Spurlock v. Saul, CIVIL ACTION NO. 3:19-cv-00476

Decision Date14 May 2020
Docket NumberCIVIL ACTION NO. 3:19-cv-00476
PartiesCHRISTOPHER E. SPURLOCK, Plaintiff, v. ANDREW SAUL, Commissioner of Social Security, Defendant.
CourtU.S. District Court — Southern District of West Virginia

Plaintiff Christopher E. Spurlock ("Claimant") seeks review of the final decision of the Commissioner of Social Security (the "Commissioner") denying his applications for Disability Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401-33, and for Supplemental Security Income under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-83f. By standing order entered on January 4, 2016, and filed in this case on June 26, 2019, 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. 4.) Presently pending before this Court are Claimant's motion for judgment on the pleadings and supporting memorandum (ECF Nos. 13, 14) and the Commissioner's Brief in Support of Defendant's Decision (ECF No. 15).

Having fully considered the record and the arguments of the parties, the undersigned respectfully RECOMMENDS that the presiding District Judge GRANT Claimant's request to reverse the Commissioner's decision (ECF No. 13), DENY the Commissioner's request to affirm his decision (ECF No. 15), REVERSE the final decision of the Commissioner, and REMAND this matter to the Commissioner for further proceedings.

A. Information about Claimant and Procedural History of Claim

Claimant was 39 years old at the time of his alleged disability onset date and 43 years old on the date of the decision by the Administrative Law Judge ("ALJ"). (See Tr. at 1040.)2 He is a high school graduate. (Id. at 1044, 1294.) Most recently, he worked as a train operator for a railroad, and he has also been employed as a heavy equipment operator, welder, and general laborer at a railroad, as a recovery coach at a mental health facility, and as a heavy equipment salesperson and store manager. (Id. at 1044-47, 1069-70.) Claimant alleges that he became disabled on December 18, 2014, due to chronic obstructive pulmonary disease, narcolepsy, "Myocardial Infarction EF 30%," sleep apnea, and pulmonary hypertension. (Id. at 1293-94.)

Claimant protectively filed his applications for benefits on March 26, 2015. (Id. at 1222-47; see id. at 1252-57.)3 His claims were initially denied on November 23, 2015, and again upon reconsideration on April 11, 2016. (Id. at 1149-62, 1168-72.) Thereafter, on June 2, 2016, Claimant filed a written request for hearing. (Id. at 1173-74.) Anadministrative hearing was held before an ALJ on November 20, 2017, in Dayton, Ohio. (Id. at 1033-76.) On May 1, 2018, the ALJ entered an unfavorable decision. (Id. at 51-76.) Claimant then sought review of the ALJ's decision by the Appeals Council on July 3, 2018. (Id. at 1214-21.) The Appeals Council denied Claimant's request for review on May 8, 2019, and the ALJ's decision became the final decision of the Commissioner on that date. (Id. at 1-7.)

Claimant timely brought the present action on June 25, 2019, seeking judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g). (ECF No. 2.) The Commissioner filed an Answer (ECF No. 10) and a transcript of the administrative proceedings (ECF No. 11). Claimant subsequently filed his motion for judgment on the pleadings and supporting memorandum (ECF Nos. 13, 14), and in response, the Commissioner filed his Brief in Support of Defendant's Decision (ECF No. 15). As such, this matter is fully briefed and ready for resolution.

B. Relevant Medical Evidence

The undersigned has considered all evidence of record, including the medical evidence, pertaining to Claimant's arguments and summarizes it here for the convenience of the United States District Judge.

1. Treatment for Cardiac Conditions

On October 23, 2014, Claimant presented to the emergency room, complaining of chest pain, shortness of breath, and lightheadedness. (Tr. at 1661.) Upon physical examination, his cardiovascular system was normal. (See id.) Testing conducted at the hospital was also largely normal, and Claimant "refused an inpatient stress test." (Id. at 1662.) Claimant reported feeling better after being treated at the emergency room. (Id.) The attending physician opined, "His chest pain and shortness of breath was [sic] likelyrelated to anxiety." (Id.) Claimant was discharged in "stable" condition the same day and directed to follow up with his primary care provider. (Id.)

