154, 1156 (9th Cir. 1975); see, e.g., Cox v. Colvin, 2014 WL 6882390,

5 (C.D.Cal. 2014) (“Absent expert medical assistance, the ALJ could not competently translate

the medical evidence into a residual functional capacity assessment.”).

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The ALJ’s analysis of Miranda’s back impairment is similarly brief. He states simply

that “because there is little evidence following his surgery and because the surgery went well,

the claimant’s back impairment is durationally nonsevere.” (Tr. 23) The fact that the surgery

“went well,” however, is not substantial evidence that Miranda’s back impairment has been

reduced to “a slight abnormality” having “no more than a minimal effect” on his ability to work.

See Smolen v. Chater, 80 F.3d 1273, 1290 (9th Cir. 1996). 

The ALJ further notes that there is little evidence of Miranda’s condition post surgery.

But if he believed the medical record was incomplete, the ALJ should have supplemented the

record, not simply deny the claimant’s application at step two. See Webb v. Barnhart, 433 F.3d

683, 687 (9th Cir. 2005) (“[T]he ALJ had an affirmative duty to supplement Webb’s medical

record, to the extent it was incomplete, before rejecting Webb’s petition at so early a stage in

the analysis.”).

The ALJ further argues that Miranda’s record of daily activities supports his decision

denying benefits. He notes that Miranda is “able to clean around the house, go for walks, and

use public transportation.” (Tr. 24) The ability to engage in these activities, however, is not

evidence that Miranda is completely recovered and can lift objects weighing 50 to 60 pounds

again. 

In her brief, the Commissioner cites other aspects of the record that support the decision

of the ALJ. This court, however, may not affirm the decision of the ALJ by referring to

evidence that he did not discuss. Burrell v. Colvin, __ F.3d__, __, 2014 WL 7398892, 4 (9th

Cir. 2014); Connett v. Barnhart, 340 F.3d 871, 874 (9th Cir. 2003).

The court does not reach the claimant’s alternate arguments for remand.

IT IS ORDERED that the final decision of the Commissioner is reversed. The case is

remanded for further proceedings. 

The Clerk of the Court is directed to prepare a judgment and close this case.

DATED this 5th day of February, 2015.

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