REPORT AND RECOMMENDATION

ALICIA M. OTAZO-REYES, Magistrate Judge.

REPORT AND RECOMMENDATION

THIS CAUSE came before the Court upon Plaintiff Abner Monzon's ("Claimant") Motion for Summary Judgment (hereafter, "Claimant's Motion for Summary Judgment") [D.E. 20] and Defendant Nancy A. Berryhill, Acting Commissioner of Social Security's ("Commissioner") Motion for Summary Judgment and Response to Claimant's Motion for Summary Judgment (hereafter, "Commissioner's Motion for Summary Judgment") [D.E. 21]. The administrative transcript (hereafter, "TR.") has been filed [D.E. 18].1 For the reasons stated below, the undersigned respectfully recommends that Claimant's Motion for Summary Judgment be GRANTED, the Commissioner's Motion for Summary Judgment be DENIED, and the Commissioner's decision be REMANDED to the Commissioner for further proceedings in accordance with this Report and Recommendation.

PROCEDURAL HISTORY

Claimant filed applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") on January 31, 2013, alleging a disability onset date of December 1, 2011. TR. 32. The applications were denied initially and upon reconsideration. Id. Pursuant to a written request, a hearing was held on May 26, 2015 before Administrative Law Judge Lornette Reynolds ("ALJ Reynolds"), which was continued to allow Medical Expert Haddon Alexander III, M.D. ("ME Alexander") to review recently filed evidence. Id. at 90-111. On the same date, Claimant amended his alleged disability onset date to August 1, 2013. Id. at 358. A continued hearing was held on July 7, 2015 before ALJ Reynolds, at which Claimant, ME Alexander and Vocational Expert Nicholas Fidanza ("VE Fidanza") testified. Id. at 50-89. On November 18, 2015, ALJ Reynolds issued an Unfavorable Decision, finding the following:

On January 12, 2017, the Appeals Council denied a request for review of AU Reynolds' Unfavorable Decision. Id. at 1-8. On February 14, 2017, pursuant to 42 U.S.C. § 405(g), Claimant filed this action seeking reversal of ALJ Reynolds' final administrative decision [D.E. 1].

In support of his contention that ALJ Reynolds' Unfavorable Decision should be reversed, Claimant argues that All Reynolds' findings with regard to his mental RFC were not supported by substantial evidence. The undersigned finds merit in this contention.

RELEVANT MEDICAL EVIDENCE

I. Treating sources

A. Miami Behavioral Health Center and Spectrum Programs ("Miami Behavioral Health")

On August 2, 2013, Claimant underwent a psychiatric evaluation at Miami Behavioral Health. Id. at 1087-91. Upon mental status examination, Claimant's affect was blunted; his mood was depressed and anxious; he was oriented to time, place, and person; his recent and immediate memory was impaired; his insight and judgment were fair; his sleep was poor; his thought process was racing; his thought content was paranoid; and he had auditory hallucinations and paranoid delusions. Id. at 1089. Claimant was diagnosed with schizoaffective disorder, bipolar type and assigned a Global Assessment of Functioning ("GAF") score of 47. Id. at 1090.6

On May 11, 2015, Sandra Fujita, Advanced Registered Nurse Practitioner ("ARNP Fujita") and Manuela Georgescu, M.D. ("Dr. Georgescu") completed a Medical Assessment of Ability to Do Work Related Activities (Mental) for Claimant (hereafter, "Medical Source Statement"). Id. at 1078-81. ARNP Fujita and Dr. Georgescu reported that Claimant had been treated at Miami Behavioral Health since July 8, 2013. Id. at 1080. ARNP Fujita and Dr. Georgescu opined that Claimant had "poor" or no ability to do the following: follow work rules; relate to co-workers; deal with the public; use judgment; interact with supervisors; deal with work stress; function independently; maintain attention and concentration; understand, remember and carry out simple, detailed, and complex job instructions; maintain personal appearance; behave in an emotionally stable manner; relate predictably in social situations; and demonstrate reliability. Id. at 1078-79. ARNP Fujita and Dr. Georgescu opined that Claimant suffered from a schizophrenic, paranoid or other psychotic disorder, but did not suffer from an affective disorder or a substance addiction disorder. Id. at 1081. ARNP Fujita and Dr. Georgescu noted that Claimant's impairment affected all activities of life. Id. at 1080.

