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Williams v. Berryhill

United States District Court, S.D. Mississippi, Northern Division

February 11, 2019




         Plaintiff appeals the final decision denying her application for Supplemental Security Income (SSI). The Commissioner requests an order pursuant to 42 U.S.C. §405(g), affirming the final decision of the Administrative Law Judge. Having carefully considered the hearing transcript, the medical records in evidence, and all the applicable law, the undersigned recommends that this cause be affirmed.

         In March 2010, Plaintiff's mother filed an SSI application on her behalf, alleging a disability date of December 1, 1992, due to Tetralogy of Fallot, blood problems, and heart trouble. Plaintiff was 17 years old at the time of the filing but turned 18 years old prior to her administrative hearing. The application was denied initially and later upon reconsideration. Following agency denials of her application, Administrative Law Judge (“ALJ”) Charles Pearce rendered an unfavorable decision finding that Plaintiff had not established a disability within the meaning of the Social Security Act. The Appeals Council granted Plaintiff's request for review and remanded the case, with instructions to obtain additional evidence and further evaluate Plaintiff's disability claim.

         Upon further review and a second administrative hearing, ALJ Pearce issued a second unfavorable decision on October 10, 2013. The Appeals Council denied Plaintiff's second request for review, and she appealed the denial to this Court on October 9, 2014.

         On appeal, United States Magistrate Judge F. Keith Ball found that ALJ Pearce failed to satisfy his duty to develop the record, rendering his decision unsupported by substantial evidence -- specifically determining that the ALJ erred in failing to include the recognized restrictions on overhead reaching in his hypothetical and, in failing to engage in the analysis under 20 C.F.R. § 404.1527(c). Williams v. Colvin (Williams I), No. 3:14CV785-FKB, 2016 WL 1306281 (S.D.Miss. Mar. 31, 2016). On March 21, 2016, this case was reversed and remanded to the Commissioner for further consideration.

         On remand, this matter was reassigned to ALJ Laurie H. Porciello, who was directed by the Appeals Council to take any further action needed to complete the administrative record, including obtaining additional evidence and issuing a new decision. Upon review, ALJ Porciello observed that while Plaintiff's prior application was pending in federal court, she filed a new application on November 18, 2014. The ALJ consolidated Plaintiff's new application with her previous claim and considered Plaintiff's complete medical history pursuant to 20 C.F.R. § 416.912(d), in accordance with both the childhood standard of disability for the time period prior to Plaintiff turning 18, and the adult standard of disability after she turned 18. After considering additional evidence and conducting a new administrative hearing, ALJ Porciello concluded that Plaintiff had not established a disability within the meaning of the Social Security Act. The Appeals Council denied Plaintiff's third request for review. She now appeals that decision.

         Although ALJ Porciello evaluated Plaintiff's claims pursuant to both the childhood and adult disability standards, Plaintiff challenges only the evidence and findings under the adult standard in the instant appeal.

         At step one of the five-step sequential evaluation for adult claimants, [1] the ALJ determined that Plaintiff may have engaged in substantial gainful activity since her application was initially filed in March 2010, but she declined to make a definitive finding at this step of the evaluation.[2] At step two of the evaluation, the ALJ found that although Plaintiff's status post repair Tetralogy of Fallot;[3] status post attempted stenting with displacement and subsequent removal and reconsideration; impulse control disorder not otherwise specified; and, mood disorder were severe, they did not meet or medically equal any listing. At step four, the ALJ found that since turning 18 years old, Plaintiff has had the residual functional capacity to perform light work with the following limitations:

she should never climb ladders, ropes or scaffolds and should only occasionally balance, stoop, kneel, crouch, crawl, or climb ramps or stairs; she cannot reach overhead with the non-dominant upper extremity; and she is limited to performing only simple, routine tasks, with only occasional interaction with the public or coworkers.[4]

         Based on vocational expert testimony, the ALJ concluded that given Plaintiff's age, education, work experience, and residual functional capacity, she could perform light work as a cleaner, bench assembler, and small parts assembler. Although the ALJ did not make an alternative step-five finding, she also observed that even if limited to sedentary work with the same non-exertional limitations, Plaintiff could perform sedentary work as an electronics worker.

         Standard of Review

         Judicial review in social security appeals is limited to two basic inquiries: “whether (1) the final decision is supported by substantial evidence and (2) whether the Commissioner used the proper legal standards to evaluate the evidence.'” Whitehead v. Colvin, 820 F.3d 776, 779 (5th Cir. 2016) (citation omitted). Evidence is substantial if it is ''relevant and sufficient for a reasonable mind to accept as adequate to support a conclusion; it must be more than a scintilla, but it need not be a preponderance.'' Leggett v. Chater, 67 F.3d 558, 564 (5th Cir. 1995) (quoting Anthony v. Sullivan, 954 F.2d at 295 (5th Cir. 1992)). This Court may not re-weigh the evidence, try the case de novo, or substitute its judgment for that of the ALJ, even if it finds evidence that preponderates against the ALJ's decision. Bowling v. Shalala, 36 F.3d 431, 434 (5th Cir. 1994).


