Tracy M. v. Comm'r of Soc. Sec. Admin.
| Decision Date | 29 March 2019 |
| Docket Number | CIVIL ACTION FILE NO. 1:17-cv-04713-AJB |
| Parties | TRACY M., Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant. |
| Court | U.S. District Court — Northern District of Georgia |
Plaintiff brought this action pursuant to §§ 205(g) and 1631(c) of the Social Security Act ("the Act"), 42 U.S.C. §§ 405(g) and 1383(c)(3), to obtain judicial review of the final decision of the Commissioner of the Social Security Administration ("the Commissioner") partially denying her application for Supplemental Security Income ("SSI") and Disability Insurance Benefits ("DIB").2 The parties consented tomagistrate judge jurisdiction. (Dkt. Entry dated 5/25/18). For the reasons set forth below, the Commissioner's decision is REVERSED AND REMANDED.
On January 30, 2014, Plaintiff filed her application for SSI and DIB alleging a disability onset date of January 26, 2014. [Record (hereinafter "R")16]. These claims were denied initially and upon reconsideration, [R169, 175], and Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"), [R173]. A hearing was held before an ALJ on August 11, 2016, at which both Plaintiff, who was represented by an attorney, and a vocational expert ("VE"), testified. [R33-96]. On October 18, 2016, the ALJ denied Plaintiff disability benefits prior to December 11, 2015. [R15-27]. Plaintiff then filed for review by the Appeals Council, [see R7], which review wasdenied on September 19, 2017, making the ALJ's decision the final decision of the Commissioner. [R1-6]. Henry v. Comm'r of Soc. Sec., 802 F.3d 1264, 1267 (11th Cir. 2015) (quotation marks and alteration omitted).
Plaintiff filed this action on November 11, 2017, seeking review of the Commissioner's decision. [Doc. 3]. The answer and transcript were filed on March 21, 2018. [Docs. 8-9]. On May 23, 2018, Plaintiff filed a brief in support of her claim that the Commissioner committed reversible error, [Doc. 14], and on June 22, 2018, the Commissioner filed a response in support of the decision, [Doc. 15], to which Plaintiff replied, [Doc. 16]. The matter is now before the Court upon the administrative record, and the parties' pleadings and briefs,3 and it is accordingly ripe for review pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3).
Plaintiff claims that the ALJ erred by finding, without the advice of a medical expert, that Plaintiff was disabled as of December 11, 2015, but not before that date. [Doc. 14 at 1].
Plaintiff was born in January 1958 and was 56 years old on the alleged onset date of January 31, 2014. [R260]. Plaintiff completed high school and worked in the past in sales, but discontinued work on December 31, 2009 due to "lack of work." [R300-01]. She completed a year of college and has a certificate in interior design. [R38-39]. Sheinitially alleged disability due to ascites,4 cirrhosis,5 thrombocytopenia,6 anemia, hypothyroidism,7 acute kidney injury, jaundice, and Graves' disease.8 [R299].
At the hearing before the ALJ, Plaintiff testified that she lives alone in a two-story, single-family home, but lives downstairs, sleeps on the sofa, and only goes upstairs to shower. [R41]. She has a driver's license and can drive. [R42]. Plaintiff testified that she spends most days watching television from the sofa. [R76]. She can do laundry, but cannot vacuum due to her hand. [R77]. She testified that she has trouble going to the mailbox and fell badly in May 2016 trying to get groceries out of the car, but did not seek medical attention. [R77].
Plaintiff stated that, since her alleged onset date, she briefly worked answering phones at an office (as a temporary replacement while her friend was on medical leave) from 10 a.m. until four or five p.m., earning just over $3,000 in three months. [R42]. She related that the work was very hard, but they understood her limits, it was not a busy office, and she could get up and sit down as needed. [R78]. However, she did not think that she could continue doing that work, even under those conditions, because sheis now in more pain with her knees and has a harder time getting up and down. [R78-79].
Plaintiff testified that she "had major depression for a long time" and if affects her "job performance and anything I do." [R50]. She stated that she does not "want to go out of the house." [Id.]. She testified that she takes prescription antidepressants, which make her very tired and fall asleep. [R51].
Plaintiff also testified that she has cirrhosis of the liver as a result of drinking everyday, but that she has not drank since January 2014. [R52]. She reported that she went to Alcoholics Anonymous for eight weeks and has had some wine since then. [R53]. Most recently, she was told that her liver is functioning at 87 percent. [Id.]. She takes medication for her liver, which she claims prevents her from working because it causes her to fall asleep. [Id.]. She also testified that she has hypothydroidism which makes her hands shake such that she always drops things. [R54-55]. Plaintiff reported that her distance vision is blurry with her glasses and she has not been able to go to an eye doctor as she lacks health insurance. [R56-7, 41]. However, she can read with her current glasses. [R59].
