Ramos-Oquendo v. Commissioner of Social Security

Filing 19

OPINION AND ORDER: The Commissioner's decision is affirmed. Signed by US Magistrate Judge Bruce J. McGiverin on 3/31/2021. (jm)

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
PHILLIP RAMOS-OQUENDO,
Petitioner,
v.

Civil No. 19-1305 (BJM)

COMMISSIONER OF SOCIAL
SECURITY,
Defendant.
OPINION AND ORDER
Phillip Ramos-Oquendo (“Ramos”) seeks review of the Commissioner’s finding that he is
not disabled and thus not entitled to disability benefits under the Social Security Act (the “Act”).
42 U.S.C. § 423. Ramos argues the Commissioner’s decision should be reversed because the
administrative law judge (“ALJ”)’s residual functional capacity (“RFC”) finding and step five nondisability determination were not supported by substantial evidence. Docket Nos. 1, 12. The
Commissioner opposed. Docket Nos. 10, 15. This case is before me on consent of the parties.
Docket Nos. 6-7. After careful review of the administrative record and the briefs on file, the
Commissioner’s decision is affirmed.
STANDARD OF REVIEW
After reviewing the pleadings and record transcript, the court has “the power to enter a
judgment affirming, modifying, or reversing the decision of the Commissioner.” 20 U.S.C. §
405(g). The court’s review is limited to determining whether the Commissioner and his delegates
employed the proper legal standards and found facts upon the proper quantum of evidence. MansoPizarro v. Secretary of Health & Human Services, 76 F.3d 15, 16 (1st Cir. 1996). The
Commissioner’s findings of fact are conclusive when supported by substantial evidence, 42
U.S.C.§ 405(g), but are not conclusive when derived by ignoring evidence, misapplying the law,
or judging matters entrusted to experts. Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir. 1999); Ortiz v.
Secretary of Health & Human Services, 955 F.2d 765, 769 (1st Cir. 1991). Substantial evidence
means “‘more than a mere scintilla.’ . . . It means—and means only—'such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.’” Biestek v. Berryhill, 139 S.
Ct. 1148, 1154 (2019) (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938))
(internal citation omitted). The court “must affirm the [Commissioner’s] resolution, even if the
record arguably could justify a different conclusion, so long as it is supported by substantial

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evidence.” Rodríguez Pagán v. Secretary of Health & Human Services, 819 F.2d 1, 3 (1st Cir.
1987).
A claimant is disabled under the Act if he is unable “to engage in any substantial gainful
activity by reason of any medically determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be expected to last for a continuous period
of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). Under the statute, a claimant is unable to
engage in any substantial gainful activity when he “is not only unable to do his previous work but
cannot, considering his age, education, and work experience, engage in any other kind of
substantial gainful work which exists in the national economy.” 42 U.S.C. § 423(d)(2)(A). In
determining whether a claimant is disabled, all of the evidence in the record must be considered.
20 C.F.R. § 404.1520(a)(3).
The Commissioner employs a five-step evaluation process to decide whether a claimant is
disabled. 20 C.F.R. § 404.1520; see Bowen v. Yuckert, 482 U.S. 137, 140-42 (1987); Goodermote
v. Secretary of Health & Human Services, 690 F.2d 5, 6-7 (1st Cir. 1982). At step one, the
Commissioner determines whether the claimant is currently engaged in “substantial gainful
activity.” If so, the claimant is not disabled. 20 C.F.R. § 404.1520(b). At step two, the
Commissioner determines whether the claimant has a medically severe impairment or combination
of impairments. 20 C.F.R. § 404.1520(c). If not, the disability claim is denied. At step three, the
Commissioner must decide whether the claimant’s impairment is equivalent to a specific list of
impairments contained in the regulations’ Appendix 1, which the Commissioner acknowledges are
so severe as to preclude substantial gainful activity. 20 C.F.R. § 404.1520(d); 20 C.F.R. § 404,
Subpt. P, App. 1. If the claimant’s impairment meets or equals one of the listed impairments, he is
conclusively presumed to be disabled. If not, the ALJ assesses the claimant’s RFC, which is used
at steps four and five. An individual’s RFC is his ability to do physical and mental work activities
on a sustained basis despite limitations from his impairments. 20 C.F.R. § 404.1520(e) and
404.1545(a)(1). The ALJ determines at step four whether the impairments prevent the claimant
from doing the work he has performed in the past. If the claimant is able to perform his previous
work, he is not disabled. 20 C.F.R. § 404.1520(f). If he cannot perform this work, the fifth and
final step asks whether the claimant is able to perform other work available in the national economy
in view of his RFC, as well as his age, education, and work experience. If the claimant cannot,
then he is entitled to disability benefits. 20 C.F.R. § 404.1520(g).