         Plaintiff's sole issue on appeal challenges ALJ Porciello's evaluation on remand of the medical opinions submitted by her treating specialists at the University of Mississippi Medical Center (UMMC). Specifically, Plaintiff claims that the ALJ failed to follow the proper legal standards by failing to give due consideration to the medical opinions submitted by her treating pediatric cardiologist, Dr. Charles Gaymes.

         Dr. Gaymes is a pediatric cardiologist within the Department of Pediatric Cardiology at UMMC, where Plaintiff has reportedly been followed for her heart condition since childhood. Although both Plaintiff and Dr. Gaymes assert that he has seen her every 6-12 months since her birth, as observed in Williams I, the administrative record does not include records dating back to her birth. Medical records show that Plaintiff was also followed by UMMC pediatric cardiologists, Dr. James Clinton Smith and Dr. Avichal Aggarwal, as well as others in the department. Dr. Smith's treatment notes, which begin in 2009, indicate that he treated Plaintiff on a regular basis until May 2011. When he retired, Dr. Aggarwal took over Plaintiff's cardiac care and treated her in August 2011 and January 2012. Plaintiff was also followed by Dr. Gaymes, whom she saw in May 2012, June 2012, August 2012, March 2013, April 2013, May 2014, and June 2015. Prior to this later treatment, Dr. Gaymes also performed the insertion of Plaintiff's defibrillator and catheterization in April 2010.[5]

         Medical records show Plaintiff has undergone several surgical procedures over the years as a result of her congenital heart condition, including repair, stent placement, and pacemaker placement, with the last occurring in 2010. Although she has not undergone any additional surgery since becoming an adult, she continues to report chest pain, shortness of breath, and fatigue. At the administrative hearing before ALJ Porciello, Plaintiff testified that her chest pain is so severe that she spends most of the day in bed, getting up only to use the bathroom. The pain - reportedly a seven or eight on a scale of ten - increases when she bends and stoops; prevents her from performing any household chores; and, prohibits her from leaving the house except for appointments. She also experiences constant fatigue because she sleeps only two or three hours a night and has occasional dizziness which causes her to fall a lot. She cannot sit for longer than 30 minutes; stand longer than 5 to 10 minutes; or, raise her left arm without pain because of her pacemaker. As of her last administrative hearing, Plaintiff was 5 feet, 4 inches tall weighing 224 pounds, and testified that despite losing approximately 74 pounds, her mobility has gotten worse. In addition to her physical limitations, she also suffers from mental impairments, including crying spells, anger issues, and excessive stress.

         Treating Specialists

         1. Dr. Smith

         The administrative record does not include a medical source statement or many records from Dr. Smith. On examination in February 2011, he notes that Plaintiff had persistent chest pain post-operatively to a 2008 repair but no significant chest pain since an “automatic implantable cardioverter-defibrillator was subsequently placed by Dr. Gaymes.” In May 2011, he notes that Plaintiff was experiencing occasional chest pain after falling in a bathtub. He diagnosed her with chest wall pain secondary to trauma and prescribed Ibuprofen.[6]

         2. Dr. Gaymes

         The record contains several opinions from Dr. Gaymes concerning Plaintiff's physical and mental limitations. The first and only narrative opinion, dated July 2012, was submitted after he took over her care from Dr. Aggarwal, and was quoted by the ALJ in full as follows:

This 20-year-old female has a history of complex medical disease including congenital heart disease, mental health problems, and obesity. Haley underwent surgical repair of her congenital heart disease (Tetralogy of Fallot) with a modified right Blalock-Taussig shunt in September 1992. She then underwent ligation of the BT shunt and full repair with a pulmonary homograft in June 1994 with residual mild homograft stenosis and insufficiency. In December 2008, she underwent revision of the homograft with a Rastelli homograft. She then underwent an electrophysiology study in April 2010 and was noted to have ventricular tachycardia and therefore underwent placement of an implantable cardiac defibrillator. Haley continues to have residual mild homograft stenosis and insufficiency, mild to moderate pulmonary stenosis and mild pulmonary insufficiency. Haley has been followed for the above diagnosis since birth and her prognosis is stable. She is currently taking multiple medications for her heart disease as well as her psychiatric problems. She continues to be symptomatic with severe chest pain which makes it hard for her ...

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