Searching over 5,500,000 cases.

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Mazyck v. Saul

United States District Court, D. South Carolina

September 11, 2019

ANDREW M. SAUL, Commissioner of Social Security, Defendant.


          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 he was denied a period of 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) and Supplemental Security Income (SSI)[1] on April 11, 2012 (protective filing date), alleging disability beginning November 15, 2007 due to shoulder problems, lower back problems, high blood pressure, pancreatitis, hypertension, and a stroke. (R.pp. 327, 329, 429, see also R.p. 155). Plaintiff's claims were denied both initially and upon reconsideration. Plaintiff then requested a hearing before an Administrative Law Judge (ALJ), which was held on July 24, 2014. (R.pp. 63-78). The ALJ thereafter issued a partially favorable decision on March 26, 2015, finding that Plaintiff became disabled on July 24, 2014 but was not disabled or entitled to disability benefits before that time. (R.pp. 154-166). Plaintiff requested review of the decision (R.pp. 152, 253-254), and the Appeals Council granted review, vacated the prior decision, [2] and remanded the case back to the ALJ to consider whether Plaintiff met the special earning requirements (i.e., whether he had insured status) at the time he was found to be disabled, [3]to obtain additional evidence concerning Plaintiff's impairments, to reconsider Plaintiff residual functional capacity (RFC), and to obtain vocational expert (VE) evidence to clarify the effects of the assessed limitations on Plaintiff's occupational base (R.pp. 177-179).

         The ALJ then held another administrative hearing on June 16, 2016. (R.pp. 43-62). Thereafter, the ALJ again issued a partially favorable decision, this time finding that Plaintiff did not become disabled until January 4, 2017, and that he was not disabled before that date. (R.pp. 17-32). The Appeals Council denied Plaintiff's request for a review this decision, thereby making the June 16, 2016 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 remanded for further proceedings. The Commissioner contends that the decision to deny benefits prior to January 4, 2017 is supported by substantial evidence, and that Plaintiff was properly found not to be disabled prior to that time.

         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

         On October 25, 2007, Dr. William Estes, an orthopedist at Charleston Bone and Joint, evaluated Plaintiff as part of a Workers' Compensation claim based on complaints of constant, sharp, and non-radiating pain that had lasted one month. An MRI revealed a partial rotator cuff tear, and it was noted that Plaintiff had had four sessions of physical therapy that he reported had helped minimally. Dr. Estes diagnosed a SLAP (superior labrum anterior and posterior) tear and injected Plaintiff's shoulder. (R.pp. 1064-1065). Plaintiff subsequently underwent SLAP repair surgery on December 19, 2007, but continued to complain of shoulder pain thereafter. (R.pp. 1067-1073).

         On April 24, 2008, Plaintiff was treated at East Cooper Medical Center (ECMC) for slurred speech that had started four days prior and was intermittent, but had returned that morning. Plaintiff's blood pressure was 201/111, he had right facial weakness, and an ECG showed possible ischemia, but he had no weakness in his lower extremity. A CT scan of the brain revealed a 1.8 centimeter parenchymal hemorrhage within the region of the left subinsular white matter with slight surrounding edema and slight mass effect in the sylvian cortex that looked like a hypertensive hemorrhage. The assessment was hypertensive hemorrhage and hypertensive emergency. (R.pp. 641-647, 706-709, 763).

         Plaintiff returned to see Dr. Estes on May 22, 2008 with complaints of continued right shoulder pain. Plaintiff stated that his employer would not let him return to work with light or limited duty. (R.p. 1073). A June 2008 MRI of Plaintiff's right shoulder showed postoperative change consistent with a prior labral repair; mild fraying of the glenoid labrum which might be related to prior postoperative change or nondisplaced tearing; partial tearing of the supraspinatus, infraspinatus, and subcapularis tendon; and prominent sentinel cyst associated with the supraspinatus tendon. (R.pp. 1074-1075). On October 14, 2008, Plaintiff was evaluated at the CARES Clinic (CARES) for a history of high blood pressure and a stroke six months prior. He reported he could no longer afford Norvasc since losing his job, complained of sleep loss due to shoulder pain, and reported he needed to have his blood pressure better controlled before shoulder surgery could be performed. Norvasc and HCTZ were prescribed. (R.pp. 549-550).