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At steps one through four, the claimant has the burden of proving he cannot return to his
former employment because of the alleged disability. Rosario v. Secretary of Health & Human
Services, 944 F.2d 1, 5 (1st Cir. 1991). Once a claimant has done this, the Commissioner has the
burden under step five to prove the existence of other jobs in the national economy the claimant
can perform. Ortiz v. Secretary of Health & Human Services, 890 F.2d 520, 524 (1st Cir. 1989).
Additionally, to be eligible for disability benefits, the claimant must demonstrate that his
disability existed prior to the expiration of his insured status, or his date last insured. Cruz Rivera
v. Secretary of Health & Human Services, 818 F.2d 96, 97 (1st Cir. 1986).
BACKGROUND
The following is a summary of the treatment record, consultative opinions, and selfreported symptoms and limitations as contained in the Social Security transcript (“Tr.”).
Ramos was born on December 16, 1971, does not understand the English language
(communicates in the Spanish language), completed high school, and worked as a carpenter
(medium work, semi-skilled). Ramos applied for disability insurance benefits, claiming to be
disabled since October 3, 2014 (onset date) at age 421 due to low back and cervical spine pain,
blurred left-eye vision, a thyroid condition, and a severe psychiatric condition. Ramos met the
insured status requirements of the Act through March 31, 2018. Tr. 58, 336, 348, 368-369, 483484, 494-495.
Treating Sources
State Insurance Fund
Ramos was treated for lower back pain under the auspices of the State Insurance Fund
(“SIF”) from July 2000 to November 2003. Most notes are illegible. Medications and physical
therapy were prescribed. Tr. 91-124, 567-595.
At initial interview on July 18, 2000, Ramos reported having felt a strong pain in his lower
back while lifting steel scaffolding. Tr. 112, 586. A July 27, 2000 lumbosacral spine x-ray showed
negative results. The intervertebral disc spaces and vertebral bodies height were well maintained.
Bony alignment was intact. No bony lesions or fractures were noted. Tr. 111-112, 585-586. Notes
from August to November 2000 show treatment for a lumbosacral sprain. Ramos reported pain in

1

Ramos was considered to be a younger individual (Tr. 29), and “[i]f you are a younger person
(under age 50), we generally do not consider that your age will seriously affect your ability to adjust to
other work.” 20 C.F.R. 404.1563(c).

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his lower back and left leg when raising it. He showed limited flexion and extension. He reported
that the medication did not ease the pain. Tr. 104-110, 124, 579-584, 595.
October 2000 progress notes also show a diagnosis of iliolumbar myositis. He showed a
mild shortening in his hamstrings. Gait was normal. SLR test was at 90 degrees bilateral on
October 22 and at 80 degrees bilateral on October 27. On October 2, Ramos complained of constant
pain in his lower back, which got worse with force exertion. He took medication daily because he
felt constant pain. He was sensitive to pressure in the sacral-coccyx area. There was no spasm in
the paravertebral-lumbar region. He could squat. Ramos felt better on October 27 and was taking
less medication but complained of discomfort in the coccyx area during prolonged sitting. Tr. 122123, 593-594
In January 2001, Ramos reported feeling a stabbing sensation in the coccyx area when he
slept on his left side. He showed a mild shortening in his hamstrings, a normal gait, and no pain at
pressure or spams in the lumbosacral area of the coccyx. Straight Leg Raise (“SLR”) test was
positive on both sides at 90 degrees. Tr. 118, 590.
Notes indicate that Ramos finished physical therapy in February 2001 but still felt pain.
Ramos was referred to a neurosurgeon. A March 27, 2001 MRI of the lumbosacral spine showed
herniated discs (herniated nucleus pulposus or “HNP”) at the L5-S1 level, which appeared to be
impinging on the thecal sac and dorsal root. In March, April and May 2001, Ramos felt pain with
swelling in his lower back radiating to his left leg. Sensation was diminished in his left side and
big toe. SLR test was positive. Tr. 98-103, 114, 573-578, 588.
A note from December 2002, indicates a diagnosis for HNP at the L5-S1 level, and that
Ramos came in with pain but his range of motion was complete and he had no spasms. Tr. 93, 596.
In October 2003, Ramos reported pain on the right side of his back, radiating to his left and
foot, and pain and muscle spasm at flexion of his right lateral trunk. Ramos was administered
Toradol 60 mg and Kenalog 40 mg. He was also prescribed medications (Neurontin, Skelaxin). Tr.
97, 572.
On November 13, 2003, he was referred to receive physical therapy for his lower back
pain. Prognosis was fair. Tr. 94-95, 570.

2

Progress note translation incorrectly states 2001. The original progress note states “2 octubre
2000.” Tr. 123, 594.

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Ponce Health Sciences University
From November 2010 to April 2017, Ramos was treated for major depression, recurrent.
Medications were prescribed. Tr. 168-183, 287-307, 316-335, 641-656, 810-830, 874-893.
A psychiatric evaluation dated September 17, 2013 indicates that Ramos had been
receiving treatment for more than ten years. He was cooperative, logical, coherent, and relevant.
Ramos claimed to sometimes having visual hallucinations but denied having suicidal or homicidal
ideas. His Global Assessment of Functioning (“GAF”) score was 60. Tr. 169-170, 642-643, 655.
Ramos’s mood in November 2010 was check-marked as depressed. His attitude was
cooperative, and his motor activity was calm. His affect was appropriate. He showed no cognitive
difficulties. His thought process was intact, and he showed no suicidal or homicidal thoughts.
There is a rectangle drawn around the word hallucinations in this progress note. GAF score was at
80. Tr. 183, 656.
Progress notes from February 2011, December 2012, June 2013, September 2014, and
January 2015 show that Ramos’s attitude was cooperative. His mood was euthymic, and his affect
was appropriate. He showed no cognitive difficulties, and his thought process was intact. He
showed no suicidal or homicidal thoughts, psychosis, or obsessions. His insight, judgment, and
reliability were good. GAF score wat at 65. Tr. 171-172, 177, 179, 182, 644-645, 650, 652.
A psychiatric evaluation dated September 17, 2013 indicates that Ramos’s main complaint
was anxiety and hallucinations. He indicated undergoing treatment for more than ten years. He
was approachable, cooperative, affable, organized, logical, coherent, and relevant. He sometimes
had visual hallucinations. He denied having homicidal or suicidal thoughts. His GAF score was at
60. Tr. 306-307, 829-830.
Progress notes from November 2014 show that his mood was depressed and anxious, his
speech was slow, and he had cognitive difficulties in attention. Tr. 173, 646.
Notes from January, April, July, and October 2015 indicate that Ramos was cooperative
and calm. His mood was euthymic, his affect appropriate, his speech normal, and his thought
process intact. He had no cognitive difficulties. He had no suicidal or homicidal ideas or psychosis.
His insight, judgment, and reliability were good. His condition was stable. His GAF score was at
65. Tr. 812-815.

