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Daniel J. v. Berryhill

United States District Court, W.D. Washington, Seattle

April 16, 2019

DANIEL J., Plaintiff,


          BRIAN A. TSUCHIDA Chief United States Magistrate Judge

         Plaintiff Daniel J. seeks review of the denial of his Supplemental Security Income application. He contends that the ALJ erred in evaluating the medical evidence, his testimony, and the lay witness evidence, and that the resulting residual functional capacity finding and finding of nondisability are thus erroneous. Dkt. 18. The Court REVERSES the Commissioner's final decision and REMANDS the matter for further administrative proceedings under sentence four of 42 U.S.C. § 405(g).


         Plaintiff is currently 53 years old, has a high school education, and does not have past relevant work. Tr. 225, 247, 255. He applied for benefits in January 2015, alleging disability as of July 2001; he later amended his alleged onset date to January 28, 2015, the date he filed his application. Tr. 223, 255. After his application was denied initially and on reconsideration, the ALJ conducted a hearing and, on April 28, 2017, issued a decision finding plaintiff not disabled. Tr. 22-37. The Appeals Council denied plaintiff's request for review, making the ALJ's decision the Commissioner's final decision.[1] Tr. 1.


         Utilizing the five-step disability evaluation process, [2] the ALJ found that plaintiff had not engaged in substantial gainful activity since the alleged onset date; he had the following severe impairments: cervical spine degenerative disc disease, lumbar spine degenerative disc disease, and bilateral carpal tunnel syndrome, status post release surgeries; and these impairments did not meet or equal the requirements of a listed impairment.[3] Tr. 24-26. The ALJ found that plaintiff had the residual functional capacity to perform light work with additional postural, manipulative, and environmental limitations. Tr. 27. The ALJ found that plaintiff had no past relevant work, but, as there were jobs that existed in significant numbers in the national economy that plaintiff could perform, he was not disabled. Tr. 35-37.


         A. Medical evidence

         Plaintiff argues that the ALJ failed to properly evaluate the medical evidence. In general, the ALJ must give specific and legitimate reasons for rejecting a treating or examining doctor's opinion that is contradicted by another doctor, and clear and convincing reasons for rejecting a treating or examining doctor's uncontradicted opinion. Lester v. Chater, 81 F.3d 821, 830-31 (9th Cir. 1996).

         1.Dr. Lang and evidence prior to December 2014

         In January 2014, Robert Lang, M.D., plaintiff's treating neurosurgeon, diagnosed plaintiff with uncontrolled carpal tunnel syndrome. Tr. 385. He noted that an EMG nerve conduction study from October 2013 was positive for slight worsening of carpal tunnel syndrome in both wrists. Id. Dr. Lang opined that plaintiff had persistent bilateral carpal tunnel syndrome despite bilateral open carpal tunnel release with internal neurolysis. Id.

         By March 2014, Dr. Lang noted that plaintiff had residual discomfort following his carpal tunnel release surgery and he did not benefit from injections. Tr. 394. He opined that plaintiff was quite incapacitated by his ongoing discomfort. Id. Dr. Lang stated that while plaintiff should follow up if his symptoms worsened, he had no additional treatment recommendations at that time. Id. Dr. Lang opined that plaintiff was unable to work full-time because of his ongoing discomfort and objective clinical findings, including weakness in his hands and inability to fully oppose thumb to little finger, and he recommended approval of Social Security disability. Id.

         The ALJ did not address Dr. Lang's treatment notes or the opinions contained therein. Plaintiff argues that this is harmful legal error, as the ALJ cannot disregard without explanation the findings and opinions of a treating specialist, especially where those findings and opinions contradict the ALJ's residual functional capacity assessment. Dkt. 18 at 4. Plaintiff also identifies treatment notes from other providers dated March 2014 through October 2014, and asserts that the ALJ also erred by failing to discuss these notes. Id.

         The Commissioner responds that the evidence plaintiff cites to is from more than a year before the alleged onset date and, for this reason, is not significant and probative evidence that the ALJ is required to discuss. Dkt. 19 at 13. This statement is misleading at best. The earliest treatment note from Dr. Lang that plaintiff identifies is dated January 15, 2014, which is one year and 13 days before the alleged onset date. Dr. Lang's March 2014 note is from eight months before the alleged onset date. Even if the ALJ could properly discount the January 15, 2014 treatment note because it was dated more than a year before the alleged onset date, all the other evidence plaintiff identifies does not fall within this timeframe.

         Moreover, the nature of the opinions contained in Dr. Lang's treatment notes undermine the Commissioner's argument that they are not relevant or probative to plaintiff's current claim. Dr. Lang provided follow-up treatment after plaintiff's carpal tunnel surgery; he found that the surgery did not provide relief of plaintiff's ongoing discomfort and that injections did not confer more than a temporary benefit. He opined that there were no further treatment options available to plaintiff. These notes show unsuccessful treatment attempts and a lack of additional treatment options in the period leading ...

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