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Hills v. Commissioner of Social Security

United States District Court, E.D. New York

July 7, 2017

Debra Hills, Plaintiff,
Commissioner of Social Security, Defendant.


          JOSEPH F. BIANCO United States District Judge.

         Pro se plaintiff Debra Hills (“plaintiff”) commenced this action, pursuant to 42 U.S.C. § 405(g) of the Social Security Act (“SSA”), challenging the final decision of the Commissioner of Social Security (the “Commissioner”) denying plaintiff's application for disability insurance benefits. An Administrative Law Judge (“ALJ”) found that plaintiff had the residual functional capacity to perform the full range of work at all exertional levels with certain nonexertional limitations, of which there were a significant number of jobs in the national economy, and, therefore, that plaintiff was not disabled. The Appeals Council denied plaintiff's request for review.

         The Commissioner now moves for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c). Plaintiff did not file an opposition or a cross-motion. In any event, the Court has still considered the merits of the petition. For the reasons set forth below, the Court finds that the Commissioner's decision was based upon the application of the correct legal standards and is supported by substantial evidence. Accordingly, the Commissioner's motion for judgment on the pleadings is granted.

         I. Background

         A. Facts

         The following summary of the relevant facts is based on the Administrative Record (“AR”) developed by the ALJ. (ECF No. 10.)

         1. Personal History

         Plaintiff was born on January 6, 1988 and resides in Farmingdale, New York. (AR 31.) Education records from Brennan High School reflect that, in testing performed when she was 16 years old, plaintiff achieved a full-scale IQ score of 95, a performance IQ score of 100, and a verbal IQ score of 87. (Id. 235.) Plaintiff received counseling and special education services for emotional and behavioral difficulties. (Id. 234, 268, 273.) She was schooled in a New York State regular assessment program with accommodations. (Id. 234, 265.)

         2. Relevant Medical History

         Plaintiff received mental health care from Nurse Practitioner (“NP”) Michele Kelly in February 2013, when she complained of depression, weight gain, and difficulty finding a job. (Id. 321-22.) NP Kelly recorded plaintiff's subjective complaints and prescribed a three-month supply of Vyvanse, a central nervous system stimulant; and Cymbalta, a medication for depression and anxiety; as well as Ativan, to use on an as-needed basis for anxiety. (Id.) The following month, NP Kelly again documented plaintiff's subjective complaints and noted that plaintiff reported no adverse reaction to the medication. (Id. 322.) In April 2013, NP Kelly adjusted plaintiff's medication regimen, which had not caused any side effects, but was ineffective. (Id. 323.) Plaintiff next saw NP Kelly twice in June 2013, and she did not alter plaintiff's medication regimen. (Id.) NP Kelly again documented plaintiff's reported condition, and plaintiff was reportedly happier on her new medications and sleeping better. (Id.)

         Plaintiff was evaluated by endocrinologist Dr. Nicoleta Ionica in June 2013. (Id. 341-44.) Plaintiff reported weight gain, back pain, anxiety, emotional lability, depression, and sleep disturbances. (Id. 342.) Upon examination, plaintiff was fully oriented, alert, and appropriate, and her thyroid was normal. (Id. 342-43.) Her sensation was intact, a motor exam revealed no dysfunction, and her strength and reflexes were normal. (Id. 343.) Dr. Ionica also observed that plaintiff's eyes, lungs, heart, abdomen, and skin were normal. (Id.) Dr. Ionica assessed polycystic ovary syndrome (“PCOS”), ordered lab work, and instructed plaintiff to follow up in two weeks. (Id. 343-44.)

         The following month, Dr. Ionica's physical examination findings were unchanged. (Id. 345-47.) Dr. Ionica again assessed PCOS, reviewed the results of a blood test, recommended fish oil, encouraged exercise, and prescribed treatment for a Vitamin D deficiency and to improve plaintiff's insulin sensitivity. (Id. 348.)

         Plaintiff next saw NP Kelly in August 2013, at which point NP Kelly adjusted plaintiff's medication regimen. (Id. 324.) At her next visit in September 2013, NP Kelly attributed much of plaintiff's anxiety and depression to a possible hormonal imbalance. (Id. 325.) Notes reflected dyslexia, a sleep disorder, panic attacks with agoraphobia, and attention deficit hyperactivity disorder (“ADHD”). (Id. 326.) In October 2013, plaintiff expressed an interest in losing weight, noting that she was distracted but not depressed. (Id. 334.) Plaintiff expressed difficulty finding work in November 2013. (Id. 327.) NP Kelly again recorded plaintiff's subjective complaints and detailed her medication regimen. (Id.)

         During a January 2014 visit, NP Kelly conducted a mental status examination of plaintiff in which she described plaintiff's appearance as casual and clean, and her attitude as cooperative; noted that plaintiff related well; and rated plaintiff's speech as within normal limits. (Id. 357-58.) NP Kelly observed that plaintiff maintained good eye contact and an appropriate affect, but that she exhibited a depressed and anxious mood. (Id. 358.) NP Kelly found plaintiff's thought processes to be oriented, goal-directed, and coherent, and that she measured full thought content without hallucinations and paranoia. (Id.) Plaintiff's fund of information, attention, and concentration were all “fair.” (Id.) Subsequent treatment visits with NP Kelly, in March, April, May, and July 2014, did not reflect a material change in plaintiff's condition or further examination findings. (Id. 359-64.)