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Ramos continued treatment at the University’s Wellness Center from January 2016 to April
2017 for major depressive disorder, recurrent, severe with psychotic symptoms. Medications
(Ativan, Paxil, Risperdal, Trazodone) were prescribed. Tr. 316-335, 874-893.
Notes from January 2016 show that Ramos was cooperative, calm, with a euthymic mood,
appropriate affect, normal speech, intact thought process, and no suicidal or homicidal thoughts or
psychosis. He showed cognitive difficulties in his short-term memory. His insight, judgment, and
reliability were fair. Tr. 893.
Notes from April 2016 indicate that his mood was anxious and he had auditive
hallucinations. Tr. 879. Notes from October 2016, and January and April 2017 indicate that his
attitude was alert and cooperative, his motor activity was calm, his mood was euthymic, and his
affect was appropriate. There was no perceptual distortion. He did not have hallucinations, or
suicidal or homicidal thoughts. He acknowledged his problem (had insight), and had adequate
judgment and impulse control, and appropriate self-esteem. He was open to and could relate to his
interviewer. Tr. 875-876, 883-884, 889. Notes from January and April 2017 also indicate that
Ramos’s condition was stable. Ramos was asymptomatic with therapy. He denied having suicidal
or homicidal ideation. He understood to immediately seek medical attention if his physical or
emotional status deteriorated. He was oriented to avoid operating machinery or motor vehicles
while under the influence of his medications. Tr. 884, 890.
Ponce Advance Medical Group
Ramos was treated by Dr. Norma Santos at the Ponce Advance Medical Group for low
back pain, herniated lumbar disc, and hypothyroidism from January 2013 to July 2017.
Handwritten notes are mostly illegible. Medications and physical therapy were prescribed. Ramos
was also frequently administered intramuscular injections. In 2013, he was injected two to three
times monthly, about every other month. The record also reflects referrals for evaluation by an
endocrinologist, rheumatologist, physiatrist, and ophthalmologist. Tr. 125-167, 192-218, 233-286,
598-640, 720-741, 756-801.
A lumbosacral spine CT scan dated February 17, 2014, performed by Dr. Jorge Torres (“Dr.
Torres”), reveals minimal central protrusion of the nucleus pulposum at the C3-C4 and C4-C5
level, causing compression of the thecal sac. Nerve roots appeared to be normal. The rest of the
intervertebral disc spaces were preserved. Facet joints were normal and the surrounding soft tissues
were within normal limits. Tr. 130, 596, 603. An x-ray also showed evidence of central protrusion

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of the nucleus pulposum at the L5-S1 level, causing compression of the thecal sac and nerve roots.
The same goes as to the L2-L3, L3-L4, and L4-L5 levels, but with minimal compression of the
thecal sac. Tr. 206, 732.
A cervical spine CT scan dated October 1, 2014 revealed central protrusion of the nucleus
pulposum at the L2-L3, L3-L4, L4-L5, and L5-S1 level, causing compression of the thecal sac.
There was also compression of the nerve roots at the L5-S1 level. Tr. 597.
On October 29, 2014, neurosurgeon Dr. Ramón Del Prado evaluated Ramos and found that
the neurological exam showed no evidence of chord or nerve compression. He recommended
physical therapy, but not surgery. Tr. 268, 783.
A cervical MRI dated May 8, 2015, revealed significant disc herniation at C3-C4 with
cervical cord impingement and, to a lesser extent at C4-C5. Tr. 196, 691, 724, 801. Lumbar MRI
revealed degenerative facet joint changes and small central and left-sided disc herniation at L5-S1.
Tr. 197, 690, 725, 800.
A CT scan of the lumbosacral spine from February 2016 revealed evidence of central and
lateral protrusion of the nucleus pulposum at the L5-S1 level , causing compression of the thecal
sac and nerve roots. There was also evidence of narrowing of the intervertebral disc space and
degenerative changes of the facet joints. Tr. 847-848.
A thoracic CT dated June 2017 shows focal left-sided osteophytosis of the posterior
vertebral endplates at T8-T9 impinging the spine, and mild thoracic central spinal canal stenosis
at T10-T11 and T11-T12. Tr. 900.
There is also evidence of treatment for hypothyroidism and gastritis from November 2013
to September 2015 by endocrinologist Dr. Ismael Rodríguez upon referral from Dr. Santos, but the
handwritten notes are illegible. An ultrasound of the thyroid gland at Tr. 222, dated May 5, 2015
revealed that it was normal bilaterally in the upper limits, with an inhomogeneous echogenicity,
suggestive of goiter. Bilateral nodules suggested benign nodules. This portion of the record
contains a lot of lab results. Tr. 219-284, 742-801. A progress note from June 2014 indicates that
Ramos visited Dr. José Torres-Vega, gastroenterologist, who prescribed medications for gastritis.
Tr. 267.
Dr. José Torres-Vega
Dr. José Torres-Vega, gastroenterologist, treated Ramos from October 2013 to July 2017
for gastroesophageal reflux disease (“GERD”), irritable bowel syndrome (“IBS”), HNP,