On May 13, 2015, ARNP Fujita reported that Claimant's appearance was appropriate; his affect was constricted; his mood was depressed and anxious; he was oriented to time, place and person; he was alert; his immediate and recent memory was impaired; his speech was unremarkable; his sleep, appetite, eye contact, reliability, concentration, insight, and judgment were fair; his thought process was psychotic; his thought content had obsessions; he had auditory hallucinations and paranoid and religious delusions; but he was not suicidal or homicidal. Id. at 1085. ARNP Fujita reported that Claimant was not improving with treatment as expected, and that a change in medication was needed. Id. at 1086.

B. Enrique Pelayo, M.D., P.A. ("Dr. Pelayo")

Claimant received treatment from Dr. Pelayo from July 1, 2013 to May 5, 2014. Id. at 983-1047. On November 21, 2013, Claimant visited Dr. Pelayo for lab work for medical clearance for an umbilical hernia repair. Id. at 991. Claimant reported that he felt fine and that he had no chest pain or shortness of breath. Id. On February 27, 2014, Claimant reported that his joint pain felt better, his hypertension was controlled, his mood was better, and that his psychiatrist had increased the dosage of his medication. Id. at 983.

C. Rosie Lee Wesley Health Center, Jackson Health System ("Wesley Health")

On March 4, 2015, Claimant presented as a new patient at Wesley Health to establish care and obtain medication refills. Id. at 1139. Claimant reported that he was no longer taking antidepressants. Id. On April 10, 2015, Claimant visited Wesley Health for the flu and reported that he was being seen by a psychiatrist, and that he had received psychiatric medication at the psychiatrist's office. Id. at 1131.

D. Community Health of South Florida, Inc. ("Community Health")

On May 28, 2013, Claimant visited Community Health for a biopsychosocial assessment. Id. at 916-925. Claimant reported exacerbation of depressive symptoms, impaired daily functioning, lack of motivation, multiple health stressors, physical pain limitations, unemployment, limited resources, impaired sleep patterns, daily crying spells, isolation, alienation, increased anhedonia, hopelessness and helplessness; and denied suicidal or homicidal ideations. Id. at 924. Claimant also stated that he was not interested in case management or psychotherapy at the time. Id. Claimant was diagnosed with major depressive disorder, severe; was assigned a GAF score of 51; and was recommended to undergo a psychiatric evaluation. Id. at 925-26.7

E. Kendall Regional Medical Center

On April 14, 2013, Claimant underwent a cardiac catheterization, which noted nonobstructive coronary artery disorder and reduced ejection fraction ("EF") of 35%. Id. at 950. On the same date, a Doppler test revealed an EF of 50 to 55%. Id. at 978. On April 15, 2013, Claimant underwent a Computer Tomography ("CT") scan of his chest, which showed a 44% EF. Id. at 975.

F. Heartwell

On September 12, 2014, Claimant visited Heartwell for a follow-up visit. Id. at 1064-66. Doctors noted that Claimant's blood pressure was controlled; that he had no chest pain; and that his cardiac artery disorder was stable. Id. at 1064-65. On October 24, 2014, doctors noted that Claimant's hypertension was benign and his sleep apnea condition was stable. Id. at 1105. In July, September, and October of 2014, upon physical examination, Claimant's gait was normal and he was able to exercise. Id. at 1105, 1110, 1115.

G. Reuven Bromberg, M.D. ("Dr. Bromberg")

Dr. Bromberg treated Claimant for rheumatoid arthritis and fibromyalgia. Id. at 1048-52. On August 11, 2014, Dr. Bromberg noted that Claimant continued to improve with Humira. Id. at 1048. Claimant reported having 5 minutes of stiffness in his hands and knees, but that he was able to continue all his activities. Id. Upon physical examination, the swelling in Claimant's proximal interphalangeal joints, metacarpophalangeal joints, wrists, knees, and ankles had resolved; his musculoskeletal strength was 5/5; there were no gross sensory or motor deficits; and Claimant ambulated with a limp. Id. at 1049.

