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Sanders v. Commissioner of Social Security

United States District Court, N.D. Indiana, Fort Wayne Division

March 13, 2017

TARA SANDERS on behalf of K.S., Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, sued as Nancy A. Berryhill, Social Security Administration, [1] Defendant.


          Susan Collins, United States Magistrate Judge

         Plaintiff Tara Sanders, on behalf of K.S., a minor, appeals to the district court from a final decision of the Commissioner of Social Security (“Commissioner”) denying K.S.'s application for Supplemental Security Income (“SSI”).[2] (DE 1). For the following reasons, the Commissioner's decision will be AFFIRMED.


         Sanders applied on K.S.'s behalf for SSI in April 2012, alleging disability as of March 30, 2012 (DE 9 Administrative Record (“AR”) 24, 121-29); the Commissioner denied the application initially and upon reconsideration (AR 70-73, 77-82). A hearing was held on September 18, 2013, before Administrative Law Judge Maryann S. Bright (“the ALJ”), at which K.S. and Sanders, who were represented by counsel, testified. (AR 45-67). On February 18, 2014, the ALJ rendered an unfavorable decision, concluding that K.S. was not disabled. (AR 24-39). The Appeals Council denied Sanders's request for review, at which point the ALJ's decision became the final decision of the Commissioner. (AR 1-6).

         Sanders on behalf of K.S. filed a complaint with this Court on August 24, 2015, seeking relief from the Commissioner's final decision. (DE 1). Sanders advances just one argument in this appeal-that the ALJ improperly found that K.S. did not meet or equal Listing 114.02(A), the listing for Systemic Lupus Erythematosus (“SLE”). (DE 19 at 7-9).


         A. K.S's Testimony at the Hearing

         Sanders alleges that K.S. is disabled due to SLE with resulting arthritis and kidney disease. (DE 19 at 2). At the time of the hearing, K.S. was 11 years old and in the sixth grade; he rode the bus to school. (AR 49, 55-56). He stated that he had no problems with using a computer, writing, or completing his homework. (AR 50, 53). After school, he watches television or plays with his siblings. (AR 51). He helps with household tasks, such as using a knife to cut vegetables. (AR 53-54). K.S. stated that he can run and jump, but that his legs start hurting afterward. (AR 51-52). He reported that he is good at throwing and catching a ball, but his arm sometimes “locks up sideways, ” though this had never happened at school. (AR 52). He enjoys playing laser tag and has no problems with kicking. (AR 53). He was planning on trying out for the school basketball team; he also wanted to participate in cross country, but thought that he probably would not be able to do that. (AR 52-53).

         B. Sanders's Testimony at the Hearing

         Sanders reported that K.S. was diagnosed with SLE in March 2012. (AR 56). When asked how K.S. is different from other children his age, Sanders responded that he cannot play contact sports such as football. (AR 56). She added that while he can play and have a good time during the day, by the end of the day she might have to carry him upstairs because he cannot walk (AR 56, 62); she also said that some mornings he wakes up and cannot walk. (AR 56). Sanders acknowledged that K.S. was “doing well” with his medications (prednisone, methotrexate, naproxen, and plaquenil) without any report of side effects, but stated that he still has some bad days when he complains of aches and pains or swelling. (AR 56-58). She had taken him to the emergency room on several occasions for various complaints. (AR 57).

         Sanders stated that K.S. is able to perform his own self care; help with household chores; and walk, run, jump, and climb. (AR 59). But she tries to not let him do too much, concerned that if he does, “he's going to be hurting” later. (AR 59). She clarified, however, that there are times that he goes for walks and does not experience pain later. (AR 59). She estimated that he has two to four “flare-ups” a week, where he doesn't feel well, has a reduced appetite, and has pain and swollen joints. (AR 60). However, he had missed just one day of school in the sixth grade and “a few days” in the fifth grade.[4] (AR 57, 63). She stated that sometimes he has swelling in his fingers, but then conceded that “he ha[d]n't really had too much of that.” (AR 60). He was not receiving any special services at school, other than that Sanders had requested one of his teachers keep K.S.'s books in the classroom so that he did not have to carry them. (AR 60-61). Sanders agreed that K.S. has no learning problems, that he gets along well with others, and that he completes his homework. (AR 61-62).

         C. Summary of the Relevant Medical Evidence

         On March 13, 2012, K.S. was seen at the St. Joseph Medical Group for a rash and swelling. (AR 215-23). He complained of chest pain and congestion; he did not have a fever. (AR 215-17).

