United States District Court, D. South Carolina
REPORT AND RECOMMENDATION
Bristow Marchant United States Magistrate Judge.
Plaintiff filed the complaint in this action pursuant to 42
U.S.C. § 405(g), seeking judicial review of the final
decision of the Commissioner wherein she was denied
disability benefits. This case was referred to the
undersigned for a report and recommendation pursuant to Local
Civil Rule 73.02(B)(2)(a), (D.S.C.).
applied for Supplemental Security Income (SSI) and Disability
Insurance Benefits (DIB) on September 14, 2012 (protective
filing date), alleging disability as of February 17,
due to congestive heart failure, hypertension, and
depression. (R.pp. 23, 32, 160, 280, 286, 362).
Plaintiff's claims were denied initially and upon
reconsideration. Plaintiff then requested a hearing before an
Administrative Law Judge (ALJ), which was held on January 16,
2014. (R.pp. 67-94). The ALJ thereafter denied
Plaintiff's claims in a decision issued March 7, 2014.
(R.pp. 160-168). However, on November 10, 2014, the Appeals
Council remanded the case to the ALJ for further action and a
new decision. (R.pp. 174-175). A second hearing was then held
on March 25, 2015; (R.pp. 38-64); following which the ALJ
thereafter denied Plaintiff's claims in a decision issued
June 2, 2015. (R.pp. 23-32). On January 8, 2016, the Appeals
Council denied Plaintiff's request for a review of the
ALJ's decision, thereby making the determination of the
ALJ the final decision of the Commissioner. (R.pp. 1-5).
then filed this action in this United States District Court,
asserting that there is not substantial evidence to support
the ALJ's decision, and that the decision should be
reversed and remanded for further consideration. The
Commissioner contends that the decision to deny benefits is
supported by substantial evidence, and that Plaintiff was
properly found not to be disabled.
42 U.S.C. § 405(g), the Court's scope of review is
limited to (1) whether the Commissioner's decision is
supported by substantial evidence, and (2) whether the
ultimate conclusions reached by the Commissioner are legally
correct under controlling law. Hays v. Sullivan, 907
F.2d 1453, 1456 (4th Cir. 1990); Richardson v.
Califano, 574 F.2d 802, 803 (4th Cir. 1978); Myers
v. Califano, 611 F.2d 980, 982-983 (4th Cir. 1980). If
the record contains substantial evidence to support the
Commissioner's decision, it is the court's duty to
affirm the decision. Substantial evidence has been defined
evidence which a reasoning mind would accept as sufficient to
support a particular conclusion. It consists of more than a
mere scintilla of evidence but may be somewhat less than a
preponderance. If there is evidence to justify refusal to
direct a verdict were the case before a jury, then there is
“substantial evidence.” [emphasis added].
Hays, 907 F.2d at 1456 (citing Laws v.
Celebrezze, 368 F.2d 640 (4th Cir. 1966)); see
also, Hepp v. Astrue, 511 F.3d 798, 806 (8th
Cir. 2008)[Noting that the substantial evidence standard is
even “less demanding than the preponderance of the
Court lacks the authority to substitute its own judgment for
that of the Commissioner. Laws, 368 F.2d at 642.
“[T]he language of [405(g)] precludes a de
novo judicial proceeding and requires that the court
uphold the [Commissioner's] decision even should the
court disagree with such decision as long as it is supported
by ‘substantial evidence.'” Blalock v.
Richardson, 483 F.2d 773, 775 (4th Cir. 1972).
medical records show that in August 2010, she was treated at
the Good Neighbor Medical Clinic in Beaufort, South Carolina
for complaints of knee pain. (R.p. 443). A left knee MRI in
September 2010 showed some degeneration of the anterior horn
of Plaintiff's lateral meniscus with some vertical signal
abnormality which appeared to extend to the inferior and
superior joint surfaces which was concerning for a
degenerative tear. (R.p. 459).
5, 2012, after experiencing several weeks of chest pain,
Plaintiff was hospitalized overnight at Beaufort Memorial
Hospital. A chest x-ray showed borderline cardiomegaly
(enlarged heart). However, there was no sign of acute
pulmonary disease, and an echocardiogram revealed no acute
changes and myocardial infarction was ruled out. Plaintiff
was transferred to the Medical University of South Carolina
(MUSC) for further testing of unstable angina, reports of
coronary artery disease, hypertension, tobacco use, and
medical non-compliance. (R.pp. 471-472, 479-480, 488-510).
Plaintiff was thereafter hospitalized at MUSC from June 6 to
7, 2012. A coronary arteriography indicated non-obstructive
coronary artery disease and uncontrolled hypertension, but on
physical examination Plaintiff had a regular heart rate and
rhythm, no JVD (jugular vein distention), good and even
peripheral pulses, no edema in her arms and legs, 5/5 (full)
strength, and no focal neurological deficits. The
cardiologist characterized Plaintiff's chest pain as
noncardiac in nature and diagnosed chest pain likely
secondary to costochondritis.Plaintiff's medications were
adjusted, daily aspirin and a statin were added, and
Plaintiff was encouraged to quit smoking. (R.pp. 490-510).
September 25, 2012, Dr. David M. Waggoner at Good Neighbor
Medical Clinic (where Plaintiff was primarily treated during
the relevant time period) evaluated Plaintiff for depression,
sleep problems, and pain and swelling in her left knee.
Plaintiff also complained of chest pain that was eased by
nitroglycerin. Dr. Waggoner ordered a left knee x-ray and
referred Plaintiff for an orthopedic consultation. (R.p.
