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Velaquez v. Colvin

United States District Court, D. Colorado

December 1, 2015

ELIGIO JOSE VELASQUEZ, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

ORDER

RAYMOND P. MOORE UNITED STATES DISTRICT JUDGE.

This matter is before the Court on Plaintiff Eligio Jose Velasquez’s (“Plaintiff”) request for judicial review pursuant to 42 U.S.C. § 405(g). (ECF No. 2.) Plaintiff challenges the final decision of Defendant Carolyn W. Colvin, Acting Commissioner of the Social Security Administration, by which she denied Plaintiff’s applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) respectively under Titles II and XVI of the Social Security Act (“Act”). The Administrative Law Judge (“ALJ) ruled Plaintiff was not disabled within the meaning of the Act and therefore not entitled to DIB or SSI.

Defendant provided the Court with the administrative record[1]. (ECF Nos. 12; 12-1; 12-2; 12-3; 12-4; 12-5; 12-6; 12-7; 12-8; 12-9; 12-10.) The parties have fully briefed the matter and it is ripe for adjudication. (ECF Nos. 19; 22; 23.)

For the reasons set forth below, the Court affirms Defendant’s denial of Plaintiff’s DIB and SSI applications.

I. BACKGROUND

Plaintiff applied for DIB and SSI in August 2011, alleging he was disabled as of April 1, 2010, due to the following conditions that limit his ability to work: knees, back, shoulders, and mental. (Admin. R. (“Tr.) 73, 156-171, 184.) After Plaintiff’s applications were initially denied, Plaintiff requested a hearing before an ALJ. (Tr. 94-100.) The ALJ denied Plaintiff’s applications. (Tr. 12-28.) Plaintiff requested review of the ALJ’s decision and, in April 2014, the Appeals Council denied such review. (Tr. 1-6.) Plaintiff timely requested judicial review before the Court.

A. Background and Relevant Medical Evidence

Plaintiff was born in 1962. (Tr. 156.) Plaintiff has a GED. (Tr. 76.) Plaintiff’s past relevant work history, as referenced in the Dictionary of Occupational Titles, includes: construction labor; material handler; and plumber’s helper. (Tr. 64.)

Plaintiff claims he became disabled on April 1, 2010 due to a combination of physical and mental health impairments. (Tr. 73, 156.) Plaintiff has an extensive medical history during the relevant time period.

1. Department of Veteran’s Affairs (“VA”) Treatment

In June 2010, Plaintiff sought mental health care at the VA during which he stated he had a history of depression and substance abuse but had been sober (except for marijuana) for a few years and doing well until a recent series of stressful life events. (Tr. 500.) But on June 4, 2010, Plaintiff reported he relapsed with alcohol and “received a DUI.” (Tr. 500.) His employer at the time then terminated his employment when Plaintiff informed it of the DUI. (Tr. 500.)

In July 2010, Plaintiff established primary care. (Tr. 505.) Plaintiff reported a history of bipolar/depression. (Tr. 505.) Plaintiff reported past knee and wrist surgery and a left hand injury. (Tr. 505.) Further, Plaintiff reported a history of arthritis in his hands and knees. (Tr. 507.) The family nurse practitioner evaluated Plaintiff to have a depressed mood. (Tr. 507.) Plaintiff was also confirmed to have Hepatitis C. (Tr. 509.) The family nurse practitioner prescribed motrin for Plaintiff’s shoulder pain. (Tr. 509.) Plaintiff tested positive for PTSD. (Tr. 511.) Subsequent x-rays of Plaintiff’s left knee showed degenerative changes of the knee with probable loose bodies. (Tr. 409.)

In August 2010, Plaintiff underwent a mental health-intake assessment. (Tr. 479-80.) Plaintiff reported that for the “past 8 years he has only had alcohol about 4 times each year, but reports when drinks he drinks to intoxication.” (Tr. 480.) Plaintiff reported smoking marijuana daily. (Tr. 480.) Plaintiff reported that he had been treated with antidepressants in 2001 but was abusing alcohol at the time and did not remain on the medications. (Tr. 480.) Plaintiff reported alcoholism; chronic depression; Hepatitis C; knee pain; back pain; shoulder pain; and headaches. (Tr. 483.) Plaintiff was taking ibuprofen for pain/inflammation management. (Tr. 484.) Plaintiff appeared “alert and attentive.” (Tr. 484.) Plaintiff reported “auditory hallucinations[;] [i]n [the] past 8 years when sober; [and he was] aware of hearing voices at times during the day.” (Tr. 485.) The initial examiner provided an initial diagnosis of depressive disorder; alcohol abuse in partial remission; marijuana abuse; hepatitis C; headaches; and a GAF score of 50. (Tr. 485-86.)

In September 2010, Plaintiff reported that ibuprofen had been somewhat helpful for his pain related to bicipital tendinitis and that he would like to increase the dose. (Tr. 477-78.) Subsequently, also in September 2010, Plaintiff complained of panic attacks for 3-4 days in a row. (Tr. 469.) The panic attacks were “resolved” prior to his treatment in September 2010. (Tr. 469.) Additionally, Plaintiff saw a mental health provider for psychotherapy and medication management. (Tr. 471-75.) Plaintiff was determined to have a Global Assessment Functioning of 50. (Tr. 474.) Plaintiff reported hearing voices at the volume of a whisper but that his thought process was logical. (Tr. 472.) In October 2010, Plaintiff saw a mental health provider and reported no psychotic symptoms. (Tr. 465.)