         On March 23, 2012, K.S. saw Dr. Susan Ballinger, a pediatric rheumatologist at Riley Hospital for Children (“Riley”), for a two-month history of joint pain and swelling. (AR 234). He had also complained of increased fatigue and a recent fever of 103 degrees. (AR 234). His symptoms included progressive swelling throughout the day, mostly around his knees. (AR 234). He was hospitalized for one week. (AR 234, 367). Laboratory testing revealed that his ANA was high and that his C3 and C4 were both low. (AR 235). Dr. Ballinger suspected SLE. (AR 234).

         At a follow-up examination on April 4, 2012, Dr. Ballinger noted that K.S. had stiff fingers, pain on wrist flexion and extension, right elbow swelling, and ankle swelling bilaterally with decreased subtalar motion. (AR 275). Otherwise, he had a normal gait, full range of motion, no swelling or tenderness, normal strength, and no rash or lesions. (AR 275). Dr. Ballinger's impression was SLE, and she prescribed prednisone. (AR 275). Two weeks later, on April 19, 2012, Dr. Ballinger indicated that K.S. had “been doing great since his last visit.” (AR 271). He was without new complaints, other than some nausea in the morning. (AR 271). On exam, K.S. had trace swelling in his knees bilaterally, but otherwise he had full range of motion, a normal gait, and no swelling or tenderness. (AR 272). A physical therapy evaluation that same day revealed no functional limitations, though he did have some swelling in his middle fingers and left knee, poor hand strength, decreased grip, and reduced finger flexion. (AR 261). He told his physical therapist that he had been doing better since taking medications. (AR 261).

         In May 2012, K.S. was seen by Dr. Kathleen O'Neil, chief pediatric rheumotologist at Riley. (AR 257). She noted that K.S. had developed nausea and diarrhea in the last week but that it had resolved within 48 hours. (AR 257). He was feeling much better and was “nearly back to normal, ” although his mother worried that he was sleeping more and not playing quite as much as usual; his mother suspected, however, that K.S.'s decreased interest in playing was related to their recent move. (AR 257). He had no fevers but did have some night sweats; he had experienced some weight gain since starting on prednisone. (AR 257). His only joint complaint was intermittent anterior knee pain when playing on his knees with his baby brother; otherwise, all of his joint complaints had resolved. (AR 257). On exam, K.S. showed no abnormalities other than skin irritation. (AR 257-58). Dr. O'Neil's impression was SLE with probable early renal involvement. (AR 258). She noted that he was on a very high dose of prednisone, which she hoped to taper somewhat. (AR 258).

         Also in May 2012, Dr. Steven Roush, a state agency physician, reviewed K.S.'s record and completed a childhood disability evaluation form. (AR 237-42). Dr. Roush concluded that K.S. had a severe impairment but that it did not meet or equal a listing. (AR 237). Dr. Roush found a “Less Than Marked” limitation in the domain of health and physical well-being, but no limitation in any of the other five domains of acquiring and using information, attending and completing tasks, interacting and relating with others, moving about and manipulating objects, and caring for yourself. (AR 237-40). He noted that K.S. was responding to medications and had been doing great since April 19, 2012. (AR 240).

         In early June 2012, K.S. saw his pediatrician, reporting that he had “lots of pain.” (AR 330). His prednisone dosage was being weaned down. (AR 330).

         In late June 2012, K.S. saw Dr. Sharon Andreoli, a pediatric nephrologist at Indiana University. (AR 367-68). K.S. reported fatigue, back pain, leg pains, and nosebleeds. (AR 367). His mother stated that his activity level had been significantly decreased since being diagnosed with SLE. (AR 367). A physical exam was unremarkable. (AR 367). Laboratory testing revealed a normal protein-creatinine ratio, normal renal function, normal blood pressure, and no hematuria. (AR 368).

         On July 2, 2012, K.S. returned to Dr. Ballinger, reporting that he had been doing well in terms of his joint pain and swelling. (AR 264). He had no fever, weight loss, or similar symptoms. (AR 264). He had been weaning from his prednisone pursuant to the doctor's weaning schedule. (AR 264). He had been complaining of some low back pain in the past few days, mostly at night. (AR 264). His mother thought that his knees looked a little swollen, but he had no joint pain and no significant medication side effects. (AR 264). Dr. Ballinger found that he was “doing well overall.” (AR 265).

         On July 11, 2012, Dr. Ballinger wrote a letter to the state agency noting K.S.'s diagnosis of SLE and his two major symptoms of SLE-arthritis and kidney disease. (AR 304). She indicated that he had “some limitations of his activity because of back pain from his arthritis, ” and that he “missed days of school last school year” due to his SLE. (AR 304). Due to concerns ...

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