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hypothyroidism, hyperglycemia, glaucoma, and ocular infarction. Ramos was placed on a high
fiber diet and his conditions were controlled with medications. Notes from 2015 indicate that
Ramos was doing well. Notes from 2016 indicate that Ramos is well while taking his medications.
Tr. 657-689, 908-916.
Dr. José Vázquez-Díaz and Dr. Noel De León
Ramos was examined by ophthalmologist Dr. José Vázquez from January to October 2015
(Tr. 802-809) and by retinologist Dr. Noel De León from February to December 2016. This
evidence consists of progress notes with numbers and medical abbreviations and eye imaging
results, unintelligible to the lay person. Tr. 849-899. The record indicates that on January 2015,
Ramos reported seeing blurry through his right eye. Tr. 266. There is a diagnosis for central retinal
vein occlusion and glaucoma by ophthalmologist Dr. Vázquez. Tr. 255, 260-264.
Procedural History
On March 17, 2015, Ramos applied for disability insurance benefits claiming to be disabled
since October 3, 2014 (Tr. 18, 483) and filed a function report, describing the effects of severe pain
in his cervical area, shoulders, and back. His legs and feet would get numb. He could not apply
strength or hold objects. He had lost vision in his left eye. He was depressed, anxious, and in low
spirits. Ramos reported that due to his conditions, he could not squat, bend, reach, lean, stand, sit,
or walk for long periods. He could lift ten pounds or less. He could walk one block and needed to
rest for five to ten minutes before resuming walking. Also, Ramos claimed he could not remember,
concentrate, or sleep well, and had difficulty following instructions and handling changes in his
routine. He would forget spoken instructions quickly and had to read written instructions several
times. Ramos got along well with authority figures. He handled stress with medications and by
being alone. Ramos also claimed seeing shadows. Tr. 72-78, 517-523.
As to daily activities, Ramos ate his meals and took his medications, and spent his days
lying down or watching television. His wife helped him with his personal care (dress, bathing,
shaving). He needed to be motivated and reminded to take care of his needs, including medication
intake. He did not cook, do house or yard work, go shopping, or socialize. He went out three to
four times a month for medical appointments and could get around in a car but did not drive. He
could count change but not pay bills, handle a savings account or use a checkbook because he had
problems remembering and concentrating. Tr. 73-77, 518-522.

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The Disability Determination Program (“DDP”) referred the case to clinical psychologist
Dr. Mariela León for a consultative psychological evaluation. Dr. León diagnosed on July 7, 2015
major depressive disorder, recurrent, with psychotic features. Prognosis was reserved. Dr. León
noted that during the interview, Ramos exhibited moderate signs of depression. He was calm and
cooperative during the evaluation, and his speech was coherent, relevant, and spontaneous. He was
oriented in time, place, person, and circumstances. Ramos established a good rapport and showed
effort in giving details about his medical and working history, and mental status. His psychomotor
activity was adequate. There was no evidence of disorganization of thought process, ideas of
reference, delusions, or suicidal or homicidal tendencies. Upon memory testing, his immediate and
recent memory were good, and his short-term and long-term memory were excellent. His attention
and concentration level and intellectual ability were excellent. Social judgment, however, was
poor, and his mental health condition presented a severe impairment in social, occupational, and
interpersonal functioning. Tr. 184-191, 692-699.
The case was also referred to Dr. David Blas for a consultative neurological evaluation of
Ramos’s chronic thoracic and lumbar musculoskeletal pain. Dr. Blas reported on July 17, 2015
that Ramos was alert, relevant, coherent, cooperative, and oriented in place, person, and time. He
had good recent and past memory. Ramos showed normal motor and sensory functions. Ramos’s
spine showed no deviations. There was tenderness to palpation over the shoulders and thoracic and
lumbar paraspinal muscles. Some ROM lumbar restrictions were present. Gait was normal. He did
not favor a leg or limp and could stand over heels and toes. Lumbar spine flexion was at 65 (on a
scale of 0-90). SLR test was negative. Tests for pathological reflexes in his hands (Babinski, Tinel,
Phalen) were negative. Hand muscle strength was four out of five. Sensory functions were normal
(intact to soft touch, pin prick, vibration, and proprioception). Dr. Blas assessed that Ramos’s
physical exam was remarkable for subtle bilateral hand weakness and tenderness to palpation over
shoulders, thoracic, and lumbar paraspinal muscles. Ramos could sit, stand, walk, and travel. He
could also handle and lift common objects. Ramos could bilaterally grip, grasp, pinch, finger tap,
oppose fingers, button a shirt, pick up a coin, and write. Tr. 700-708.
The case was referred to Dr. Luis Umpierre, non-examining psychologist, for a mental RFC
assessment. After considering Ramos’s severe condition and allegations under listing 12.04 for
affective disorders, Dr. Umpierre assessed on August 17, 2015 that based on the evidence in record,
Ramos retained the RFC for simple, unskilled tasks. He could learn, understand, remember, and

