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Ko v. Colvin

United States District Court, D. Arizona

May 31, 2016

Masako Ko, Plaintiff,
v.
Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant.

          ORDER

          Bridget S. Bade United States Magistrate Judge.

         Masako Ko (Plaintiff) seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner) denying her application for benefits under the Social Security Act (the Act). The parties have consented to proceed before a United States Magistrate Judge pursuant to 28 U.S.C. § 636(b), and have filed briefs in accordance with Rule 16.1 of the Local Rules of Civil Procedure. For the following reasons, the Court reverses the Commissioner’s decision and remands for a determination of benefits.

         I. Procedural Background

         On February 15, 2012, Plaintiff filed an application for a period of disability and disability insurance benefits under Title II of the Act. (Tr. 12.)[1] Plaintiff alleged that she had been disabled since July 1, 2011. (Id.) After the Social Security Administration (SSA) denied Plaintiff’s initial application and her request for reconsideration, she requested a hearing before an administrative law judge (ALJ). (Tr. 71-72.) After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 12-21.) This decision became the final decision of the Commissioner when the Social Security Administration Appeals Council denied Plaintiff’s request for review. (Tr. 1-6; see 20 C.F.R. § 404.981 (explaining the effect of a disposition by the Appeals Council).) Plaintiff now seeks judicial review of this decision pursuant to 42 U.S.C. § 405(g).

         II. Administrative Record

         The record before the Court establishes the following history of diagnosis and treatment related to Plaintiff’s alleged impairments. The record also includes opinions from state agency physicians who reviewed the records related to Plaintiff’s impairments, but who did not examine Plaintiff or provide treatment.

         A. Medical Treatment Evidence

         In June 2011, Plaintiff began treatment with Vasilios Kaperonis, M.D., at Mediterranean Mental Health Center, P.C. (Mediterranean). (Tr. 347-49.) During her first appointment with Dr. Kaperonis, Plaintiff reported having problems with a supervisor at work. (Tr. 347.) Plaintiff complained of anxiety attacks that lasted up to twenty minutes at a time. (Id.) On a mental status examination, Dr. Kaperonis noted that Plaintiff was well dressed, well groomed, and oriented. (Tr. 348.) Her mood was sad and anxious, and she had a tearful affect. (Id.) Plaintiff had no hallucinations, delusions, or suicidal ideations. (Id.) Dr. Kaperonis diagnosed anxiety disorder not otherwise specified, and prescribed Xanax. (Id.) Dr. Kaperonis also recommended that Plaintiff take an antidepressant, but she “was somewhat hesitant to do that at [that] time.” (Id.)

         During a July 8, 2011 appointment, Plaintiff reported that the day before her supervisor was scheduled to return to work she developed cold sores and decided “to take vacation time off and be away for a month . . . .” (Tr. 346.) Plaintiff reported that she had “a hard time motivating herself, a hard time concentrating, [was] easily derailed and distracted, [and did] not complete tasks . . . .” (Id.) Dr. Kaperonis observed that Plaintiff was adequately groomed, alert, and oriented. (Id.) She had no delusions, hallucinations, or suicidal ideations. (Id.) Dr. Kaperonis continued Plaintiff’s prescription for Xanax and also prescribed Viibryd. (Id.) Dr. Kaperonis later adjusted Plaintiff’s medications because she reported experiencing headaches after she started taking Viibryd, (Tr. 345.)

         During an August 21, 2011 appointment, Plaintiff reported that she was reluctant to return to work. (Tr. 344.) She reported that she was sleeping better. (Id.) On a mental status examination, Plaintiff was well dressed, well groomed, cooperative, and alert. (Id.) She had an anxious mood and a constricted affect. (Id.) She had no delusions, hallucinations, or suicidal ideations. (Id.) During an August 29, 2011 appointment, Plaintiff reported anxiety and depression and stated that she “dread[ed] the idea of being back at work with a supervisor that she [could not] possibly work with.” (Tr. 343.) Plaintiff reported disturbed sleep with nightmares and “occasional anxiety attacks.” (Id.) Plaintiff stated that she had a hard time motivating herself and staying on task. (Id.) On examination, Plaintiff was adequately groomed, alert, and oriented. (Id.) She had no delusions, hallucinations, or suicidal ideations. (Id.) Dr. Kaperonis continued Plaintiff’s medications and stated that she would “not be able to return to work at least for two years.” (Id.) Treatments notes from an October 3, 2011 appointment include the same complaints and observations. (Tr. 342.)

