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Fuentes v. Colvin

United States District Court, W.D. New York

February 13, 2015



MARIAN W. PAYSON, Magistrate Judge.


Plaintiff Ricardo Fuentes ("Fuentes") brings this action pursuant to Section 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security (the "Commissioner") denying his application for Disability Insurance Benefits ("DIB"). Pursuant to 28 U.S.C. § 636(c), the parties have consented to the disposition of this case by a United States magistrate judge. (Docket # 14).

Currently before the Court are the parties' motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. (Docket ## 9, 11). For the reasons set forth below, this Court finds that the decision of the Commissioner is supported by substantial evidence in the record and is in accordance with the applicable legal standards. Accordingly, the Commissioner's motion for judgment on the pleadings is granted, and Fuentes's motion for judgment on the pleadings is denied.


I. Procedural Background

Fuentes applied for DIB on March 10, 2010, alleging disability beginning on February 26, 2009, due to migraines, back injury, arthritis, depression, anxiety, shortness of breath, dizziness, frequent vomiting, chronic pain, tiredness, sleep disorder and panic attacks. (Tr. 164, 169).[1] On May 24, 2010, the Social Security Administration denied Fuentes's claim for benefits, finding that he was not disabled. (Tr. 73-74). Fuentes requested and was granted a hearing before Administrative Law Judge Richard J. Ortiz-Valero (the "ALJ"). (Tr. 81-82, 106-10). The ALJ conducted a hearing on June 27, 2011 in Rochester, New York. (Tr. 35-72). Fuentes was represented at the hearing by his attorney Gregory Phillips, Esq. (Tr. 35, 37). In a decision dated July 13, 2011, the ALJ found that Fuentes was not disabled and was not entitled to benefits. (Tr. 23-31).

On February 22, 2013, the Appeals Council denied Fuentes's request for review of the ALJ's decision. (Tr. 1-5). Fuentes commenced this action on April 19, 2013, seeking review of the Commissioner's decision. (Docket # 1).

II. Relevant Medical Evidence[2]

A. Treatment Records

Treatment notes from Rochester Mental Health Center indicate that Fuentes received mental health treatment between September 2010 and May 2011. (Tr. 239-61). Those same notes suggest that Fuentes had previously received mental health treatment earlier in 2010, but had been discharged from treatment because he failed to "follow[] through." (Tr. 260). During his evaluation in September 2010, Fuentes reported symptoms of depression, anxiety, interpersonal conflict and psychosocial stressors. (Id. ). He was diagnosed with depressive disorder, not otherwise specified, and anxiety disorder, not otherwise specified. (Id. ). According to Fuentes, his symptoms included sleeplessness, fatigue, low mood, tearfulness, hopelessness, feelings of worthlessness and instrusive worry. (Tr. 259). Renee Scanlon ("Scanlon"), MSW CASAC, Fuentes's primary therapist, recommended that he attend biweekly sessions and be evaluated by a psychiatrist. (Tr. 258). Treatment notes indicate that Fuentes was recently divorced, unemployed and having trouble obtaining medical insurance. (Tr. 255-56, 259).

On November 4, 2010, Fuentes reported that his symptoms of depression persisted. (Tr. 253). He canceled his remaining appointments in November and did not attend another appointment until December 7, 2010. (Tr. 250-52). During that appointment, Fuentes reported that he had been charged with DUI. (Tr. 250). Fuentes also reported that he had not been able to obtain medical insurance. (Id. ). The treatment records indicate that Fuentes either cancelled or missed several appointments and did not attend another appointment until March 9, 2011. (Tr. 244-49). During that appointment, Fuentes was evaluated by Dr. Muhammad Cheema, who prescribed Remeron to aid sleep. (Tr. 244). On April 5, 2011, Fuentes attended an appointment with Scanlon, who advised Fuentes of the "importance of regular attendance to therapy for maximum benefit." (Tr. 243). During the appointment, Fuentes reported experiencing instrusive worry and depressive symptoms. (Id. ).

Fuentes attended two more appointments with Scanlon in April 2011. (Tr. 241-42). During those appointments Fuentes reported that he continued to experience intrusive worry and depressive symptoms and that he had begun drug and alcohol therapy. (Tr. 241). During a May 2011 appointment with Scanlon, Fuentes reported that he was feeling better because his legal concerns had been resolved. (Tr. 239). Despite this, Fuentes reported that he continued to feel depressed and requested an evaluation for medication because he had successfully obtained medical benefits. (Id. ).

