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Monzon v. Berryhill

United States District Court, S.D. Florida

May 8, 2018

ABNER MONZON, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         THIS CAUSE came before the Court upon Plaintiff Abner Monzon's ("Claimant") Motion for Summary Judgment (hereafter, "Claimant's Motion for Summary Judgment") [D.E. 20] and Defendant Nancy A. Berryhill, Acting Commissioner of Social Security's ("Commissioner") Motion for Summary Judgment and Response to Claimant's Motion for Summary Judgment (hereafter, "Commissioner's Motion for Summary Judgment") [D.E. 21]. The administrative transcript (hereafter, "TR.") has been filed [D.E. 18].[1] For the reasons stated below, the undersigned respectfully recommends that Claimant's Motion for Summary Judgment be GRANTED, the Commissioner's Motion for Summary Judgment be DENIED, and the Commissioner's decision be REMANDED to the Commissioner for further proceedings in accordance with this Report and Recommendation.


         Claimant filed applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") on January 31, 2013, alleging a disability onset date of December 1, 2011. TR. 32. The applications were denied initially and upon reconsideration. Id. Pursuant to a written request, a hearing was held on May 26, 2015 before Administrative Law Judge Lornette Reynolds ("ALJ Reynolds"), which was continued to allow Medical Expert Haddon Alexander III, M.D. ("ME Alexander") to review recently filed evidence. Id. at 90-111. On the same date, Claimant amended his alleged disability onset date to August 1, 2013. Id. at 358. A continued hearing was held on July 7, 2015 before ALJ Reynolds, at which Claimant, ME Alexander and Vocational Expert Nicholas Fidanza ("VE Fidanza") testified. Id. at 50-89. On November 18, 2015, ALJ Reynolds issued an Unfavorable Decision, finding the following:

(1) Claimant met the insured status requirements of the Social Security Act through December 31, 2015. Id. at 34.
(2) Claimant had not engaged in substantial gainful activity since August 1, 2013, the alleged disability onset date (20 C.F.R. §§ 404.1571 et seq. and 416.971 et seq, ). 14
(3) Claimant had the following severe impairments: history of congestive heart failure ("CHF"), coronary artery disease and/or cardiomyopathy, hypertension, osteoarthritis, rheumatoid arthritis and/or fibromyalgia, and depressive disorder (20 C.F.R. §§ 404.1520(c) and 416.920(c)). Id
(4) Claimant did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926). Id. at 36.[2]
(5) Claimant had the residual functional capacity (hereafter, "RFC") to perform sedentary work, subject to certain limitations. Id. at 37.[3]
(6) Claimant was unable to perform any past relevant work (20 C.F.R. §§ 404.1565 and 416.965). Id. at 41.[4]
(7) Claimant was born on September 26, 1970 and was 42 years old, which is defined as a younger individual age 18-49, on the alleged disability onset date (20 C.F.R. §§ 404.1563 and 416.963). Id.
(8) Claimant had at least a high school education and was able to communicate in English (20 C.F.R. §§ 404.1564 and 416.964). Id. at 42.
(9) Transferability of job skills was not material to the determination of disability because using the Medical-Vocational Rules as a framework supported a finding that Claimant was "not disabled, " whether or not Claimant had transferable job skills (See SSR 82-41 and 20 C.F.R. Part 404, Subpart P, Appendix 2). Id.[5]
(10) Considering Claimant's age, education, work experience, and RFC, there were jobs that existed in significant numbers in the national economy that Claimant could perform (20 C.F.R. §§ 404.1569, 404.1569(a), 416.969, and 416.969(a)). Id.
(11) Claimant had not been under a disability, as defined in the Social Security Act, from August 1, 2013, through the date of the Unfavorable Decision (20 C.F.R. §§ 404.1520(g) and 416.920(g)). Id. at 43.

         On January 12, 2017, the Appeals Council denied a request for review of ALJ Reynolds' Unfavorable Decision. Id. at 1-8. On February 14, 2017, pursuant to 42 U.S.C. § 405(g), Claimant filed this action seeking reversal of ALJ Reynolds' final administrative decision [D.E. 1].

         In support of his contention that ALJ Reynolds' Unfavorable Decision should be reversed, Claimant argues that ALJ Reynolds' findings with regard to his mental RFC were not supported by substantial evidence. The undersigned finds merit in this contention.


