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Coca v. Saul

United States District Court, D. New Mexico

September 13, 2019

FERNANDO COCA,, Plaintiff,
ANDREW SAUL, Commissioner of the Social Security Administration,, Defendant.



         THIS MATTER is before the Court on the Social Security Administrative Record (Doc. 17) filed January 7, 2019 in support of Plaintiff Fernando Coca's (“Mr. Coca”) Complaint (Doc. 2) seeking review of the decision of Defendant Andrew Saul, Commissioner of the Social Security Administration (“Commissioner”), denying Plaintiff's claims for Title II disability benefits and Title XVI supplemental security income benefits. On March 7, 2019, Plaintiff filed his Motion to Reverse or Remand Administrative Agency Decision and Memorandum Brief in Support. (Docs. 20, 21.) The Commissioner filed a Brief in Response on May 3, 2019 (Doc. 23), and Plaintiff filed a Reply on June 30, 2019. (Doc. 28.) The Court has jurisdiction to review the Commissioner's final decision under 42 U.S.C. §§ 405(g) and 1383(c). Having meticulously reviewed the entire record and being fully advised in the premises, the Court recommends that the Motion to Reverse or Remand be GRANTED.

         I. Background

         Mr. Coca is a forty-two-year-old man who attended special education classes, completed the ninth grade, [2] and never earned his GED. (Administrative Record (“AR”) 035, 263.) He worked full time as a route salesman delivering milk from 1998 until 2004 when he lost his driver's license.[3] (AR 035-36, 040-41, 045, 263.) Thereafter, Mr. Coca worked for his mother's distributing company, then was self-employed as a greeter at a barbershop until he became unable to work in January 2016. (AR 038-40, 250-51, 341.)

         Mr. Coca attributes his inability to work primarily to symptoms related to post-traumatic stress disorder (“PTSD”), a condition he traces to witnessing his father's murder when he was fifteen. (AR 044-45). He also attributes his inability to work to depression, anxiety, bipolar disorder, anger issues, memory and cognitive problems, back pain and spasms, leg pain, chronic pain, and “[i]njuries [s]ustained from [p]rior [motor vehicle accidents].”[4] (AR 262.)

         Following the motor vehicle accident in January 2016 in which he was rear-ended, Mr. Coca began seeing Dr. Rick Cardenas, M.D., at Epoch Integrated Health Services (Epoch). (AR 437.) During his course of treating Mr. Coca, Dr. Cardenas diagnosed Mr. Coca with “severe anxiety” and PTSD and referred him for psychiatric evaluation and treatment. (AR 439.) Mr. Coca began seeing Kevin Heiskala, LCSW[5], at Epoch for psychotherapy related to his PTSD. (AR 438.) In a July 2016 to-whom-it-may-concern letter, LCSW Heiskala indicated that Mr. Coca's symptoms included “intrusive thoughts about the past, anxiety, avoidance[, ] and difficulty being in public places.” (AR 438.) Mr. Coca additionally established as a patient of Sarah Skinner, CNS[6], PMHNP[7] (“CNS Skinner”), at The Community Lighthouse in February 2016. (AR 473-77.) CNS Skinner diagnosed Mr. Coca as having PTSD and bipolar II disorder and began treating him with clonazepam, Lamictal, Zoloft, and trazadone. (AR 471, 476-77.) She continued treating him and titrating his medications over the next several months to address his various symptoms, which included panic attacks, nightmares, insomnia, anger outbursts, mood swings, crying, avoidance, and isolation. (AR 457-508.) She initially opined that his prognosis was “poor” but later indicated improved prognoses of “fair” and even “good” on two occasions. (AR 460, 466, 471, 477, 493, 498, 503, 508.) However, in September 2016, her prognosis returned to “poor” despite Mr. Coca's compliance with his medications and overall responsiveness to treatment. (AR 488.) In her October 2016 treatment notes, the last available in the administrative record, CNS Skinner indicated that Mr. Coca's prognosis was “fair.” (AR 483.) In a November to-whom-it-may-concern letter, Dr. Cardenas opined that Mr. Coca “is unable to work and maintain a normal work[] schedule” and that he “needs psychiatric care.” (AR 440.)