         During a November 4, 2011 appointment, Plaintiff reported that “Xanax has helped her anxiety.” (Tr. 341.) On examination, Plaintiff was well dressed, well groomed, alert, and oriented. (Id.) She had no delusions or hallucinations. (Id.) Plaintiff “denied suicidal intentions despite occasional suicidal thoughts.” (Id.) During a December 5, 2011 appointment, Plaintiff reported a “lessening of her anxiety with the adjustment of her medications.” (Id.) Plaintiff reported that she “was trying to keep herself occupied and [was] spending more time with other people but still tend[ed] to isolate significantly.” (Tr. 340.) Plaintiff “talked about playing the piano and hiking.” (Id.) On examination, Plaintiff was well dressed, well groomed, alert, and oriented. (Id.) She had no delusions, hallucinations, or suicidal ideations. (Id.)

         During a January 27, 2012 appointment, Plaintiff reported being more active during the day, talking with friends, and feeling calmer. (Tr. 339.) Dr. Kaperonis noted that Plaintiff “still isn’t sleeping well, having nightmares and awakening with anxiety attacks.” (Id.) Plaintiff was tearful on examinaton. (Id.) She admitted having suicidal thoughts without a specific plan. (Id.) Dr. Kaperonis prescribed Remeron in addition to Xanax and Lexapro. (Id.) During a March 27, 2012 appointment, Plaintiff reported that she was calmer on Lexapro, but that she was more motivated when she took Wellbutrin. (Tr. 337.) Plaintiff reported that she was hiking “on occasions up to 4 miles a day and this seems to help.” (Id.) She reported that she was still having problems with her appetite, anxiety, depression, and “her interests.” (Id.) On examination, Plaintiff was well dressed, well groomed, alert, and oriented. (Id.) Her mood was anxious and she had a tense affect. She avoided eye contact. (Id.) She had no delusions, hallucinations, or suicidal ideations. (Id.) Dr. Kaperonis continued Lexapro and Xanax, and added Wellbutrin XL. (Id.)

         In April 2012, Plaintiff reported feeling “more stable.” (Tr. 336.) She was hiking once a week and was considering volunteering at a senior center. (Id.) Plaintiff reported that she checked on an elderly neighbor twice a day. (Id.) Plaintiff also reported that she continued to have nightmares and occasionally awoke with panic attacks. (Id.) On examination, Plaintiff was well dressed, well groomed, alert, and oriented. (Id.) Her mood was anxious, she had a tense affect, and she continued to avoid eye contact. (Id.) She had no delusions, hallucinations, or suicidal ideations. (Id.) Dr. Kaperonis continued Plaintiff’s medications. (Id.)

         In July 2012, Plaintiff reported visiting a friend in South Dakota and stated that she “seemed to relax while she was there.” (Tr. 335.) However, she ran out of Lexapro and Wellbutrin for two and a half weeks, during which time she felt more depressed and anxious. (Id.) Dr. Kaperonis renewed Plaintiff’s prescriptions for those medications. (Id.) Plaintiff reported that she still tried to take care of her elderly neighbor. (Id.) On mental status examination, Plaintiff was well dressed, well groomed, alert, and oriented. (Id.) Her “mood was sad and anxious and her affect was tense.” (Id.) She had no delusions, hallucinations, or suicidal ideation. (Id.) During an August 14, 2012 appointment Plaintiff’s mental status examination was the same. (Tr. 334.) She reported that she was trying to stay active, but it was difficult. (Id.) She reported having difficulty with decision-making and memory. (Id.) Plaintiff also reported depression, lack of confidence, anxiety, and panic attacks. (Id.) Dr. Kaperonis continued Plaintiff’s medications. (Id.) In September 2012, Plaintiff reported that she was “trying to be more active but still experience[d] anxiety and ha[d] difficulty making decisions and ha[d] memory problems.” (Tr. 333.) On mental status examination, Plaintiff was well dressed, well groomed, alert, and oriented. (Id.) Her mood was “somewhat anxious and sad and her affect was tense.” (Id.) She avoided eye contact. (Id.) She had no delusions, hallucinations, or suicidal ideations. (Id.) Dr. Kaperonis continued Plaintiff’s medications.

