Acosta Cuevas v. Comm'r of Soc. Sec.
| Docket Number | 20-CV-0502 (AJN) (KHP) |
| Decision Date | 29 January 2021 |
| Parties | HILDA MARGARITA ACOSTA CUEVAS, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant. |
| Court | U.S. District Court — Southern District of New York |
REPORT & RECOMMENDATION
Plaintiff Hilda Margarita Acosta Cuevas (“Plaintiff”), who is represented by counsel, commenced this action against Defendant Commissioner of the Social Security Administration (the “Commissioner”), pursuant to the Social Security Act (the “Act”), 42 U.S.C. 405(g). Plaintiff seeks review of the Commissioner's decision that Plaintiff was not disabled under section 1614(a)(3)(A) of the Act from October 30, 2018, the date her application for Social Security Disability benefits (“SSD”) and Supplemental Security Income benefits (“SSI”) was filed, through the date of the decision.
The parties submitted a Joint Stipulation (“J.S.”) in lieu of cross-motions for judgment on the pleadings (ECF No. 23), pursuant to this Court's Order at ECF No. 9. For the reasons set forth below, this Court respectfully recommends that the Commissioner's motion be DENIED and that Plaintiff's motion be GRANTED.
Plaintiff Ms. Acosta Cuevas, was born in 1982 and was 34 years old on January 1, 2017, the onset date of her alleged disability. (R. 51-52.) Ms. Acosta Cuevas is married and has two children. (R. 637.) She also has a high school education and attended some college in the Dominican Republic, but did not obtain a degree. (R. 44). Ms. Acosta Cuevas's past relevant work was as a home health aide and a shipping order clerk. (R. 54-55.)
On October 30, 2018, Plaintiff protectively filed an application for SSD and SSI alleging disability due to mental health and physical impairments, principally depression (or mood and bipolar disorders), [1] Sjogren's syndrome, [2] and fibromyalgia, [3] beginning January 1, 2017.
(Administrative Record (“R.”) 62-63, 288-305, ECF No. 15.) The Commissioner initially denied Plaintiff's application on January 11, 2019 (R. 106-115) and, upon reconsideration, again on March 25, 2019. (R.131-42.) Plaintiff then filed a request for a hearing before an Administrative Law Judge (“ALJ”) on April 2, 2019, which was granted. (R. 147-48.) Plaintiff appeared and testified at a hearing held before ALJ Andrea Addison on August 7, 2019. (R. 3961.) Plaintiff had counsel at the hearing. The ALJ denied Plaintiff's application by written decision dated September 6, 2019. (R. 9-32.) Then, on December 17, 2019, the Appeals Council denied Plaintiff's request for review of the ALJ's decision, constituting the Commissioner's final act. (R. 1-8.)
The Administrative Record reflects that Plaintiff had three main medical sources, consisting of a primary physician, a rheumatologist, and a mental health clinic, N.Y. Psychotherapy and Counseling Center (“NYPCC”). Plaintiff also went to two health clinics, BronxCare Health System (“BronxCare) and MLK Health Center (“MLK Center”) for medical treatment. The record also reveals there were four consulting examiners (“CEs”) in this case, two for Plaintiff's mental health record, and two for her physical health record. These treating and consulting medical sources are summarized below, as reflected in the Administrative Record.
Chaula Patel, M.D., a board-certified internist, was Plaintiff's primary physician in the Administrative Record. Plaintiff saw Dr. Patel for both mental and physical health reasons. Plaintiff's first visit with Dr. Patel was October 5, 2018 and her last visit was July 22, 2019.
In the visit record from October 5, 2018, Dr. Patel indicated that Plaintiff's reasons for her initial appointment were due to her history of depression and recent hospitalization due to gastrointestinal issues. (R. 774.) Regarding Plaintiff's mental health, Dr. Patel asked Plaintiff questions from a questionnaire to which Plaintiff responded she had general feelings of depression and some suicidal thoughts. (Id.) Dr. Patel concluded Plaintiff had moderate depression and noted a suicide assessment risk should be considered. (Id.) Regarding Plaintiff's physical health, Plaintiff described symptoms of chronic muscle and joint pain, as well as a history of Sjogren's syndrome and related care with a rheumatologist, Dr. Arlene Tieng (discussed below). (Id.) Dr. Patel assessed the following relevant conditions for Plaintiff: sicca syndrome (i.e. Sjogren's syndrome) with organ involvement, depressive episodes, and history of musculoskeletal and connective tissue issues. (R. 775.) Regarding Plaintiff's Sjogren's syndrome, Dr. Patel advised her to continue taking the two medications she had already been prescribed. (R. 777.) Regarding Plaintiff's depression, Dr. Patel referred her to a psychiatrist and psychologist, which led to Plaintiff going to NYPCC, as discussed below.
