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Shelley v. Berryhill

United States District Court, E.D. Tennessee, Knoxville

September 29, 2017

NANCY A. BERRYHILL,[1] Acting Commissioner of Social Security, Defendant.


         This case is before the undersigned pursuant to 28 U.S.C. § 636(b), Rule 72(b) of the Federal Rules of Civil Procedure, and the consent of the parties [Doc. 17]. Now before the Court is the Plaintiff's Motion for Summary Judgment and Memorandum in Support [Docs. 18 & 19] and the Defendant's Motion for Summary Judgment and Memorandum in Support [Docs. 20 & 21]. Damien Shelley (“the Plaintiff”) seeks judicial review of the decision of the Administrative Law Judge (“the ALJ”), the final decision of the Defendant Nancy A. Berryhill, Acting Commissioner of Social Security (“the Commissioner”). For the reasons that follow, the Court will GRANT the Plaintiff's motion, and DENY the Commissioner's motion.


         On January 11, 2013, the Plaintiff filed an application for disability insurance benefits pursuant to Title II of the Social Security Act, 42 U.S.C. § 401 et seq., claiming a period of disability that began on July 7, 2012. [Tr. 18, 136-42]. After his application was denied initially and upon reconsideration, the Plaintiff requested a hearing before an ALJ. [Tr. 97]. Following a hearing [Tr. 30-54], the ALJ found the Plaintiff was “not disabled” [Tr. 15-29]. The Appeals Council denied the Plaintiff's request for review [Tr. 1-6], making the ALJ's decision the final decision of the Commissioner.

         Having exhausted his administrative remedies, the Plaintiff filed a Complaint with this Court on July 11, 2016, seeking judicial review of the Commissioner's final decision under Section 405(g) of the Social Security Act. [Doc. 1]. The parties have filed competing dispositive motions, and this matter is now ripe for adjudication.


         When reviewing the Commissioner's determination of whether an individual is disabled pursuant to 42 U.S.C. § 405(g), the Court is limited to determining whether the ALJ's decision was reached through application of the correct legal standards and in accordance with the procedure mandated by the regulations and rulings promulgated by the Commissioner, and whether the ALJ's findings are supported by substantial evidence. Blakley v. Comm'r of Soc. Sec., 581 F.3d 399, 405 (6th Cir. 2009) (citation omitted); Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004).

         Substantial evidence is “more than a scintilla of evidence but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Cutlip v. Sec'y of Health & Human Servs., 25 F.3d 284, 286 (6th Cir. 1994) (citations omitted). It is immaterial whether the record may also possess substantial evidence to support a different conclusion from that reached by the ALJ, or whether the reviewing judge may have decided the case differently. Crisp v. Sec'y of Health & Human Servs., 790 F.2d 450, 453 n.4 (6th Cir. 1986). The substantial evidence standard is intended to create a “‘zone of choice' within which the Commissioner can act, without the fear of court interference.” Buxton v. Halter, 246 F.3d 762, 773 (6th Cir. 2001) (quoting Mullen v. Bowen, 800 F.2d 535, 545 (6th Cir. 1986)). Therefore, the Court will not “try the case de novo, nor resolve conflicts in the evidence, nor decide questions of credibility.” Garner v. Heckler, 745 F.2d 383, 387 (6th Cir. 1984) (citation omitted).

         On review, the plaintiff “bears the burden of proving his entitlement to benefits.” Boyes v. Sec'y. of Health & Human Servs., 46 F.3d 510, 512 (6th Cir. 1994) (citation omitted).


         The Plaintiff alleges disability based on hypertrophic cardiomyopathy.[2] [Tr. 55, 71]. His cardiac impairment is treated by cardiologist, Gregory Brewer, M.D. The Plaintiff first presented to Dr. Brewer on July 17, 2012, due to a history of chest pain. [Tr. 256]. Diagnostic testing, including a 2D/M mode echocardiogram and color flow doppler echocardiogram, indicated hypertrophic cardiomyopathy. [Tr. 258]. The Plaintiff often complained of chest pain, shortness of breath, severe headaches, edema in all four extremities, nausea, sweating, light-headedness, dizziness, and fainting spells. [Tr. 218, 256-75, 380-89]. During a three day hospitalization on August 31, 2012, for severe chest pain, a heart catheterization was performed, revealing extensive muscle bridging in the mid and distal left anterior descending coronary artery with narrowing up to 70-80% in multiple areas. [Tr. 266, 278].

