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Lanieka N. Wise v. Michael J. Astrue

September 17, 2012


The opinion of the court was delivered by: Sheila K. Oberto United States Magistrate Judge



Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security (the "Commissioner" or "Defendant") denying her application for Supplemental Security Income ("SSI") pursuant to Title XVI of the Social Security Act (the "Act"). 42 U.S.C. §§ 405(g); 1383(c)(3). 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.*fn1


A. Procedural Background

Plaintiff was born in 1981, has a high school education, and previously worked in a warehouse packing clothing, shoes, or breaking down boxes; Plaintiff also worked for several years as a cook in a fast food restaurant. (Administrative Record ("AR") 28, 37, 104, 123.) On December 20, 2001, Plaintiff filed an application for SSI alleging disability since March 9, 2000, due to depression and paranoia. (AR 10.) Plaintiff's claim was denied initially and on reconsideration; subsequently, Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"). A hearing was held and a decision was issued on April 4, 2003, denying the claim. (AR 10.) Plaintiff filed a request for review by the Appeals Council, which was granted, and the case was remanded for further proceedings. (AR 10.)

A supplemental hearing was held on December 9, 2004, and a new decision was issued on January 13, 2005, denying Plaintiff's claim at the Second Step of the sequential analysis. (AR 10, 55-67.) That decision was not appealed. (AR 10.)

On March 31, 2008, Plaintiff filed another application for SSI, which is the application currently on appeal, alleging disability beginning July 1, 2007. (AR 123-29.)

B. Relevant Medical Evidence

On June 8, 2007, Plaintiff was evaluated by a social worker, M. Heffron. (AR 246.) Plaintiff reported she was afraid to leave the house and she complained of a depressed mood. (AR 248.) The progress note indicates that Plaintiff had not received any treatment since 2003. (AR 248.) A diagnosis of schizophrenia was provided, and a Global Assessment of Function ("GAF") score was listed as 32. (AR 246.)*fn2

On November 7, 2007, a mental status examination was conducted by Kevin Marmolejo, M.D., a psychiatrist. (AR 241.) Dr. Marmolejo diagnosed Plaintiff as "psychotic NOS [not otherwise specified]" and noted that schizophrenia paranoid type versus schizoaffective disorder needed to be considered. (AR 241.) Dr. Marmolejo noted that Plaintiff was "fairly groomed," and had normal cognition, speech, thought content, and orientation. (AR 241.) Dr. Marmolejo indicated that Plaintiff's insight and judgment were "normal," although her affective range was constricted. (AR 241.) Dr. Marmolejo prescribed psychotropic medication to address symptoms and recommended face-to-face meetings with Plaintiff to monitor symptoms as well as case management or psychotherapy as needed. (AR 243.) Plaintiff did not appear for a follow-up visit with Dr. Marmolejo in January 2008, cancelled her appointment in March 2008, and did not appear for a scheduled appointment in June 2008. (AR 234-35, 260-62.)

On June 4, 2008, the claimant was examined by John Champlin, M.D., a psychiatrist. (AR 259.) Dr. Champlin noted that Plaintiff was well groomed and cooperative; she had normal cognition, orientation, and thought content. (AR 259.) Plaintiff's mood was noted as depressed, her affective range was "constricted," her intelligence was "average," but her insight and judgment were impaired. (AR 259.) Dr. Champlin diagnosed Plaintiff with schizoaffective disorder, and noted that Plaintiff had financial difficulties. (AR 259.) Dr. Champlin assigned Plaintiff a GAF score of 45, but did not increase Plaintiff's prescription mediation and recommended that she continue with her therapy.

On July 3, 2008, Plaintiff was seen by Dr. Champlin again. (AR 257.) He assigned Plaintiff a GAF score of 45, noting that Plaintiff's mood was depressed and her affective range was restricted. (AR 257.) He increased Plaintiff's prescription for Abilify, reduced her prescription for Prozac, and recommended that Plaintiff's other medications remain the same. (AR 257.) Plaintiff missed two follow-up appointments with Dr. Champlin on July 18, and July 22, 2008. (AR 255-56.) Plaintiff consulted with Dr. Champlin on July 23, 2008, and indicated that she had not been sleeping well, felt paranoid around white people, and felt that she was being followed by someone who wanted to hurt her. (AR 254.) She denied suicidal or homicidal intentions. (AR 254.) Dr. Champlin noted Plaintiff was well groomed, alert, and had normal speech, cognition, and orientation. (AR 254.) Dr. Champlin recommended that Plaintiff's current medications remain unchanged, but prescribed Haldol, Cogentin, and Klonopin. (AR 254.)

On July 12, 2008, Plaintiff was examined by agency consultative physician, Ekram Michiel, M.D. (AR 249-52.) Plaintiff reported that she gets paranoid around people and that she hears voices. (AR 249.) Plaintiff reported that she was able to take care of her personal hygiene, but indicated that she does not do anything else by herself. (AR 250.) Dr. Michiel noted that Plaintiff was "fairly groomed" with adequate personal hygiene. (AR 250.) Dr. Michiel also indicated that Plaintiff was a "fairly good historian," but he noted that her conduct during the hearing did not conform to her claim of hearing voices all the time and being paranoid around people. (AR 249-50.) Dr. Michiel diagnosed Plaintiff with psychotic disorder, NOS, and assigned Plaintiff a GAF score of 55 to 60. (AR 251.) He opined that Plaintiff would be able to maintain attention and concentration and would be able to carry out simple job instructions. (AR 251.)

Plaintiff's next appeared for a follow-up examination on April 17, 2009. (AR 342.) Dr. Jorge A. Urbina, M.D., a psychiatrist, examined Plaintiff. (AR 342.) Dr. Urbina noted that Plaintiff was well groomed, cooperative, and her cognition, speech, and orientation were normal. (AR 342.) Plaintiff's mood was noted as depressed, her affective range was restricted, but her insight and judgment were found to be normal. (AR 342) Plaintiff denied any suicidal or homicidal ideation, and Dr. Urbina diagnosed Plaintiff with schizophrenia, paranoid type. (AR 342.) On June 10, 2009,social worker, Cathy Leyva, noted that Plaintiff had missed her follow-up appointment with Dr. Urbina, and that Plaintiff missed additional appointments with ...

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