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Maldonado v. Berryhill

United States District Court, D. Massachusetts

September 4, 2019

EDDIE ECHEVARRIA MALDONADO, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.

          REPORT AND RECOMMENDATION RE: PLAINTIFF'S MOTION TO REVERSE OR REMAND THE DECISION OF THE COMMISSIONER (DOCKET ENTRY # 16); DEFENDANT'S MOTION TO AFFIRM THE COMMISSIONER'S DECISION (DOCKET ENTRY # 18)

          Marianne B. Bowler, United States Magistrate Judge.

         Pending before this court are cross motions by the parties, plaintiff Eddie Echevarria Maldonado (“plaintiff”) and defendant Nancy A. Berryhill, Acting Commissioner of the Social Security Administration (“the Commissioner”). Plaintiff seeks to reverse or remand the decision of the Commissioner pursuant to 42 U.S.C. § 405(g). (Docket Entry # 16). The Commissioner moves for an order to affirm the decision. (Docket Entry # 18). On March 4, 2019, this court conducted a hearing and thereafter took both motions (Docket Entry ## 16, 18) under advisement.

         PROCEDURAL HISTORY

         In early 2013, plaintiff filed an application for disability insurance benefits. (Docket Entry # 13-8, Tr. 529- 30). Plaintiff filed an additional application for supplemental security income (“SSI”) in December 2013. (Docket Entry # 13-8, Tr. 538-46). In both applications, plaintiff alleged disability rendering him unable to work as of January 25, 2013. (Docket Entry # 13-8, Tr. 529, 538). The Social Security Administration (“SSA”) denied both claims on June 27, 2014. (Docket Entry # 13-7, Tr. 442-55). Plaintiff then filed a request for reconsideration, which was denied on November 18, 2014. (Docket Entry # 13-7, Tr. 461-62, 466-76).

         Plaintiff requested a hearing before an Administrative Law Judge (“AJL”) on December 1, 2014. (Docket Entry # 13-7, Tr. 477-78). The AJL conducted a hearing on April 29, 2016. (Docket Entry # 13-5, Tr. 294-338). Both plaintiff and a vocational expert (“VE”) testified at the hearing (Docket Entry # 13-5, Tr. 294-338). In an August 26, 2016 decision, the ALJ concluded that plaintiff was not disabled under 42 U.S.C. §§ 216(i), 223(d), 1614(a)(3)(A) for the period of January 25, 2013 through the date of the ALJ's decision. (Docket Entry # 13-2, Tr. 15-32).

         Plaintiff requested a review of the ALJ's decision by the Appeals Council on October 21, 2016. (Docket Entry # 13-7, Tr. 526-28). The Appeals Council denied the request for review on May 7, 2018, thereby affirming the ALJ's decision as final. (Docket Entry # 13-2, Tr. 1-4). Plaintiff subsequently filed this action against the Commissioner pursuant to 42 U.S.C. § 405(g).

         FACTUAL BACKGROUND

         I. Plaintiff's Age, Education, and Work History

         Plaintiff, born on October 30, 1967, was 45 years old on the date of his application for disability insurance benefits, and 46 years old on the date of his application for supplemental security income. (Docket # 13-8, Tr. 529, 538). He holds a high school diploma and has past relevant work experience as an auto parts salesperson and a handyman. (Docket Entry # 13-5, Tr. 306, 308-10). Plaintiff alleged an inability to work as of January 25, 2013 and claimed that he suffered from both physical and psychological conditions. (Docket Entry # 13-5, Tr. 311-23, 529) (Docket Entry # 13-8, Tr. 538).

         II. Plaintiff's Medical History

         A. Physical Conditions [1]

         On February 10, 2013, plaintiff was admitted to the emergency room at St. Luke's Memorial Hospital in Ponce, Puerto Rico for bilateral leg pain. (Docket Entry # 13-23, Tr. 1915-17). The attending physician, Alexandra Vega Lagares, M.D. (“Dr. Vega Lagares”) observed no edema in plaintiff's extremities and attributed his discomfort to uncontrolled blood glucose levels. (Docket Entry # 13-23, Tr. 1916). Dr. Vega Lagares subsequently diagnosed plaintiff with peripheral neuropathy.[2] (Docket Entry # 13-23, Tr. 1916).

         On April 23, 2013, plaintiff completed an adult function report.[3] (Docket Entry # 13-9, Tr. 576-84). Therein, he reported that his physical ailments negatively impact his ability to care for himself, indicating that he struggles to raise and lower his legs when dressing and bathing. (Docket Entry # 13-9, Tr. 578). Plaintiff reported that he prepares his own meals, but only spends ten to 15 minutes at a time preparing food, as it is painful for him to spend more than short periods of time on his feet. (Docket Entry # 13-9, Tr. 578). Plaintiff further indicated that he is unable to independently complete tasks around the house, such as washing clothes or cleaning, and depends on his wife to do the shopping. (Docket Entry # 13-9, Tr. 579-80). Plaintiff reported that because of the strong pain in his legs, he leaves the house only when he has medical appointments. (Docket Entry # 13-9, Tr. 580). Plaintiff indicated that he remains capable of managing his own money and paying bills. (Docket Entry # 13-9, Tr. 580).

