Quintana v. Colvin

          MEMORANDUM DECISION AND ORDER

          SUZANNE H. SEGAL UNITED STATES MAGISTRATE JUDGE

         I.

         INTRODUCTION

         Maria Alicia Quintana (“Plaintiff”) seeks review of the final decision of the Commissioner of the Social Security Administration (“the Agency, ” “the Commissioner”) denying her application for Disability Insurance Benefits (“DIB”). The parties consented, pursuant to 28 U.S.C. § 636(c), to the jurisdiction of the undersigned United States Magistrate Judge. For the reasons stated below, the decision of the Commissioner is REVERSED and REMANDED for further proceedings.

         II.

         PROCEDURAL HISTORY

         Plaintiff filed an application for Disability Insurance (“DIB”) on February 2, 2012. (Administrative Record (“AR”) 18). Plaintiff alleged disability beginning on April 1, 2011. (AR 160). Plaintiff’s application was initially denied on April 30, 2011, and denied on reconsideration on October 31, 2012. (AR 96-99, 87-94). On November 14, 2012, Plaintiff requested a hearing before an administrative law judge. (AR 105-06). A hearing was held before Administrative Law Judge (“ALJ”) Richard A. Urbin on August 8, 2013 (“the ALJ Hearing”), at which Plaintiff was represented by counsel and testified. (AR 44-47). The ALJ issued an unfavorable decision on December 13, 2013 finding that Plaintiff was not disabled within the meaning of the Social Security Act. (AR 38-51). Plaintiff requested review of the ALJ’s decision on January 6, 2014, which the Appeals Council denied on April 15, 2015. (AR 1-10). As a result, the ALJ’s decision became the final decision of the Commissioner. Plaintiff filed this action on October 6, 2015.

         III.

         FACTUAL BACKGROUND

         Plaintiff was born on June 23, 1966. (AR 78). Plaintiff is married and has four children, the youngest of which was born in February 2011. (AR 50, 63). Plaintiff is a high school graduate and attended some college. (AR 50). Prior to her alleged disability, Plaintiff worked as an insurance biller from 1996 to 1997, a receptionist from 1998 to 2001, an office manager from 2003 to 2005, and again as an insurance biller from 2006 to February 2011. (AR 170-74). Plaintiff identified April 1, 2011 as the onset date of her disability. (AR 78). Plaintiff testified that she suffers from depression, social anxiety, difficulty sleeping, numbness on her right side, back pain, pain in her right knee, diabetes, and high blood pressure. (AR 57-69). Plaintiff also testified that she was overweight at 207 pounds. (AR 67).

         A. Medical History And Treating Doctors’ Opinions

         1. Physical and Mental State

         a. Eric Fernandez, M.D. - Primary Care Physician

         On June 20, 2011, Dr. Fernandez examined Plaintiff and assessed her lower back pain, knee joint pain, anxiety, insomnia, diabetes, and recurring major depression. (AR 243-44). Dr. Fernandez referred Plaintiff to physical therapy for her knee pain, instructed Plaintiff to manage her diabetes, and advised Plaintiff to continue her depression/anxiety medication. (AR 244). On July 28, 2011, Dr. Fernandez noted similar complaints from Plaintiff. (AR 243-47). Dr. Fernandez changed Plaintiff’s depression medication from Wellbutrin to Celexa because Wellbutrin reportedly made Plaintiff ill. (AR 245). On December 12, 2011, Dr. Fernandez noted that Plaintiff had “eruption” of acne due to stress. (AR 251). Dr. Fernandez also addressed Plaintiff’s lower back pain and cautioned Plaintiff to “avoid heavy lifting” and to take pain medication as directed. (AR 251).

         On March 30, 2012, Dr. Fernandez examined Plaintiff’s x-rays and found that there was a loss of the lordotic curve, ^[1] a possible small osteophyte, ^[2] and possible scoliosis.^[3] (AR 257). Plaintiff also complained of intermittent numbness in her neck with spasms. (AR 257). On September 26, 2012, Dr. Fernandez noted that Plaintiff was taking Xanax and Citalopram for depression/anxiety and increased her dosage of Citalopram because Plaintiff was “still emotional.” (AR 273). On December 4, 2012, Dr. Fernandez noted that Plaintiff started taking Cymbalta and Abilify for depression/anxiety and that she was “still emotional.” (AR 301).