Plaintiff saw Dr. Patel at least seven more times throughout the record. (R. 750-79.) At those visits, Dr. Patel would conduct a review of plaintiff's systems, soliciting Plaintiff's complaints as to, among other things, her myalgia, neurology, and psychology. For the most part, Plaintiff would report feeling depressed and anxious, mostly without suicidal ideation, sometimes appearing fatigued and depressed to Dr. Patel, and other times appearing alert and well oriented. However, there are some records with Dr. Patel indicating that Plaintiff did have suicidal ideations and was doing worse at times, mentally and physically, then others. (See e.g., R. 775, 765.) At various times throughout her time with Plaintiff, Dr. Patel diagnosed Plaintiff with Bipolar disorder, Sjogren's, and major depressive disorder, recurrent, severe with psychotic symptoms. (See 750-79.)
Plaintiff saw rheumatologist Arlene Tieng, MD as her primary medical source for her Sjogren's syndrome and fibromyalgia beginning on or around October 26, 2018, but may have seen her for issues related to her Sjogren's syndrome as far back as November 2014.[4] (R. 556- 57.) Plaintiff saw Dr. Tieng on at least four subsequent visits, with the last visit in the record occurring on April 25, 2019. (R. 583-54, 576-77, 581-82, 738-39.)
During her visits with Dr. Tieng, Plaintiff would report on her physical symptoms from Sjogren's syndrome and fibromyalgia. These complaints often included symptoms of muscle and joint pain, fatigue, dry mouth, dry eyes, and dry skin. (Id.) Dr. Tieng regularly noted Plaintiff was positive for an antibody evidencing the presence of Sjogren's syndrome. (See e.g., R. 583.) Dr. Tieng also conducted physical examinations of Plaintiff during these meetings. With the exception of the last-in-time record, dated July 22, 2019, Dr. Tieng noted positive fibromyalgia tender points in Plaintiff's knees, but none in her shoulders, elbows, or wrists. Nonetheless, Dr. Tieng maintained a diagnosis of fibromyalgia throughout the entirety of the available medical records.
Additionally, Dr. Tieng began prescribing Plaintiff a nerve-pain medication called Gabapentin starting with Plaintiff's October 26, 208 visit. (R. 557.) At subsequent visits, Dr. Tieng increased the Gabapentin dosage, starting with 300mg on December 14, 2018 (R. 583- 84), and ending with a 600mg prescription which Dr. Tieng refilled for Plaintiff at least once. (R. 582, 577, 738.)
N.Y. Psychotherapy and Counseling Center (Rafaelina Hildago, MSW, Dr. Anthony Sanchez, Dr. James Herivaux)
Following Dr. Patel's referral on October 5, 2018, Plaintiff began going to NYPCC for mental health treatment. At NYPCC, Plaintiff received a range of treatment, including, in chronological order, a screening interview, a psychiatric evaluation, regular individual psychotherapy counseling sessions, and psychotropic medication.
During Plaintiff's first month going to NYPCC, on October 12 and 23, 2018, Plaintiff received psychiatric exams, first from MSW Roberta Fernandez (R. 517) and then from Dr. Anthony Sanchez. (R. 541.) At the October 12 visit, MSW Roberta Fernandez MSW filled out a long checklist questionnaire, including a section entitled “Level of Interference with Functioning.” (R. 512.) MSW Fernandez diagnosed her with major depressive disorder, recurrent, with psychological features. (R. 517.) Shortly thereafter, on October 23, Dr. Sanchez conducted a psychiatric functional evaluation of Plaintiff which revealed fair memory, a mildly anxious and depressed mood, a mildly constricted affect, mildly to moderately impaired insight, fair to mildly impaired judgment, fair to mildly impaired impulse control, and average attention span. (R. 542.) Dr. Sanchez listed Plaintiff's primary diagnosis as unspecified mood/bipolar disorder, with other diagnoses of major depressive disorder, recurrent, with psychological features, unspecified bipolar disorder, and unspecified anxiety disorder and prescribed Plaintiff two psychotropic medications to be taken as necessary.
From October 15, 2018 through at least May 10, 2019, Plaintiff had individual therapy sessions with MSW Rafaelina Hildago at NYPCC. The records from these meetings are fairly consistent, indicating that Plaintiff often appeared depressed and fatigued, usually did not have aggressive or suicidal ideations, complained of the difficulties in dealing with her parents, husband, and children in light of her mental impairments, and had trouble sleeping and being fatigued. However, there were occasional visits in which Plaintiff did state she had aggressive or suicidal thoughts and otherwise appeared in a more depressive state.
Finally Plaintiff saw Dr. James Herivaux on at least two...
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