         On July 3, 2013, plaintiff underwent a consultative examination with Nilma E. Rosado Villanueva, M.D. (“Dr. Rosado Villanueva”). (Docket Entry # 13-12, Tr. 858-69). At the examination, plaintiff reported a history of uncontrolled diabetes, high blood pressure, multiple heart attacks, and chest pain. (Docket Entry # 13-12, Tr. 858). Plaintiff reported being hospitalized six times between 1998 and 2013 due to chest pain, coronary artery disease, and uncontrolled diabetes, including a hospitalization for the placement of four stents in his heart. (Docket Entry # 13-12, Tr. 858-59). Plaintiff further reported experiencing frequent cramping, numbness, and spasms in his legs and shortness of breath during moderate physical activity. (Docket Entry # 13-12, Tr. 859). Dr. Rosado Villanueva noted that plaintiff used a cane for gait stability on his right side. (Docket Entry # 13-12, Tr. 858, 860). Upon physical examination, Dr. Rosado Villanueva observed “[p]alpable peripheral pulses” and lack of edema in plaintiff's legs. (Docket Entry # 13-12, Tr. 860). Plaintiff also exhibited a full range of motion and normal muscle strength in the upper and lower extremities. (Docket Entry # 13-12, Tr. 860, 865-66). Dr. Rosado Villanueva ultimately assessed diabetes, diabetic neuropathy, and left ventricular hypertrophy in addition to plaintiff's history of coronary artery disease and high blood pressure. (Docket Entry # 13-12, Tr. 861).

         State agency physician Ivan Arzola, M.D. (“Dr. Arzola”) completed a physical portion of a “Disability Determination Explanation” at the initial level on September 21, 2013. (Docket Entry # 13-6, Tr. 339-49). He determined that plaintiff suffers from multiple medically determinable impairments, including ischemic heart disease, which Dr. Arzola assessed as severe, as well as essential hypertension, diabetes, and peripheral neuropathy, all of which Dr. Arzola assessed as non-severe. (Docket Entry # 13-6, Tr. 347). Dr. Arzola's physical residual functional capacity (“RFC”) assessment reflects that plaintiff is capable of lifting 50 pounds occasionally and 25 pounds frequently. (Docket Entry # 13-6, Tr. 347-48). Dr. Arzola also assessed that plaintiff can stand and/or walk with normal breaks for approximately six hours in an eight-hour workday. (Docket Entry # 13-6, Tr. 348). Dr. Arzola's RFC assessment further notes that plaintiff is capable of sitting with normal breaks for approximately six hours in an eight-hour workday. (Docket Entry # 13-6, Tr. 348).

         On September 23, 2013, plaintiff was admitted to the emergency room at Lowell General Hospital. (Docket Entry # 13-12, Tr. 895-929). He complained of persistent bilateral leg pain and estimated that it began in January 2013. (Docket Entry # 13-12, Tr. 898). Emergency Department Nurse Tracey Correia-Mcgowan, RN prescribed plaintiff acetaminophen and tramadol for the pain. (Docket Entry # 13-12, Tr. 909-27). Plaintiff was additionally given educational materials relating to peripheral neuropathy, a diabetic diet, and the health effects of smoking. (Docket Entry # 13-12, Tr. 909-27).

         On October 1, 2013, plaintiff established care with Mukund Gupta, M.D. (“Dr. Gupta”) at Lowell Community Health Center. (Docket Entry # 13-14, Tr. 1088-90). As part of his medical history, plaintiff reported current tobacco use and estimated smoking between 11 and 19 cigarettes per day. (Docket Entry # 13-14, Tr. 1088). Upon a physical examination, Dr. Gupta observed no edema and noted that despite plaintiff's knees being sensitive to palpitation, plaintiff exhibited a normal range of motion in his extremities. (Docket Entry # 13-14, Tr. 1089). Dr. Gupta assessed plaintiff's diabetes as poorly controlled and referred him to diabetic management for counseling on diet. (Docket Entry # 13-14, Tr. 1089). Dr. Gupta also referred plaintiff to Scott Sigman, M.D. (“Dr. Sigman”), an orthopedist, for possible osteoarthrosis in plaintiff's knees. (Docket Entry # 13-14, Tr. 1089).

         On November 13, 2013, plaintiff saw Dr. Sigman at Merrimack Valley Spine Center. (Docket Entry # 13-13, Tr. 1040-42). Dr. Sigman observed that plaintiff ambulated with a normal gait and did not walk with any assistive device. (Docket Entry # 13-13, Tr. 1041). Upon a physical examination, Dr. Sigman noted that plaintiff had a small open wound on his left calf. (Docket Entry # 13-13, Tr. 1041). Dr. Sigman further observed normal range of motion in both knees, despite tenderness when palpitated, and general atrophy in both right and left quadriceps. (Docket Entry # 13-13, Tr. 1041). Plaintiff underwent x-rays in both knees on the same day and Dr. Sigman assessed patellofemoral chondromalacia. (Docket Entry # 13-13, Tr. 1041-42). Dr. Sigman recommended “outpatient physical therapy and bilateral knee braces, ” and noted that he would not recommend or consider cortisone injections until plaintiff's blood sugars were under control and the wound on his left leg had healed. (Docket Entry # 13-13, Tr. 1041-42).

