Karla J. v. Kijakazi
| Decision Date | 30 January 2023 |
| Docket Number | Civil Action 3:22-cv-00125 |
| Parties | KARLA J., Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Southern District of West Virginia |
PROPOSED FINDINGS & RECOMMENDATION
Plaintiff Karla J. (“Claimant”) seeks review of the final decision of the Commissioner of Social Security (the “Commissioner”) denying her application for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 401-33. (ECF No. 2.) By standing order entered on January 4, 2016 and filed in this case on March 11, 2022, this matter was referred to the undersigned United States Magistrate Judge to consider the pleadings and evidence and to submit proposed findings of fact and recommendations for disposition pursuant to 28 U.S.C. § 636(b)(1)(B). (ECF No. 3.) Presently pending before this Court are Plaintiff's Brief in Support of Complaint (ECF No. 9), Commissioner's Brief in Support of Defendant's Decision (ECF No. 12) and Plaintiff's Reply Brief (ECF No 13). Having fully considered the record and the arguments of the parties, the undersigned respectfully RECOMMENDS that the presiding District Judge DENY Claimant's request to reverse the Commissioner's decision (ECF No 9), GRANT the Commissioner's request to affirm her decision (ECF No. 12), AFFIRM the final decision of the Commissioner, and DISMISS this action from the Court's docket.
Claimant was 50 years old on her alleged disability onset date and 52 years old on the date of the decision by the Administrative Law Judge (“ALJ”). (Tr. 206.)[1] Claimant has a general-equivalency degree, and her work history includes jobs as a medical-office worker, food-service worker, and sleep-lab technician. (Tr. 97, 267.) Claimant alleges she became disabled on January 17, 2019, due to COPD, hyperthyroidism, chronic cough, endometriosis, coccydynia, osteoarthritis in the knees, lumbar pain with bilateral sciatica, failed right shoulder, anxiety, depression, and PTSD. (Tr. 121, 206.)
Claimant protectively filed her application for DIB on January 23, 2019. (Tr. 206212.) Her claim was initially denied on August 6, 2019, and again upon reconsideration on January 7, 2020. (Tr. 81-113.) Thereafter, on February 20, 2020, Claimant filed a written request for hearing. (Tr. 140.) An administrative hearing was held before an ALJ by videoconference on May 20, 2021. (Tr. 47.) On July 22, 2021, the ALJ rendered an unfavorable decision. (Tr. 22.) Claimant then sought review of the ALJ's decision by the Appeals Council that same day. (Tr. 1.) The Appeals Council denied Claimant's request for review on January 10, 2022, and the ALJ's decision became the final decision of the Commissioner on that date. (Tr. 1-7.)
Claimant timely brought the present action on March 8, 2022, seeking judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g). (ECF No. 2.) The Commissioner filed a timely Answer (ECF No. 7) and a transcript of the administrative proceedings (ECF No. 8). Claimant subsequently filed her Brief in Support of Complaint (ECF No. 9), and in response, the Commissioner filed her Brief in Support of Defendant's Decision (ECF No. 12). Plaintiff then filed a timely Reply Brief. (ECF No. 13). As such, this matter is fully briefed and ripe for resolution.
The undersigned has considered all evidence of record, including the medical evidence, pertaining to Claimant's arguments and summarizes it in relevant part here for the convenience of the United States District Judge. The vast majority of Claimant's medical records significantly predate Claimant's alleged onset date of January 17, 2019, by several years.
On December 15, 2009, Claimant presented to her primary care physician, Breton L. Morgan, M.D. (Tr. 646.) She reported “having, for the last several years, chronic back pain, an achy low back, stiff and achy, especially when sitting down and first moving around.” (Tr. 646.)
On July 3, 2013, Claimant presented to Dr. Morgan for follow up on her lumbar spine disorder. (Tr. 610.) It was noted that Claimant had “long standing bilateral sacroiliitis and coccydynia,” and that Dr. Morgan was trying to help Claimant lose weight “to help these orthopedic issues.” (Tr. 610.) Claimant had been on Zanaflex, but it was noted that she did not tolerate it. (Tr. 610.) Claimant followed up with Dr. Morgan on August 30, 2013, where it was noted that Claimant was doing “better” following a switch to Diclofenac for chronic anti-inflammatory therapy. (Tr. 608.)
A gallbladder ultrasound from February 25, 2014 was unremarkable, and Claimant's gallbladder was found to be unremarkable in shape and size, with no evidence of cholecystitis, cholelithiasis, or biliary dilation. (Tr. 680.)
