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Correa v. Commissioner Social Security Administration

United States District Court, D. Connecticut

October 5, 2017



          Hon. Vanessa L. Bryant, United States District Judge

         Virgen Correa (“Correa”) brings this action under § 205(g) of the Social Security Act, 42 U.S.C. § 405(g), to challenge the final decision of the Commissioner of Social Security (“Commissioner”) denying Correa's application for supplemental security income and social security disability benefits. Correa moves to reverse or remand the Commissioner's decision, arguing the ALJ erred in finding her severe impairments of bipolar disorder and anxiety did not match or medically equal a listing under 20 C.F.R. Part 404, Subpart P, Appendix 1. The Commissioner moves for Judgment on the Pleadings, arguing the ALJ properly evaluated Correa's claim at Step Three. For the following reasons, the Court AFFIRMS the Commissioner's decision.


         I. Medical History

         The Court has reviewed the evidence and accepts the facts from the parties' joint stipulation of undisputed facts, hereby incorporating them into this opinion. [Dkt. 18-1]. In October 2011, Correa visited Staywell Health Center, where she received primary care, and she reported feelings of anxiety, depression, and sleep disturbance during both visits. Id. ¶ 1. Her primary care physician, Dr. Luis Leon, referred her to St. Mary's Hospital Behavioral Health (“St. Mary's”) where she began outpatient mental health treatment on February 23, 2012. Id. ¶ 2; see Tr. 477. Correa received her outpatient treatment primarily from Elizabeth Korn, APRN, see generally [Dkt. 18-1], who diagnosed her with bipolar disorder with most recent episode mixed, severe with psychotic features, anxiety disorder NOS, post-traumatic stress disorder, and cocaine abuse in remission, id. ¶ 12. In March, Correa started her treatment on a weekly basis, but thereafter visited St. Mary's on a biweekly basis in April and May, and on a monthly basis during the fall of 2012. See Id. ¶¶ 5-10, 12-17, 18-19, 21-25. Nurse Korn also diagnosed Correa with cannabis abuse in September 2012. Id. ¶ 19. Correa visited St. Mary's monthly from January through July of 2013, but after she only visited St. Mary's once, in October, for the rest of that year. See Id. ¶¶ 31-40. Correa visited St. Mary's on a monthly basis in 2014. See Id. ¶¶ 46-52.

         Nurse Korn's observations are relatively consistent throughout the duration of Correa's treatment. Correa reported feelings of anxiety and depression, and she periodically reported difficulty with sleep and appetite as well as auditory and visual hallucinations. See, e.g., ¶¶ 6, 13, 19, 32, 37, 41, 47, 49. Nurse Korn nearly uniformly documented Correa's insight, judgment, memory, and concentration as “fair, ” although in September 2012 Nurse Korn indicated Correa's insight and judgment were “poor.” See, e.g., Id. ¶ 10, 19, 37, 41. Correa was usually described has having normal speech and grooming, although at times she did not, and she typically appeared alert and oriented. See, e.g., Id. ¶ 7, 8, 16, 18, 23, 34, 41. But see Id. ¶ 13. When Correa failed to take her medications, her symptoms worsened. See, e.g., Id. ¶¶ 13-14. Over the course of her treatment, her Global Assessment of Functioning (“GAF”) score varied from as low as 34 in January 2013 to as high as 48 in July 2013, February 2014, and August 2014. See Id. ¶ 31, 38, 46, 52.

         In addition to the treatment Correa received at Staywell and St. Mary's, several examiners evaluated Correa. In January 2013, Dr. Diana Badillo Martinez conducted a consultative examination of Correa on behalf of the Connecticut Disability Determination Services. Id. ¶¶ 27-30. Dr. Badillo Martinez observed her “attention span” and “ability to perform mental operations” were “below the norm;” that she “forgets directions, derails, and does not focus well;” and that her insight and introspective abilities were low and her judgment was poor. Id. Correa “cannot remember one sentence after delay of 15 even when a cue.” Id. Notably, Dr. Badillo Martinez opined that her anxiety, easy agitation and disorganization would make it difficult to find and maintain employment. Id. ¶ 30. Dr. Mario Perez also completed a form for the State of Connecticut Department of Social Services, opining that Correa could not be expected to work for 12 months or longer and assigning a GAF score of 44. Id. ¶ 42. Other consultative examiners assessed Correa's medical records on behalf of the Social Security Administration, and Dr. Gitlow specifically testified at Correa's administrative hearing. See Tr. 21.