         Plaintiff presented to internist Dr. Scott Stein at Stony Brook Internists in August 2014 for a check-up. (Id. 368.) Plaintiff complained of worsening headaches, and Dr. Stein ordered a magnetic resonance imaging (“MRI”) scan of the brain to monitor her prolactinoma. (Id.) Dr. Stein also observed an obese abdomen. (Id. 370.) He diagnosed plaintiff with anxiety, prolactinoma, PCOS, multiple nevi (atypical moles), an ingrown toenail, high cholesterol, and diabetes. (Id. 370-71.) In assessing a treatment plan, Dr. Stein characterized plaintiff's depression as stable and noted that she was cooperative; had an appropriate mood, affect, and normal judgment; and was non-suicidal. (Id.) He recommended that plaintiff continue taking Lexapro and advised her to avoid fatty foods. (Id. 371.) An MRI scan of the brain and pituitary gland was performed four days later and revealed a small, stable left-sided macroadenoma that was unchanged from a prior examination. (Id. 372.)

         3. Medical Opinion Evidence

         On July 2, 2013, plaintiff's gynecologist, Dr. Lisa Rimpel, opined that plaintiff had no functional limitations and was not disabled. (Id. 289-93.)

         Plaintiff attended an internal medicine consultative examination with Dr. Andrea Pollack on July 23, 2013. (Id. 300-03.) Plaintiff reported that she had been taking oral medication for “prediabetes” since 2013 and had been experiencing neck and hip pain since a car accident in 2009. (Id. 300.) She also noted left ankle pain since age 15 after tearing ligaments in gym class, but was never hospitalized for these conditions. (Id.) Plaintiff stated that she was able to cook, clean, do laundry, shop, shower, and dress on a daily basis, and that she also watched television and socialized with friends. (Id. 301.) Dr. Pollack's physical examination findings noted slightly reduced flexion and adduction of the left hip. (Id. 301-02.) X-rays of plaintiff's lumbosacral spine and ankle were negative. (Id. 303-05.) Dr. Pollack assessed prediabetes, neck pain, left hip pain, and left ankle pain, for which plaintiff's prognosis was “good.” (Id. 303.) Vocationally, Dr. Pollack opined that plaintiff had a mild restriction in walking, climbing stairs, and standing. (Id. 303.)

         Plaintiff also appeared for a psychological consultative examination with Dr. Kathleen Acer on July 23, 2013. (Id. 296-99.) Plaintiff drove herself to the examination and reported difficulty sleeping, increased appetite, depressive symptoms, distractibility, and panic attacks several times per year. (Id. 296.) She denied symptoms of mania, a thought disorder, or thoughts of suicide. (Id.) Plaintiff acknowledged that she could dress, bathe, groom herself, cook, clean, wash laundry, shop and drive. (Id. 298.) She did not manage finances. (Id.) Plaintiff socialized with friends and otherwise spent her time taking care of her birds and doing household chores. (Id.)

         Upon mental status examination, Dr. Acer observed that plaintiff was pleasant and cooperative, dressed appropriately, well groomed, that her motor behavior was normal, and that she exhibited appropriate eye contact. (Id. 297.) Plaintiff's speech was clear and fluent, she exhibited adequate language skills, and her thought processes were coherent and goal directed. (Id.) Plaintiff exhibited the full range of affect, a euthymic (normal) mood, and clear senses. (Id.) She was fully oriented, and her attention, concentration, and memory were all intact. (Id.) Dr. Acer measured plaintiff's “intellectual skills” as average, her fund of information as appropriate to experience, and her insight and judgment as “good.” (Id. 297-98.)

         Dr. Acer diagnosed dysthymic disorder. (Id.) Vocationally, Dr. Acer opined that plaintiff did “not appear to be significant[ly] limit[ed] in her ability to follow and understand directions and instructions, perform tasks, maintain attention and concentration, and maintain a regular schedule.” (Id.) Dr. Acer said that plaintiff “may have some difficulty dealing with stress and making appropriate decisions.” (Id.) Dr. Acer concluded that “[t]he results of the evaluation d[id] appear to be consistent with some psychiatric issues; however, in and of themselves they d[id] not appear to be significant enough to interfere with functioning on a daily basis.” (Id.)

         4. Other Source Opinion Evidence

         NP Kelly completed a “Psychiatric Assessment for Determination of Employability” form regarding plaintiff for the Suffolk County Department of Social Services on April 10, 2013. (Id. 286-87.) She noted diagnoses of anxiety not otherwise specified (“NOS”), panic disorder with agoraphobia, depression NOS, ADHD, and a Global Assessment of Functioning (“GAF”) score of 35-50. (Id. 286.) NP Kelly checked boxes on the form indicating that plaintiff never experienced acute psychiatric hospitalization, hospitalization for alcohol/drug use or attempted suicide; that she occasionally needed medical hospitalization or emergency room visits and occasionally decompensated; and that plaintiff experienced frequent loss of job or failure to complete an education or training program, and behavior that interferes with activities of daily living. (Id. 287.) NP Kelly also checked boxes corresponding to “[n]o evidence of limitation” for “[m]aintains basic standards of personal hygiene and grooming, ” and “[a]bility to use public transportation.” (Id. 287.) NP Kelly checked boxes corresponding to “[m]oderately limited” for “[u]nderstands and remembers simple instructions, ” “[m]aintains attention and concentration, ” “[i]nteracts appropriately with others, ” “[m]aintains socially acceptable behavior, ” and ability to perform “[l]ow stress, simple tasks.” (Id.) NP Kelly ...

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