         Plaintiff underwent right arthroscopic rotator cuff repair, right biceps open tenodesis, and right shoulder labral debridement at ECMC on November 3, 2008. (R.pp. 652-653). He returned to the hospital on November 19, 2008, with complaints that his right foot and leg were not moving correctly. His blood pressure was 181/106 and a CT scan of his head showed extensive bilateral white matter changes in the subcortical white matter of his cerebral hemispheres, indicating progressive white matter ischemic changes, greater on the left. There was no evidence of an acute hemorrhage or mass defect. (R.pp. 769-770, 791).

         On January 3, 2009, Dr. Estes continued Plaintiff s work restrictions of “no lifting >10 lbs. No. work.” (Rpp. 1081-1082). Dr. Estes administered a right shoulder injection on February 13, 2009, and the assessment was “activity as tolerated.” (R.pp. 1083-1085). On May 14, 2009, Plaintiff reported that his right shoulder was painful and had “crunching” with movement. His strength was 4/5. (R.pp. 1088-1089). A May 2009 MRI of Plaintiff s right shoulder showed contrast dissected along the undersurface of the infraspinatus to the musculotendinous junction consistent with an unhealed or recurrent partial tear. There was a torn and retracted long head of the biceps, and widening of the acromioclavicular joint which was felt to be post-operative or due to an old sprain. (R.p. 1093). Dr. Estes assessed Plaintiff on May 29, 2009 with complete rupture of his rotator cuff, planned to see Plaintiff as needed, and stated he would offer an impairment rating. (R.pp. 1090-1091).

         Plaintiff was prescribed Metroprolol in addition to HCTZ and Amlodipine at CARES to treat his high blood pressure on July 30, 2009. He admitted to drinking 6-7 beers a day. (R.p. 547). He returned to CARES in December 2009 with elevated blood pressure (he said he had run out of medication). Examination revealed that Plaintiff had mild right shoulder pain with an empty can test. Right rotator cuff inflammation and hypertension were assessed and Plaintiff was directed to take his anti-hypertensive medications and to use NSAIDs for his right shoulder. (R.p. 546). Examination at CARES on January 14, 2010 revealed a positive empty can test, that his biceps tendon was tender to palpation, and he had loss of range of motion. Plaintiff's blood pressure medication was increased, and a referral was made for physical therapy. (R.p. 545).

         At his second session of physical therapy on February 9, 2010, Plaintiff inquired about vocational rehabilitation. It was observed that he had a greater range of motion than when asked to perform motion in functional use. The physical therapist assessed chronic shoulder pain with limited rehabilitation potential. (R.p. 551).

         On July 14, 2010, Plaintiff was treated at ECMC for complaints of head, neck, and back pain, as well as tingling and pain in both hands after he fell off a ladder. Oxycodone was prescribed for cervical strain. A CT of Plaintiff's head showed diffuse cortical atrophy, chronic small vessel ischemic change in the white matter, and several old lacunar infarcts with findings more advanced than average for his age. CT of his cervical spine showed degenerative disc disease throughout Plaintiffs cervical spine with moderate diffuse disc bulge at ¶ 6-7. The impression was cervical strain. (R.pp. 590-591, 593-594, 730-733).

         Plaintiff returned to CARES on December 14, 2010. with complaints of right and left shoulder pain (which had been present for six months), and intermittent sharp chest pain every 30 to 45 minutes that did not cause any issues. On examination, Plaintiff was not able to actively abduct or extend or flex his arms past 90 degrees due to pain, but his range of motion was slightly increased with passive movement. His blood pressure was 196/110. Blood pressure medication and physical therapy were prescribed. (R.pp. 921-922). On January 18, 2011, a physical therapist assessed Plaintiff with severe left shoulder pain and extremely limited function, noted that strength and range of motion could not be tested secondary to pain, and thought Plaintiff would benefit from orthopedic referral and imaging. (R.p. 629).

         Plaintiff complained of abdominal pain and lip swelling at ECMC on January 22, 2011. Examination revealed moderate abdominal tenderness in all quadrants with voluntary guarding. A CT of Plaintiff s abdomen and pelvis indicated that the head of Plaintiff s pancreas was enlarged, there was streakiness/fluid/ascites around the head and body of the pancreas, the common bile duct was dilated, and his stomach was distended. The impression was angioedema (due to the ACE inhibitor he was taking) and ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.