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Mood v. Berryhill

United States District Court, D. South Carolina

August 24, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         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 Disability Insurance Benefits (DIB) on August 29, 2013, alleging disability beginning June 30, 2010, [1] due to a blood clot disorder, a blood disorder, anxiety, anemic low iron, and damage to her left leg. (R.pp. 27, 172, 198). Plaintiff's claim was denied both initially and upon reconsideration. Plaintiff then requested a hearing before an Administrative Law Judge (ALJ), which was held on November 23, 2015. (R.pp. 40-55). The ALJ thereafter denied Plaintiff's claim, finding in a decision issued on January 28, 2016, that Plaintiff was not disabled during the relevant time period (i.e., from the alleged onset date of June 30, 2010 through June 30, 2014, the date Plaintiff was last insured for DIB benefits[2]). (R.pp 27-35). 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 United States District Court. Plaintiff asserts that the ALJ's decision is not supported by substantial evidence, and that this case should be reversed and remanded to the Commissioner for further proceedings. 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');">368 F.2d 640 (4th Cir. 1966)); see also Hepp v. Astrue, 511 F.3d 798, 806 (8th Cir. 2008)[Nothing 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 Record

         Plaintiff has a history of deep vein thrombosis (DVT) and pulmonary embolism, and her medical records show that she underwent a VNUS closure procedure on her left lower extremity in July 2009. (R.pp. 364-365). As previously noted, Plaintiff was awarded disability benefits following this surgery through January 12, 2010, but was determined to no longer be disabled after that date.

         On May 5, 2010, Plaintiff received follow up care from Dr. Edward Morrison of Coastal Vascular and Vein (Coastal). Examination showed no evidence of significant edema or venous distension in her legs. Plaintiff reported having lost twenty pounds and that she was feeling better, although she still had some pain in and around her anterior right thigh right before menstruation. Dr. Morrison advised Plaintiff to lose weight, as she was at high risk for DVT. He also opined that it was reasonable to consider Plaintiff stopping taking Coumadin (a blood thinner) for a period of time. (R.p. 342).

         On September 22, 2010 (which was now after Plaintiff alleges her condition became disabling again on June 30, 2010), Plaintiff was seen by Physician Assistant (PA) Brandy Englert at Coastal for her venous stasis disease. Plaintiff reported that she continued to have swelling and pain in her large dilated varicose vein in her left leg that extended from her foot to her thigh, and that this affected her quality of life and efficiency at work. Examination revealed that her left leg was slightly more edematous than the right with a mildly dilated varicose vein. (R.p. 341). At follow up appointments with Dr. Morrison and PA Englert in January 2011, Plaintiff reported swelling in her left lower extremity, especially in the afternoon. Examination showed mild edema from her left knee down and an anterior shin varicosity that was very phlebitic, while scans showed chronic common femoral vein and superficial venous phlebitic changes without fresh clot. Plaintiff was advised to continue to use compression stockings, to lose weight, and to exercise. (R.pp. 339-341, 347-357).

         On May 30, 2012, Plaintiff was treated by Dr. Gretchen Meyer of Lowcountry Hematology and Oncology. Plaintiff reported she was on chronic anticoagulation medication and that she was having continued difficulty with pain and swelling in her legs following a recent pregnancy (she had given birth in January 2012). Plaintiff was noted to weigh 329 pounds, and examination revealed that her left leg was slightly larger than the right and that she had trace bilateral lower extremity edema. An ultrasound showed chronic deep vein thrombus in the left common femoral, left sapheous femoral junction, left femoral, and left popliteal veins. Dr. Meyer's impression was left lower extremity deep venous thrombus/pulmonary embolism in 2006 while on birth control medication, history of iron deficiency, and chronic thrombosis of her left lower leg. She advised Plaintiff to continue with indefinite anticoagulation medication secondary to her obesity, decreased mobility, and chronic thrombosis. (R.pp. 305-306).

         Plaintiff began care with Dr. Noemi Pagan at Moncks Corner Primary Care on November 5, 2012. Plaintiff reported that she was on Coumadin for a history of DVT and pulmonary embolism, that she had chronic pain and swelling in her leg, and had anxiety and panic attacks which had worsened. She also said she had a video game/dancing program and had lost weight. Dr. Pagan assessed Plaintiff with pulmonary embolism, DVT in her leg, back pain, leg pain, morbid obesity, and depression with anxiety. Zoloft was prescribed for Plaintiff's depression with anxiety. (R.pp. 264-265).

         On March 20, 2013, Plaintiff reported to Dr. Meyer that she had pain in her left lower leg, especially if she was on her feet for a long period, but that she had improvement with elevation. Dr. Meyer continued Plaintiff's Coumadin and directed her to continue with elevation and compression stockings. (R.pp. 299-300). On June 26, 2013, Plaintiff complained that her legs still hurt. However, on examination Plaintiff was able to move all of her extremities without difficulty with full range of motion and normal strength. Dr. Meyer noted that Plaintiff had trace bilateral lower extremity edema, that her left leg was still slightly larger than her right leg, and that her DVT symptoms were fairly stable. (R.pp. 296-297).

