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Timestamp: 2020-04-04 00:28:53
Document Index: 70789006

Matched Legal Cases: ['§ 422', '§ 404', '§ 404', '§ 404', '§ 404', '§ 404']

FindACase™ | Becerra v. Berryhill
Becerra v. Berryhill
ROBERTO BECERRA, Plaintiff,
THIS MATTER is before the Court upon Plaintiff Roberto Becerra's (“Plaintiff's”) “Motion to Reverse and Remand for a Rehearing with Supporting Memorandum” [ECF No. 16], filed December 8, 2017, and its accompanying “Memorandum in Support of Motion to Reverse and Remand for a Rehearing” (“Motion”).[1] ECF No. 17. The Motion is fully briefed. See ECF No. 23 (Commissioner's Response); ECF No. 25 (Plaintiff's Reply). Having meticulously reviewed the entire record and the parties' briefing, the Court concludes that the Administrative Law Judge's (“ALJ's”) ruling should be AFFIRMED. Therefore, and for the further reasons articulated below, the Court will DENY Plaintiff's Motion.
Plaintiff was born December 3, 1973. Administrative R. (“AR”) 76. Plaintiff previously worked at a warehouse and on an irrigation project. AR 656. He then worked as a casino dealer for several years, and was fired after he could not return to work because of pain following a car accident. AR 43. Plaintiff filed an application for Supplemental Security Income (“SSI”) on August 1, 2014, and for disability insurance benefits (“DIB”) on October 2, 2014. AR 13. In both applications, Plaintiff alleged onset of disability beginning October 1, 2005. AR 13. The Social Security Administration (“the SSA”) denied Plaintiff's claim initially and on reconsideration. AR 13. Plaintiff then requested a hearing, which was held in front of ALJ Lillian Richter on November 30, 2016. AR 13. Plaintiff testified at the hearing, as did Mary D. Weber, a vocational expert (“VE”). AR 13. Plaintiff was represented by counsel at the hearing [AR 13], but represents himself in the instant appeal.[2]
On March 2, 2017, ALJ Richter issued her decision that with respect to his DIB application, Plaintiff was not disabled from October 1, 2005, through December 31, 2011, which was the date last insured. AR 24. Regarding his SSI application, ALJ Richter concluded that Plaintiff has been disabled since August 1, 2014, the date that the application was filed. AR 24. Plaintiff subsequently asked the SSA's Appeals Council (“AC”) to review ALJ Richter's decision with respect to his DIB and SSI applications, but the AC denied his request on June 7, 2017. AR 1. With his request, Plaintiff also submitted to the AC letters he wrote to N. Phoenix Anderson, Ph.D., and David LaCourt, Ph.D., as well as his affidavit and a letter from Gabriel Becerra, his brother. AR 2. The AC found that the evidence did not “show a reasonable probability that it would change the outcome of the decision[, ]” and “did not consider and exhibit this evidence.” AR 2. As a consequence, the ALJ's decision became the final decision of the Commissioner. 20 C.F.R. § 422.210(a) (2018). Plaintiff timely filed his appeal in this Court on August 10, 2017. ECF No. 1.
Plaintiff advances three primary[3] claims of legal error. First, he argues that the ALJ erred by inferring, without requesting assistance from a medical advisor, that the onset date of his disability was February 2, 2014. Pl.'s Mot. 6-23, ECF No. 17. Next, Plaintiff asserts that the VE's testimony is not supported by substantial evidence because the ALJ did not include all of Plaintiff's impairments in her hypothetical question to the VE. Id. at 18. Finally, Plaintiff alleges that the AC erred by refusing to review the evidence he submitted to it following the hearing, by not requesting that an expert review that evidence, and by not entering that evidence into the AR. Id. at 24-25.