         Dr. Brewer referred the Plaintiff to the cardiology division at the Cleveland Clinic. [Tr. 261]. An echocardiogram and MRI was performed on September 12, 2012, confirming hypertrophic cardiomyopathy with mid-cavitary obliteration. [Tr. 217, 233-35]. The examining physician suggested further diagnostic testing, including a right heart catheterization and imaging, and for the Plaintiff to continue medication prescribed by Dr. Brewer. [Tr. 218]. Based on recommendations from the Cleveland Clinic, Dr. Brewer ordered a cardiac PET scan on September 24, 2012, to evaluate for ischemia. [Tr. 268]. Imaging results were negative for transmural ischemia, but did indicate abnormal left ventricular ejection fraction of 47%[3] with mild global hypokinesis[4] and increased septal thickness with increased radiopharmaceutical uptake. [Tr. 269]. On January 9, 2013, after the Plaintiff received a second opinion from the University of Tennessee Medical Center [Tr. 274], Dr. Brewer noted that both tertiary referral centers had reached the same conclusion: that the Plaintiff required medial management and unroofing or stenting on the left anterior descending artery was not recommended. [Tr. 277].

         The Plaintiff continued to present to Dr. Brewer through July 2014 with complaints of chest pain, shortness of breath, edema, and elevated diastolic blood pressure. [Tr. 377, 380, 383, 386, 389]. On May 9, 2013, the Plaintiff reported passing out six times from coughing. [Tr. 380]. On July 1, 2013, another echocardiogram was performed, revealing left atrial enlargement with asymmetrical ventricle septal hypertrophy with ejection-fraction of 65%. [Tr. 383]. Dr. Brewer opined that the Plaintiff had non-obstructive hypertrophic cardiomyopathy[5] manifesting itself as asymmetrical septal hypertrophy[6] with a long segment of muscle bridging with persistent chest pain. [Tr. 385]. Dr. Brewer concluded that medical management was still the appropriate course of treatment. [Id.].

         The record includes four medical opinions from Dr. Brewer. The first one, dated October 29, 2012, is an attending physician statement completed for a private insurer in connection with a request for long term disability benefits. [Tr. 402-04]. Therein, Dr. Brewer opined that the Plaintiff suffers from hypertrophic cardiomyopathy with muscle bridging - recurrent refractory chest pain. [Tr. 402]. Hypertension was listed as a secondary condition contributing to disability. [Tr. 403]. Symptoms of chest pain, shortness of breath, and edema were also indicated. [Id.]. Dr. Brewer opined that over the course of an eight-hour workday, the Plaintiff could not stand, sit, walk, or drive; he could use his upper extremities for repetitive functions such as simple grasping, pushing and pulling, and fine manipulation; he could occasionally bend, squat, climb, reach above shoulder level, kneel, crawl, use feet for foot controls, and drive; and he could lift or carry up to 10 pounds. [Tr. 404]. In terms of mental limitations, the Plaintiff had no limitation relating to other people beyond giving and receiving instructions, but was moderately limited in completing and following instructions and performing simple and repetitive tasks, and extremely limited in performing complex and varied tasks. [Id.]. Dr. Brewer rated the Plaintiff's cardiac functional capacity as a “Class 4 (complete limitation).”[7] [Id.].

         A “Chest Pain Questionnaire” was also completed by Dr. Brewer on February 1, 2013. [Tr. 255]. Dr. Brewer described the Plaintiff's chest pain as occurring on the left side of his chest, lasting one hour to two days in duration, and radiating to his neck and down his left arm. [Id.]. Dr. Brewer did not identify any precipitating factors but indicated that the Plaintiff experienced pain with or without exertion and experienced evaluated blood pressure as an associated symptom. [Id.].

         A second “Chest Pain Questionnaire” was completed on May 9, 2013. [Tr. 348]. Dr. Brewer described the Plaintiff's chest pain as occurring in the upper part of his chest, radiating to the arms, and worsened with exertion. [Id.]. Exertion was also identified as sometimes being a precipitating factor of chest pain. [Id.]. When the Plaintiff ...

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