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Mateo v. Colvin

United States District Court, M.D. Pennsylvania

March 28, 2018

JULIA MATEO, Plaintiff,
v.
CAROLYN COLVIN, Acting Commissioner of Social Security, Defendant.

          Mannion Judge.

          REPORT AND RECOMMENDATION

          Martin C. Carlson United States Magistrate Judge.

         I. Introduction

         This case involves a disability claim by Julia Mateo, a younger worker in her late-30s, who claimed that she was totally disabled due to bipolar disorder, depression and anxiety. With respect to this disability claim, the Administrative Law Judge, (“ALJ”), was presented with three primary medical opinions: a treating source opinion, a consultative examining source opinion, and the opinion of a non-examining state agency expert. These three medical sources reached differing conclusions regarding Mateo's residual functional capacity (“RFC”) to work, but some of this medical opinion evidence supported the conclusion that Mateo could still work despite her disabilities. After evaluating all of the medical evidence, including the medical opinion evidence which found that Mateo retained the ability to work, and concluding that Mateo's claims of total disability were not fully credible, the Social Security Administrative Law Judge (“ALJ”) who heard Mateo's disability claim denied that claim. (Tr. 10-24.)

         We recognize that Mateo doubtless faces significant and on-going mental health challenges. However, in evaluating her case on appeal we are constrained by the deferential standard of review that applies to all Social Security Appeals, which calls upon us simply to determine whether substantial evidence supports the ALJ's findings. Under this very deferential standard of review, we conclude that substantial evidence exists in this case which justified the ALJ's decisions that led to the denial of this particular claim. Therefore, for the reasons set forth below, we recommend that the district court affirm the decision of the Commissioner in this case.

         II. Statement of Facts and of the Case

         On March 30, 2012, Julia Mateo applied for Social Security Disability Insurance benefits and Supplemental Security Income, alleging an onset of disability beginning on April 30, 2011. (Tr. 155-65.) Mateo's presenting medical impairments were emotional and psychological, consisting of a bipolar disorder, anxiety disorder and major depressive disorder. (Tr. 16.)

         With respect to these mental health conditions, Mateo had a longstanding medical history which predated her disability application. Thus, Mateo began treating for these conditions in 2006, five years before the alleged onset of her disability in 2011. Between 2006 and 2008 she received mental health treatment and was evaluated as having a global assessment of function, or GAF score, which ranged between 58 and 60, and were consistent with only a moderate degree of emotional impairment. (Tr. 279-91.)[1] In 2009 Mateo was seen by a different mental health caregiver, who evaluated her as experiencing somewhat more severe emotional impairments, and assigned her GAF scores which ranged between 40 and 48. (Tr. 300-308.)

         Mateo's mental health treatment history during the relevant time period embraced by this disability claim continued to document significant on-going emotional impairments, but also indicated that, with the exception of occasional sever episodes, Mateo was only moderately impaired due to these mental health conditions. During the period following the alleged onset of Mateo's disability in 2001, Mateo was twice hospitalized briefly in 2012 due to her mental health impairments. The first hospitalization took place in January of 2012, when Mateo was experiencing hallucinations. (Tr. 310-15.) Mateo's GAF score at the time of her admissions was rated between 25 and 30, GAF scores which signified severe impairment. (Tr. 310, 315.) However, three days later, at the time of her discharge, Mateo was assessed with a GAF score of 65, which indicated only a mild degree of impairment on her part. (Tr. 311.)

         Through the Spring of 2012, Mateo was seen and treated by mental health professionals at The Metropolitan Center for Mental Health (“MCMH”) in New York City. (Tr. 333-43.) During this time frame her treating physicians consistently evaluated Mateo's GAF score at 55, indicating that she was experiencing a moderate degree of impairment. (Id.)