         Beginning on November 20, 2013, plaintiff attended six sessions of outpatient physical therapy at Northeast Rehabilitation Hospital Network (“Northeast”), which was ultimately halted at the direction of plaintiff's physician.[4](Docket Entry # 13-13, Tr. 999-1007). Plaintiff attended a second round of physical therapy sessions at Northeast the following year from June 20 to August 13, with no change in plaintiff's overall level of pain. (Docket Entry # 13-15, Tr. 1182-96).

         On December 8, 2013, plaintiff was admitted to the emergency room at Lowell General Hospital complaining of numbness in his right leg from his knee down to his toes. (Docket Entry # 13-13, Tr. 965-94). The attending physician, Barry Fisher, M.D. ordered and subsequently reviewed the results of a CT scan of plaintiff's brain. (Docket Entry # 13-14, Tr. 1096). The CT scan noted no intracranial hemorrhaging and ultimately found that no intracranial pathology could be identified based on the scan. (Docket Entry # 13-14, Tr. 1096). He ultimately diagnosed plaintiff with paresthesia. (Docket Entry # 13-13, Tr. 968).

         Plaintiff saw his primary care provider, Dr. Gupta, for a follow-up visit several days later on December 9, 2013. (Docket Entry # 13-14, Tr. 1083-85). Dr. Gupta examined plaintiff and observed no edema in his extremities, but noted that plaintiff appeared to be experiencing decreased sensation to light touch in his right leg, and referred plaintiff to a neurologist for electromyography[5] (“EMG”). (Docket Entry # 13-14, Tr. 1085). On December 13, 2013, plaintiff saw Vladan Milosavljevic, M.D. (“Dr. Milosavljevic”) at New England Neurological Associates, P.C. (Docket Entry # 13-14, Tr. 1125). Dr. Milosavljevic performed the EMG and found the results to be abnormal “showing mostly axonal sensory polyneuropathy.” (Docket Entry # 13-14, Tr. 1125-26).

         On January 8, 2014, plaintiff saw his orthopedist, Dr. Sigman. (Docket Entry # 13-13, Tr. 1037-39). Plaintiff underwent x-rays of his lumbar spine and pelvis. (Docket Entry # 13-13, Tr. 1038). Dr. Sigman reviewed the results and observed “no significant degenerative change.” (Docket Entry # 13-13, Tr. 1039). He also reviewed plaintiff's EMG results from a month prior and opined there was clear evidence of axonal sensory polyneuropathy in plaintiff's right leg consistent with diabetic neuropathy. (Docket Entry # 13-13, Tr. 1039). Dr. Sigman ordered an MRI of plaintiff's right knee to assess any intra-articular pathology and noted that if no obvious surgical pathology was found to be present, conservative pain management with a regular exercise program would be appropriate treatment. (Docket Entry # 13-13, Tr. 1039). Dr. Sigman further noted that due to plaintiff's poor diabetic control, he was unwilling to consider a cortisone injection at that time. (Docket Entry # 13-13, Tr. 1039).

         Plaintiff saw Dr. Sigman again on February 3, 2014. (Docket Entry # 13-13, Tr. 1034-36). At the appointment, plaintiff reported continued pain and discomfort in his right knee, as well as anterior thigh and leg pain radiating down into his ankles. (Docket Entry # 13-13, Tr. 1034). Dr. Sigman reviewed the results of an MRI of plaintiff's right knee and observed “articular cartilage fissuring over the patella consistent with patellofemoral chondromalacia.” (Docket Entry # 13-13, Tr. 1035). Dr. Sigman ordered an arterial ultrasound on plaintiff's right lower leg to test for peripheral vascular disease before evaluating further treatment. (Docket Entry # 13-13, Tr. 1035).

         On February 19, 2014, plaintiff's primary care provider, Dr. Gupta, completed an EAEDC[6] Medical Report in support of an application by plaintiff to the Massachusetts Department of Transitional Assistance (“DTA”) for state disability benefits. (Docket Entry # 13-13, Tr. 1008-16). In the report, Dr. Gupta assessed only plaintiff's physical health. (Docket Entry # 13-13, Tr. 1011-16). Under the “[c]onclusions” section of the report, Dr. Gupta checked a box indicating that plaintiff suffers from “a physical, mental health, or cognitive impairment(s) that does not meet or equal the Department's Medical Standards or the SSI Listing of Impairments but does affect his or her ability to work.” (Docket Entry # 13-13, Tr. 1015). Under the same section of the report, Dr. Gupta indicated that plaintiff's impairment was expected to last six to 12 months. (Docket Entry # 13-13, Tr. 1015).

         On February 20, 2014, plaintiff began meeting with Pamela Smith, RN (“Smith”) for regular counseling on diabetes management. (Docket Entry # 13-14, Tr. 1079-80). A random blood sugar test administered by Smith during the visit revealed that plaintiff's glucose levels were very high at 332 mg/dl. (Docket Entry # 13-14, Tr. 1079). Smith discussed with plaintiff the importance of adhering to a diabetic diet and testing his blood sugar levels regularly. (Docket Entry # 13-14, Tr. 1079). Smith further advised plaintiff that an increase or change in medication might be necessary to obtain better control of his glucose levels. (Docket Entry # 13-14, Tr. 1079).