When the Appeals Council denies a claimant's request for review, the ALJ's decision becomes the final decision of the agency.[4] The Court's review of that final agency decision is both factual and legal. See Maes v. Astrue, 522 F.3d 1093, 1096 (10th Cir. 2008) (citing Hamilton v. Sec'y of Health & Human Servs., 961 F.2d 1495, 1497-98 (10th Cir. 1992)) (“The standard of review in a social security appeal is whether the correct legal standards were applied and whether the decision is supported by substantial evidence.”)
The SSA has devised a five-step sequential evaluation process to determine disability. See Barnhart v. Thomas, 540 U.S. 20, 24 (2003); 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4) (2018). At the first three steps, the ALJ considers the claimant's current work activity, the medical severity of the claimant's impairments, and the requirements of the Listing of Impairments. See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4), & Pt. 404, Subpt. P, App'x 1. If a claimant's impairments are not equal to one of those in the Listing of Impairments, then the ALJ proceeds to the first of three phases of step four and determines the claimant's residual functional capacity (“RFC”). See Winfrey, 92 F.3d at 1023; 20 C.F.R. §§ 404.1520(e), 416.920(e). In phase two, the ALJ determines the physical and mental demands of the claimant's past relevant work, and in the third phase, compares the claimant's RFC with the functional requirements of his past relevant work to determine if the claimant is still capable of performing his past work. See Winfrey, 92 F.3d at 1023; 20 C.F.R. §§ 404.1520(f), 416.920(f). If a claimant is not prevented from performing his past work, then he is not disabled. 20 C.F.R. §§ 404.1520(f), 416.920(f). The claimant bears the burden of proof on the question of disability for the first four steps, and then the burden of proof shifts to the Commissioner at step five. See Bowen v. Yuckert, 482 U.S. 137, 146 (1987); Talbot v. Heckler, 814 F.2d 1456, 1460 (10th Cir. 1987).
If the claimant cannot return to his or her past work, then the Commissioner must show at the fifth step that the claimant is nonetheless capable of performing other jobs existing in significant numbers in the national economy. See Thomas, 540 U.S. at 24-25; see also Williams v. Bowen, 844 F.2d 748, 750-51 (10th Cir. 1988) (discussing the five-step sequential evaluation process in detail).
At step one, the ALJ found that Plaintiff met the insured status requirements of the Social Security Act through December 31, 2011, and had not engaged in substantial gainful activity since the alleged disability onset date of October 1, 2005.[5] AR 14. At step two, the ALJ determined that Plaintiff had the following severe impairments: glossopharyngeal neuralgia (“GN”), post-subarachnoid hemorrhage, cranial nerve VII unilateral, persistent depressive disorder, anxiety disorder, post-traumatic stress disorder (“PTSD”), sleep disorder, somatic symptom disorder, severe disruptive mood dysregulation disorder, degenerative disc disease of the cervical spine, and paresthesia of the left upper extremity. AR 15. The ALJ also determined that Plaintiff's tinnitus and seborrheic keratosis were non-severe “because they do not significantly limit [Plaintiff's] physical or mental abilities to do basic work activities.” AR 16. The ALJ found that Plaintiff's allegation of vertigo was not a medically determinable impairment due to a “lack of medical signs or laboratory findings established by medically acceptable clinical or laboratory diagnostic techniques showing the existence of vertigo.” AR 16. The ALJ also concluded that since October 1, 2005, Plaintiff “has not had an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments[, ]” and used the Psychiatric Review Technique (“PRT”) to determine that the severity of Plaintiff's mental impairments “do not meet or medically equal the severity of one of the listed impairments” in listings 12.02, 12.04, and 12.06. AR 16.
At step four, the ALJ determined Plaintiff's RFC as follows:
After careful consideration of the entire record, I find that prior to February 3, 2014, the date [Plaintiff] became disabled, [Plaintiff] had the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b). [Plaintiff] could lift, carry, push and pull 20 pounds occasionally and 10 pounds frequently. [Plaintiff] could stand/and or walk for 6 hours in an 8-hour workday; and sit for up to 6 hours in an 8-hour workday. [Plaintiff] could never balance[, ] climb ladders, ropes and or scaffolds. [Plaintiff] should avoid exposure to unprotected heights and hazardous machinery. [Plaintiff] could frequently reach in all directions bilaterally, and could frequently handle[, ] finger[, ] and feel. [Plaintiff] was limited to simple[, ] routine work and could have occasional interaction with supervisors, coworkers and members of the public.