         II. Procedural History and the ALJ's Decision

         Mr. Coca filed applications for supplemental security income (“SSI”) and disability insurance benefits (“DIB”) on May 31, 2016 and October 26, 2016, respectively, alleging disability beginning January 1, 2016.[8] (AR 012.) In December 2016, Mr. Coca was referred to Thomas Dhanens, Ph.D., for a consultative psychological evaluation.[9] (AR 515-18.) Dr. Dhanens administered intelligence, achievement, reading, and spelling tests, assessed Mr. Coca as having a full-scale IQ of 52, and diagnosed him as having a “[m]ild intellectual disability[.]” (AR 516-17.) He additionally documented that Mr. Coca had a 3.7 grade level equivalency in reading and 1.8 grade level in spelling and that his “[p]rocessing was slow.”[10] (AR 516-517.) Regarding vocational implications, Dr. Dhanens stated, “[i]t is not clear if PTSD would affect him in any way . . . in terms of working at this point.” (AR 516.) He went on to state, “The vocational issue would be his intellectual disability, plus any physical problems he may have.” (Id.) Specifically, Dr. Dhanens explained, “The question is whether he could stay focused and work steadily at a competitive pace with a simple repetitive job after he was taught the basic job duties.” (Id.) Dr. Dhanens offered no answer to that question, only the observation that while Mr. Coca reported being “fidgety” and having trouble staying focused, he did not observe any such symptoms during his one-on-one visit with Mr. Coca. (Id.)

         Mr. Coca's applications for SSI and DIB were initially denied on January 18, 2017 and again upon reconsideration on May 9, 2017. (AR 089, 108-09, 135, 159.) Mr. Coca requested a hearing before an administrative law judge (“ALJ”), and ALJ Cole Gerstner held an administrative hearing on February 20, 2018. (AR 031, 176-77.) Mr. Coca and an impartial vocational expert (“VE”), Sandra Trost, testified. (AR 012, 031.)

         In his decision, the ALJ found that Mr. Coca suffers from the following severe impairments: hernias, osteoarthritis, intellectual disability, anxiety disorder, and PTSD. (AR 015.) Because he found that none of those impairments, alone or in combination, were presumptively the disposition of this appeal, the Court does not discuss the evidence of record related to Mr. Coca's physical disabling under any of the Listings (AR 015-18), see 20 C.F.R. pt. 404, subpt. P, app. 1, pt. A, he proceeded to assess Mr. Coca's residual functional capacity (“RFC”). (AR 018-24.) In relevant part, he found that Mr. Coca “is limited to simple, routine tasks and simple work-related decisions. He can interact with supervisors, coworkers, and members of the public frequently.” (AR 018-19.)

         In discussing the evidence supporting this RFC, the ALJ accorded “great weight” to the opinions of state agency psychological consultants Richard Sorenson, Ph.D., who opined that Mr. Coca “could understand, remember, and carry out simple instructions, make simple decisions, attend and concentrate for two hours at a time, interact adequately with others at work, and respond to routine work changes[, ]” and Howard Atkins, Ph.D., who opined that Mr. Coca “was capable of unskilled work.” (AR 022.) After recognizing Dr. Cardenas as Mr. Coca's “treating physician[, ]” the ALJ accorded “little weight” to his opinions that Mr. Coca could not work or maintain a normal work schedule. (AR 023.) The reasons he gave for assigning this weight to Dr. Cardenas's opinions were:

First, the opinion is merely a one[-]sentence conclusory statement that does not offer any medical evidence or objective testing as support for the conclusion. Second, the doctor does not assert any specific functional limitations, making it even less probative. Finally, Dr. Cardenas' assessment that [Mr. Coca] cannot work is an issue reserved to the Commissioner and is, thus, not given any special significance under CFR 404.1527(d)(3) and 416.927(d)(3).

(AR 023.) The ALJ also gave “little weight” to the opinions of Dr. Dhanens because despite Dr. Dhanens' expressed belief that Mr. Coca “might have trouble staying focused and working steadily at a competitive pace[, ]” Dr. Dhanens “did not report on any specific functional limitations[.]” (AR 023.) The ALJ's decision refers to neither LCSW Heiskala nor CNS Skinner, though the ALJ included selected pieces of evidence from CNS Skinner's medical records in his summary of the evidence supporting the assessed RFC. (AR 020-21.)

         Although the ALJ found that Mr. Coca could not perform past relevant work given the RFC he assessed (AR 024-25), he found that Mr. Coca would be able to perform other jobs that exist in significant numbers in the national economy. (AR 025-26.) He therefore found that Mr. Coca was “not disabled.” (AR 026.) Mr. Coca sought review by the Appeals Council, which denied Mr. Coca's request. (AR 001-5, 238-39.) Mr. Coca then appealed to this Court. (Doc. 2.)