         On February 24, 2014, plaintiff returned to Merrimack Valley Spine Center to see Dr. Sigman. (Docket Entry # 13-13, Tr. 1031-33). Plaintiff underwent an arterial ultrasound to gauge the possibility of peripheral vascular disease. (Docket Entry # 13-13, Tr. 1031). Dr. Sigman assessed the results of the vascular study as “unremarkable.” (Docket Entry # 13-13, Tr. 1032). Plaintiff received a cortisone injection in his right knee in an effort to keep treatment conservative. (Docket Entry # 13-13, Tr. 1032-33). Dr. Sigman noted that he also reviewed a patellofemoral home exercise program with plaintiff. (Docket Entry # 13-13, Tr. 1033).

         On April 2, 2014, plaintiff saw Dr. Gupta at Lowell Community Health Center for a follow-up appointment. (Docket Entry # 13-14, Tr. 1077-78). Plaintiff reported that while the pain in his right knee had improved after the cortisone injection by Dr. Sigman in February, he continued to experience persistent pain in his right thigh and leg. (Docket Entry # 13-14, 1077). Dr. Gupta noted that plaintiff's diabetes was poorly controlled, with a random blood sugar draw measuring plaintiff's glucose levels at 310 mg/dl. (Docket Entry # 13-14, Tr. 1077). Dr. Gupta counseled plaintiff on the importance of compliance with treatment, directed him to increase his Lantus insulin dosage and instructed him to follow up with Smith for further counseling on diabetes management. (Docket Entry # 13-14, Tr. 1077). At the conclusion of the visit, Dr. Gupta provided plaintiff with a letter recommending accommodations in the form of a first-floor apartment due to plaintiff's ambulatory difficulties. (Docket Entry # 13-13, Tr. 1029).

         On April 21, 2014, plaintiff underwent a consultative examination by Asha Saxena, M.D. (“Dr. Saxena”) at University of Massachusetts Disability Evaluation Services. (Docket Entry # 13-14, Tr. 1070-72). At the examination, plaintiff reported a history of bilateral knee pain, hand and leg pain and cramping, diabetes, chondromalacia, and depression. (Docket Entry # 13-14, Tr. 1070-71). Plaintiff also reported smoking approximately half a pack of cigarettes per day. (Docket Entry # 13-14, Tr. 1071). When questioned, plaintiff admitted to being able to perform activities of daily living normally. (Docket Entry # 13-14, Tr. 1072). Dr. Saxena observed that plaintiff's gait was slow and that he appeared to walk with a slight limp. (Docket Entry # 13-14, Tr. 1071). Dr. Saxena further noted that plaintiff struggled to rise to his feet from a seated or reclined position, was unable to walk on his heels or toes, and could not perform a squat. (Docket Entry # 13-14, Tr. 1071). Additionally, Dr. Saxena observed a restricted range of movement in plaintiff's knees, and noted that plaintiff experienced moderate pain upon extension and rotation of his knees. (Docket Entry # 13-14, Tr. 1071). Plaintiff reported to Dr. Saxena that his knees occasionally lock up and that he wears knee braces for added stability. (Docket Entry # 13-14, Tr. 1071). Dr. Saxena observed slightly weakened motor strength in both legs. (Docket Entry # 13-14, Tr. 1071). Plaintiff self-reported “feeling tired” when “he stands or walks for more than 10-15 minutes” at a time and being unable to walk for more than half a block. (Docket Entry # 13-14, Tr. 1072).

         On May 12, 2014, plaintiff saw Dr. Gupta at Lowell Community Health Center for a follow-up appointment. (Docket Entry # 13-14, Tr. 1075-76). Plaintiff complained of persistent pain in both his right and left knees. (Docket Entry # 13-14, Tr. 1075). Dr. Gupta noted that plaintiff's diabetes was poorly controlled and opined that the pain plaintiff was experiencing in his extremities was linked to diabetic neuropathy. (Docket Entry # 13-14, Tr. 1075-76).

         On May 19, 2014, state agency physician Jane McInerny, M.D. (“Dr. McInerny”) completed a physical RFC at the initial level (Docket Entry # 13-6, Tr. 382-83). Dr. McInerny's physical RFC reflects that plaintiff is capable of lifting 50 pounds occasionally, and 20 pounds frequently. (Docket Entry # 13-6, Tr. 382). Dr. McInerny further assessed that plaintiff could stand or walk, with normal breaks, for approximately six hours in an eight-hour workday and could sit, with normal breaks, for the same length of time. (Docket Entry # 13-6, Tr. 382-83). Additionally, Dr. McInerny indicated that plaintiff has postural limitations allowing him to climb stairs frequently, climb ladders or scaffolds occasionally, stoop frequently, and kneel, crouch, and crawl occasionally. (Docket Entry # 13-6, Tr. 383). Dr. McInerny did not find that plaintiff had any manipulative, visual, communicative, or environmental limitations. (Docket Entry # 13-6, Tr. 383).

         On May 30, 2014, plaintiff saw Smith for diabetes counseling at Lowell Community Health Center. (Docket Entry # 13-14, Tr. 1146-47). Smith noted that plaintiff's diabetes was poorly controlled, and that he was not using his insulin injections properly. (Docket Entry # 13-14, Tr. 1146). Smith provided plaintiff with written instructions in Spanish on the correct order, time, and dosage of insulin. (Docket Entry # 13-14, Tr. 1146). During a follow-up appointment on June 11, 2014, Smith noted that plaintiff's blood glucose levels had improved with the correction in plaintiff's use of insulin. (Docket Entry # 13-14, Tr. 1143-44). Plaintiff continued to go to the Lowell Community Health Center for diabetes counseling for the next six months. (Docket Entry # 13-14, Tr. 1139-40) (Docket Entry # 13-24, Tr. 1933-49).