         On July 17, 2012, Mateo underwent a consultative examination by Sally Morcos, Psy.D., as part of this disability claim process. (Tr. 344-49.) Following this examination, Dr. Morcos issued a report which found that Mateo denied any current hallucinations, while acknowledging “loud thoughts.” (Tr. 346.) Upon examination, Dr. Morcos concluded that Mateo displayed an appropriate appearance and affect; adequate speech and coherent goal directed thought; fair insight and judgment; a neutral mood; intact attention and concentration; average cognitive functioning; and a mildly impaired memory. (Tr. 347.) Dr. Morcos also found that Mateo could understand simple directions and instructions; perform simple tasks independently and complex tasks with supervision; maintain attention and concentration; maintain a regular schedule and learn new tasks; make appropriate decisions and relate adequately with others. (Tr. 348.) While these findings were all consistent with a determination that Mateo retained the ability to work, Dr. Morcos' July 2012 opinion qualified this judgment in one significant way. Dr. Morcos observed that Mateo could not appropriately deal with stress and “in itself this may significantly enough [sic] to interfere with the claimant's ability to function on a daily basis.” (Tr. 348-9.)

         Following this consultative examination, on August 13, 2012, a state agency expert, Dr. Harding, reviewed Mateo's medical records and concluded that she had mild restrictions on her activities of daily living and moderate difficulties in social functioning and maintaining concentration, persistence and pace. (Tr. 360.) While Dr. Harding acknowledged this degree of impairment for Mateo, the doctor ultimately concluded that Mateo retained the RFC to perform unskilled work on a sustained basis. (Tr. 366.)

         Shortly after Dr. Harding completed this assessment, Mateo was briefly hospitalized for a second time on August 23, 2012, complaining of emotional distress, fear, flight of ideas, and hallucinations. (Tr. 235.) Following this hospitalization, Mateo continued to be seen and treated by health care professionals at MCMH. (Tr. 254, 402, 409.)

         Medical records relating to this on-going mental health treatment provided to Mateo in 2013 are mixed and equivocal. For example, on April 4, 2013, Mateo's treating physician, Dr. David Cohen, opined that Mateo was “not ready for employment” due to her mental health conditions. (Tr. 254.) However, May 2013 treatment notes indicated that Mateo “has made significant progress, ” and assessed her GAF score at 55, a score which was merely consistent with a moderate level of impairment. (Tr. 398-9.) A contemporaneous impairment questionnaire competed by Dr. Cohen, (Tr. 402-7), assessed Mateo's GAF score at 50-55, a score which signified moderate emotional impairment, but the doctor concluded that Mateo was not capable of working, even in a low stress environment, an opinion which appeared more restrictive than the doctor's GAF score clinical assessment of moderate impairment. (Id.) Finally, despite Dr. Cohen's 2013 opinions regarding Mateo's disability, treating sources continued to indicate that she was only moderately impaired in their treatment records. For example, treatment records documenting Mateo's mental health care in 2014 continued to consistently evaluate her GAF score at 55, an assessment which reflected a clinical judgment that Mateo faced only moderate impairment. (Tr. 413-14.)

         It was against this equivocal medical and factual backdrop that the ALJ conducted the most recent hearing[2] considering Mateo's disability application on January 14, 2015. (Tr. 31-49.) Following this hearing, on January 22, 2015, the ALJ issued a decision denying Mateo's application for disability benefits. (Tr. 10- 24.) In this decision, the ALJ first found that Mateo met the insured requirements of the Act through June 30, 2016, (Tr. 15), and then at Step 2 of the five-step sequential analysis process that applies to Social Security disability claims concluded that Mateo experienced the following severe impairments: bipolar disorder, major depressive disorder, anxiety and generalized anxiety disorder. (Tr. 16.) At Step 3 of this sequential analysis, the ALJ concluded that none of Mateo's impairments met a listing that would define her as per se disabled. (Tr. 16-19.)