B. Medical Opinion Evidence

On May 14, 2010, state examiner Dr. Christine Ransom ("Ransom") conducted a consultative psychiatric evaluation of Fuentes. (Tr. 194-97). During the evaluation, Fuentes reported that he had completed the ninth grade in special education classes. (Id. ). The report incorrectly indicates that Fuentes "has never held a job." (Id. ). Fuentes reported that he had experienced depression for a long time, had difficulty sleeping, awakened frequently during the night, had an erratic appetite and experienced crying spells, irritability and low energy. (Id. ). He also reported experiencing panic attacks and difficulty concentrating. (Id. ).

Fuentes reported that he was able to care for his personal hygiene, but was inconsistent in cooking, cleaning, laundry and shopping due to his low motivation. (Id. ). He reported that he was able to drive. (Id. ). According to Fuentes, he did not socialize and avoided contact with family and friends. (Id. ).

Upon examination, Ransom noted that Fuentes appeared unkempt with poor personal hygiene. (Id. ). Ransom opined that Fuentes had slow, halting speech, coherent and goal-directed thought processes, moderately dysphoric and tense affect, clear sensorium, good orientation, and borderline intellectual functioning with a somewhat limited general fund of information. (Id. ). Ransom noted that Fuentes's attention and concentration were moderately impaired. (Id. ). According to Ransom, Fuentes could count backwards, perform two out of three simple calculations, but had difficulty with serial threes. (Id. ). Ransom opined that Fuentes's attention and concentration appeared impaired by depression, anxiety and limited intellectual capacity. (Id. ). Ransom found Fuentes's immediate memory skills moderately impaired. (Id. ). According to Ransom, Fuentes could recall one out of three objects immediately and could complete three digits forward and two digits backward. (Id. ). Ransom opined that Fuentes's insight was good, but that his judgment was poor because he continued to consume alcohol. (Id. ).

According to Ransom, Fuentes could follow and understand simple directions and instructions, perform simple tasks independently, maintain attention and concentration for tasks, maintain a regular schedule and learn simple tasks. (Id. ). Ransom opined that Fuentes would have moderate difficulty performing complex tasks independently, relating adequately with others and appropriately dealing with stress due to major depressive disorder, currently moderate, panic disorder without agoraphobia, currently moderate, and probable borderline intellectual capacity. (Id. ). According to Ransom, Fuentes's prognosis was fair. (Id. ).

On May 21, 2010, agency medical consultant Dr. M. Apacible ("Apacible") completed a Psychiatric Review Technique. (Tr. 202-15). Apacible concluded that Fuentes's mental impairments did not meet or equal a listed impairment. (Tr. 202, 205, 207, 210). According to Apacible, Fuentes suffered from mild limitations in his activities of daily living and moderate limitations in his ability to maintain social functioning and to maintain concentration, persistence or pace. (Tr. 212). In addition, according to Apacible, there was insufficient evidence to determine whether Fuentes had suffered from repeated episodes of deterioration. (Id. ). Apacible completed a mental Residual Function Capacity ("RFC") assessment. (Tr. 216-19). Apacible opined that Fuentes suffered from moderate limitations in his ability to understand, remember and carry out detailed instructions; work in coordination with or proximity to others without being distracted by them; complete a normal workday and workweek without interruptions; interact appropriately with the general public; accept instructions and respond appropriately to criticism from supervisors; get along with coworkers or peers without distracting them or exhibiting behavioral extremes; maintain socially appropriate behavior; respond appropriately to changes in a work setting; travel in unfamiliar places or use public transportation and set realistic goals or make plans independently of others. (Tr. 217). According to Apacible, Fuentes is able to perform the basic demands of simple, unskilled work. (Tr. 218).

On April 5, 2011, Scanlon completed a Psychological Assessment for Determination of Employability form regarding Fuentes. (Tr. 220-24). Scanlon indicated that Fuentes had been a patient for approximately six months. (Tr. 221). Scanlon opined that Fuentes was moderately limited in his ability to follow, understand and remember simple directions and instructions, to perform simple and complex tasks independently, to maintain attention and concentration for rote tasks, to regularly attend to a routine and maintain schedule, to maintain basic standards of grooming, and to perform low stress and simple tasks. (Tr. 223). The form provided that "moderately limited" meant that an individual would be unable to function approximately ten to twenty percent of the time. (Id. ). According to Scanlon, Fuentes was unable to participate in any activities except treatment or rehabilitation for the next three months. (Id. ).

On April 19, 2011, Fuentes was evaluated by an addiction counsel at Rochester General Hospital Addiction Services. (Tr. 225-37). Fuentes was diagnosed with alcohol abuse and depression, not otherwise specified. (Tr. 237). The counselor ...

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