         II. ALJ Decision

         The ALJ issued its determination on March 27, 2015, the findings of which are subject to review by this Court. Tr. 23. The ALJ determined Correa has not engaged in substantial gainful activity since the alleged onset Dated: March 9, 2011. Tr. 13. Correa suffers from the following severe impairments: bipolar disorder, anxiety, and cannabis use. Id. Her non-severe impairments include hypertension, carpal tunnel syndrome, and peripheral neuropathy. Tr. 14.

         The ALJ then determined Correa does not have an impairment or combination of impairments that meets or medically equals the severity of a listed impairment under 20 C.F.R. Part 404, Subpart P, Appendix 1. Id. The specific listings identified for comparison were § 12.04 (affective disorders), § 12.06 (anxiety related disorders), and § 12.09 (substance addiction disorders). The ALJ did not apply Correa's medical history to each listing in detail, but rather concluded that with respect to paragraph B of sections 12.04 and 12.06, Correa possessed “mild restriction of activities of daily living; moderate difficulties in maintaining social functioning; moderate difficulties in maintaining concentration, persistence or pace; and no episodes of decompensation.” Id. To satisfy this element of the listing standards, Correa would have had to demonstrate two of the following: “marked restriction” of the first three categories, and repeated episodes of decompensation of extended duration. Id. This she did not do.

         The ALJ discussed in depth Correa's residual functional capacity (“RFC”). See Tr. 15-22. Specifically, the ALJ determined Correa could “perform a full range of work at all exertional levels” but with various nonexertional limitations. Id. He addressed Correa's testimony and concluded she was “not entirely credible for the reasons explained in this decision.” Tr. 16. To support his reasoning, the ALJ set forth an in-depth chronology of Correa's medical history from October 2011 until August 2014. See Tr. 16-20. The ALJ also stated that the treatment history does not support her complaints, particularly because she was not hospitalized and her condition worsened when she was not taking medication. Tr. 20. Importantly, the ALJ noted that Correa could successfully complete many activities of daily living such as living alone in a house, cooking for herself and her dog, washing dishes, completing housework, watching television, taking the bus, getting dressed, collecting cans, cleaning the apartment, ironing, shopping, and handling finances. Id.

         The ALJ made several determinations regarding the physicians involved in this case. He assigned “little probative weight” to Dr. Badillo Martinez because she only interviewed Correa on one occasion and did not provide a description of discrete functional limitations regarding Correa's mental impairments. Tr. 20. The ALJ similarly did not give Dr. Perez “substantial probative weight, ” ruling Dr. Perez's conclusions that Correa possessed “marked limitations in remembering locations and work-like procedures” did not match with treating physicians. Tr. 20-21. However, the ALJ afforded “significant probative weight” to the State agency psychological consultant and Dr. Gitlow because the conclusions were consistent with the medical history. Tr. 21.

         Lastly, the ALJ concluded that Correa could perform past relevant work as a packer and cleaner, which were classified by the vocational expert as a “light exertional level, medium as performed and unskilled, and light and unskilled.” Tr. 22.

         Legal Standard

         “In reviewing a final decision of the SSA, this Court is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard.” Lamay v. Comm'r of Soc. Sec., 562 F.3d 503, 507 (2d Cir. 2009) (citing 42 U.S.C. § 405(g)). “Substantial evidence is more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Id. (internal quotation marks and citations omitted). “[A district court] must consider the whole record, examining the evidence from both sides, because an analysis of the substantiality of the evidence must also include that which detracts from its weight.” Petrie v. Astrue, 412 F. App'x 401, 403-04 (2d Cir. 2011) (quoting Williams ex rel. Williams v. Bowen, 859 F.2d 255, 258 (2d Cir. 1988)) (internal quotation marks omitted). “Even if the Commissioner's decision is supported by substantial evidence, legal error alone can be enough to overturn the ALJ's decision.” Ellington v. Astrue, 641 F.Supp.2d 322, 328 (S.D.N.Y. 2009) (citing Johnson v. Bowen, 817 F.2d 983, 986 (2d Cir. 1987)).

         To be “disabled” under the Social Security Act, a claimant must demonstrate an “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A).

         The SSA has promulgated the following five-step procedure to evaluate disability claims:

1. First, the [Commissioner] considers whether the claimant is currently engaged in substantial gainful activity ...

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