AR 16. Following February 3, 2014, the ALJ determined Plaintiff's RFC as follows:
After careful consideration of the entire record, I find that beginning on February 3, 2014, [Plaintiff] has the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a) and 416.967(a). Specifically, [Plaintiff] could lift, carry, push and pull 10 pounds occasionally and 5 pounds frequently, [and] could stand/walk for 2 hours and sit for 6 hours in an 8-hour day. [Plaintiff] can never balance or climb ladders, ropes and or scaffolds. [Plaintiff] should avoid exposure to unprotected heights and hazardous machinery. [Plaintiff] can frequently reach in all directions bilaterally, and can occasionally handle, finger[, ] and feel. [Plaintiff] is limited to simple[, ] routine work and can have occasional interaction with supervisors, coworkers[, ] and members of the public. [Plaintiff] is limited to work that is primarily performed at the workstation. Lastly, [Plaintiff] may require frequent and unscheduled breaks throughout the workday, in addition to the scheduled work breaks.
AR 19.
In determining Plaintiff's RFCs, the ALJ considered Plaintiff's testimony [AR 42-64], the extensive medical record, and other non-medical evidence. AR 16-21. In evaluating Plaintiff's credibility, the ALJ concluded that while Plaintiff's “medically determinable impairments could reasonably be expected to cause the alleged symptoms . . . [Plaintiff's] statements concerning the intensity, persistence and limiting effects of these symptoms are not credible prior to February 3, 2014, as [they are] not supported by the substantial evidence of record.” AR 17. The ALJ considered the opinions of psychological consultative examiner (“CE”) N. Phoenix Anderson, Ph.D. [AR 636-639], psychological CE David LaCourt, Ph.D. [AR 656-661], and state agency disability consultants Charles Friedman, M.D. [AR 76-83, 94-96], Suzanne Castro, Psy.D. [AR 83, 86-94, 96-98], Joy Kelley, Ph.D. [AR 112, 115-16, 125-27, 129-31], and James Metcalf, M.D. [AR 114, 125, 128-29]. The ALJ also considered letters from Augustine Chavez, M.D.[6] [AR 813], Plaintiff's treating physician at First Choice Community Healthcare, certified Family Nurse Practitioner Lisa Brazil[7] [AR 758], and Bill E. Galbreth, [8]D.M.D. [AR 755].
The ALJ considered records from Eric Thomas, M.D. [AR 341-45], hospital records from Presbyterian Healthcare Services [AR 346-372, 731-62, 769-818], the University of New Mexico Hospital (“UNMH”) and University of New Mexico (“UNM”) Clinic [AR 373-631, 763-65], New Mexico Orthopedics [AR 641-55, 718-30], Lovelace Medical Center [AR 662-97], and Albuquerque Health Partners [AR 698-717, 766-68]. Finally, with respect to third party function reports, the ALJ considered reports from Plaintiff's brother, Gabriel Becerra [AR 252-62, 319, 336-40], and from Plaintiff's parents, Roberto Becerra [AR 316, 318-19] and Bernadette Becerra [AR 318].
Dr. N. Phoenix Anderson, Ph.D.
Dr. Anderson, a psychological CE, evaluated Plaintiff on January 28, 2015. AR 636. The ALJ accorded this opinion great weight because she found it “consistent with [Plaintiff's] abstraction and coping skills on examination, and the other mental health findings, and also consistent with Dr. LaCourt's opinion.” AR 20 (internal citations omitted). Dr. Anderson observed that Plaintiff's head had limited movement “due to severe neck pain . . . [i]ntermittently, he places his hand on his right ear and rocks back and forth with his eyes closed; occurs several times an hour.” AR 636. Plaintiff reported that he “thinks about suicide daily but does not want to do it because ‘it will kill my mom because she's in bad health. It would break her heart and I can't do that to my family.'” AR 636. Plaintiff stated that his desire to commit suicide is “always on the top of my mind.” AR 637. Plaintiff also reported waking during the night because of “ear attacks.” AR 636.