Plaintiff testified that she no longer has strength in her right hand and cannot pull anything or hold anything heavy. [R59]. Plaintiff testified that she had Cortisoneshots9 in her shoulder, which still hurts, because she could not move it at all. [R68]. She further explained that her foot and ankle surgery caused her equilibrium to be off, her toes do not bend, her knees "are giving out[,]" and it is very difficult to even go up the two stairs to get into her home or get out of the sofa. [R59-60]. Plaintiff admitted that the walker she brought to the hearing was not prescribed and she got it at a garage sale. [R60]. Plaintiff testified that Robin Carey, a D.O. at Grady, recommended a walker. [R68-69]. She also stated that, in 2015, another doctor at Grady told her the only treatment for her foot would be another operation. [R69-70].
Plaintiff recounted that she had "brain surgery" in 2014 due to an aneurysm.10 [R71]. She later clarified that the vessel did not explode, as it was caught and repaired in time, but she was bleeding two weeks afterwards from the operation. [R72]. Shereported that she returned to the emergency room and had low blood pressure and hemoglobin and received a blood transfusion, but has since been okay. [R73].
Plaintiff testified that, after her foot surgery, she planned to return to work, but her foot never got better. [R75]. She further testified that she cannot stay seated long and must get up every 20-30 minutes because she gets stiff. [R75]. She opined that she cannot lift more than five pounds with her right arm and 10 with her left. [R75-76]. She could stand for about 10 minutes before needing to sit, and can walk for 10 minutes. [R76].
On July 15, 2012, Plaintiff was seen at Gwinnett Medical Center with chest pain and was diagnosed with left chest wall pain and a right foot injury due to a motor vehicle accident the previous month. [R1841]. Chastain Resurgens Orthopaedics saw her on September 13, 2012, and she was diagnosed as suffering from a possible non-union of her TMT joints11 in her foot. [R383]. She also had some chronic heelvalgus problems12 and a tight calf with pain primarily in the midfoot and a collapsed flatfoot with a TMT fracture. [Id.]. She was prescribed a scooter and crutches. [Id.]. Plaintiff returned on October 4, 2012 for her TMT fracture dislocation, midfoot degenerative joint disease, hindfoot valgus and midfoot collapse, and she was determined to be ready for reconstructive surgery. [R382].
On October 12, 2012, Plaintiff was admitted to North Fulton Hospital and diagnosed with was a collapsed right foot with tight calf and TMT degenerative joint disease. [R355]. The secondary diagnosis was depression, asthma, hypertension, thyroid disorder, Graves' disease, prior surgery to the left ankle, and prior surgery to the right shoulder. [Id.]. Her discharge instructions were touchdown weightbearing plus elevation and use of a walker. [Id.]. The operative report indicated a right posterior tibial tendon13 with talonavicular capsule/spring ligament reefing,14 right footmedial column flexor digitorum longus transfer,15 right first, second, and third TMT joint fusion, and a right gastrocnemius recession.16 [R360].
Plaintiff returned to Chastain Resurgens Orthopaedics on October 24, 2012 for extensive foot realignment and fusion of first, second, and third TMT joint. [R381]. She was stable, had steri-strips installed, and received a short leg cast with arch and toeplate which was placed in neutral. [Id.]. Plaintiff followed-up on November 7, 2012 for her post foot alignment and fusion and was stable, cleaned, redressed, and recasted. [R380]. Plaintiff continued her treatment on November 26, 2012 for her TMT degenerative joint disease and was stable and recasted in a short leg cast with an arch and toe plate. [R379].
On December 26, 2012, Plaintiff was again assessed at Chastain Resurgens and determined to be stable, with her midfoot much more stable and pain-free. [R378]. Her foot was again recasted. [Id.]. She returned on January 16, 2013 and was assessed with continued/recurrent collapsed foot at the talonavicular joint, with heel valgus, mildly improved with prior surgery but not completely realigned. [R377]. On February 1, 2013, Plaintiff returned again and was assessed with a questionable union at the first, second, and third TMT joint fusion site and a continued collapsed foot with the uncovering of the talar head17 in the heel valgus. [R375].
On February 7, 2013, Plaintiff was admitted to North Fulton Hospital for a CT scan of her foot that determined that the...
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