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execute simple and detailed instructions; maintain attention and concentration for at least two-hour
periods with minimal interruptions due to his depressed mood; could perform at a consistent pace;
could adjust to changes in work routines and environments; and could interact with public, coworkers, and supervisors. Tr. 341, 344-347, 367.
Under paragraph “B” criteria of listing 12.04, Dr. Umpierre found that Ramos had a mild
restriction of activities of daily living; mild difficulties in maintaining social functioning; moderate
difficulties in maintaining concentration, persistence, or pace; and no repeated episodes of
decompensation, each of extended duration. Tr. 341, 361.
The case was also referred to Dr. Pedro Nieves, non-examining physician, for an internist
evaluation. Dr. Nieves considered listing 1.04 for spine disorders and assessed on August 20, 2015
that the alleged effect of Ramos’s impairments was not supported by the medical evidence. The
record showed Ramos had normal gait, no foot drop or limping, no radicular signs, and normal
motor strength of the extremities. Ramos retained the physical RFC for a full range of light work.
Ramos could occasionally 3 lift and/or carry (including upward pulling) twenty pounds, and
frequently4 ten pounds; stand and/or walk with normal breaks for a total of about six hours in an
eight-hour workday; sit with normal breaks for a total of about six hours; push and/or pull
unlimitedly, including operation of hand or foot controls; frequently climb ramps, stairs, ladders,
ropes, or scaffolds; frequently balance, kneel, crouch or crawl; and occasionally stoop. Ramos did
not have manipulative, visual, communicative, or environmental limitations. Tr. 341, 343-344,
714.
Ramos’s claim for disability benefits was denied on August 21, 2015. Tr. 50, 349-350, 374.
Ramos requested reconsideration of the initial denial, claiming that all his conditions
worsened, and reiterated what he reported in his first function report. Tr. 80-87, 353, 378, 525-542.
In a pain questionnaire dated October 5, 2015, Ramos described his neck, shoulders and
low back pain as constant, acute, and pulsing, and lasting all day. The cervical pain radiated to his
arms and shoulders, and his back pain radiated to his hips and legs. His legs would go numb and
moving or standing for too long worsened the pain. The pain had changed within the last twelve
months in that it was worse and now he also felt pain in the genital area. He reported that his pain

3
4

“[O]ccasionally is cumulatively 1/3 or less of an 8 hour day.” Tr. 343.
“[F]requently is cumulatively more than 1/3 up to 2/3 of an 8 hour day.” Tr. 343.

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medications (Tramadol and Sulindac), and use of hot pads and ointments, were not very effective.
Tr. 88-89, 543-544.
The case was referred to Dr. Jennifer Cortés for a non-examining psychiatric evaluation.
On November 4, 2015, Dr. Cortés found that the medical evidence presented did not constitute a
base to add mental limitations and affirmed the initial RFC assessment as written. Tr. 361-362,
367.
Dr. José González-Méndez, non-examining internist, affirmed the physical RFC as well.
Tr. 363-364, 369, 833.
The case was also referred to Dr. Gary Spitz for a special sense review of Ramos’s alleged
visual impairment, who assessed on November 10, 2015 that Ramos’s impairment was non-severe.
Tr. 360-361, 835.
On November 12, 2015, the case was denied on reconsideration, with a finding that the
previous determination denying Ramos’s claim for disability benefits was correct. Claimant
retained the RFC for light work. Tr. 54, 368-369, 379.
At his request (Tr. 427), a hearing before ALJ Gerard Picó was held on August 11, 2017.
Ramos and vocational expert (“VE”) Alina Kurtanich testified.5 Tr. 36-49.
Ramos testified that he worked for seventeen years as a carpenter, but towards the end of
that period, everything hurt, and he felt like he couldn’t do the job anymore. His back started
hurting first, followed by his arm, wrist, shoulders and neck. He was injected in the cervical area
and prescribed medications for the pain. His medications did not help him much and he felt
constant pain. He visited his attending physicians every three months or when needed. At home,
he walked around the house and watched television, and sometimes helped his children water the
plants. He didn’t leave the house much. He also walked with pain, so he was limited to walking
short distances and leaned on walls to rest a bit before continuing forth. He could lift about a halfgallon of milk, but not overhead. He did not have much strength in his hands. He could not drive.
Tr. 39-45.
The ALJ offered to the VE that the claimant was a carpenter, with a vocational profile of
four, semi-skilled position, medium work. The ALJ asked if a hypothetical person with claimant’s
vocational profile and the following limitations could work: lift, carry, or raise twenty pounds
5

The hearing was held by video. Ramos appeared in Ponce, Puerto Rico. The ALJ presided from
Columbia, Missouri. Tr. 18.

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occasionally and ten pounds frequently; six for six hours in an eight-hour workday; stand and/or
walk six hours; frequently climb ladders and ramps; frequently balance himself, kneel, crouch, and
crawl; but occasionally bend down. The VE answered that there was work in the national economy
that such a person could do with a vocational profile of two, unskilled position, light work, such
as cleaner, inspector and hand packager, and garment sorter. Tr. 45-46.
The VE was then asked if such a person could work if he could additionally learn,
understand, remember, and carry out simple and detailed instructions; maintain attention and
concentration for two-hour periods; and interact with co-workers and supervisors, but only
occasionally with the public. The VE answered that he could perform the jobs mentioned. The VE
added that such a person was limited to standing and walking for four hours of the eight-hour
workday. The VE answered that he could perform the sorter and inspector and hand packager jobs,
but not the cleaner job, and that with the four-hour limitation he could also be an electronics
worker. Tr. 46-47.
Counsel for Ramos asked the VE if a person that could not bend forward, needed at least
two additional breaks during the day due to pain, and could interact for less than an hour in a
workday with supervisors, co-workers, and clients, could work. The VE answered that there would
be no jobs for such a person. Counsel also asked if this person could work if he could occasionally
be in contact with supervisors and co-workers, but never clients, and needed two additional breaks
at a minimum of thirty minutes each to rest. The VE answered that there would be no jobs for him
to perform. Tr. 47-48.
On November 3, 2017, the ALJ found that Ramos was not disabled under sections 216(i)
and 223(d) of the Act. Tr. 12-35. The ALJ sequentially found that Ramos:
(1) had not engaged in substantial gainful activity since his alleged onset date (Tr. 20);
(2) had a severe impairments which caused more than minimal functional limitations in his
ability to perform basic work activities as required by SSRs 85-28 (L5-S1 central and lateral
protrusion of the nucleus pulposum, causing compression of the thecal sac and nerve roots,
osteophytosis of the posterior vertebral endplates at T8-9 impinging the spinal cord, central spinal
canal stenosis at T10-11, and depression (Tr. 20);
(3) did not have an impairment or combination of impairments that met or medically
equaled the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 CFR
404.1520(d), 404.1525, 404.1526) (Tr. 21);