         During a November 1, 2012 appointment, Plaintiff reported that she continued to experience anxiety and depression and was not sleeping well. (Tr. 332.) She reported that she was not very active and had been socially withdrawn. (Id.) On examination, Plaintiff was well dressed, well groomed, alert, and oriented. (Id.) Her “cognitive functioning [was] grossly intact.” (Id.) Plaintiff’s “recent and remote and immediate” memory were “overall good.” (Id.) She had a sad and anxious mood and her affect was “broad in range.” (Id.) “There [was] no loosening of associations[, ] no pressure of speech[, ] and no flight of ideas.” (Id.) There was no thought blocking. (Id.) Plaintiff had no delusions, hallucination, referential thoughts, or suicidal thoughts. (Id.) Plaintiff had good insight and judgment, and her “reality testing” was intact. (Id.) Dr. Kaperonis continued Plaintiff’s medications. (Id.) A November 7, 2012 treatment note includes similar findings on mental status examination. (Tr. 331.)

         During a January 16, 2013 appointment, Plaintiff continued to report anxiety, “symptoms of panic and problems with sleep.” (Tr. 380.) On mental status examination, Dr. Kaperonis made findings similar to those he made on November 1, 2012. (Compare Tr. 380 with Tr. 332.) Dr. Kaperonis continued Plaintiff’s medications. (Tr. 380.) During a February 26, 2013 appointment, Plaintiff reported feeling tired, unmotivated, and depressed. (Tr. 377.) She was worried about her memory and thought it was getting worse. (Id.) On examination, Dr. Kaperonis made findings similar to those he made on November 1, 2012 and January 16, 2013. (Compare Tr. 377 with Tr. 380 and Tr. 332.) Dr. Kaperonis continued Plaintiff’s medications with some adjustments. (Tr. 377.)

         During a March 26, 2013 appointment, Plaintiff reported some increased energy and activity on a new dosage of Wellbutrin. (Tr. 376.) She reported experiencing anxiety attacks “almost weekly.” (Id.) Dr. Kaperonis’s examination findings were similar to those he made in November 2012 and in January and February 2013. (See Tr. 376, 332, 380, 377.) Dr. Kaperonis continued Plaintiff’s medications. (Tr. 376.) An April 25, 2013 treatment note includes reports and findings similar to the March 26, 2013 treatment note. (Compare Tr. 375 with Tr. 376.)

         B. Medical Opinion Evidence

         1. Winston Brown, M.D.

         On June 1, 2012, Dr. Brown reviewed the record and completed a Mental Residual Functional Capacity (RFC) Assessment as part of the initial determination on Plaintiff’s application for benefits. (Tr. 283-86.) Dr. Brown opined that Plaintiff was moderately limited in the following areas: her ability to accept instructions and respond appropriately to criticism from supervisors; her ability to get along with co-workers or peers without distracting them or exhibiting extreme behavior; her ability to respond appropriately to changes in the work setting; and her ability to set realistic goals or make plans independently of others. (Tr. 285.) Dr. Brown found that the medical record and Plaintiff’s activities of daily living (ADLs) “show[ed] some motivational deficit. Moderate ADLs/Sx’s [symptoms] are credible.” (Tr. 286.)

         On June 1, 2012, Dr. Brown also completed a Psychiatric Review Technique form. (Tr. 287.) Dr. Brown identified Plaintiff’s diagnosis as anxiety disorder not otherwise specified. (Tr. 287, 292.) Dr. Brown opined that Plaintiff was mildly limited in her activities of daily living and in her ability to maintain concentration, persistence, or pace. (Tr. 297.) Dr. Brown found Plaintiff moderately limited in her ability to maintain social functioning. (Id.)

         2. Sheri L. Simon, Ph.D

         On December 17, 2012, as part of the reconsideration determination, Dr. Simon reviewed the record and completed a Case Analysis form. (Tr. 352) Dr. Simon stated that she “reviewed all of the evidence in the file.” (Tr. 352.) She concluded that Plaintiff was “functional.” (Id.) She stated that “[w]hile there are some difficulties, the [Plaintiff] is independent in personal care, makes simple meals, does [household] chores, drives, goes out alone, shops, manages finances, socializes with 1 friend.” (Id.) Dr. Simon found that ...


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