United States District Court, S.D. Florida
REPORT AND RECOMMENDATION
M. OTAZO-REYES, UNITED STATES MAGISTRATE JUDGE
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.
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.
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
(1) Claimant met the insured status requirements of the
Social Security Act through December 31, 2015. Id.
(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)).
(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
(5) Claimant had the residual functional capacity (hereafter,
"RFC") to perform sedentary work, subject to
certain limitations. Id. at 37.
(6) Claimant was unable to perform any past relevant work (20
C.F.R. §§ 404.1565 and 416.965). Id. at
(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).
(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.
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
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.
Miami Behavioral Health Center and Spectrum Programs
("Miami Behavioral Health")
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.
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
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.
Enrique Pelayo, M.D., P.A. ("Dr. Pelayo")
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.
Rosie Lee Wesley Health Center, Jackson Health System
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.
Community Health of South Florida, Inc. ("Community
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
Kendall Regional Medical Center
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
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 ...