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Ortiz v. Colvin

United States District Court, W.D. New York

July 31, 2014



MICHAEL A. TELESCA, District Judge.


Plaintiff, Luzeleina Oritz ("Plaintiff" or "Ortiz"), brings this action under Titles II and XVI of the Social Security Act ("the Act"), claiming that the Commissioner of Social Security ("Commissioner" or "Defendant") improperly denied her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI").

Currently before the Court are the parties' competing motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons set forth below, I grant the Commissioner's motion, deny the Plaintiff's cross-motion, and dismiss the Complaint.


On February 15, 2011, Plaintiff filed applications for DIB and SSI, alleging disability as of May 10, 2010, which were denied. Administrative Transcript [T.] 143-144, 85-99. A hearing was held on May 22, 2012 before administrative law judge ("ALJ") John P. Costello, at which Plaintiff, Plaintiff's friend Henry Baggling ("Baggling"), and a vocational expert ("VE") testified. T. 39-75. On August 9, 2012, the ALJ issued a decision finding that Plaintiff was not disabled during the relevant period. T. 13-25.

On July 3, 2013, the Appeals Councils denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. T. 1-6. This action followed.


Relevant Medical Evidence

Plaintiff's Physical Health History

Following a December 4, 2007 motor vehicle accident, Plaintiff was seen at the Rochester Brain and Spine Center ("RBSC") for back pain. T. 376-377. An MRI of Plaintiff's lumbosacral spine showed a herniated lumbar disc. T. 377. She was initially treated with steroid injections, and later underwent a surgical right discectomy and foraminatomy. T. 377-379. Following her surgery, Plaintiff was treated on a continued basis at RBSC and also received chiropractic treatments. T. 345-353, 357-366.

In October 2010, Plaintiff met with Roger Ng, M.D. at RBSC, who assessed intervertebral disc displacement lumbar without myelopthay. T. 353. Upon examination, Dr. Ng reported that Plaintiff's gait was normal, her neck and spinal regions were within normal limits to inspection and palpation, but that Plaintiff exhibited tenderness to palpation in the lumbar spine and sacroiliac joint. T. 351-352. Plaintiff's motor strength was intact, her muscle tone was normal, her range of motion was physiologic and full, heel toe walking was normal, her straight leg raises produced low back pain, and her trunk rotation was positive bilaterally. T. 352. Dr. Ng noted that Plaintiff's Patrick test was positive bilaterally, her sensation was grossly intact to light touch, her reflexes were 2 and symmetric, her cranial nerves were intact and she had no coordination deficits. T. 352.

In December 2010 and January 2011, Plaintiff was seen at Unity Spine Center ("USC"), complaining of continued sharp pain in her lower back to hip that radiated into her right leg. T. 664, 667. Treatment notes show that Plaintiff's lumbar mobility was decreased and her sensory and motor strength in the right lower extremity were slightly decreased due to pain. T. 668. An MRI of Plaintiff's lumbar spine from January 2011 showed stable postoperative findings and no recurrent herniation. T. 603. Plaintiff returned to USC in February 2011, at which time she reported that sitting, standing or walking for long durations aggravated her back pain. T. 670. Treatment notes show that Plaintiff had no motor weakness, her gait was slow with a slight limp, and her right lower extremity at L2 was decreased. T. 670.

In October 2011, Plaintiff was seen at Unity Rehab and Neurology, complaining of continued back pain. Plaintiff's supine straight leg raises were negative, she had no motor weakness, and her sensation was decreased at L2 in the right lower extremity. Plaintiff was diagnosed with right leg and bilateral foot pain. T. 1122.

Also in October 2011, Plaintiff saw Dr. Ng complaining of back pain and right foot pain. T. 1034-1035. Dr. Ng assessed intervertebral disc displacement and degeneration lumbar without myelopthy. T. 1034-1035.

Plaintiff's Mental Health History

In 2010, Plaintiff was treated at Huther-Doyle for chemical dependency. T. 336-343. Substance abuse counselor Brenda Brightful ("Brightful") diagnosed alcohol and cannabis dependence and assessed a Global Assessment Functioning ("GAF") score of 55. T. 342. Notes from Plaintiff's discharge summary report dated September 16, 2010 show that Plaintiff had completed all treatment, her goals were met, no additional treatment was necessary, and her GAF score was assessed at 75. T. 336-337.

While attending counseling at Huther-Doyle, Plaintiff was also treated at St. Mary's Mental Health Clinic for depression. Plaintiff's mental status examinations showed depressed mood, but were otherwise generally unremarkable. T. 400-461. While there, Plaintiff attended group therapy when she was able to find child care. In November 2010 Plaintiff was assessed a GAF score of 65. T. 402. Treatment notes from 2011 show that Plaintiff continued to complain of depressed mood and financial stressors, but that she was expressing herself well in therapy and reported feeling relief by attending these sessions. T. 703-734. In April 2011, Plaintiff was assessed a GAF score of 50. T. 731.

In January 2012, treatment notes show that Plaintiff continued to be actively engaged in group therapy, her mood was euthymic, and she was assessed a GAF score of 55. T. 1038-1040.

Consultative Examinations/Opinions

In March 2010, Plaintiff underwent a consultative examination with Adele Jones, Ph.D. who assessed that Plaintiff could follow and understand simple directions, perform simple tasks independently, maintain attention and concentration, maintain a regular schedule, learn new task, perform complex tasks independently, make appropriate decisions, and relate adequately with others. Dr. Jones diagnosed post-traumatic stress disorder, depressive disorder, and alcohol, cocaine, and cannibis dependence. T. 1022. Dr. Jones recommended continued psychiatric and drug addiction treatment. T. 1023.

Also in March 2010, Plaintiff underwent a consultative examination by George Alexis Sirontenko, D.O. who diagnosed morbid obesity, history of depression, musculoskeletal ligamentous degenerative back pain. T. 1032. He assessed moderate limitations for kneeling, squatting, bending, and climbing stairs, inclines and ladders on a repetitive basis. He also assessed that Plaintiff needed to avoid lifting objects over her head on a repetitive basis. T. 1032.

In April 2010, V. Reddy, Ph.D. completed a mental residual functional capacity assessment in which he opined that Plaintiff could follow, understand, and perform simple instructions, directions, and tasks, maintain attention, concentration and a regular work schedule, make appropriate decisions, relate adequately with others, but had difficulty dealing with stress. Dr. Reddy opined that Plaintiff "appears capable of performing the basic functional requirements of unskilled work." T. 1026.

Also in April 2010, Marvin Blase, M.D. completed a mental residual functional capacity assessment form and reported that he was in agreement with Dr. Reddy's assessment and that no "additional documentation was needed." T. 1028-1029.

In February 2011, Plaintiff underwent a consultative examination with Christine Ransom, Ph.D. who opined that Plaintiff could follow and understand simple directions and instructions, perform simple tasks independently, maintain attention and concentration for simple tasks, maintain a simple regular schedule, and learn simple new tasks. She opined further that Plaintiff had moderate difficulty performing complex tasks, relating adequately with others and appropriately dealing with stress due to major depressive disorder. Dr. Ransom diagnosed major depressive disorder, alcohol and ...

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