H. Mario Mangas, M.D. ("Dr. Mangas")

On September 10, 2014, Claimant visited Dr. Mangas for dyspnea and a consultation for sleep apnea. Id. at 1053. Dr. Mangas noted that Claimant's dyspnea had fluctuated and episodes occurred frequently, and that his symptoms were moderately severe. Id. Dr. Mangas also noted that Claimant experienced depression, difficulty with concentration, gasping during sleep, insomnia, and poor or worsening memory. Id. A baseline sleep study was conducted on October 10, 2014, which revealed insomnia with sleep apnea, and a titration study was recommended. Id. at 1059.

II. State Agency Medical Determiners

On February 27, 2013, state agency single decision maker Keith Lackey ("SDM Lackey") reported that Claimant could occasionally lift and/or carry up to 20 pounds; frequently lift and/or carry up to 10 pounds; and stand and/or walk and sit each for about 6 hours in an 8-hour workday. Id. at 116. On May 20, 2013, state agency determiner Harry Beecham, M.D. ("Dr. Beecham") adopted SDM Lackey's findings. Id. at 132-34.

RELEVANT HEARING TESTIMONY

A hearing was held on July 7, 2015 before All Reynolds, at which Claimant, ME Alexander, and VE Fidanza testified. TR. 50-89.

I. Claimant

Claimant testified that he last worked in 2012, when he was self-employed as a driver. Id. at 58. Claimant also identified his past work as a gardener, pest control worker, merchandise stocker, laundry folder, maintenance worker, and parking ticket taker. Id. at 59-60.

Claimant testified that he forgot things frequently; that he was not able to keep up with a routine; and that he experienced pain in his hands and legs. Id. at 62. Claimant stated that, since six months before when he experienced changes with depression and his marriage, he had spent a typical day laying down or sitting in a chair. Id. at 62-63. Claimant also stated that he experienced problems sleeping; that his medication did not help with his sleep; and that he heard voices. Id. at 63. Claimant testified that he could stand for about 10 minutes at a time, but did not have problems sitting down. Id. at 64. Claimant stated that he was able to concentrate for "given moments" but got lost when reading and was not able to keep up with conversation well. Id. at 65.

Regarding his treatment, Claimant testified that he started treatment with a psychiatrist over three years before. Id. at 61. Claimant stated that he was taking about eight to nine medications, including Cymbalta, Metroprolol, Lisinopril, and Humira; and that the medication helped him enough to keep him stable. Id. at 62. Claimant also testified that he had been using a walker for about a year, which was prescribed to him by Dr. Judy Valencia because his knees were getting swollen a lot. Id. at 64. Claimant stated that his doctors were not able to do a hernia repair. Id. at 67.

II. ME Alexander

ME Alexander identified Claimant's impairments as coronary artery disease, rheumatoid arthritis, fibromyalgia, ventral umbilical hernia, and obstructive sleep apnea, and testified that none of these impairments met or equaled the listing of impairments. Id. at 68-69, 71. Regarding Claimant's coronary artery disease, ME Alexander discussed Claimant's various EF rates and opined that Claimant had some degree of cardiomyopathy that limited his activity to light sedentary work, and in combination with his ventral hernia, Claimant had limited ability to lift and carry. Id. at 72-73.