         I. Treating sources

         A. Miami Behavioral Health Center and Spectrum Programs ("Miami Behavioral Health")

         On August 2, 2013, Claimant underwent a psychiatric evaluation at Miami Behavioral Health. Id. at 1087-91. Upon mental status examination, Claimant's affect was blunted; his mood was depressed and anxious; he was oriented to time, place, and person; his recent and immediate memory was impaired; his insight and judgment were fair; his sleep was poor; his thought process was racing; his thought content was paranoid; and he had auditory hallucinations and paranoid delusions. Id. at 1089. Claimant was diagnosed with schizoaffective disorder, bipolar type and assigned a Global Assessment of Functioning ("GAF") score of 47. Id. at 1090.[6]

         On May 11, 2015, Sandra Fujita, Advanced Registered Nurse Practitioner ("ARNP Fujita") and Manuela Georgescu, M.D. ("Dr. Georgescu") completed a Medical Assessment of Ability to Do Work Related Activities (Mental) for Claimant (hereafter, "Medical Source Statement"). Id. at 1078-81. ARNP Fujita and Dr. Georgescu reported that Claimant had been treated at Miami Behavioral Health since July 8, 2013. Id. at 1080. ARNP Fujita and Dr. Georgescu opined that Claimant had "poor" or no ability to do the following: follow work rules; relate to co-workers; deal with the public; use judgment; interact with supervisors; deal with work stress; function independently; maintain attention and concentration; understand, remember and carry out simple, detailed, and complex job instructions; maintain personal appearance; behave in an emotionally stable manner; relate predictably in social situations; and demonstrate reliability. Id. at 1078-79. ARNP Fujita and Dr. Georgescu opined that Claimant suffered from a schizophrenic, paranoid or other psychotic disorder, but did not suffer from an affective disorder or a substance addiction disorder. Id. at 1081. ARNP Fujita and Dr. Georgescu noted that Claimant's impairment affected all activities of life. Id. at 1080.

         On May 13, 2015, ARNP Fujita reported that Claimant's appearance was appropriate; his affect was constricted; his mood was depressed and anxious; he was oriented to time, place and person; he was alert; his immediate and recent memory was impaired; his speech was unremarkable; his sleep, appetite, eye contact, reliability, concentration, insight, and judgment were fair; his thought process was psychotic; his thought content had obsessions; he had auditory hallucinations and paranoid and religious delusions; but he was not suicidal or homicidal. Id. at 1085. ARNP Fujita reported that Claimant was not improving with treatment as expected, and that a change in medication was needed. Id. at 1086.

         B. Enrique Pelayo, M.D., P.A. ("Dr. Pelayo")

         Claimant received treatment from Dr. Pelayo from July 1, 2013 to May 5, 2014. Id. at 983-1047. On November 21, 2013, Claimant visited Dr. Pelayo for lab work for medical clearance for an umbilical hernia repair. Id. at 991. Claimant reported that he felt fine and that he had no chest pain or shortness of breath. Id. On February 27, 2014, Claimant reported that his joint pain felt better, his hypertension was controlled, his mood was better, and that his psychiatrist had increased the dosage of his medication. Id. at 983.

         C. Rosie Lee Wesley Health Center, Jackson Health System ("Wesley Health")

         On March 4, 2015, Claimant presented as a new patient at Wesley Health to establish care and obtain medication refills. Id. at 1139. Claimant reported that he was no longer taking antidepressants. Id. On April 10, 2015, Claimant visited Wesley Health for the flu and reported that he was being seen by a psychiatrist, and that he had received psychiatric medication at the psychiatrist's office. Id. at 1131.

         D. Community Health of South Florida, Inc. ("Community Health")

         On May 28, 2013, Claimant visited Community Health for a biopsychosocial assessment. Id. at 916-925. Claimant reported exacerbation of depressive symptoms, impaired daily functioning, lack of motivation, multiple health stressors, physical pain limitations, unemployment, limited resources, impaired sleep patterns, daily crying spells, isolation, alienation, increased anhedonia, hopelessness and helplessness; and denied suicidal or homicidal ideations. Id. at 924. Claimant also stated that he was not interested in case management or psychotherapy at the time. Id. Claimant was diagnosed with major depressive disorder, severe; was assigned a GAF score of 51; and was recommended to undergo a psychiatric evaluation. Ia\ at 925-26.[7]

         E. Kendall Regional Medical Center

         On April 14, 2013, Claimant underwent a cardiac catheterization, which noted nonobstructive coronary artery disorder and reduced ejection fraction ("EF") of 35%. Id. at 950. On the same date, a Doppler test revealed an EF of 50 to 55%. Id. at 978. On April 15, 2013, Claimant underwent a Computer Tomography ("CT") scan of his chest, which showed a 44% EF. 14 at 975.

         F. Heartwell

         On September 12, 2014, Claimant visited Heartwell for a follow-up visit. Id. at 1064-66. Doctors noted that Claimant's blood pressure was controlled; that he had no chest pain; and that his cardiac artery disorder was stable. Id. at 1064-65. On October 24, 2014, doctors noted that Claimant's hypertension was benign and his sleep apnea condition was stable. Id. at 1105. In July, September, and October of ...

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