Regarding activities of daily living, Plaintiff stated that “he spends most of his day lying down, ” and his favorite activities were lying down and listening to music. AR 636. Lying down helped his pain. AR 636. Plaintiff's brother did all of the house and yard work, grocery shopping, transporting Plaintiff to appointments, and ran Plaintiff's errands due to Plaintiff's “limited range of motion and severe, intermittent[ ] [e]ar attacks.” AR 637. Plaintiff was capable of managing his medication, communicating with others, and “tending to his bedtime routine.” AR 637. Plaintiff reported, however, that he showered only once every three days because if water hit his right ear, it would set off an attack. AR 637. Plaintiff also stated that he experienced vertigo. AR 637. Plaintiff stated that his relationship with his parents has always been excellent, and he also has a good relationship with his brother. AR 636. Plaintiff lived with his brother. AR 636.
With respect to Plaintiff's mental health, he told Dr. Anderson that he “gets confused easily, has memory problems, anxiety attacks, fears that people will judge him . . . [and] fears leaving the house due to attacks, which cause him to rock back and forth.” AR 637. Plaintiff also felt that he is “mentally slower than others.” AR 637. Plaintiff admitted that he never received mental health care, stating that “he does not see how mental health services can help relieve his pain.” Plaintiff denied ever being diagnosed with a mental illness, did not take psychotropic medications, had never engaged in self-harm, and denied attempting suicide. AR 637.
Dr. Anderson opined that Plaintiff “was able to provide historical detail and dates regarding his past experiences, ” and thus was a credible, reliable historian. AR 637. Plaintiff was able to recall three out of four words after a five minute delay, and Dr. Anderson concluded that his long term memory was intact. AR 637. Dr. Anderson also concluded that Plaintiff's mood was “dysthymic [and] blunted, ” and opined that “[s]hould his mother pass, it is highly likely that [Plaintiff] will commit suicide.” AR 638. Dr. Anderson further found Plaintiff to have an average fund of knowledge, average intelligence, fair judgment, and normal decision making. AR 638. Plaintiff's coping ability, however, was exhausted. AR 638.
Dr. Anderson ultimately diagnosed Plaintiff with mood disorder due to GN, anxiety disorder due to GN, PTSD, sleep disorder (insomnia) due to GN, and concluded that despite his daily suicidal ideation, Plaintiff had a Global Assessment of Functioning score of 70.[9] Dr. Anderson further opined that Plaintiff's “mood disturbance appears to be the direct physiological consequence of a chronic medical condition and not a primary mood disorder[, ]” and noted that Plaintiff's daily suicidal ideation “does not seem to be correlated with the impaired judgment of a person experiencing major depressive disorder.” AR 638. “Instead, [Plaintiff, who is] of sound mind, has determined that death would be the best alternative to living a life with severe, possibly degenerative pain. Throughout the session, and in the waiting room, [Plaintiff] would freeze, close his eyes, grab his right ear, and rock. His face was flushed and each episode would last for at least one minute.” AR 638. Plaintiff described these painful episodes as ear attacks and stated that it was “the most severe, excruciating pain he could imagine anyone could experience. He also elaborated that it occurs throughout the 24 hour day with no respite.” AR 638.