         On June 16, 2014, plaintiff saw Dr. Gupta at Lowell Community Health Center for a follow-up appointment. (Docket Entry # 13-14, Tr. 1141-42). Dr. Gupta noted that plaintiff's glucose levels had improved since beginning diabetes counseling. (Docket Entry # 13-14, Tr. 1141-42). Dr. Gupta further noted that plaintiff was continuing to struggle with pain in his right inner thigh, and referred him to Dr. Milosavljevic for further testing. (Docket Entry # 13-14, Tr. 1141-42). Dr. Milosavljevic subsequently performed an EMG on July 16, 2014 and observed no change since plaintiff's prior test. (Docket Entry # 13-14, Tr. 1127).

         On August 1, 2014, plaintiff saw Dr. Gupta at Lowell Community Health Center for a routine follow-up appointment. (Docket Entry # 13-14, Tr. 1137-38). Dr. Gupta assessed plaintiff's diabetes as once again poorly controlled, at least in part due to poor adherence to treatment. (Docket Entry # 13-14, Tr. 1137).

         On August 4, 2014, Dr. Sigman of Merrimack Valley Spine Center reviewed the results of plaintiff's recent EMG and noted no major changes from plaintiff's previous test. (Docket Entry # 13-14, Tr. 1173-74). Dr. Sigman further observed that plaintiff had experienced excellent results with the cortisone injection in his right knee and recommended that plaintiff “continue physical therapy and use of a brace.” (Docket Entry # 13-14, Tr. 1173-74). At a follow-up appointment on October 6, 2014, Dr. Sigman administered a cortisone injection to plaintiff's left knee following plaintiff's complaints of pain and discomfort. (Docket Entry # 13-18, Tr. 1526-28).

         On September 2, 2014, plaintiff completed another adult function report. (Docket Entry # 13-10, Tr. 654-57). He reported his daily activities as consisting of taking his medication, watching television, preparing meals, and bathing. (Docket Entry # 13-10, Tr. 654). He indicated that the constant pain in his legs interferes with his ability to sleep, and that he struggles to bend his knees, which makes dressing and bathing difficult. (Docket Entry # 13-10, Tr. 655). He also indicated that the pain in his legs causes him significant mental stress and has contributed to his depression. (Docket Entry # 13-10, Tr. 655). Plaintiff indicated that he occasionally forgets to take his medication. (Docket Entry # 13-10, Tr. 656). Plaintiff wrote that he prepares his own meals daily, often eating cereal for breakfast and sandwiches for lunch and dinner. (Docket Entry # 13-10, Tr. 656). Plaintiff further reported that he is able to do his own laundry and perform “basic” cleaning and other chores around the house. (Docket Entry # 13-10, Tr. 656). Plaintiff noted that he does these “things with difficulty” and at his own pace. (Docket Entry # 13-10, Tr. 656). Plaintiff reported going outside only when he feels well enough to do so or when he has “an appointment.” (Docket Entry # 13-10, Tr. 657). Plaintiff also noted that he shops for groceries every two weeks and is able to pay his own bills and manage a checking account. (Docket Entry # 13-10, Tr. 657).

         On November 11, 2014, state agency physician K. Malin Weeratne, M.D. (“Dr. Weeratne”) completed a physical RFC at the reconsideration level. (Docket Entry # 13-6, Tr. 408-09). Dr. Weeratne offered an opinion of plaintiff's physical RFC matching that previously given by Dr. McInerny in May 2014. (Docket Entry # 13-6, 382-83, 408-09).

         On March 9, 2015, plaintiff underwent a diabetic eye examination by John Capino, M.D. (“Dr. Capino”). (Docket Entry # 13-17, Tr. 1444-45). Dr. Capino assessed bilateral diabetic macular edema, noting that it was “[c]linically significant” and at “[h]igh risk of progression.” (Docket Entry # 13-17, Tr. 1445). Dr. Capino further assessed “non-proliferative diabetic retinopathy” and “hypertensive retinopathy.” (Docket Entry # 13-17, Tr. 1445).

         On April 13, 2015, plaintiff saw Dr. Gupta at Lowell Community Health Center for a follow-up appointment. (Docket Entry # 13-24, Tr. 1922-23). Dr. Gupta observed continued ulcers on plaintiff's left leg and prescribed a topical antibacterial ointment. (Docket Entry # 13-24, Tr. 1922). Dr. Gupta further observed that plaintiff's diabetes was “poorly controlled.” (Docket Entry # 13-24, Tr. 1923). During this appointment, plaintiff admitted to missing his most recent diabetes counseling appointment. (Docket Entry # 13-24, Tr. 1922). At a subsequent appointment on April 27, 2015, Dr. Gupta noted that the ulcer on plaintiff's left leg had improved somewhat, but that plaintiff's blood glucose levels continued to be “poorly controlled.” (Docket Entry # 13-24, Tr. 1921). Dr. Gupta discussed with plaintiff at length the “need for improved compliance” with treatment. (Docket Entry # 13-24, Tr. 1921).