ME Alexander also opined that the medical evidence of record did not support the need for Claimant's use of a walker because he did not find target evaluations for weight bearing joints in the record. Id. at 73. As to Claimant's functional limitations, ME Alexander opined that Claimant could lift or carry 10 pounds occasionally and 5 pounds frequently; walk and stand each for 20 minutes at a time and 4 hours each during an 8-hour work day; and sit without limitation, with an option to sit or stand at one workstation. Id. at 75-76. As to postural limitations, ME Alexander testified that Claimant should not be required to climb ropes, ladders, or scaffolds; but that he could occasionally navigate stairs and ramps, balance, bend, stoop, crouch, kneel, and crawl; and that he had no limitations as to manipulation, vision, and communication. Id. at 76. ME Alexander also testified that Claimant should not be exposed to unprotected heights, and that he should not have concentrated exposure to working around heavy machinery with rapid moving parts. Id.

III. VE Fidanza

VE Fidanza classified Claimant's prior work as follows:

Id. at 79.

VE Fidanza testified that a hypothetical individual with the same age, education, work history, and RFC as Claimant could perform the following representative jobs:

Id. at 80-83.

STANDARD OF REVIEW

A federal court's "review of a social security case is demarcated by a deferential reconsideration of the findings of fact and exacting examination of the conclusions of law." Williams v. Astrue, 416 F. App'x 861, 862 (11th Cir. 2011). Thus,

Kieser v. Barnhart, 222 F.Supp.2d 1298, 1305 (M.D. Fla. 2002) (citations omitted). However, the Commissioner's "conclusions of law, including applicable review standards, are not presumed valid." Williams, 416 F. App'x at 862.

REGULATORY FRAMEWORK: THE FIVE-STEP SEQUENTIAL PROCESS

The Social Security Regulations outline a five-step "sequential" evaluation process used to determine whether a claimant is disabled.

First, the ALJ must determine whether a claimant is engaged in "substantial gainful activity" (hereafter, "SGA"). If the All finds that the claimant is engaging in SGA, then the ALJ must find that the claimant is not disabled. Phillips v. Barnhart, 357 F.3d 1232, 1237 (11th Cir. 2004). In this case, ALJ Reynolds determined that Claimant was not engaged in SGA since the alleged disability onset date of August 1, 2013, and proceeded to step two. TR. 34.

At the second step, the ALJ must determine if a claimant's impairments are "medically severe." If the ALJ determines that the claimant's impairments are medically severe, then he or she must proceed to the third step. Phillips, 357 F.3d at 1237. In this case, ALJ Reynolds found that Claimant suffered from severe impairments of history of CHF; coronary artery disease and/or cardiomyopathy; hypertension; osteoarthritis; rheumatoid arthritis and/or fibromyalgia; and depressive disorder. TR. 34. ALJ Reynolds then proceeded to step three. Id. at 36.

At step three, the All must determine if a claimant's impairment(s) "meet or equal" any of the listed impairments in the regulations. Phillips, 357 F.3d at 1238. If so, the ALJ must find the claimant disabled; if not, then the ALJ should proceed to step four. Id. Here, ALJ Reynolds determined that Claimant did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments. TR. 36. Therefore, ALJ Reynolds proceeded to step four. Id. at 37.

Step four is a two-pronged process, which first requires the determination of a claimant's RFC and then, based on that RFC, a determination of whether the claimant can return to any "past relevant work." Phillips, 357 F.3d at 1238. As to the first prong, ALJ Reynolds determined that Claimant had the RFC:

[T]o perform sedentary work as defined in 20 C.F.R. §§ 404.1567[(a)] and 416.967[(a)], in that in an 8-hour workday, the claimant had no limitations with sitting. He could lift and carry 10 pounds occasionally and 5 pounds frequently. He could walk 20 minutes at a time, and stand 20 minutes at a time, or shift positions (i.e. get up and walk around in the workspace). Standing and walking is limited to a total of 4 hours in an 8-hour workday. He should not climb ropes, ladders, or scaffolds. He could occasionally climb ramps and stairs. He could occasionally balance, bend, stoop, kneel, crouch and crawl. He had no manipulative, visual or communicative limitations. Environmentally, the claimant should avoid working at unprotected heights and should avoid concentrated exposure to dangerous moving machinery or moving mechanical parts.

TR. 37. Based on Claimant's RFC, ALJ Reynolds moved to prong two of step four and concluded that Claimant was unable to perform any of his past relevant work. Id. at 41. ALJ Reynolds then proceeded to the fifth and final step. Id.