Regarding Plaintiff's vocational abilities, Dr. Anderson concluded that although there were “no mental health issues that directly impair [Plaintiff's] vocational abilities[, ]” or cognitive issues that “negatively impact his vocational abilities[, ]” “the mental fatigue and exhaustion he experiences from his alleged medical condition would lend him unable to work [sic].” AR 638. Dr. Anderson further found that Plaintiff had the following limitations: moderate impairment in the ability to carry out simple instructions, and marked impairments in: (1) the ability to understand and remember complex instructions, (2) the ability to make judgments on complex, work-related decisions, (3) the ability to interact appropriately with the public, (4) the ability to respond appropriately to usual work situations, and (5) the ability to respond appropriately to changes in a routine setting.[10] AR 639.
Dr. David LaCourt, Ph.D.
Dr. LaCourt, a psychological CE, evaluated Plaintiff on November 1, 2016. AR 656. Plaintiff was referred to Dr. LaCourt by the New Mexico Disability Determination Services (“DDS”). AR 656. The ALJ accorded his opinion great weight because it is “based on his finding on mental status examination, and consistent with” Dr. Anderson's opinion. AR 20. Dr. LaCourt interviewed Plaintiff and reviewed “available background materials, ” which included “a prior psychological evaluation performed for the DDS[.]” AR 656. Dr. LaCourt noted that Dr. Anderson's observations concerning Plaintiff's “apparent severe pain, ” including that Plaintiff closes his eyes, holds his right ear, and rocks back and forth, were also present during his examination of Plaintiff. AR 656.
During Plaintiff's episodes of intense pain, Plaintiff also cursed “repeatedly at this clinician during and after the first such episode, a notable inconsistency potentially relating to the extent of actual incapacity.” AR 657. Dr. LaCourt observed “three distinct, measurable episodes” that lasted between 25 to 40 seconds each and “several others with very brief eye closures” lasting one or two seconds. AR 657. Dr. LaCourt noted that each of the three longer episodes started right after he asked Plaintiff a question. AR 657. Plaintiff stated that he typically experienced twenty to thirty episodes an hour, which is “twice what was exhibited today.” AR 657. Dr. LaCourt further observed that “the episodes presented as clearly momentarily incapacitating for [Plaintiff].” AR 657.
Regarding sleep, Plaintiff stated that he could not lay on his right side at all, and that listening to music was sometimes helpful, although he continued to experience tinnitus. AR 657. Dr. LaCourt opined that “[r]ecall and memory were somewhat vague about seemingly significant information (such as the date of his last surgery and specifics about his medications)[, ]” but Plaintiff nonetheless did not have any “obvious gaps or fillers to his retrieval and relating of sampled events.” AR 657. Dr. LaCourt found that Plaintiff's affect was partially appropriate, and his mood was pessimistic and depressed. AR 657. Plaintiff “acknowledged continuing to have self-harm ideation; he denied actually trying to hurt himself and there are no known episodes of attempted self-harm.” AR 657. Dr. LaCourt also opined that Plaintiff's fund of general information was somewhat variable but he did not have any serious gaps, and Plaintiff's intellectual functioning was about average, but adversely impacted by his previously diagnosed medical condition. AR 657.
Dr. LaCourt ultimately diagnosed Plaintiff with severe somatic symptom disorder with predominant pain, disruptive mood dysregulation disorder, generalized anxiety disorder, and severe persistent depressive disorder. AR 658. Dr. LaCourt identified the following functional, vocational limitations:
No to mild limitation in:
Understanding and remembering very short information or instructions Mild limitation in:
Adaptation to changes in the workplace Moderate limitation in:
Social interaction with supervisor Awareness of normal hazards and reacting appropriately to them Moderate to marked limitation in:
Social interaction with the public and co-workers Marked limitation in:
Understanding and remembering detailed/complex instructions Sustained concentration and task persistence for carrying out instructions Attending and concentrating Working without supervision Ability to individually travel
AR 658.
Dr. Charles Friedman, M.D.
