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Ortiz v. Commissioner of Soc. Sec.

United States District Court, D. Massachusetts

January 26, 2015


Page 119

For Nilsa Yolanda Ortiz, Plaintiff: William J. Gately, Jr, LEAD ATTORNEY, Fall River, MA.

For Commissioner of Social Security, Defendant: Anita Johnson, LEAD ATTORNEY, United States Attorney's Office, John Joseph Moakley Federal Courthouse, Boston, MA.

For Social Security Administration, Interested Party: Thomas D. Ramsey, LEAD ATTORNEY, Office of the General Counsel, Boston, MA.

Page 120




Nilsa Yolanda Ortiz (" Ortiz" ) has brought this action pursuant to section 205(g) of the Social Security Act, 42 U.S.C. § 405(g)(" Act" ) seeking judicial review of a final decision made by the Commissioner of the Social Security Administration (" Commissioner" ) denying her application for Social Security disability benefits. Ortiz has filed Plaintiffs Motion For Judgment (Docket No. 12). Defendant, Commissioner of Social Security, has filed Defendant's Motion for an Order Affirming the Decision of the Commissioner (Docket No. 17).

Procedural History

In or about March 2009, Ortiz filed applications with the Social Security Administration (" SSA" ) for Social Security disability benefits (" DBI" ) and supplemental security income (" SSR')( Tr., at pp. 161-62, 165-171)[1] alleging she had been disabled since February 1, 2008[2]. Ortiz alleged that she was limited in her ability to work due to degenerative disc disease of the lumbar spine, diabetes mellitus, asthma, obesity, right elbow epicondylitis, acute sarcoidosis, vision problems related to her diabetes, depression and right shoulder impairment.[3] Pl's Brief in Sup. Of Mot. for J. (Docket No. 12-1), at the fourth page. The claim was denied on the grounds that Ortiz is not disabled within the meaning of the Act. Ortiz seeks reversal of the Commissioner's decision on the grounds that the findings of the Administrative Law Judge (" ALJ" ) are not supported by the substantial evidence in the record. The Commissioner asserts that the ALJ's decision is supported by substantial evidence on the record and therefore, should be affirmed.


Summary of Ortiz's Educational and Occupational History

Ortiz was 45 years old at the time that the ALJ denied her claim for SSI and DBI. She has a high school education and completed one year of college. Her past relevant work included employment at a recycling company as a separator/reclaimer, van driver, machine operator and sales clerk ( Tr., at pp. 36-40, 43, 195, 236). Ortiz testified she last worked in 2007, but felt she was capable of working through 2008 ( Id., at p. 44). She remained insured for purposes of the Title II disability insurance program through June 30, 2011 ( Id., at pp. 172-175)

Page 121

Summary of Medical History

In December 2009, when seen at University of Massachusetts Medical Center/Memorial Campus for an initial visit, Ortiz reported no current complaints and indicated her blood sugar levels were well controlled. ( Id., at p. 436). Examination findings at this time were generally normal. ( Id.) The doctor who examined her, Dr. Rosa, discussed with her the need to exercise and lose weight to help control her diabetes and hypertension, as well as the need to stop smoking (Ortiz indicated she was not ready to stop smoking).

In January 2010, Ortiz reported elevated blood sugar levels despite maintaining a relatively healthy diet and increased hearing loss over the preceding three months ( Id., at 437). In-office testing indicated seemingly significant bilateral hearing loss. ( Id.) In February 2010, it was noted that Ortiz had been taking her insulin incorrectly at home, and she was given additional instructions on proper administration of insulin ( Id, at 438).

In March 2010, Ortiz told Dr. Rosa that testing had shown total hearing loss in her left ear ( Id., at p. 439). Dr. Rosa noted that she had lost 10 pounds and encouraged her to continue losing weight ( Id.). Ortiz continued to have diabetic kidney problems ( Id.). In April 2010, Ortiz reported a two-week history of ankle pain and swelling ( Id., at p. 440). Her weight was stable ( Id.). She said her morning blood sugar levels were generally in the low 100s ( Id.). Later that month, Dr. Rosa stated that plaintiff' s ankle swelling had resolved after a medication adjustment and that she was doing well now ( Id., at 442). Ortiz told Dr. Rosa that she had no complaints and felt great, but had recently developed a cold ( Id.).

In May 2010, Ortiz reported she felt well overall, but had just developed bilateral neck swelling ( Id., at p. 443). The examining nurse diagnosed mumps ( Id.). In June 2010, Dr. Rosa noted that testing had ruled out mumps and that the gland swelling was likely due to a viral infection ( Id., at p. 444). Ortiz was diagnosed as suffering from an acute sinus infection. ( Id.)

In August 2010, Ortiz reported that she had felt unwell since gland swelling had begun eight weeks previously and had lost 30 pounds ( Id. at p. 446). Blood sugars had been low, but were now well-controlled ( Id ). It was noted that she had been hospitalized for pneumonia and a lung CT had shown possible malignancy or sarcoidosis ( Id.). Later that month Dr. Rosa noted that when hospitalized, Ortiz had also been suffering from acute kidney failure ( Id., at p. 449). Blood pressure was still low ( Id.). Ortiz reported that she continued to suffer from fever, chills and a poor appetite, and had lost another seven pounds ( Id.). Dr. Rosa noted that a lung tissue biopsy had ruled out malignancy, but was consistent with sarcoidosis ( Id.). On August 23, 2010, Dr. Rosa wrote a letter " To whom it may concern," indicating that Ortiz's health had recently deteriorated, that she could not currently work, and it was unlikely she would be able to work in the future ( Id., at p. 416). Dr. Rosa did not elaborate as to a diagnosis or provide any basis for his conclusion that Ortiz would be unable to work in the future. ( Id.)

In September 2010, Ortiz told Dr. Rosa that she had been doing very well; she had recently flown to Puerto Rico for the funeral of a brother and was feeling much stronger and no longer suffered from fever, chills, nausea or vomiting ( Id., at p. 451). She had regained a little weight, but found it difficult to get up and down the stairs at her home, as she lived on the third floor ( Id.). She reported feeling down, lacking energy, and not enjoying things, but had no suicidal thoughts ( Id.).

Page 122

Dr. Rosa described her as " [w]ell-appearing" and characterized her sarcoidosis as stable ( Id.). Ortiz indicated that her blood sugar was under control; she thought her improved diet and weight loss had helped with her blood sugar control ( Id.).

In November 2010, Ortiz told Dr. Rosa that she was feeling better and stronger ( Id., at 453). Tests showed no signs of malignancy and were consistent with Dr. Rosa's working diagnosis of sarcoidosis. ( Id.) In December 2010, Dr. Smyrnios noted that symptoms associated with Ortiz's lymph swelling were ...

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