Step five requires the All to determine whether the claimant is able to do any work considering the claimant's age, education, work experience, and RFC. Phillips, 357 F.3d at 1239-40. ALJ Reynolds determined that, given Claimant's age, education, work experience and RFC, there were jobs that existed in significant numbers in the national economy which Claimant could perform. TR. 42. Therefore, ALJ Reynolds concluded that Claimant was not under a disability, as defined in the Social Security Act, from August 1, 2013 through the date of the Unfavorable Decision. Id. at 43.

DISCUSSION

As noted above, Claimant contends that ALJ Reynolds' findings with regard to his mental RFC were not supported by substantial evidence. Specifically, Claimant argues that:

The undersigned finds merit in both arguments.

I. Whether All Reynolds failed to fully and fairly develop the medical evidence of record

"[T]he ALJ has a basic obligation to develop a full and fair record." Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997). However, this obligation does not relieve the claimant of her burden of proving that she is disabled, Thompson v. Astrue, No. 09-20486-CV, 2010 WL 1796885, at *3 (S.D. Fla. Apr. 30, 2010), or the accompanying responsibility of producing evidence in support of her claim. Ellison v. Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003). "[T]he duty to develop a full and fair record merely requires the [ALJ] to develop the [claimant's] medical history for the twelve months preceding the filing of the disability application." Ludden v. Astrue, No. 808-CV-1704-T-30TGW, 2009 WL 4891838, at *3 (M.D. Fla. Dec. 15, 2009) (citing Ellison, 335 F.3d at 1276). Eleventh Circuit has held that an ALJ "is not required to order a consultative examination as long as the record contains sufficient evidence for the administrative law judge to make an informed decision." Ingram v. Comm'r of Soc. Sec. Admin., 496 F.3d 1253, 1269 (11th Cir. 2007).

In assessing Claimant's mental RFC, ALJ Reynolds assigned "little weight" to ARNP Fujita and Dr. Georgescu's Medical Source Statement. Id. at 41. ALJ Reynolds stated that:

Id. at 41.

Claimant argues that ALJ Reynolds failed to fully and fairly develop the record given her assessment of little weight to the only mental opinion evidence of record. See Claimant's Motion for Summary Judgment [D.E. 10-11]. Claimant also challenges ALJ Reynolds' development of the record by arguing that she failed to consider the May 28, 2013 biopsychosocial assessment and the May 13, 2015 psychiatric evaluation. Id. at 7-8. ALJ Reynolds found that these evaluations, which she explained were the "only psychiatric treatment notes of record," were "hardly legible." TR. 41. To the extent ALJ Reynolds found them illegible, these treatment notes were not fully developed as part of the record. See Eubanks v. Comm'r of Soc. Sec., No. 6:16-CV-437-ORL-DCI, 2017 WL 4050162, at *4 (M.D. Fla. Sept. 13, 2017) ("the illegibility of important evidentiary material can warrant a remand for clarification and supplementation.") (citing Miller v. Heckler, 756 F.2d 679, 680-81 (8th Cir. 1985); Brissette v. Heckler, 730 F.2d 548, 550 (8th Cir. 1984); Cutler v. Weinberger, 516 F.2d 1282, 1285 (2d Cir. 1975)).

Additionally, the remaining treatment notes that ALJ Reynolds discussed in assessing Claimant's mental RFC are from his treatment for physical impairments, TR. 983, 988, 991, 1014, 1036, 1139, and there is no mental opinion evidence of record other than the Medical Source Statement, which ALJ Reynolds discounted. Because the record does not appear to contain sufficient evidence for ALJ Reynolds to have made an informed decision regarding Claimant's mental RFC, the undersigned recommends that the case be remanded to the Commissioner to fully and fairly develop the medical evidence of record as to Claimant's mental impairments. See Graham, 129 F.3d at 1422; Ingram, 496 F.3d at 1269; Eubanks, 2017 WL 4050162, at *4, 6 ("Because the Court is not capable of meaningfully reviewing the All's decision given the illegibility of the treatment notes of Claimant's only treating physician, this matter must be remanded for further proceedings.").