Dr. Friedman was a consultative non-examining physician with DDS and evaluated Plaintiff's medical records on December 21, 2014. AR 82. The ALJ granted “significant weight” to Dr. Friedman's opinion, but noted that she “assessed [Plaintiff] with additional limitations based on his subjective reports, and the medical evidence of record. Where the residual functional capacity differs from [Dr. Friedman's opinion], those differences [were resolved] in favor of [Plaintiff].” AR 21. Dr. Friedman reviewed Dr. Anderson's report, medical records from Presbyterian Healthcare Services, UNM Clinic, and UNMH, Gabriel Becerra's report, Plaintiff's report, and Plaintiff's pain form. AR 90. With respect to Plaintiff's DIB claim, Dr. Friedman concluded that there was insufficient evidence as of the date last insured (“DLI”), which was December 31, 2011.[11] AR 82. With respect to Plaintiff's SSI claim, Dr. Friedman opined that Plaintiff had a spine disorder, which had primary priority and was severe. AR 92.
Dr. Friedman also made an unfavorable credibility determination, concluding that one or more of Plaintiff's medically determinable impairments could reasonably be expected to produce his pain or other symptoms, but also concluded that Plaintiff's statements about the intensity, persistence, and functionally limiting effects of his symptoms were not substantiated by the objective medical evidence alone. AR 94. Confusingly, however, Dr. Friedman later opined, “[Plaintiff's medically determinable impairments of GN, tinnitus, and cervicalgia] can reasonably be expected to produce the alleged pain and symptoms, and the objective medical evidence alone reasonably substantiates [Plaintiff's] allegations about the intensity, persistence and functionally limiting effects of the symptoms.” AR 96.
Dr. Friedman opined that Plaintiff could occasionally lift or carry twenty pounds, frequently lift or carry ten pounds, stand or walk for six hours in an eight hour day, sit for six hours in an eight hour day, and had unlimited ability to push and pull. AR 95. Dr. Friedman found that Plaintiff did not have any postural, manipulative, visual, communicative, or environmental limitations. AR 95. Ultimately, Dr. Friedman concluded that the medical evidence of record supported a light residual functional capacity.[12] AR 96.
Dr. Suzanne Castro, Psy.D.
Dr. Castro was a consultative non-examining physician with DDS, and evaluated Plaintiff's medical records on February 19, 2015. AR 94. The ALJ granted “significant weight” to Dr. Castro's opinion, but noted that she “assessed [Plaintiff] with additional limitations based on his subjective reports, and the medical evidence of record. Where the residual functional capacity differs from [Dr. Castro's opinion], those differences [were resolved] in favor of [Plaintiff].” AR 21. Dr. Castro reviewed Dr. Anderson's report, medical records from Presbyterian Healthcare Services, UNM Clinic, and UNMH, Gabriel Becerra's report, Plaintiff's report, and Plaintiff's pain form. AR 90.
Regarding Plaintiff's DIB application, Dr. Castro noted that there was no medical evidence of record prior to the DLI and therefore the “evidence is insufficient for the DIB portion of the claim.”[13] AR 83. Accordingly, Dr. Castro also noted that Plaintiff did not have any medically determinable impairments for DIB purposes. AR 83.
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;With respect to Plaintiff&#39;s SSI application, Dr. Castro opined that Plaintiff suffered from anxiety disorder and affective disorders, both severe. AR 92. Using the PRT, Dr. Castro opined that Plaintiff&#39;s disorders did not meet their listings. AR 93. Dr. Castro also opined that Plaintiff had mild restriction of activities of daily living, moderate difficulties in maintaining social functioning, moderate difficulties in maintaining concentration, persistence, or pace, and no repeated episodes of decompensation, each of extended duration.[14] AR 93. Dr. Castro concluded that Plaintiff's “[s]tatements regarding allegations are generally consistent throughout the [medical evidence of record] and are considered credible. Some weight is given to the psych[ological] CE opinions; [h]owever, the marked opinions given for responding to changes and responding appropriately to usual work situations are not consistent with . . . the overall [medical evidence of record].” AR 93-94. Dr. Castro further reflected that Plaintiff “is not in current mental health treatment, has had no psychiatric decompensations of extended ...