         On May 4, 2015, plaintiff underwent a doppler ultrasound and waveform analysis on both of his lower legs to determine the root cause of his chronic ulcers. (Docket Entry # 13-17, Tr. 1449). Paul Burke, M.D. (“Dr. Burke”) performed the examination at Non-Invasive Vascular Diagnostics located in North Chelmsford, Massachusetts. (Docket Entry # 13-17, Tr. 1449). He noted that the study was ultimately inconclusive, as he observed normal circulation in both extremities. (Docket Entry # 13-17, Tr. 1449). A subsequent ultrasound performed by Calin Vasiliu, M.D. (“Dr. Vasiliu”) on June 25, 2015 at Non-Invasive Vascular Diagnostics revealed “chronic venous insufficiency” in plaintiff's right leg. (Docket Entry # 13-17, Tr. 1452). Dr. Vasiliu assessed plaintiff as failing conservative therapy with conservative measures, resulting in lifestyle-limiting symptoms. (Docket Entry # 13-17, Tr. 1452).

         On June 30, 2015, plaintiff established care with Miguel Ariza, M.D. (“Dr. Ariza”) at the Lowell Diabetes & Endocrine Center in North Chelmsford. (Docket Entry # 13-18, Tr. 1458-61). Plaintiff reported poor glycemic control and admitted to missing insulin injections once per day. (Docket Entry # 13-18, Tr. 1458). Dr. Ariza agreed that plaintiff's glycemic control was very poor and assessed major barriers to improvement due to lack of diabetes education and plaintiff's longstanding non-compliance with treatment. (Docket Entry # 13-18, Tr. 1459). Dr. Ariza recommended that plaintiff follow up with the diabetes center to receive further education and assistance with management of his condition. (Docket Entry # 13-18, Tr. 1459).

         On August 29, 2015, plaintiff was admitted to the emergency room at Lowell General Hospital for chronic ulcers on his left leg that had recently become infected. (Docket Entry # 13-21, Tr. 1681-1755). Plaintiff reported recently having returned from a visit to Puerto Rico “and the infection worsened during that time.” (Docket Entry # 13-21, Tr. 1692). Doris Pliskin, M.D. performed an incision and drainage of plaintiff's wound. (Docket Entry # 13-21, Tr. 1691). The infectious disease unit noted “significant improvement in the infection” following the procedure, and plaintiff was discharged shortly thereafter. (Docket Entry # 13-21, Tr. 1692).

         On September 15, 2015, plaintiff underwent an ultrasound on his right leg at Non-Invasive Vascular Diagnostics. (Docket Entry # 13-17, Tr. 1450). Dr. Vasiliu reviewed the results of the ultrasound and met with plaintiff again on October 8, 2015. (Docket Entry # 13-17, Tr. 1452). Dr. Vasiliu stated that she was unwilling to “recommend an ablation” at this stage, and noted that gaining control over plaintiff's diabetes was of greater immediate concern. (Docket Entry # 13-17, Tr. 1452).

         On December 29, 2015, plaintiff saw Dr. Ariza at Lowell Diabetes & Endocrine Center for a follow-up appointment. (Docket Entry # 13-18, Tr. 1466-68). Plaintiff reported poor glycemic control and recounted several hyperglycemic episodes that had occurred while he was visiting family in Puerto Rico. (Docket Entry # 13-18, Tr. 1466). Plaintiff reported suffering from low blood glucose levels three times per week on average. (Docket Entry # 13-18, Tr. 1466). Dr. Ariza noted that plaintiff was not compliant with a diabetic diet and had never followed up with the diabetes center. (Docket Entry # 13-18, Tr. 1466). Dr. Ariza ordered diagnostic labs to be completed by the following week at the latest. (Docket Entry # 13-18, Tr. 1468).

         On February 2, 2016, Dr. Ariza reviewed the results of the labs and noted that plaintiff's blood glucose control was “very poor.” (Docket Entry # 13-18, Tr. 1470-71). Dr. Ariza further noted that plaintiff should bring his glucose meter to his next appointment, as the blood glucose readings that plaintiff had self-reported to Dr. Ariza's office did not match the lab results. (Docket Entry # 13-18, Tr. 1472). On February 3, 2016, plaintiff spoke to a representative from Dr. Ariza's office by phone and informed her that he had not yet scheduled a follow-up appointment with the diabetes center. (Docket Entry # 13-18, Tr. 1471). Plaintiff further reported to the representative that he had been complying with treatment for his high cholesterol levels, but a subsequent phone call to plaintiff's pharmacy revealed that his cholesterol medication had not been refilled since July 2015. (Docket Entry # 13-18, Tr. 1471).

         On February 25, 2016, plaintiff saw Damian Folch, M.D. (“Dr. Folch”). (Docket Entry # 13-23, Tr. 1882). Plaintiff complained of pain in his left arm, and Dr. Folch ordered an x-ray. (Docket Entry # 13-23, Tr. 1882). The x-ray was taken the same day by Bruce Hall, M.D. (“Dr. Hall”), who noted “no fracture or dislocation.” (Docket Entry # 13-23, Tr. 1894-95). Dr. Hall did observe moderate degenerative change in the acromioclavicular joint “without significant hypertrophy” and noted that it was an otherwise normal exam. (Docket Entry # 13-23, Tr. 1895).

