Valora v. Kijakazi

• Decision Date: 10 February 2022
• Docket Number: CIVIL 1:20-CV-1224
• Parties: ARMANDO VALORA Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security[1] Defendant.
• Court: U.S. District Court — Middle District of Pennsylvania

ARMANDO VALORA Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security^[1] Defendant.

CIVIL No. 1:20-CV-1224

United States District Court, M.D. Pennsylvania

February 10, 2022

Mariani, Judge

REPORT AND RECOMMENDATION

Martin C. Carlson United States Magistrate Judge

I. Introduction

The Supreme Court has underscored for us the limited scope of our substantive review when considering Social Security appeals noting that:

The phrase “substantial evidence” is a “term of art” used throughout administrative law to describe how courts are to review agency factfinding. T-Mobile South, LLC v. Roswell, 574 U.S. __, __, 135 S.Ct. 808, 815, 190 L.Ed.2d 679 (2015). Under the substantial-evidence standard, a court looks to an existing administrative record and asks whether it contains “sufficien[t] evidence” to support the agency's factual determinations. Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) (emphasis deleted). And whatever the meaning of “substantial” in other contexts, the threshold for such evidentiary sufficiency is not high. Substantial evidence, this Court has said, is “more than a mere scintilla.” Ibid.; see, e.g., Perales, 402 U.S. at 401, 91 S.Ct. 1420 (internal quotation marks omitted). It means-and means only-“such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Consolidated Edison, 305 U.S. at 229, 59 S.Ct. 206. See Dickinson v. Zurko, 527 U.S. 150, 153, 119 S.Ct. 1816, 144 L.Ed.2d 143 (1999) (comparing the substantial-evidence standard to the deferential clearly-erroneous standard).

Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019).

Armando Valora is a pizza chef and former small business owner. Though he had previously been relatively focused on his fitness and wellbeing, the stresses of owning his own restaurant contributed to a decline in his health beginning in 2015, when he started gaining weight and was eventually hospitalized after developing diabetes. Since then, Valora has experienced a myriad of physical health problems including congestive heart failure, for which he underwent aortic valve replacement surgery in November of 2016, obesity, and migraine headaches. He also underwent emergency surgery for an umbilical hernia in 2017, and has dealt with gallstones, sleep apnea, and other physical ailments.

Despite Valora's acute and ongoing medical issues, he has consistently maintained employment, with small gaps for surgery and recovery, since at least 1997, when his work history began, including at the time of his disability hearing when he was working part-time as a pizza baker. He also lives alone and attends to many of his own daily activities.

Against this backdrop, Valora applied for supplemental security income under Title XVI of the Social Security Act on January 13, 2017, alleging a physical disability commencing on September 15, 2016. A hearing was held before an Administrative Law Judge (“ALJ”), who found that Valora was not disabled since the date his application was filed. Valora now appeals this decision, arguing that the ALJ's decision is not supported by substantial evidence. However, after a review of the record, and mindful of the fact that substantial evidence “means only-‘such relevant evidence as a reasonable mind might accept as adequate to support a conclusion, '” Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019), we find that substantial evidence supported the ALJ's findings in this case. Therefore, for the reasons set forth below, we will recommend that the court affirm the decision of the Commissioner.

II. Statement of Facts and of the Case

Valora filed the instant Title XVI claim for disability benefits on January 13, 2017 alleging an onset date of his disability of September 15, 2016. (Tr. 15). His claim was denied on May 22, 2017. (Tr. 82). Valora filed an untimely request for a hearing, with Good Cause due to his open-heart surgery, (Tr. 88-89), and on February 6, 2019, appeared before an ALJ. (Tr. 35). He alleged disability due to cardiomyopathy, aortic valve replacement surgery, visual disturbances, hernias, gall bladder problems, high cholesterol, hypertension, and diabetes. (Tr. 194). Valora has less than a high school education, having completed 6^th grade when he stopped going to school in Mexico at age 11. (Tr. 39-40). Though it is his second language, he can speak, read, write, and understand English. (Tr. 193). His past work history indicates he worked as a pizza cook from 1997 until 2011, then owned his own pizza restaurant from 2011 until the date of the alleged onset of his disability, September 15, 2016. (Tr. 195). At the time of his hearing, he was working part-time as a pizza cook. (Tr. 49).

