Rodriguez v. Berryhill, Civil Action No. 16–30163–MGM

323 F.Supp.3d 232

Yesenia RODRIGUEZ, Plaintiff,

v.Nancy A. BERRYHILL,¹ Acting Commissioner of Social Security, Defendant.

Civil Action No. 16–30163–MGM

United States District Court, D. Massachusetts.

Signed June 26, 2018

Tricia M. Jacobs, Law Offices of Thomas Libbos, Springfield, MA, for Plaintiff.

Karen L. Goodwin, United States Attorney's Office, Springfield, MA, for Defendant.

MEMORANDUM AND ORDER REGARDING PLAINTIFF'S AND DEFENDANT'S MOTIONS FOR JUDGMENT ON THE PLEADINGS

(Dkt. Nos. 12 and 20)

MASTROIANNI, U.S.D.J.

I. INTRODUCTION

This is an action for judicial review of a final decision by the acting Commissioner of the Social Security Administration ("Commissioner") regarding an individual's entitlement to Supplemental Security Income ("SSI") and Social Security Disability Insurance ("SSDI") under Titles XVI and II, respectively, of the Social Security Act (the "Act"). See 42 U.S.C. §§ 405(g), 1383(c)(3). Yesenia Rodriguez ("Plaintiff") argues that the Commissioner's decision denying her SSI and SSDI—memorialized in a April 14, 2015 decision of an administrative law judge ("ALJ")—rested on legal error. Plaintiff has filed a motion to reverse that decision and the Commissioner has moved to affirm. For the reasons and to the extent set forth below, the court DENIES the Commissioner's motion (Dkt. No. 20) and GRANTS Plaintiff's motion (Dkt. No. 12).

II. BACKGROUND AND PROCEDURAL HISTORY

Plaintiff applied for the SSI and SSDI on April 13, 2010, claiming disability with an onset date of May 1997. (Administrative Record ("A.R.") at 269–82.) She was 33 years old when she initially applied; she is now 41 years old. (Id. at 133). She has a high school education and her relevant prior work experience involved approximately one year as a part-time ticket agent for an airline in or around 1996. (Id. at 20, 23, 56–57). The record also indicates that Plaintiff received workers' compensation benefits for several months after that employment ended due to injury to her back, neck, and shoulders. (Id. at 58). At the time of her first administrative hearing she subsisted on government benefits. (Id. )

On December 1, 2010, the Social Security Administration ("SSA") advised Plaintiff that both her SSI and SSDI applications were denied. (Id. at 142–47). Plaintiff sought reconsideration on February 3, 2010, (id. 151–52), which was denied on August 4, 2011, (id. at 153–58). Roughly two months later Plaintiff sought a hearing before an ALJ. (Id. at 159). The hearing took place over a year later, on November 27, 2012. (Id. at 48–84, 184–99). At that hearing Plaintiff asserted disability due to both physical and mental impairments. Her claimed physical impairments included: asthma, back pain that spread to her shoulders and legs, ankle problems, arthritis, and headaches. (Id. at 58–80). Claimed mental impairments included depression with suicidal ideation, anxiety, and panic attacks. (Id. )

On January 18, 2013, the ALJ issued a decision finding Plaintiff was disabled as of April 13, 2010 due to major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, panic disorder, headaches, anemia, right ankle pain, chronic arthralgia and myalgia, obesity, asthma, chronic bilateral wrist/hand numbness and weakness, and chronic back pain. (Id. at 89–112). The ALJ also expressly found that Plaintiff was not disabled due to any impairments prior to that date and, because Plaintiff's date last insured preceded that date by over a year, denied the SSDI application. As for Plaintiff's SSI application, the ALJ granted with an onset date of April 13, 2010. (Id. at 105).

Plaintiff then appealed that decision to the SSA Appeals Council in an effort have the SSDI denial reversed.² The Council granted review and issued a decision entirely unfavorable to Plaintiff, essentially forcing the ALJ to reverse the decision to grant SSI and affirming the SSDI denial sub silencio .³ Specifically, the Council held the ALJ's finding that Plaintiff would be "off task for at least 25 percent of the workday due to secondary effects of chronic pain and psychiatric symptoms [was] not supported by substantial evidence." (Id. at 114). Citing particular items of evidence discussed below, the Council remanded and ordered to the ALJ to "further consider" Plaintiff's functional limitations. (Id. at 114–16). After a second hearing held on November 17, 2014, the ALJ issued her decision in accordance with the Council's directives on April 14, 2015, finding Plaintiff not disabled during all relevant timeframes and denying both her SSI and SSDI applications. (Id. at 14–47, 118–41). That denial resulted from a second Residual Functional Capacity ("RFC") assessment that did not include the limitation of being "off task" for 25 percent of each work day. Plaintiff again made an administrative appeal, which was denied, and ultimately sought judicial review in the instant case on September 27, 2016.