         III. Applicable Law

         A. Standard of Review

         Judicial review of the Commissioner's denial of disability benefits is limited to whether the final decision is supported by substantial evidence and whether the Commissioner applied the correct legal standards to evaluate the evidence. 42 U.S.C. § 405(g); Hamlin v. Barnhart, 365 F.3d 1208, 1214 (10th Cir. 2004). In making these determinations, the Court must meticulously examine the entire record but may neither reweigh the evidence nor substitute its judgment for that of the Commissioner. Flaherty v. Astrue, 515 F.3d 1067, 1070 (10th Cir. 2007). In other words, the Court does not reexamine the issues de novo. Sisco v. U.S. Dep't of Health & Human Servs., 10 F.3d 739, 741 (10th Cir. 1993). The Court will not disturb the Commissioner's final decision if it correctly applies legal standards and is based on substantial evidence in the record.

         “Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Langley v. Barnhart, 373 F.3d 1116, 1118 (10th Cir. 2004) (internal quotation marks omitted). Substantial evidence is “more than a scintilla, but less than a preponderance.” Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007). A decision “is not based on substantial evidence if it is overwhelmed by other evidence in the record[, ]” Langley, 373 F.3d at 1118 (internal quotation marks omitted), or “constitutes mere conclusion.” Musgrave v. Sullivan, 966 F.2d 1371, 1374 (10th Cir. 1992). The Court's examination of the record as a whole must include “anything that may undercut or detract from the ALJ's findings in order to determine if the substantiality test has been met.” Grogan v. Barnhart, 399 F.3d 1257, 1262 (10th Cir. 2005).

         B. Disability Benefits and the Sequential Evaluation Process

         Disability under the Social Security Act is defined as the “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). A claimant is disabled under the Act if his “physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work in the national economy[.]” 42 U.S.C. § 423(d)(2)(A). “To qualify for disability benefits, a claimant must establish a severe physical or mental impairment expected to result in death or to last for a continuous period of twelve months which prevents the claimant from engaging in substantial gainful activity.” Thompson v. Sullivan, 987 F.2d 1482, 1486 (10th Cir. 1993).

         When considering a disability application, the Commissioner uses a five-step sequential evaluation process. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); Bowen v. Yuckert, 482 U.S. 137, 140 (1987). At the first four steps of the evaluation process, the claimant must show that: (1) he is not engaged in “substantial gainful activity”; and (2) he has a “severe medically determinable . . . impairment . . . or a combination of impairments” that has lasted or is expected to last for at least one year; and (3) his impairment(s) meet or equal one of the Listings[11] of presumptively disabling impairments; or (4) he is unable to perform his “past relevant work.” 20 C.F.R. §§ 404.1520(a)(4)(i-iv), 416.920(a)(4)(i-iv). If the claimant can show that his impairment meets or equals a Listing at step three, the claimant is presumed disabled and the analysis stops. 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii). If at step three the claimant's impairment is not equivalent to a listed impairment, the ALJ must next consider all of the relevant medical and other evidence and determine what is the “most [the claimant] can still do” in a work setting despite his physical and mental limitations. 20 C.F.R. §§ 404.1545(a)(1)-(3), 416.945(a)(1)-(3). This is called the claimant's residual functional capacity. 20 C.F.R. §§ 404.1545(a)(1) & (a)(3), 416.945(a)(1) & (a)(3). The claimant's RFC is used at step four of the process to determine if he can perform the physical and mental demands of his past relevant work. 20 C.F.R. §§ 404.1520(a)(4)(iv), 404.1520(e), 416.920(a)(4)(iv), 416.920(e). If the claimant establishes that he is incapable of meeting those demands, the burden of proof then shifts to the Commissioner at step five to show that the claimant is able to perform other work in the national economy, considering his RFC, age, education, and work experience. 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v); Grogan, 399 F.3d at 1261.

         C. Consideration and Evaluation of Evidence

         The ALJ must consider “all relevant evidence in the case record” in making a disability determination. SSR 06-03P, 2006 WL 2329939, at *4 (Aug. 9, 2006).[12] Although an ALJ is not required to discuss every piece of evidence, “[t]he record must demonstrate that the ALJ considered all of the evidence[.]” Clifton v. Chater, 79 F.3d 1007, 1009-10 (10th Cir. 1996). The ALJ must discuss not only the evidence supporting his decision but also “the uncontroverted evidence he chooses not to rely upon, as well as significantly probative evidence he rejects.” Id. at 1010. The ALJ's decision must demonstrate application of the correct legal standards applicable to different types of evidence, and failure to follow the ...

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