On March 31, 2014, an MRI of Claimant's right shoulder was obtained. (Tr. 678.) The radiologist found acromioclavicular joint arthropathy, as well as abnormal signal intensity in the supraspinatus tendon, suggesting a partial-thickness tear or tendinopathy. (Tr. 678.) Claimant was told to follow up. (Tr. 678.)
On June 20, 2014, Claimant presented to Dr. Morgan for follow-up on her complaint of right shoulder impingement. (Tr. 598.) An MRI was not remarkable; vertebral bodies and disc spaces were intact, with minimal degenerative disc disease changes identified at ¶ 5-6 and C6-7, and T2-3 level. (Tr. 598, 704.) No significant evidence of spinal or foraminal stenosis was seen, and no additional significant disc bulging, disc herniation, abnormal signal intensity in the spinal cord, or other significant findings were suggested. (Tr. 704.) Claimant was seen by a specialist who did not recommend any particular treatment of this issue, even though the MRI did show arthritis and supraspinatus tendonopathy. (Tr. 598.) An EMG of the right upper extremity was normal. (Tr. 598.) Claimant was given an injection, but reported that she did not feel that the injection was effective for her. (Tr. 600.)
On December 9, 2014, Claimant presented to Dr. Morgan to follow up after surgery on a large mass on the right side of her neck which was revealed to be salivary gland tissue. (Tr. 590, 698.) Dr. Morgan noted that the mass was negative for malignancy, with the incision area healing nicely. (Tr. 590.)
On January 22, 2015, a transvaginal pelvic ultrasound showed unevenness of the sonographic texture of the uterus but was otherwise unremarkable, with no evidence of uterine mass lesions. (Tr. 326.)
Claimant presented to Dr. Morgan again on June 30, 2015. (Tr. 582.) She reported having a lot of gastrointestinal distress as well as continued trouble with coccydynia and increasing trouble with right shoulder pain, carpal tunnel in her right hand, and dropping things with the right hand. (Tr. 582.) Dr. Morgan noted a normal EMG and also noted that “[t]he grips are okay.” (Tr. 582.)
The following year on August 10, 2016, Claimant was again seen by Dr. Morgan. (Tr. 485.) Claimant complained of her extreme coccydynia and was noted to be very frustrated. (Tr. 485.) She stated that she did not want to be referred to orthopedics, so she was continued on Valium and Norco. (Tr. 485.) Dr. Morgan also noted that Claimant had tried injection therapy for her coccydynia but “has failed,” and that she failed on Neurontin and Lyrica as well due to side effects. (Tr. 486, 580.)
On August 18, 2016, a CT of the abdomen and pelvis showed that the cecum is rather low in position with the tip of the cecum in the mid-right lower pelvis. (Tr. 332.) The sacrum and coccyx appeared intact. (Tr. 332.) A portion of the bladder wall showed increased thickness with suggestion of a precancerous 1-cm sized polypoid lesion. (Tr. 333, 775.)
On October 13, 2016, an MRI of the abdomen and pelvis was inconclusive for evaluating Claimant's bladder lesions and further evaluation with cystoscopy was recommended. (Tr. 338.) The bony pelvis was found to be within normal limits. (Tr. 340.)
On November 11, 2016, Claimant followed up with Dr. Morgan. (Tr. 482.) She complained of lower back and pelvic pain, but it was noted that her head and neck examination was unremarkable. (Tr. 482.) She was prescribed narcotic pain medication and scheduled to follow up in a month. (Tr. 482.)
On December 13, 2016, Claimant underwent endometrial ablation. (Tr. 534.) On December 20, 2016, Claimant was seen for chronic pelvic pain, and had a diagnostic laparoscopy with lysis of adhesions and pelvic biopsies. (Tr. 361, 839.) Endometrial adhesions were diagnosed. (Tr. 362.) The abdominal examination was benign and there was no pelvic pathology identified on a CT scan of the abdomen and pelvis. (Tr. 362.) Claimant was instructed to continue on her home progestin regimen for suppression of potential residual underlying endometriosis; further, the option of a hysterectomy for chronic pain symptoms not able to be adequately managed medically was discussed. (Tr. 362.)
The following January 18, 2017, Claimant was hospitalized for bilateral pneumonia and a pulmonary embolism; she was found to have a possible autoimmune disorder given multiple elevated autoimmune markers. (Tr. 366.) A CT of the abdomen showed multilevel degenerative disc disease. (Tr. 394.) On March 3, 2017, a CT angiogram of the chest showed no acute process in the upper abdomen. (Tr. 569.) The pulmonary arteries were enhanced normally and there was no evidence of pulmonary embolism. (Tr. 569.)
Claimant presented to Dr. Morgan on June 7, 2017. (Tr. 474.) She continued to complain of chronic pain in her low back and tailbone regions, and Dr. Morgan continued her prescription for pain...
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