United States District Court, D. Connecticut
MEMORANDUM OF DECISION
Vanessa L. Bryant United States District Judge
Rivera brings this 42 U.S.C. § 405(g) action to
challenge the final decision of the Commissioner of Social
Security (“Commissioner”) denying Rivera's
application for supplemental security income
(“SSI”) benefits. Rivera moves to reverse the
Commissioner's decision, arguing as a general matter the
Administrative Law Judge (“ALJ”) erred by failing
to provide substantial evidence of his decision and
credibility determinations. The Commissioner moves to affirm,
contending the ALJ properly evaluated Plaintiff's claim
at Steps Two, Three Step Four, and Five. For the following
reasons, the Court reverses and remands for proceedings
consistent with the policy considerations of the Social
Security Administration (“SSA”) and this
Court accepts the facts from the parties' joint
stipulation of undisputed facts and hereby incorporates them
into this opinion. Dkt. 20 (Joint Stipulation of Facts).
Briefly, Rivera was born on January 27, 1960. Tr. 257. He
completed high school and worked as a loading dock helper,
dishwasher, and prep cook. Dkt. 20, at 16. Rivera's last
earnings date back to 2005, as Rivera was hit in the head by
a forklift and ceased working after the accident.
Id. at 16-17.
experiences chronic pain in his hips, back, and shoulder. In
2003, Rivera suffered a hip injury when a motor vehicle fell
on his hip, which resulted in multiple visits to the
emergency room. He went to the emergency room after this
incident. Id. at 2. He was diagnosed with a right
hip contusion, id., and went back to the emergency
room in August 2009 complaining of the same pain for the same
reason. Id. at 2-3. Rivera last reported left hip
pain in December 2010. Id. at 6. Since that date he
has neither complained of nor received treatment for his hip
February 2009 through July 2013 Rivera was treated for
chronic back pain. In October 2009 an MRI revealed disc
desiccation, disc bulging, and degenerative joint disease.
Id. at 4. By March 2012 an evaluation by Dr. Thomas
J. Stevens indicated no clinical evidence of acute issues
with the back and Dr. Stevens classified his pain instead as
“garden-variety sciatica.” Id. at 10.
Since then he has neither complained of nor received
treatment for his degenerative joint disease.
also received treatment for right shoulder pain in 2010 due
to a fall in the shower that occurred November 2009.
Id. At 4. Aside from this incident, he has neither
complained of nor received treatment of his degenerative
Rivera has also been treated for insomnia, hypertension and
diabetes mellitus; id. at 2, 7; 3, 5, 15; and 7, 15,
respectively; however, the record does not contain any
information concerning the debilitating effects of these
has a history of mental health and substance abuse issues.
See Id. at 2-3. In February 2012, Rivera received a
psychiatric evaluation by Dr. Jay M. Cudrin. Id. at
8. Dr. Cudrin evaluated Rivera and determined Rivera to have
a Full Scale IQ of 66, Verbal IQ of 67, and Performance IQ of
70. Id. He scored Rivera's word recognition at a
standard of 62 (third grade level). Id. In 2014,
Rivera reported symptoms of depression. Id. at
15-16. Rivera reported symptoms of episodic depression
following the murders of his brother and nephew. Id.
at 9. Finally, Rivera is addicted to alcohol and
methamphetamine. See Id. at 2-3.
has been evaluated on multiple occasions by each of the
following doctors: Dr. B. Gould (Primary Care), Dr. Stanley
Glassman (Primary Care), Dr. Gary Italia (Chiropractor), and
Dr. Stevens (Orthopedics). Dr. Cudrin (Psychologist) met with
Rivera on one occasion and performed a psychological testing
evaluation. Id. at 8-9. Several State agency
consultants, Dr. Adrian Brown (Psychology), Dr. Lois Wurzel
(Medical), Dr. Kenneth Bangs (Psychology), Dr. Abraham
Bernstein (Medical), also evaluated his case. These
evaluations in conjunction with objective medical evidence
form the primary basis for the ALJ's decision.
Brief Procedural Overview
following facts are also taken from the parties' joint
stipulation of undisputed facts. Dkt. 20. Rivera filed an
application for supplemental security income (SSI) payments
on July 17, 2012, alleging an onset date of July 30, 2008.
See Id. at 1; Tr. 257 (onset date of July 30, 2008).
Rivera's application and reconsideration were both
denied. Dkt. 20 at 1. Plaintiff then requested a hearing
before an ALJ and subsequently amended the onset date to July
17, 2012. Id. The hearing before the ALJ took place
on July 23, 2014, and on August 20, 2014, the ALJ issued a
decision finding Rivera was not disabled. Id. Rivera
sought review by the Appeals Council, but review was denied.
Id. at 1-2. This appeal followed.
The ALJ's Decision
issued the following findings. Rivera did not engage in
substantial gainful activity since January 17, 2012. Tr. 14.
Rivera suffered from the following severe impairments: lumbar
spondylosis, stenosis, and borderline intellectual
functioning. Id. Rivera suffered from the following
nonsevere impairments: hypertension, hyperlipidemia, diabetes
mellitus, diabetic ketoacidosis, memory loss from head
injury, post-concussion syndrome. Id. at 15-16.
Rivera's hypertension and hyperlipidemia appear to be
under good control with medication. Id. at 15.
Although Rivera has been admitted to the emergency room for
uncontrolled diabetes mellitus and diabetic ketoacidosis, the
hospital records indicated Rivera admitted to decreased use
of his diabetic medications and a later follow-up appointment
with his primary care physician determined his diabetes to be
under control with prescribed insulin. Id. Medical
evidence of his alleged memory loss from head injury shows
essentially normal findings and lacking traumatic brain
injury or memory loss as alleged. Id. at 16.
addition, Rivera's severe impairments, either
individually or collectively, do not meet or equal the
severity of one listed impairment under 20 C.F.R. Part 404.
Specifically, there is no evidence that Rivera's hip
impairments result in the inability to effectively ambulate,
a major dysfunction of a joint, or motor loss under Sections
1.00B2b, 1.02, and 1.04. Id. Rivera's mental
impairments do not meet or medically equal the criteria under
Listings 12.02B and 12.05D. Id.
light of Rivera's symptoms, the ALJ found that Rivera has
the residual functioning capacity to perform medium work and
carry out and remember simple instructions. Id. at
18. While noting that the medically determinable impairments
to which Rivera testified could reasonably be expected to
cause the alleged symptoms, the ALJ found that his professed
“persistence and limiting effects of these symptoms are
not entirely credible. . . .” Id. at 20.