         Approximately one month later, on March 21, 2016, plaintiff saw Benjamin Henkle, M.D. (“Dr. Henkle”) at the Lowell General Hospital Pain Center. (Docket Entry # 13-5, Tr. 283-87). Plaintiff complained of neck and left arm pain that he rated a seven on a scale out of ten. (Docket Entry # 13-5, Tr. 283). Dr. Henkle assessed “left cervical radiculopathy” and suggested physical therapy two to three times per week for a minimum of six weeks, with a transition to a home exercise program. (Docket Entry # 13-5, Tr. 287). Dr. Henkle noted that he would consider a cervical epidural steroid injection if plaintiff's pain did not improve with physical therapy. (Docket Entry # 13-5, Tr. 287).

         B. Mental Conditions

         On May 20, 2014, state agency consultant Daniel Morocco, Ed.D (“Morocco”), a psychologist, conducted a clinical diagnostic interview with plaintiff at University of Massachusetts Disability Evaluation Services. (Docket Entry # 13-14, Tr. 1098-1101). Plaintiff reported to Morocco that his daily activities consist of cleaning, cooking, doing laundry, and watching television. (Docket Entry # 13-14, Tr. 1099). He further reported difficulty dressing and bathing independently due to his knee problems. (Docket Entry # 13-14, Tr. 1099). Plaintiff described feeling “depressed almost all the time, ” but denied having any homicidal or suicidal ideations or experiencing any auditory or visual hallucinations. (Docket Entry # 13-14, Tr. 1100). Plaintiff admitted to engaging in self harm at some time in the past, but could not recall exactly when this occurred. (Docket Entry # 13-14, Tr. 1100).

         Morocco observed some impairment in plaintiff's judgment, insight, and memory, noting that plaintiff struggled to remember some “personal historical facts.” (Docket Entry # 13-14, Tr. 1099-1100). While plaintiff had some difficulty with retention and at times needed questions repeated, plaintiff nonetheless appeared to understand all of Dr. Morocco's questions and did not ultimately have any difficulty with comprehension. (Docket Entry # 13-14, Tr. 1099). Morocco noted that plaintiff appeared agitated and had some difficult relating throughout the interview. (Docket entry # 13-14, Tr. 1099). Dr. Morocco observed that plaintiff appeared uncomfortable in this type of interpersonal situation. (Docket Entry # 13-14, Tr. 1099). With respect to plaintiff's ability to adapt to work-like activities, Morocco opined that plaintiff would have “difficulty following multistep directions, ” “completing multistep tasks, ” and “relating to many different individuals.” (Docket Entry # 13-14, Tr. 1099). However, Morocco assessed that plaintiff is capable of following “short and simple” directions and completing simple tasks in a work environment. (Docket Entry # 13-14, Tr. 1099). On the basis of the interview, Morocco diagnosed plaintiff with major depressive disorder moderate with anxious distress. (Docket Entry # 13-14, Tr. 1100).

         On June 23, 2014, plaintiff underwent a consultative examination with David Husson, Psy.D (“Dr. Husson”) of Disability Determination Services. (Docket Entry # 13-14, Tr. 1119-24). Plaintiff primarily reported suffering from physical health problems, including diabetes and neuropathy. (Docket Entry # 13-14, Tr. 1119-20). When questioned by Dr. Husson, plaintiff reported feeling “sad and somewhat helpless” about his current medical problems and anxious about his health. (Docket Entry # 13-14, Tr. 1119). Plaintiff explicitly denied experiencing suicidal thoughts, hallucinations, or delusions. (Docket Entry # 13-14, Tr. 1119). Dr. Husson noted that plaintiff's affect was “mildly constricted” and that his mood throughout the interview was mildly dysphoric. (Docket Entry # 13-14, Tr. 1121). However, Dr. Husson also assessed plaintiff's thought processing as coherent, and his insight and judgment as adequate. (Docket Entry # 13-14, Tr. 1121). Dr. Husson further assessed normal cognitive functioning and found no evidence of major social impairments. (Docket Entry # 13-14, Tr. 1122). With respect to plaintiff's functional capacity, Dr. Hussson opined that plaintiff is able to follow short, basic instructions. (Docket Entry # 13-14, Tr. 1122). Dr. Husson acknowledged that plaintiff has some limitations involving pace, persistence, and concentration from an emotional perspective, but that these limitations “seem to be caused by his reported physical health problems.” (Docket Entry # 13-14, Tr. 1122).

         On June 26, 2014, state agency consultant Julie Cohen, Ph.D (“Dr. Cohen”) reviewed the records and completed a psychiatric review technique form and a mental RFC at the initial level. (Docket Entry # 13-6, Tr. 361-62, 364-66). Dr. Cohen found that plaintiff's affective and anxiety-related disorders mildly restrict plaintiff's social functioning and ability to partake in activities of daily living, and moderately restrict his ability to maintain concentration, persistence, or pace. (Docket Entry # 13-6, Tr. 362). Dr. Cohen further assessed moderate limitations in plaintiff's “ability to maintain attention and concentration for extended periods” of time, “ability to carry out detailed instructions, ” and “ability to complete a normal workday . . . without interruptions from psychologically based symptoms.” (Docket Entry # 13-6, Tr. 365). Dr. Cohen opined that while plaintiff's psychological symptoms moderately limit his “ability to sustain focus and pace for detailed tasks, ” he remains capable of successfully completing simple tasks. (Docket Entry # 13-6, Tr. 365-66). Dr. Cohen noted that plaintiff's primary difficulties appear to be medical, and that “he is experiencing some low-level down mood and anxiety secondary to his physical ailments.” (Docket Entry # 13-6, Tr. 366). Dr. Cohen emphasized that plaintiff remains “[a]ble to understand and recall simple information, ” “sustain attention and pace”[7] for simple tasks, “relate adequately” to others, and “understand and respond to simple change(s).” (Docket Entry # 13-6, Tr. 366).