Claimant presented to the emergency room again on March 17, 2015, complaining of "midsternal chest pain" that worsened with exertion. (Id. at 1946.) A physical examination and related testing were normal. (Id. at 1948.) The hospital obtained a cardiac catheterization report from February 2015, which revealed a worsening cardiac lesion when compared with a previous report. (Id.) The report also noted that Claimant's ejection fraction was measured at 55-60% and that medication and lifestyle changes were recommended. (Id. at 1948, 2072.) However, Claimant stated that he had not been using his medication or his CPAP machine, and he continued to smoke. (Id. at 1949.) Claimant was admitted to the hospital "for further evaluation and treatment." (Id. at 1948.) He underwent another cardiac catheterization on March 18, 2015, which revealed "an ischemic cardiomyopathy." (Id. at 1955.) Claimant's ejection fraction was measured at 30%. (Id.) The cardiologist recommended "aggressive risk factor modification with nicotine replacement therapy," and he suggested that Claimant "be sent to cardiac rehabilitation therapy" and "be seen by a dietitian" and "pain management." (Id.) He also increased Claimant's medications. (Id.) Claimant's "chest pain resolved" after treatment, and he was discharged in "[s]table" condition on March 19, 2015. (Id. at 1962.)

An echocardiogram conducted on October 22, 2015, revealed "[o]verall left ventricular ejection fraction" of "50-55%." (Id. at 2041.) Claimant's "[l]eft ventricular systolic function" was observed to be "normal." (Id.) "[M]ild mitral annular calcification" and "[m]ild aortic sclerosis . . . without evidence of stenosis" were present. (Id.)

At an appointment with his pulmonologist on October 27, 2015, Claimant complained of "chest tightness radiating into his jaw with activity." (Id. at 2045.) Hestated that "the pain dissipated" after he used nitroglycerin. (Id.) Upon physical examination, Claimant's heart was observed to be normal. (Id.) The pulmonologist opined that Claimant's "chest discomfort . . . may be related to angina" and "scheduled an appointment with his cardiologist." (Id. at 2046.) Claimant was directed to go to the emergency room "[i]f he experiences pain that does not resolve with nitroglycerin" and was counseled to stop smoking. (Id.)

Claimant presented to his cardiologist several days later, on October 30, 2015, and the cardiologist scheduled a stress test and encouraged Claimant to consider weight loss surgery. (Id. at 2331.) That night, Claimant went to the emergency room, complaining of "chest pressure radiating into his jaw on the left side associated with mild shortness of breath that has been persistent." (Id. at 2053.) Claimant's cardiovascular system was observed to be normal upon physical examination. (Id. at 2056.) However, an EKG showed "some T-wave flattening in load V2 and V3 in comparison to prior EKG," and Claimant was admitted to the hospital for further treatment. (Id. at 2056-57.) Imaging conducted on October 31, 2015, revealed "normal" left ventricular ejection fraction at 60%. (Id. at 2080-81.) Claimant was discharged that day in "fair" condition. (Id. at 2084.)

Claimant underwent an echocardiogram on November 10, 2015, that revealed normal left ventricular function, with an ejection fraction of 50-55%. (Id. at 2336-37.) At his follow-up appointment with his cardiologist on November 19, 2015, the cardiologist noted that Claimant's "[c]ardiomyopathy . . . has now resolved with a normal [left ventricular] systolic function." (Id. at 2328.) The cardiologist further noted that Claimant "continues to be limited from his activities because of back pain[,] anxiety[,] anddeconditioning." (Id. at 2329.) He again recommended weight loss surgery. (Id. at 2328.)

Claimant returned to his pulmonologist on November 30, 2015, and complained of "chest pain radiating into his back" and shortness of breath. (Id. at 2349.) Claimant explained that his symptoms worsened "when he is anxious." (Id.) The pulmonologist ordered a CT scan of Claimant's chest, which was normal. (Id. at 2300, 2350.)

On January 24, 2016, Claimant was admitted to the hospital "with complaints of exertional left sided chest pain with radiation to left shoulder." (Id. at 3368.) A stress test conducted on January 25, 2016, revealed "no evidence of stress-induced ischemia," and Claimant's ejection fraction was measured at 54%. (Id.) A left-side heart catheterization revealed 50% restenosis, and Claimant's ejection fraction was rated at 55%. (Id.) At an appointment with his pulmonologist on February 1, 2016, Claimant reported that his chest pain resolved with medication the pulmonologist prescribed. (Id. at 2345.)

A short while later, on February 7, 2016, Claimant presented to the emergency room after an episode during which he lost consciousness. (Id. at 3360.) His cardiac-related testing was negative. (Id. at 3371.) Of note, Claimant's ejection fraction was calculated at 55%. (Id. at 3345.) Upon discharge, Claimant wore a heart monitor for several weeks, and although he "recorded multiple symptomatic events" during that time, the results of the study were "[e]ssentially unremarkable." (Id. at 3429.)

On April 7, 2016, Claimant again presented to the emergency room, complaining of chest pain that radiated into his jaw...

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