         2. Physical Health Evidence

         a. Jennifer Shields - Registered Physical Therapist

         On March 29, 2012, Plaintiff began a series of physical therapy sessions with Jennifer Shields, a registered physical therapist. (AR 260-61). Plaintiff’s chief complaint was lower back pain, reported her pain level at “7” on a scale of one to ten. (AR 260). Ms. Shields noted “poor” posture in both standing and seated positions. (AR 260). Ms. Shields recommended a six-week plan to decrease Plaintiff’s pain as well as improve functioning level and posture. (AR 261).

         Plaintiff again attended physical therapy on April 10, 2012, and reported a pain level of “4-6.” (AR 284). On April 20, 2012, Plaintiff reported a pain level of “6.” (AR 282). On June 6, 2012, Plaintiff complained that her “neck hurts the most” and reported a pain level of “8.” (AR 281). On August 28, 2012, Plaintiff was discharged from the physical therapy sessions. (AR 280). The sessions concluded with “[g]oals partially met, ” with Plaintiff reporting a pain level of “4.” (AR 280).

         3. Mental Health Evidence

         a. Mark Simonds, M.D.

         Plaintiff first visited Dr. Simonds on June 13, 2013. (AR 328-32). Plaintiff told Dr. Simonds that she felt “somewhat socially isolated at this time.” (AR 329). Dr. Simonds increased Plaintiff’s dosage of Cymbalta and noted that she was tolerating that medication well. (AR 331). On the same day, Dr. Simonds filled out a “Medical Source Statement” for internal use by the Agency. (AR 359). Dr. Simonds indicated, via check-boxes, “[m]arkedly limited” functioning in: Plaintiff’s ability to relate and interact with co-workers; her ability to deal with the public; her ability to maintain concentration for two-hour increments, and; her ability to withstand the stresses of typical eight-hour work days. (AR 359). Dr. Simonds indicated “[m]oderately limited” functioning in: Plaintiff’s ability to carry out complex job instructions; her ability to carry out simple job instructions, and; her ability to handle funds. (AR 359).

         On July 24, 2013, Plaintiff reported that her mood symptoms were “improving somewhat” and that she was satisfied with her new Cymbalta dosage. (AR 364). Plaintiff told Dr. Simonds that her energy and motivation were higher than before, and that she was a “little less” frustrated and anxious. (AR 364).

         b. Romeo L. Isidro, M.D.

         On February, 28, 2013, Dr. Isidro, a psychiatrist, examined Plaintiff. (AR 356-57). Dr. Isidro’s handwritten notes indicate that Plaintiff complained of crying spells, lack of energy, and trouble sleeping. (AR 356). Dr. Isidro noted that Plaintiff suffered from major depression. (AR 357). Dr. Isidro concluded that Plaintiff should “restart” Cymbalta and continue with psychotherapy. (AR 357).

         Plaintiff cancelled an appointment with Dr. Isidro on April 2, 2013 and left before being seen on April 23, 2013. (AR 355). On May 21, 2013, Plaintiff was again examined by Dr. Isidro and reported that she wasn’t “cry[ing] every day anymore.” (AR 355).

         B. Examining, Non-Treating Doctors’ Opinions

         1. Independent Medical Evaluation - Physical Medicine

         a. Jorge Minor, M.D.

         On June 3, 2013, Dr. Minor, a physical medicine and pain specialist, interviewed and examined Plaintiff. (AR 433-53). During her interview, Plaintiff described her pain as “moderate most of the time, ” and that her typing ability had been “moderately change[d]” due to her current physical issues. (AR 436, 437). Upon examination, Dr. Minor found that Plaintiff’s motor strength was “5/5” on all of her upper and lower extremities. (AR 447). Dr. Minor diagnosed Plaintiff with eleven conditions including major depression, postpartum depression, eating disorder, morbid obesity, history of knee contusion and non-compliance with medical care. (AR ...