Following Plaintiff’s release from jail for a DUI, in July 2011, Plaintiff reported for medical treatment at the VA. (Tr. 460.) Plaintiff reported having a depressed mood and hearing voices. (Tr. 460.) Plaintiff was on marijuana. (Tr. 460.) Plaintiff was examined to be dysphoric and hearing voices. (Tr. 461.) Plaintiff was prescribed certain medications that he reported helped his psychotic symptoms and depression but that he had stopped taking subsequent to his release from jail. (Tr. 463-64.) The social worker described Plaintiff’s thoughts as logical during the examination. (Tr. 464.) Also in July 2011, Plaintiff received treatment for his physical ailments and received a prescription for ibuprofen. (Tr. 451-54, 458-59.) At that time, Plaintiff reported that his “shoulders and knees have been bothering him for about 2 years.” (Tr. 458.)

From August to October 2011, Plaintiff received psychotherapy and medication management for his mental symptoms. Plaintiff reported varying levels of improvement and, on occasion, problems with anxiety. (Tr. 434-38, 438-45, 445-58, 575-80, 586-90.) At one point, Plaintiff admitted that “he has been paranoid for most of his life.” (Tr. 437.)

In September 2011, Plaintiff sought treatment for back, knee, and shoulder pain. (Tr. 584-86.) Plaintiff was evaluated to have “[n]o muscle atrophy or weakness” but did have a diminished range of motion in his shoulders. (Tr. 593.) The medical provider determined that Plaintiff’s chronic left knee pain and tendinitis were poorly controlled. (Tr. 594.) The medical provider determined that Plaintiff’s depressive symptoms and auditory hallucinations were improved. (Tr. 594.)

In November 2011, Plaintiff complained of back and left knee pain after raking a yard. (Tr. 549.) The provider noted that recent x-rays showed sever spondylosis of the low back and degenerative changes with probable loose bodies in the left knee. (Tr. 549-50, 523.) The provider prescribed medications and recommended Plaintiff continue activities as tolerable and participate in physical therapy. (Tr. 550.)

In November and December 2011, Plaintiff had routine psychotherapy and medication management appointments. (Tr. 539, 543-47.)

In July 2012, Plaintiff was referred for an orthopedic evaluation of his knee and shoulders. (Tr. 721-23.) Left shoulder x-rays showed moderate degenerative changes (Tr. 727-28) and left knee x-rays showed moderate degenerative joint disease (Tr. 728-29). A knee brace was prescribed for Plaintiff’s left knee. (Tr. 710-11.)

2. Denver County Sheriff Department Health Services Treatment

From October 2010 to June 2011, Plaintiff received routine treatment for complaints including knee, shoulder, and back problem as well as depression and hearing voices. (Tr. 372-408.) Plaintiff was prescribed medication. (Tr. 376.)

3. Examinations and Review in Connection with Disability Applications

In November 2011, Plaintiff saw Mac Bradley, Ph.D., for a consultative examination. (Tr. 515-20.) Dr. Bradley found that Plaintiff did not exhibit “signs of psychotic thought process” and exhibited “no anomalies of thought content.” (Tr. 518.) Dr. Bradley found “no significant deficits in memory or intellectual functioning.” (Tr. 519.) Dr. Bradley found that Plaintiff’s report of “’hearing voices’” was not “typical of bona fide hallucinations.” (Tr. 519.) Dr. Bradley found Plaintiff not to be impaired with respect to basic work-related activities. (Tr. 519-20.)

In November 2011, James Wansrath, Ph.D., performed a review of the record and determined that Plaintiff has mild limitations in social functioning, concentration, persistence, or pace. (Tr. 77, 88.)

In November 2011, Plaintiff saw Thurman Hodge, D.O. for a consultative physical examination. (Tr. 525-30.) Hodge determined that Plaintiff’s complaint of significant low back pain “appeared mild at this exam.” (Tr. 529.) Further, Hodge found that the examination of Plaintiff’s shoulder range was “benign” other than for not allowing abduction of his arms greater than 140 degrees. (Tr. 529.) Further, Hodge found that the stated limitations were not supported by his examination and found only certain limitations. (Tr. 529.)

In April 2012, Maria Legarda, M.D., reviewed the evidence and opined that Plaintiff had limitations consistent with ability to perform a range of medium duty work. (Tr. 677).) Richard Kaspar, Ph.D., agreed with Dr. Wanstrath that Plaintiff did not have a severe mental impairment. (Tr. 675.)

4. Denver Health

In May 2012, Plaintiff received care at Denver Health. In his left knee, Plaintiff was diagnosed with a tear of his meniscus and anterior cruciate ligament, cartilage damage, and a small joint effusion with loose bodies. (Tr. 766-67, 776.) Plaintiff ...


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