II. Whether AU Reynolds improperly assigned little weight to the opinions of ARNP Fujita and Dr. Georgescu

"Medical opinions are statements from physicians and psychologists or other acceptable medical sources that reflect judgments about the nature and severity of the claimant's impairment(s), including the claimant's symptoms, diagnosis and prognosis, what the claimant can still do despite impairment(s), and the claimant's physical or mental restrictions." Winschel v. Comm'r of Soc. Sec., 631 F.3d 1176, 1178-79 (11th Cir. 2011) (quoting 20 C.F.R. §§ 404.1527(a)(2), 416.927(a)(2)). An All is "required to state with particularity the weight [given to] the different medical opinions and the reasons therefor." Sharfarz v. Bowen, 825 F.2d 278, 279 (11th Cir. 1987). "In the absence of such a statement, it is impossible for a reviewing court to determine whether the ultimate decision on the merits of the claim is rational and supported by substantial evidence." Winschel, 631 F.3d at 1179 (quoting Cowart v. Schweiker, 662 F.2d 731, 735 (11th Cir. 1981)).

"The opinion of a treating physician . . . must be given substantial or considerable weight unless `good cause' is shown to the contrary." Phillips, 357 F.3d at 1240 (citation and quotation marks omitted). The Eleventh Circuit has held that "good cause" exists where the: (1) treating physician's opinion was "not bolstered by the evidence;" (2) "evidence supported a contrary finding;" or (3) the treating physician's opinion was "conclusory or inconsistent with their own medical records." Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). "When the ALJ has articulated specific reasons for failing to give the opinion of a treating physician controlling weight, and those reasons are supported by substantial evidence, there is no reversible error." Weekley v. Comm'r of Soc. Sec., 486 F. App'x 806, 808 (11th Cir. 2012) (citing Moore, 405 F.3d at 1212).

As noted above, ALJ Reynolds assigned "little weight" to ARNP Fujita and Dr. Georgescu's Medical Source Statement that Claimant had `poor' or no ability to perform any work activities." Id. at 41. ALJ Reynolds explained that the Medical Source Statement was "inconsistent with the contemporaneous treatment notes, which document a history of depressive disorder but improvement with treatment." Id. Claimant argues ALJ Reynolds erred in assigning little weight to the Medical Source Statement because ALJ Reynolds did not provide good cause for discounting the opinion. See Claimant's Motion for Summary Judgment [D.E. 20 at 7]. Because ALJ Reynolds assessed the weight of the Medical Source Statement based in part on "hardly legible" treatment notes and a record that was not fully and fairly developed, in the course of the remand, ALJ Reynolds should re-assess the weight given to the Medical Source Statement. See Lewis, 125 F.3d at 1440; Weekley, 486 F. App'x at 808.

RECOMMENDATION

Based on the foregoing considerations, the undersigned RESPECTFULLY RECOMMENDS that Claimant's Motion for Summary Judgment [D.E. 20] be GRANTED, the Commissioner's Motion for Summary Judgment [D.E. 21] be DENIED, and the Commissioner's decision be REMANDED to the Commissioner for further proceedings in accordance with this Report and Recommendation.

Pursuant to Local Magistrate Judge Rule 4(b), the parties have fourteen days from the date of this Report and Recommendation to file written objections, if any, with the Honorable Robert N. Scola, Jr., United States District Judge. Failure to file timely objections may bar the parties from attacking the factual findings contained herein on appeal. See Resolution Tr. Corp. v. Hallmark Builders, Inc., 996 F.2d 1144, 1149 (11th Cir. 1993). Further, "failure to object in accordance with the provisions of [28 U.S.C.] § 636(b)(1) waives the right to challenge on appeal the district court's order based on unobjected-to factual and legal conclusions." See 11th Cir. R. 3-1 (I.O.P.-3).

RESPECTFULLY SUBMITTED.