534). On October 2, 2012, x-rays of Plaintiff's left knee
showed moderate joint effusion and mild medial joint space
loss. (R.p. 470). On December 20, 2012, Dr. Waggoner
evaluated Plaintiff for left knee swelling and pain in her
left arm and wrist, administered an injection in her left
knee, and diagnosed osteoarthritis. (R.p. 533).
February 2, 2013, Dr. Shaun A. Nguyen performed a
consultative examination at the request of the Commissioner.
Plaintiff reported that she was diagnosed with hypertension
in 2000, congestive heart failure in 2009, and depression in
2004. She complained of pain, shortness of breath on
exertion, intermittent lower extremity edema, and sadness at
a level of eight out of ten on most days. Plaintiff denied
anxiety and problems sleeping, but admitted to having
suicidal thoughts, seeing shadows, and seeing snakes crawling
up her feet. Plaintiff also reported that she had been
diagnosed with a torn left knee ligament in 2009; received a
series of injections in her knee over a three year period;
complained of constant, aching pain at a level of six out of
ten; and indicated she had about thirty minutes of morning
stiffness and worsening pain when she stood or walked for
very long. Dr. Nguyen noted that Plaintiff was cooperative
and appropriate in appearance; was five feet, two inches
tall; weighed 194 pounds; had lower extremity edema
bilaterally; and could perform toe-walk and heel-walk, but
was unable to hop or perform a full squat. Plaintiff's
left knee x-rays from October 2012 showed degenerative change
with moderate joint effusion. Dr. Nguyen noted that Plaintiff
complained of left knee pain when performing knee flexion,
pain radiating to her left hip when performing left hip
flexion, and pain radiating to her left hip on left leg
raise. Dr. Nguyen thought Plaintiff had possible iliotibial
band syndrome, and diagnosed Plaintiff with class II obesity
with a BMI of 35.5, depression, hypertension, congestive
heart failure with bilateral lower extremity edema (), left
knee pain radiating to her left hip, limited knee flexion
bilaterally, limited range of motion with left hip flexion,
and positive straight leg raising test both in the supine and
the sitting positions. (R.pp. 516-522).
March 12, 2013, state agency physician Dr. Mary Lang reviewed
Plaintiff's medical records and opined that Plaintiff
could lift and carry up to twenty pounds occasionally and ten
pounds frequently; stand and/or walk for about six hours and
sit for about six hours during an eight-hour workday;
occasionally push and pull with her left leg; occasionally
climb ramps, stairs, ladders, ropes, and scaffolds;
frequently stoop; occasionally kneel, crouch, and crawl; and
balance on an unlimited basis. Dr. Lang further opined that
Plaintiff should avoid concentrated exposure to pulmonary
irritants, but that she could tolerate unlimited exposure to
other environmental conditions. (R.pp. 112-114).
March 21, 2013, Plaintiff complained to Dr. Waggoner of
left-sided chest pain, left arm and wrist pain, and a painful
and swollen left knee. She requested medication for stress
and reported she used to take Lexapro. Dr. Waggoner noted
that Plaintiff had lower extremity edema and complained that
her edema was worse at night. She also reported using
nitroglycerin twice a week. Dr. Waggoner prescribed
nitroglycerin and Lexapro. (R.p. 532).
Waggoner completed a Cardiac Medical Source Statement on
March 21, 2013. He wrote that he had treated Plaintiff every
three months since 2009, noted her diagnoses were congestive
heart failure and osteoarthritis; indicated that
Plaintiff's prognosis was poor; and listed her symptoms
as chest pain, weakness, exertional dyspnea, angina
equivalent pain, exercise intolerance, orthopnea, lower
extremity peripheral edema, chronic fatigue, and
palpitations. He further stated that Plaintiff's left
chest pain and symptoms required her to take nitroglycerine
twice weekly and that she typically had to rest for one hour
after an episode of angina, although her physical symptoms
and limitations did not cause emotional difficulties and
emotional factors did not contribute to the severity of her
symptoms. Dr. Waggoner opined that Plaintiff was incapable of
even low stress work, that she would suffer severe pain in a
competitive work situation, and she could walk
“zero” city blocks without rest or severe pain.
He also estimated that Plaintiff could sit about four hours
and stand and walk less than two hours in an eight-hour
workday; needed to shift positions at will between sitting,
standing, and walking; needed to take unscheduled breaks
every two hours; and needed to elevate her legs with
prolonged sitting. He further opined that she could rarely
lift and carry less than ten pounds; could never lift and
carry ten pounds; could rarely twist, stoop, or crouch/squat;
and could never climb stairs or ladders. Dr. Waggoner
estimated that Plaintiff would be ‘off task” and
her symptoms would likely be severe enough to interfere with
the attention and concentration necessary to perform even
simple tasks ten percent of the time. He further indicated
that her symptoms were likely to produce good days and bad
days and that she would likely be absent from work more than
four days per month. Dr. Waggoner answered “yes' to
the question of whether Plaintiff's impairments (as
demonstrated by signs, clinical findings, and laboratory test
results) were “reasonably consistent with the symptoms
and functional limitations described above in this
evaluation.” (R.pp. 523-526).
April 23, 2013, state agency psychologist Dr. Kathleen
Broughan reviewed Plaintiff's medical records and opined
that Plaintiff did not have a severe mental impairment.
(R.pp. 129-130). On April 29, 2013, state agency physician
Dr. Jean Smolka reached the same findings as Dr. Lang (that
Plaintiff could perform a range of light work),
with the additional restriction that Plaintiff should avoid
concentrated exposure to hazards. (R.pp. 131-134).
1, 2013, Plaintiff was treated at the Beaufort Memorial
Hospital emergency room for chest pain. An ECG study revealed
no changes from a previous June 2012 study, while a chest
x-ray revealed cardiomegaly. She was diagnosed with atypical
chest pain, prescribed Lortab and ...