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(4) retained the RFC to perform light work as defined in 20 C.F.R. 404.1567(b) except he
could lift and carry twenty pounds occasionally and ten pounds frequently; stand and/or walk four
hours and sit six hours in an eight-hour workday; frequently climb ramps, stairs, ladders, ropes,
and scaffolds; frequently balance, kneel, crouch, or crawl; occasionally stoop or bend; frequently
reach above shoulder level; able to use judgment to understand, remember, and carry out simple
and detailed instructions; maintain concentration and attention for two-hour periods; and
frequently interact with co-workers and supervisors, and occasionally with the public (Tr. 24).
Therefore, he could not perform past relevant work (Tr. 29); but
(5) as per his age, education, work experience, and RFC, there was work that existed in
significant numbers in the national economy that Ramos could perform, such as inspector and hand
packager, garment sorter, and electronics worker. Tr. 29-30.
The ALJ considered Ramos’s other conditions, including hypertension, diabetes mellitus,
hypothyroidism, GERD, IBS, and decreased left eyesight, and found that these conditions were
either controlled with treatment or that there was insufficient evident to establish severe
impairments related to them. Tr. 20-21.
The ALJ considered at step three listings 1.04, 4.02, and 9.08. As to listing 12.04 for
depressive, bipolar, and related disorders, the ALJ found that Ramos’s condition did not satisfy the
“paragraph B” or “C” criteria. Ramos had a mild limitation in understanding, remembering, or
applying information. He showed no difficulties understanding and answering questions at the
hearing, and the mental examinations contained in the record showed intact cognitive functioning.
Ramos’s ability to provide appropriate and relevant information to physical and mental examiners
and during his testimony, and the record documents indicates he has adequate ability to perform at
least simple, routine, and repetitive tasks, and to use reason and judgment to make work-related
decisions in performing those tasks. Tr. 21-22.
Ramos was moderately limited in interacting with others. Ramos had anxiety problems that
could affect his ability to relate and interact with co-workers, but he appropriately interacted with
the ALJ at the hearing and with his medical examiners, and reported having had a good relationship
with his family, friends and neighbors. Tr. 22.
Ramos had moderate limitation with his ability to concentrate, persist, or maintain pace.
He was able to stay focused at the hearing, and exams showed that he was oriented and had intact
cognitive findings (concentration, memory, attention, thought process, thought content, and insight

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and judgment). Ramos therefore had the cognitive ability to focus on work activities and
understand and do things in a consistent and timely manner. Tr. 22-23, 27. The ALJ discounted
reports of difficulty with short-term memory, attention, and anxiety because these symptoms were
not reported in the mental exams conducted by his treating doctors. Tr. 23.
Ramos had mild limitations in his ability to adapt and manage himself. Tr. 23.
As to “paragraph C” criteria, the ALJ found that the record did not contain evidence that
Ramos relied on medical treatment, mental health therapy, psychosocial supports, or highly
structured settings to diminish symptoms. Tr. 23.
The ALJ further found that claimant’s medically determinable impairments could
reasonably be expected to cause the alleged symptoms, but his statements about intensity,
persistence, or limiting effects were inconsistent with the medical evidence. Physical exam
findings were unremarkable and exams from 2013 through 2014 lacked ROM, sensory, motor
strength, or deep tendon reflex findings that supported a disabling impairment. Records from 2014
through 2017 showed continuous treatment for his low back pain and other conditions, normal
neurological findings, and normal findings of the extremities and eyes. Tr. 25. The record also
contained many spine findings, but these were not significant or disabling. Tr. 26. Endocrine
problems were stabilized with medications. Tr. 27.
The ALJ assigned great weight to the state consultants Dr. Nieves’s and Dr. González’s
physical RFC assessments because these were consistent with the record as a whole. Tr. 27-28.
The ALJ gave little weight to state consultative examiner Dr. Blas’s opinion that Ramos could sit,
stand, walk, travel, and handle and lift common objects because the spine symptoms and diagnostic
findings supported at least a light work limitation. Tr. 28. The ALJ gave some weight to state
consultative examiner Dr. León because his assessment that Ramos had a severe impairment in
social, occupational, interpersonal, and other areas of functioning was not supported by the record.
Tr. 28.
On March 2, 2019, the Appeals Council denied Ramos’s request for review, rendering the
ALJ’s decision the final decision of the Commissioner. Tr. 1, 8, 478-482. The present complaint
followed. Docket No. 1.
DISCUSSION
Ramos claims that the ALJ failed to properly evaluate the medical evidence and gave less
weight to portions of the consultative clinical psychologist Dr. León’s report, and did not assign