         On July 6, 2013, Plaintiff was treated at the Summerville Medical Center for complaints of lower lumbar pain with radiation into her right leg after a possible twisting injury. On examination Plaintiff complained of mild lower right lumbar tenderness to palpation into the right sciatic notch. A lumbar spine x-ray was negative, with congenital variation and mild dextrorotary scoliotic curve at ¶ 4-5 lower lumbar spinal curvature noted. An ultrasound of her right leg was also negative for DVT. Plaintiff was assessed with an acute lumbar strain/pain and acute right sciatica. (R.pp. 277-283, 290-291).

         On August 7, 2013, Plaintiff complained to Dr. Meyer of nausea from the iron she was taking for anemia and about chronic leg pain and swelling that worsened throughout the day despite use of compression stockings. On examination Dr. Meyer found no pitting edema in Plaintiff's lower legs, but she complained of tenderness to palpation of her left leg. Dr. Meyer also noted that Plaintiff had ongoing DVT symptoms with chronic venous stasis changes. Even so, Dr. Meyer noted that Plaintiff could move all of her extremities without difficulty, and that she had full range of motion and normal strength. Plaintiff's schedule IV iron treatment was cancelled because Plaintiff was unable to get a babysitter for her children that day. The plan was for Plaintiff to continue compression stockings and elevation and to administer IV iron. (R.pp. 293-294).

         Plaintiff returned to Dr. Morrison at Coastal on September 24, 2013 for a recently emerged large vein on her left ankle. Dr. Morrison noted that Plaintiff had left leg swelling from the thigh down that appeared to be somewhat chronic with palpable large veins, and ultrasounds were ordered. He suspected that Plaintiff's significant weight gain and inactivity was causing venous reflux, and advised Plaintiff to lose weight. (R.pp. 334-335). On October 30, 2013, Dr. Meyer's examination showed fullness in Plaintiff's left leg compared to the right, but no pitting edema. She continued to be able to move all of her extremities without difficulty with full range of motion, and she was noted to have normal strength. Dr. Meyer wrote that Plaintiff had chronic leg pain with minimal swelling and chronic venous stasis changes, and recommended that Plaintiff continue with stockings and anticoagulation secondary to chronic thrombotic changes, obesity, and decreased mobility. (R.pp. 324-325).

         On November 1, 2013, Plaintiff complained to PA Linda Watson at Coastal about bilateral aching, throbbing, and edema in her legs which was greater on the left. Examination showed 1 left leg edema. An ultrasound of Plaintiff's right lower extremity was positive for great saphenous vein (GSV) reflux, and a left lower extremity ultrasound was positive for accessory reflux with no evidence of GSV, negative for small saphenous vein reflux, negative for right lower extremity DVT, and negative for chronic thrombus in the left common femoral vein. PA Watson assessed Plaintiff with a history of DVT and venous stasis disease and recommended continued Coumadin and conservative treatment with elevation, non-steroidal anti-inflammatory medications, increased walking, and daily stocking use. (R.pp. 330-331, 336-338).

         On November 5, 2013, state agency physician Dr. Cleve Hutson opined after a review of Plaintiff's records that Plaintiff could perform a range of light work, [3] limited to no climbing of ladders, ropes, and scaffolds; frequent stooping; only occasional kneeling, crouching, crawling, and climbing of ramps and stairs; and avoidance of concentrated exposure to hazards. (R.pp. 88-90).

         On April 9, 2014, Plaintiff was evaluated for possible gastric bypass surgery. Dr. Charles K. Mitchell noted that Plaintiff's left leg was larger than her right leg, which was presumably due to postphlebitic syndrome, but that she ambulated with a normal gait without assistance from a cane or walker and had normal strength and range of motion in all of her extremities. (R.pp. 387-390).

         On July 9, 2014, a few days after Plaintiff's deligibility for disability benefits expired on June 30, 2014, Dr. Thaddeus Bell performed a consultative examination. Plaintiff reported to Dr. Bell that she had a blood clot disorder, left leg damage, history of anxiety, history of anemia, and a history of weakness in her left leg. Plaintiff complained of pain in her left leg, of not being able to be as mobile as she had been since her pulmonary embolism diagnosis, and of experiencing swelling in her leg with ambulation and standing for long periods. Plaintiff stated that she had not worked in several months, and that she was applying for disability because of significant leg swelling that occurred mostly when she ambulated and stood for long periods of time. Even so, Plaintiff's musculoskeletal exam was completely normal with the exception that Plaintiff's left leg was somewhat impaired and she was unable to lift her left leg with straight leg testing on the left. Plaintiff's muscle strength was noted to be 5/5 (full) in all extremities, and there was no ...

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