With respect to these alleged impairments, the clinical record, medical opinions, and the plaintiff's activities of daily living revealed the following: Valora worked full-time as a pizza cook from at least 1997 until 2011. (Tr. 195). From 2011 until around the time of the onset his alleged disability^[2] he was a business owner running a pizza shop called Little Mama's. (Tr. 53, 195). He testified at the hearing that, at the time he began operating as a sole proprietor, he was healthy and weighed about 185 pounds. (Id.) According to Valora, the stress of running his business and working 80 to 90 hours per week led him to gain weight and develop diabetes, (Id.), and, around 2015, he fell very ill with diabetes and was hospitalized. (Tr. 44). Then, beginning in 2016, he began having heart failure which manifested as severe shortness of breath. A series of medical interventions began in April of 2016, when he was hospitalized for six days following severe shortness of breath, fever, and flulike symptoms. (Tr. 361). At that time, his acute diagnosis was influenza B and pneumonia which worsened his past physical ailments, (Tr. 365), and an EKG displayed moderate to severe aortic stenosis. (Tr. 358). At the time of his hospitalization, Valora admitted that he had not had any medical care or follow up in two years, (Tr. 354), and had not taken his blood pressure, cholesterol, or diabetes medications for the last year or so prior. (Tr. 365). Following his April 2016 hospitalization, Valora returned to work full-time running his pizza shop. (Doc. 19, at 3).

Valora was hospitalized again on September 17, 2016, after presenting at the emergency room with severe shortness of breath and evidence of congestive heart failure. (Tr. 289). He was diagnosed with acute congestive heart failure, cardiomyopathy, moderate to severe aortic stenosis, type two diabetes, morbid obesity, cholelithiasis, and suspected sleep apnea. (Tr. 292). He was released from the hospital after five days but returned to the emergency room just a few months later, in November of 2016, with shortness of breath and chest pain. (Tr. 417). This time, he was transferred to Geisinger Medical Center, (Tr. 448), where he underwent aortic valve replacement surgery. (Tr. 574-76). He was discharged on December 3^rd, 2016, (Tr. 604), and returned to work at his restaurant just one week after his surgery. (Tr. 45).

Valora's surgery follow-ups noted normal post-surgery condition. On January 3^rd, 2017 he was examined by Dr. Friscia for his surgery follow-up, who noted Valora was doing well overall and recommended he start cardiac rehabilitation. (503). He also had regular visits with cardiologist, Dr. Lesko. At his first postoperative cardiology appointment, Valora reported dizziness, fatigue, and some problems with upper arm strength, but denied any chest pain or shortness of breath. (Tr. 496). Dr. Lesko noted that, after learning Valora returned to work only one week after surgery, he counseled him to take things a little slower to allow himself a chance to recover. (Id.) His post-operative echocardiogram noted improvement, (Tr. 492), and a follow-up in February 2017 noted only slight shortness of breath with some squeezing in his chest with activity and some residual chest wall pain from surgery. (Tr. 843-44). Follow-ups with Dr. Lesko in March and July noted unremarkable findings from a cardiac standpoint and noted his condition was optimally medically managed. (Tr. 971, 1489). In early 2018, Valora reported feeling well at a cardiac follow-up with PA-C Roan, noting no chest pain, shortness of breath, palpitations, dizziness, syncope, orthopnea, PND, or increased lower extremity edema. (Tr. 1567). Though at his appointment in May 2018 Valora reported intermittent dizziness and changes in vision, (Tr. 1666), and his EKG report showed possible left atrial enlargement, incomplete right bundle branch bock, but normal ECG, (Tr. 1675), he reported no chest pain or shortness of breath up steps. (Tr. 1676).

In January of 2017, Valora also started seeing a neurologist and ophthalmologist for headaches and dizziness with blurred vision and temporary blindness. He reported to neurologist Dr. Schaefer on January 25, 2017 that he had headaches two to three times per week for the last two years with lightheadedness and vision dimming. (Tr. 486). Suspecting probable classic migraines, but with the unusual visual phenomenon of blindness, Dr. Schaefer referred Valora to an ophthalmologist to check for ocular causes of his symptoms. (Id.) She recommended he begin Topamax to resolve symptoms but suggested waiting until an examination with an ophthalmologist took place. (Tr. 488). Valora reported tunnel vision two to three times per week to the ophthalmologist on February 6, 2017 and was diagnosed with classic migraines and prescribed Topamax. (Tr. 1025). In January 2018, Valora reported to Dr. Schaefer that the Topamax had been helpful in reducing his visual phenomenon. (Tr. 1455), however at his next appointment in April of 2018 he reported...