United States District Court, Western District of New York
BRENDA I. RAMOS, Plaintiff,
CAROLYN W. COLVIN, COMMISSIONER OF SOCIAL SECURITY, Defendant.
DECISION & ORDER
MARIAN W. PAYSON UNITED STATES MAGISTRATE JUDGE
Plaintiff Brenda I. Ramos ("Ramos") 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 her applications for Supplemental Security Income Benefits and Disability Insurance Benefits ("SSI/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 # 15).
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 ## 11, 14). For the reasons set forth below, I hereby vacate the decision of the Commissioner and remand this claim for further administrative proceedings consistent with this decision.
I. Procedural Background
Ramos applied for SSI/DIB on September 27, 2010, alleging disability beginning on June 15, 2010, due to diabetes and cataracts in both eyes. (Tr. 133-46, 158, 162). On January 4, 2011, the Social Security Administration denied Ramos's claim for benefits, finding that she was not disabled. (Tr. 55-56). Ramos requested and was granted a hearing before Administrative Law Scott M. Staller (the "ALJ"). (Tr. 71-72, 103-07). The ALJ conducted a hearing on December 6, 2011. (Tr. 29-54). In a decision dated March 6, 2012, the ALJ found that Ramos was not disabled and was not entitled to benefits. (Tr. 16-26).
On July 24, 2013, the Appeals Council denied Ramos's request for review of the ALJ's decision. (Tr. 1-5). Ramos commenced this action on September 18, 2013 seeking review of the Commissioner's decision. (Docket # 1).
II. Relevant Medical Evidence
A. Treatment Records
1. Hyun Yoo, MD
Treatment notes indicate that Ramos began receiving treatment with Hyun Yoo ("Yoo"), MD, in July 2011. (Tr. 232). According to the notes, Ramos had a history of diabetes that had been uncontrolled for years due to lack of insurance. (Id.). Ramos reported chronic headaches and eye pain, and that she had been diagnosed with glaucoma/cataracts and advised by the eye clinic that she needed to regulate her blood sugar levels prior to treatment. (Id.). Upon examination, Ramos's eyes were reactive to light. (Id.). Treatment notes indicate that Ramos was taking Wellbutrin and Lexapro to address her ongoing depression. (Id.).
Ramos returned for another appointment with Yoo on August 2, 2011. (Tr. 229). During that appointment, her blood sugar levels showed improvement, and she requested a referral to the eye clinic to address her cataracts/glaucoma/retinopathy. (Id.). Ramos returned to Yoo on August 23, 2011 and reported that she had chronic blurry vision and had not yet seen her ophthalmologist. (Tr. 228). Yoo opined that Ramos's diabetes was better maintained, but that she had not yet achieved her goal. (Id.).
On September 27, 2011, Ramos attended a follow-up appointment with Yoo. (Tr. 227). During that appointment, Yoo again observed that Ramos's eyes were reactive to light. (Id.). Yoo noted that her blood glucose levels had improved and that she continued to take Wellbutrin for depression. (Id.).
2. Rochester General Hospital Records
Treatment records indicate that Ramos received treatment at the Ophthalmology clinic at Rochester General Hospital ("RGH") beginning in March 2011. (Tr. 248-49). The treatment notes indicate that she was evaluated for cataracts and that her vision was corrected to 20/60 in her right eye and 20/50 in her left eye. (Id.). Treatment notes indicate that surgery for cataracts was considered, but that Ramos's glucose levels were not controlled at the time. (Id.). Ramos returned to the clinic on November 29, 2011. (Tr. 250-51). Ramos was referred for a cataract evaluation. (Id.). The treatment notes also suggest that Ramos complained that her prescription glasses were not effective. (Id.).
Ramos returned to the clinic on December 19, 2011. (Tr. 255-57). Treatment notes indicate that Ramos's vision was corrected to 20/60 in her right eye and 20/50 in her left eye. (Id.). Again, the notes indicate that Ramos should have a cataract evaluation. (Id.).
3. Genesee Mental Health Center
The record contains treatment notes from Genesee Mental Health Center ("GMHC") beginning in February 2011. (Tr. 207). On February 21, 2011, Ramos met with a licensed social worker, Shawn Parker ("Parker"). (Id.). During the meeting, Ramos reported experiencing hypervigilance and negative ruminations. (Id.). Parker noted that Ramos appeared well-groomed, was cooperative, used appropriate speech and that her thought processes and content were logical and goal-directed. (Id.). According to Parker, Ramos appeared hyperactive and restless and demonstrated racing thoughts, negative ruminations and a depressed and anxious mood. (Id.). Parker recommended ongoing therapy, a psychiatric evaluation and a medication consultation. (Id.). Ramos was diagnosed with major depressive disorder, moderate and post-traumatic stress disorder. (Tr. 208).
On March 11, 2011, Ramos attended another appointment with Parker. (Tr. 212). During the appointment, Ramos reported that her mother had passed away unexpectedly the previous week and that she had been experiencing low moods, sleeplessness and tearfulness. (Id.). Ramos was considered for partial hospitalization at Strong due to her ongoing depression. (Id.). Ramos was given a seven-day supply of Lexapro. (Id.).
On March 17, 2011, Ramos returned for another appointment with Parker. (Tr. 213). Ramos reported that her mood had improved, her anxiety had decreased and she had been sleeping better. (Id.). Although Ramos remained interested in participating in the partial hospitalization program, she lacked transportation and the referral was canceled. (Id.). During the appointment, Ramos demonstrated a mildly depressed and anxious mood. (Id.).
On March 31, 2011, Ramos attended another session with Parker. (Tr. 214). During the session, Ramos reported that her mood had improved, but she continued to experience low moods at times. (Id.). Ramos reported that she continued to experience hypervigilance when others were cooking and that she experienced difficulty cooking due to her fire-related fears. (Id.).
On April 8, 2011, Ramos met with JoAnn Streb ("Streb"), a nurse practitioner. (Tr. 216). Streb diagnosed Ramos with major depressive disorder, post-traumatic stress disorder and assigned her a Global Assessment of Functioning ("GAF") of 45. (Id.). The treatment notes indicate that Ramos lost her possessions and two dogs during a 2009 fire . (Id.). According to Ramos, her nightmares and flashbacks had decreased in frequency since she had started taking Lexapro. (Id.). Ramos also reported that her depression and anxiety were better. (Id.).
On April 25, 2011, Ramos attended another session with Parker to address her ongoing hypervigilance and racing thoughts. (Tr. 219). Ramos reported experiencing little to no mood disturbance, but continued to experience hypervigilance, particularly when others were cooking. (Id.). According to Parker, Ramos's thought content was goal-directed and phobic, and she exhibited an anxious mood. (Id.). On May 3, 2011, Ramos met with Streb and reported good sleep, no nightmares or crying and less anxiety. (Tr. 220-21).
On May 9, 2011, Ramos attended another session with Parker to address her negative ruminations and anxiety. (Tr. 222). According to Parker, Ramos exhibited mild negative ruminations and a depressed and anxious mood. (Id.). Parker recommended ongoing therapy. (Id.). Ramos returned on May 24, 2011, and reported high anxiety during a family barbecue and a reoccurrence of symptoms she experienced after the fire in 2009. (Tr. 223). Parker noted that Ramos demonstrated phobic thought processes and an anxious mood. (Id.). On June 7, 2011, Ramos returned and reported symptoms of ...