         The ALJ then concluded that Mateo retained the RFC to perform a full range of work at all exertional levels but needed to work in an environment with the following non-exertional limitations: simple routine tasks, with no complex tasks and a low stress environment marked by only occasional decision-making, occasional changes in the work setting, and occasional interaction with others. (Tr. 19.) In reaching this conclusion, the ALJ considered Mateo's lengthy treatment history, as well as the expert opinions of Dr. Harding, the state agency expert, Dr. Morcos, the consulting examining expert, and Dr. Cohen, Mateo's treating physician. (Tr. 19-23.)

         While the ALJ acknowledged Mateo's two brief mental health hospitalizations, the ALJ also observed that multiple care givers over the span of many years had assigned global assessment of functioning scores of 50 or greater to Mateo, scores which were indicative of only a moderate degree of impairment. (Id.) The ALJ also weighed and assessed the three competing medical opinions in this case. On this score, the ALJ found that the opinion of Dr. Harding, the state agency expert, was entitled to great weight since that opinion, which found that Mateo could perform sustained work, was consistent with the greater body of clinical evidence and findings, which consistently rated Mateo as only moderately impaired by her emotional disabilities. (Tr. 21-2.)

         The ALJ also assigned limited weight to the consultative examining opinion of Dr. Morcos. In this regard, the ALJ noted that Dr. Morcos concluded that Mateo could understand simple directions and instructions; perform simple tasks independently and complex tasks with supervision; maintain attention and concentration; maintain a regular schedule and learn new tasks; make appropriate decisions and relate adequately with others. (Tr. 22.) The ALJ observed that Dr. Morcos had also determined that Mateo could not deal with stress, but found that this stress-related limitation was not wholly disabling and could be accommodated through simple, routine, low stress work. (Id.)

         The ALJ then assigned little weight to the opinions of Dr. Cohen, Mateo's treating source. In reaching this judgment the ALJ found that Dr. Cohen's opinions were “internally inconsistent and inconsistent with the longitudinal record, including claimant's relatively benign mental examinations, level of treatment, moderate GAF scores, and actual level of mental functioning.” (Tr. 22.)

         Finally, in making this RFC assessment, the ALJ also evaluated the credibility of Mateo's claims of disability. In this regard, the ALJ found that Mateo's impairments could be expected to cause the symptoms and challenges she described, but concluded that Mateo's statements regarding the severity of these symptoms and limitations was not fully credible. (Tr. 20.) As the ALJ explained in making this credibility determination, while Mateo was twice hospitalized in 2012, the clinical records generally indicated that her conditions were controlled through medication and therapy. (Doc. 21.) In addition, the ALJ concluded that Mateo's mental examinations and GAF scores documented only a moderate level of impairment, and not the degree of total disability described by the plaintiff. (Id.) Moreover, the ALJ found that Mateo's activities of daily living, which included household chores, travel, reading, watching television, caring for plants, and managing her personal finances, were not congruent with totally disabling impairments. (Tr. 21.)

         Having made these findings regarding Mateo's residual functional capacity to work, and having concluded that Mateo could perform simple routine tasks, with no complex tasks and a low stress environment marked by only occasional decision-making, changes in the work setting, and interaction with others, (Tr. 19), the ALJ determined at Step 4 of this sequential analysis that Mateo was able to perform her past relevant work as a warehouse worker. (Tr. 23.) Accordingly, the ALJ concluded that Mateo was not disabled and denied her claim for disability benefits. (Tr.23-4.)

         This appeal followed. (Doc. 1.) On appeal, Mateo advances a threefold argument. First, Mateo contends that the ALJ's residual functional capacity analysis is flawed. Mateo's second argument is closely related to her first claim and rests upon an assertion that this flawed RFC analysis stems out of an error in assessing the medical opinion evidence, and particularly an error in assigning little weight to the treating source opinion of Dr. Cohen. Finally, Mateo argues that the ALJ erred in not further crediting her subjective claims that her mental health conditions were totally disabling.

         This case is fully briefed and is, therefore, ripe for resolution. For the reasons set forth below, we conclude, under the deferential standard of review which applies to Social Security appeals that substantial evidence supports the findings of the ALJ. Therefore, we recommend that the district court affirm those findings.

         III. ...


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