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15

weight to the opinions of the treating sources or medical evidence, ultimately resulting in an
unsupported RFC assessment.
As to Ramos’s arguments regarding weight of the evidence, that discretion lies with the
ALJ. While a claimant is responsible for providing the evidence of an impairment and its severity,
the ALJ is responsible for resolving any evidentiary conflicts and determining the claimant’s RFC.
20 C.F.R. § 404.1545(a)(3); see also Tremblay v. Sec’y of Health & Human Servs., 676 F.2d 11, 12
(1st Cir. 1982). It was therefore the ALJ’s duty to weigh all the evidence and make certain that the
ALJ’s conclusion rested upon clinical examinations as well as medical opinions. Rodríguez v. Sec’y
of Health & Human Servs., 647 F.2d 28, 224 (1st Cir. 1981). Regulations provide that the opinion
of a treating physician is presumed to carry controlling weight as long as it is well-supported by
medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with
other substantial evidence in the record. Diagnostic evidence does not receive an assigned weight,
only medical opinions. 20 C.F.R. § 404.1527(c)(2).
In my review of the record, it is evident that the ALJ considered Ramos’s complaints, and
evidence from the treating, consultative, and non-examining physicians. The ALJ’s decision does
not contain a specific weight assigned to the evidence from the treating sources, but the ALJ
summarized, analyzed, and considered those records at Tr. 20-27. Ramos’s argument that the ALJ
did not consider this evidence is without merit. The ALJ’s lengthy summary of the treating,
examining, and consultative opinions, and the ALJ’s explanations of how these played into the
RFC assessment, are sufficient to give the court notice of the treatment given to those medical
opinions in the RFC assessment and final non-disability determination.
Moving on to the RFC finding analysis, the ALJ determined that through the date last
insured, and based on the record evidence, Ramos retained the RFC to perform light work, except
he could lift and carry twenty pounds occasionally and ten pounds frequently; stand and/or walk
four hours and sit six hours in an eight-hour workday; frequently climb ramps, stairs, ladders,
ropes, and scaffolds; frequently balance, kneel, crouch, or crawl; occasionally stoop or bend;
frequently reach above shoulder level; able to use judgment to understand, remember, and carry
out simple and detailed instructions; maintain concentration and attention for two-hour periods;
and frequently interact with co-workers and supervisors, and occasionally with the public. The
hearing transcript shows that this RFC finding was used by the ALJ to pose the hypothetical
questions to the VE.

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Where, as here, an ALJ reaches step five of the sequential evaluation process, the burden
of proof shifts to the Commissioner to show that a claimant can perform work other than her past
relevant work. Ortiz, 890 F.2d at 524. The record must contain positive evidence to support the
Commissioner’s findings regarding the claimant’s RFC to perform such other work. See Rosado
v. Secretary of Health & Human Servs., 807 F.2d 292, 294 (1st Cir. 1986). An RFC assessment is
“ultimately an administrative determination reserved to the Commissioner.” Cox v. Astrue, 495
F.3d 614, 619 (8th Cir. 2007) (citing 20 C.F.R. §§ 416.927(e)(2), 416.946). But because “a
claimant’s RFC is a medical question, an ALJ’s assessment of it must be supported by some
medical evidence of the claimant’s ability to function in the workplace.” Id. Also, when
determining which work-related limitations to include in the hypothetical question, the ALJ must:
(1) weigh the credibility of a claimant’s subjective complaints, and (2) determine what weight to
assign the medical opinions and assessment of record. See 20 C.F.R. §§ 404.1527, 404.1529.
The record contains a lengthy history of treatment for physical and mental conditions that
do not support Ramos’s claims of disability. Based on the evidence contained in the record up to
the decision date, as discussed below, I find that there is substantial evidence to support the ALJ’s
RFC finding.
Evidence of low back pain dates to 2000, with treatment from the SIF. Treatment at the SIF
ended in 2003, and there is a gap in the evidence until 2013. Ramos continuously suffered from
low back pain, which was treated with medications and physical therapy, with no worsening. CT
scans and MRIs of the spine from 2014 on consistently showed in different areas of the spine
protrusion of the nucleus pulposum which caused compression of the thecal sac, degenerative facet
joint changes, and disc herniation. Surgery was not recommended. At all times throughout the
record, Ramos was observed walking with a normal gait. Dr. Blas assessed that Ramos could sit,
stand, walk, and travel. He could also handle and lift common objects. Ramos could bilaterally
grip, grasp, pinch, finger tap, oppose fingers, button a shirt, pick up a coin, and write.
The evidence related to Ramos’s thyroid problems were mostly contained in illegible
handwritten notes and lab work or exams, but in sum appear to indicate that these conditions were
being controlled by medications. Dr. Torres, gastroenterologist, noted in 2015 and 2016 that Ramos
did well while taking medications. As to Ramos’s vision, Dr. Spitz assessed that Ramos’s visual
impairment was non-severe.

