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Seymore v. Calvin

United States District Court, D. South Carolina

April 6, 2017



          Bristow Marchant United States Magistrate Judge.

         The 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.).

         Plaintiff applied for Supplemental Security Income (SSI) and Disability Insurance Benefits (DIB)[1] on September 14, 2012 (protective filing date), alleging disability as of February 17, 2011[2] 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).

         Plaintiff 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.

         Scope of review

         Under 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 as:

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 evidence standard”].

         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 History

         Plaintiff's 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).

         On June 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.[3]Plaintiff's medications were adjusted, daily aspirin and a statin were added, and Plaintiff was encouraged to quit smoking. (R.pp. 490-510).

         On 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).

         On 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).

         On 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).

         On 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).

         Dr. 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).

         On 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), [4] with the additional restriction that Plaintiff should avoid concentrated exposure to hazards. (R.pp. 131-134).

         On May 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 ...

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