A. Medical and Documentary Evidence

The record contains volumes of medical evidence concerning both physical and mental impairments. As they relate to mental health issues,⁴ the earliest medical records derive from Northgate Medical P.C., a Springfield healthcare provider now permanently shuttered. Northgate records establish that Plaintiff visited the facility and discussed her mental health no fewer than 25 times between March 2000 and December 2007. (See id. at 542–78; 605–28). Some Northgate records indicate mental health was a primary reason for a visit, while others indicate Plaintiff presented with primary complaints that were physical in nature. In any event, her depression and/or anxiety were documented at virtually every Northgate visit. A Northgate "Follow Up Form" dated March 3, 2000 indicates that Plaintiff first presented there when 22 years old and pregnant, complaining of loss of sphincter tone and sudden "falls to the floor." (Id. at 565). She presented again at a walk-in visit two weeks later complaining of coughing, fever, wheezing, and depression. (Id. at 610). Her depression is further mentioned in Northgate records stemming from scheduled appointments and walk-ins in April, September, and October of 2000; May of 2001, June of 2003, June of 2004, July and October of 2006, January, February, May, October, and December of 2009; and March and April of 2010. (542–78; 605–28). A "Follow Up Form" dated September 22, 2000, describes Plaintiff as suffering from depression and notes that her medication was "making her sick." (Id. at 563). A "progress note" on the same form further recounted that Plaintiff had twice been to a crisis unit for suicidal ideation and that she had "wild anxiety." (Id. ) The same field suggests the reviewing doctor had intended to prescribe Wellbutrin as a replacement for Prozac but abruptly ends with a note that "patient left before the end of the visit." (Id. ) A July 2006 record noted that Plaintiff was "back in town" living at a homeless shelter. (Id. at 554). Northgate forms from October 2006 state she visited the emergency room for chest pain, when she was "going through stressful times" and had stopped taking Celexa one month prior. (Id. at 551). A handwritten note on the same form states, without elaboration, "awaiting Valley Pysch[,]" a reference to the Valley Psychiatric Services ("VPS") mental health clinic in Springfield, MA. (Id. ) Plaintiff presented again in December of 2009 complaining of hallucinations and suicidal thoughts. (Id. at 611). An October 2010 "Follow Up Form" recounts that Plaintiff presented complaining of anxiety, depression, and numerous body pains. (Id. at 562). The same document notes "longstanding depression since 1996," visits to the crisis center, "high anxiety level," and recounts prescriptions for Paxil, Celebrex, and other medications. (Id. at 562).

Records from Mercy Medical Center ("MMC") disclose Plaintiff made frequent emergency room visits as early as 2002. Only those records relevant to the instant analysis are discussed here. An admission form from a May 17, 2002 visit to the MMC ER lists "STS Sexually Assaulted" as the primary complaint and "admitting diagnosis." (Id. at 444–48). In the "clinical impression" field the reviewing physician visit cryptically noted "Anxiety Reaction" without elaboration. (Id. at 446). An R.N.'s notes from an April 24, 2003 emergency room visit state that Plaintiff presented with complaints of lack of sleep, depression, and suicidal ideation. (Id. at 443). The R.N.'s notes recite that Plaintiff had stopped taking psychotropic medications four months prior, that Plaintiff "hadn't slept" for an unspecified amount of time, and that Plaintiff had not eaten for five days. (Id. at 443). The same R.N. recorded her recommendation that Plaintiff "see psychiatrist for counseling & meds & suicidal ideation." (Id. )

Plaintiff's earliest recorded visit to a mental health facility, rather than an emergency room or urgent care clinic, date to March 9, 2002, when she first presented at VPS and received a diagnosis of dysthymia.⁵ (A.R. at 885). An "Initial Medication Evaluation" form completed for that visit by Matthew Friedman, M.D., indicates Plaintiff was 25 years old at the time and had received treatment and medication for her mental health on an "on again off again" basis since 1997. (Id. ). It also noted a history of sexual abuse and suicidal behavior. (Id. ) Freidman increased dosage of Paxil, a psychotropic drug used to treat anxiety disorders, and other prescribed medications in mostly illegible handwriting. (Id. ). He scheduled a follow up visit for May 8, 2002, but no records appear to have been produced for/from that visit.

The next relevant record is a "Diagnostic Summary," also from VPS, dated June 6, 2003. (A.R. at 878–84). Therapist Joanne Tan, M.S.W., reported in the "objective impression" section that Plaintiff appeared "to have past and current trauma issues of abuse .... She was sexually abused by her father and mom's SO from age 5 [until] age 15 and...