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17

As to Ramos’s mental conditions, to satisfy the “paragraph B” criteria of listing 12.04, a
claimant’s disorder must result in an extreme limitation of one area, or marked restrictions in two
of the following broad areas of functioning: understanding, remembering, or applying information;
interacting with others; concentrating, persisting, or maintaining pace; or adapting or managing
themselves. A marked limitation is when the claimant’s ability to function independently,
appropriately, effectively, and on a sustained basis is seriously limited. An extreme limitation is
the inability to function independently, appropriately, or effectively, and on a sustained basis.6 Tr.
21. The record does not show marked or extreme limitations in any area.
The treatment record from the Ponce School of Medicine and Ponce Health Sciences
University, from 2010 to 2017, and Dr. León’s consultative examination show that while Ramos
was depressed, his conditions did not impede him from working. At some point in 2010, 2013, and
2016 he reported having hallucinations, and having an instance in 2016 of cognitive difficulties in
his short-term memory. However, overall, the record reflects a person whose attitude was alert and
cooperative. He was oriented in time, place, person, and circumstances. His psychomotor activity
was adequate. His mood was euthymic, and his affect was appropriate. There was no perceptual
distortion. He did not have suicidal or homicidal thoughts. He acknowledged his problem (had
insight), had adequate judgment and impulse control, and appropriate self-esteem. Dr. León noted
that his memory was good, and his attention and concentration level and intellectual ability were
excellent. Dr. Blas, consultative neurological examiner, also noted that Ramos’s memory was
good, and that he was alert, relevant, coherent, cooperative, and oriented. Dr. León also assessed

6

In the five-point rating scale contained in 20 C.F.R., Pt. 404, Subpt. P, App. 1, 12.00 Mental Disorders,
the effects of a mental disorder are evaluated on each of the four areas of mental functioning based on a
five-point rating scale consisting of none, mild, moderate, marked, and extreme limitation. “To satisfy the
paragraph B criteria, your mental disorder must result in extreme limitation of one, or marked limitation
of two, paragraph B areas of mental functioning. The five rating points are:
a. No limitation – A claimant is able to function in this area independently, appropriately, effectively, and
on a sustained basis.
b. Mild limitation – A claimant’s functioning independently, appropriately, effectively, and on a sustained
basis is slightly limited.
c. Moderate limitation – Functioning in this area independently, appropriately, effectively, and on a
sustained basis is fair.
d. Marked limitation – Functioning in this area independently, appropriately, effectively, and on a
sustained basis is seriously limited.
e. Extreme limitation – A claimant is not able to function in this area independently, appropriately,
effectively, and on a sustained basis.

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18

that his social judgment was poor but notes overall show he was open to and could relate to his
interviewers. Notes from 2017 confirm that Ramos’s condition was stable and was asymptomatic
with therapy.
The treatment record also contains GAF scores of above 60.7 I note that the ALJ did not
use the GAF scores in his findings, but in conjunction with other evidence discussed above, they
add support to the non-disability findings of Ramos’s mental condition. “GAF is a scale from 0 to
100 used by mental health clinicians and physicians to subjectively rate the social, occupational,
and psychological functioning of adults.’” Hernández v. Comm’r of Soc. Sec., 989 F. Supp. 2d 202,
206 n. 1 (D.P.R. 2013) (quoting Am. Psychiatric Ass’n, Diagnostic and Statistical Manual of
Mental Disorders-IV 32 (4th ed. text rev. 2000) (“DSM–IV–TR”)). A GAF score between 51 and
60 indicates ‘moderate symptoms’ or ‘moderate difficulty in social occupational, or school
functioning.’” Hernandez v. Comm’r of Soc. Sec., 989 F. Supp. 2d 202, 206 f.n. 1 (D.P.R.
2013)(quoting Am. Psychiatric Ass’n, Diagnostic and Statistical Manual of Mental Disorders 32
(4th ed. text rev. 2000) (DSM–IV–TR)). “A GAF score of 61-70 indicates: ‘Some mild
symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational,
or school functioning (e.g., occasional truancy, or theft within the household), but generally
functioning pretty well, has some meaningful interpersonal relationships.’ DSM-IV at 34.” Lopez
v. Colvin, No. 15-cv-30200-KAR, 2017 U.S. Dist. LEXIS 49183, at f.n. 5 (D. Mass. Mar. 31,
2017).
Ultimately, it is the Commissioner’s responsibility to determine issues of credibility, draw
inferences from the record evidence, and resolve conflicts in the evidence (see Ortiz, 955 F.2d at
769 (citing Rodriguez v. Sec’y of Health & Human Servs., 647 F.2d 218, 222 (1st Cir. 1981);
Evangelista v. Sec’y of Health & Human Servs., 826 F.2d 136, 141 (1st Cir. 1987)). After
thoroughly and carefully reviewing the record, I find that there is substantial evidence to support
the ALJ’s RFC finding. The decision is therefore affirmed.
7

The SSA’s administrative memorandum AM-13066 advises adjudicators that a GAF score should
not be dispositive of impairment severity. GAF scores were discontinued in the current Diagnostic and
Statistics Manual of Mental Disorders (5th edition) (“DSM-V”), which was published in 2013, but were still
part of the DSM-IV-TR during part of Ramos’s treatment. Because the GAF scores are no longer used in
the DSM-V, the SSA directed adjudicators through the AM-13066 to continue receiving and considering
GAF scores as they would with other opinion evidence, but that the score must have supporting evidence
to be given significant weight. Valentín-Incle v. Comm'r of Soc. Sec., Civ. No. 15-2137 (MEL), 2018 U.S.
Dist. LEXIS 215060, 2018 WL 6721340, at *10 n.2 (D.P.R. Dec. 19, 2018) (citations omitted).

Ramos v. Commissioner of Social Security, Civil No. 19-1305 (BJM)

CONCLUSION
For the foregoing reasons, the Commissioner’s decision is AFFIRMED.
IT IS SO ORDERED.
In San Juan, Puerto Rico, this 31st day of March, 2021.

s/Bruce J. McGiverin
BRUCE J. MCGIVERIN
United States Magistrate Judge

19