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Weigand v. Acting Commissioner of Social Security

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

November 16, 2017

MESCAL WIEGAND, Plaintiff,
v.
ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.

          OPINION AND ORDER

          THERESA L. SPRINGMANN UNITED STATES DISTRICT COURT

         The Plaintiff, Mescal Wiegand, seeks review of the final decision of the Commissioner of the Social Security Administration denying her application for Disability Insurance Benefits and Supplemental Security Income. The Plaintiff's application was denied initially and upon reconsideration. On August 17, 2015, an administrative law judge (ALJ) held a hearing on the Plaintiff's application. On September 15, 2015, the ALJ issued a Decision holding that the Plaintiff was not entitled to benefits because she was not disabled under the relevant provisions of the Social Security Act. In November of 2016, the Appeals Council denied review of the ALJ's decision, thereby making the ALJ's decision the final decision of the Commissioner. The Plaintiff subsequently filed suit pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3).

         EVIDENCE OF RECORD

         The Plaintiff was born on October 22, 1959. (R. at 71, ECF No. 10.) She has at least a high school education. (R. at 30.) The Plaintiff has a work history that includes working as a cafeteria manager at a high school, main cook, and a cafeteria manager. (R. at 31-37.)

         In the present case, the Plaintiff claims to have become disabled on June 26, 2013, due to physical impairments, including congestive heart failure. (Pl. Br. 2, ECF No. 14.)

         THE ALJ'S HOLDING

         Disability is defined as the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). To be found disabled, the Claimant must demonstrate that her physical or mental limitations prevent her from doing not only her previous work, but also any other kind of gainful employment that exists in the national economy, considering her age, education, and work experience. § 423(d)(2)(A).

         An ALJ conducts a five-step inquiry in deciding whether to grant or deny benefits. 20 C.F.R. § 404.1520. The first step is to determine whether the claimant no longer engages in substantial gainful activity (SGA). Id. In the case at hand, the ALJ determined that the Plaintiff had not engaged in SGA since the alleged onset of disability and thus, the Plaintiff satisfied the step one inquiry. (R. at 12.) In step two, the ALJ determines whether the claimant has a severe impairment limiting the ability to do basic work activities pursuant to § 404.1520(c). Here, the ALJ determined that the Plaintiff's impairment of congestive heart failure was a severe impairment because it “caused more than [a] minimal limitation in the claimant's ability to perform basic work activities.” (Id.) The ALJ did not find that the Plaintiff's diagnoses of hypertension, venous stasis[1], and back pain were severe. (Id.) Step three requires the ALJ to “consider the medical severity of [the] impairment” to determine whether the impairment “meets or equals one of [the] listings in appendix 1 . . . .” § 404.1520(a)(4)(iii). If a claimant's impairment(s), considered singly or in combination with other impairments, rise to this level, she earns a presumption of disability “without considering [her] age, education, and work experience.” § 404.1520(d). But, if the impairment(s), either singly or in combination, falls short, an ALJ must move to step four and examine the claimant's “residual functional capacity” (RFC)-the types of things she can still do physically, despite her limitations-to determine whether she can perform this “past relevant work, ” § 404.1520(a)(4)(iv), or whether the claimant can “make an adjustment to other work” given the claimant's “age, education, and work experience.” § 404.1520(a)(4)(v).

         In the case at hand, the ALJ determined that the Plaintiff's impairment does not meet or equal any of the listings in Appendix 1 and that the Plaintiff has the RFC to perform light work, as defined by § 404.1567(b). (R. at 12-13.) However, the ALJ held that the Plaintiff is limited to occasional climbing of ramps, stairs, ladders, ropes, and scaffolds, and the Plaintiff is limited occasional balancing, stooping, kneeling, crouching, and crawling. (R. at 13.) In arriving at the RFC, the ALJ determined that the Plaintiff's medically determinable impairments could reasonably be expected to cause her alleged symptoms, “however, the claimant's statements concerning the intensity, persistence, and limiting effects of these symptoms are not entirely credible . . . .” (R. at 14.)

         The ALJ began by reviewing the medical records from the date of the Plaintiff's alleged disability onset in June of 2013. The ALJ noted that though the Plaintiff was hospitalized for a period of approximately 9 days, diagnosed with congestive heart failure, sought treatment for difficulty breathing and swelling of the legs, and her ejection fraction was 20%, [2] the Plaintiff's arteries were normal and she had no chest pain. (R. at 13-14.) During her three week follow up from this period of hospitalization, the ALJ held that the medical record demonstrates that the Plaintiff's leg edema and shortness of breath improved and that she had no palpitations. (R. at 14.) In August of 2013, the ALJ noted that the Plaintiff was ambulatory for brief periods, an irregular gallop in the Plaintiff's heartbeat was no longer present, the Plaintiff's pulses in her extremities were diminished, but intact, and the Plaintiff reported feeling stronger every day- she climbed stairs twice per week, walked in the house and yard, and shopped. (Id.) The ALJ also noted that the Plaintiff has been attending cardiac rehabilitation since October of 2013, with no worsening of her condition (though the ALJ found that the cardiac rehabilitation medical records are difficult to read to determine the Plaintiff's progress). (Id.) Also in October 2013, the Plaintiff's ejection fraction improved to 50-55%, she reported fatigue but no shortness of breath, her peripheral pulses were normal, and the range of motion of her joints was normal. (R. at 15.) By October of 2013, the ALJ noted that the Plaintiff continued with routine treatment and did not experience any exacerbation of symptoms nor was she again hospitalized.

         Finally, the ALJ recounted the Plaintiff's testimony regarding her limitations, pointing out that while the Plaintiff maintained she had limitations, she also was able to function and/or her impairments were controlled by medication and treatment. (See R. at 14 (“The claimant stated she did not have difficulty walking but did no lifting or bending . . . . [S]he did not have problems dressing, but had trouble showering and lifting her hands above her head.”).) Ultimately, the ALJ found that:

The claimant's testimony regarding her limitations between June 2013 and December 2013 are not supported by the medical evidence of record, as demonstrated by improvement in the ejection fraction and her ability to perform daily activities. The claimant was able to sit, stand, and ambulate in October 2013 with no worsening of her condition noted during the period under consideration. The claimant has not required emergency room visits or hospitalization because of congestive heart failure and has only had routine treatment on a regular basis.

(Id.) Moreover, the ALJ held that the “physical examination and objective tests fail[ed] to corroborate the claimant's testimony of debilitating functional limitations.” (Id.)

         Accordingly, the ALJ gave partial weight to Wound Care physician Dr. Robert Jackson and Registered Nurse Carolyn Smith, who saw the claimant five times between July 2013 and August 2013 for venous stasis of her lower legs and open wounds on her legs, because by August of 2013, the Plaintiff's wounds had healed. Moreover, the Plaintiff was able to sit, stand, and ambulate, her venous stasis was under control, and the Wound Care Center did not assess her ability to lift, carry, or handle objects. (Id.) The Plaintiff did not return to the Wound Care Center after August of 2013, and ...


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