         On July 23, 2014, plaintiff underwent an initial screening for mental health counseling with Ester Lam, M.Ed (“Lam”) at Lowell Community Health Center. (Docket Entry # 13-32, Tr. 2122). Plaintiff reported feeling depressed and nervous, and complained of difficulty sleeping and racing thoughts. (Docket Entry # 13-32, Tr. 2122). Lam noted that plaintiff appeared teary eyed throughout the visit, but exhibited a coherent thought process and displayed “[n]o signs of psychosis.” (Docket Entry # 13-32, Tr. 2122). Lam ultimately assessed depression and referred plaintiff to therapist Olga Madrid for individual therapy. (Docket Entry # 13-32, Tr. 2122).

         On September 15, 2014, plaintiff saw Olga Madrid (“Madrid”)[8] for an initial therapy session at Lowell Community Health Center. (Docket Entry # 13-17, Tr. 1382-85). Plaintiff reported anxiety and constant sadness, crying spells, and difficulty sleeping at night. (Docket Entry # 13-17, Tr. 1382). Additionally, plaintiff reported some auditory and visual hallucinations beginning approximately six months prior. (Docket Entry # 13-17, Tr. 1382). Plaintiff also admitted to having some suicidal thoughts, but expressed that he was able to control them by concentrating on a different activity or by telephoning a friend or family member. (Docket Entry # 13-17, Tr. 1382). Madrid assessed “[s]evere recurrent major depression with psychotic behavior.” (Docket Entry # 13-17, Tr. 1383).

         Plaintiff saw Madrid again on September 29, 2014 at Lowell Community Health Center. (Docket Entry # 13-24, Tr. 1959-61). Plaintiff reported persistence of the same symptoms as in the previous session. Plaintiff additionally reported a prior hospitalization in 2012 in Puerto Rico due to suicidal ideation and incidents of intentionally burning himself with cigarettes. (Docket Entry # 13-24, Tr. 1959-60). Madrid opined that plaintiff could “benefit from [i]ndividual therapy” to address issues underlying his depression and help him develop coping skills. (Docket Entry # 13-24, Tr. 1960). Madrid additionally recommended medication to assist in stabilizing plaintiff's mood and sleep patterns. (Docket Entry # 13-24, Tr. 1960). Overall, Madrid assessed plaintiff's prognosis as good, given his insight and strong familial support system. (Docket Entry # 13-24, Tr. 1960).

         On October 7, 2014, plaintiff saw David Patterson, MS, APRN, [9] NP (“Patterson”) at Lowell Community Health Center. (Docket Entry # 13-24, Tr. 1962-63). Plaintiff complained of persistent feelings of depression, frequent crying episodes, and some suicidal thoughts. (Docket Entry # 13-24, Tr. 1962). Patterson assessed plaintiff's mood as depressed and noted that his appearance was tearful during the visit. (Docket Entry #13-24, Tr. 1962). Patterson “[r]estarted plaintiff on reported medications.” (Docket Entry # 13-24, Tr. 1962-63). Patterson also recommended that plaintiff continue therapy with Madrid. (Docket Entry # 13-24, Tr. 1963).

         On November 10, 2014, plaintiff saw Madrid again at Lowell Community Health Center for continued therapy. (Docket Entry # 13-31, Tr. 2090). Plaintiff reported feeling better with the medication and noted that his ability to sleep had improved. (Docket Entry # 13-31, Tr. 2090). Plaintiff reported feeling well enough to travel to see his son and grandchildren over the weekend. (Docket Entry # 13-31, Tr. 2090). Plaintiff also noted a marked decrease in suicidal thoughts and ideations. (Docket Entry # 13-31, Tr. 2090). Plaintiff continued to attend regular therapy sessions with Madrid over the next six months. (Docket Entry # 13-31, Tr. 2036-84).

         On November 11, 2014, state agency consultant Joseph A. Whitehorn, Ph.D (“Dr. Whitehorn”) completed a psychiatric review technique form and a mental RFC at the reconsideration level. (Docket Entry # 13-6, Tr. 406-07, 409-11). Upon examining the record, Dr. Whitehorn concurred with Dr. Cohen's assessment that plaintiff's affective and anxiety related disorders mildly restrict plaintiff's social functioning and ability to partake in activities of daily living, and moderately restrict his ability to maintain concentration, persistence, or pace. (Docket Entry # 13-6, Tr. 362, 407). Dr. Whitehorn also offered an assessment of plaintiff's sustained concentration and persistence limitations identical to that of Dr. Cohen. (Docket Entry # 13-6, Tr. 365-66, 410-11). The only area in which Dr. Whitehorn's opinion differed from Dr. Cohen's was with regard to plaintiff's adaptational limitations. (Docket Entry # 13-6, Tr. 365, ...


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