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Sarah S. v. Commissioner, Social Security Administration

United States District Court, N.D. Georgia, Atlanta Division

March 13, 2019

SARAH S., Plaintiff,



         Plaintiff brought this action pursuant to § 1631(c) of the Social Security Act (“the Act”), 42 U.S.C. § 1383(c)(3), to obtain judicial review of the final decision of the Commissioner of the Social Security Administration (“the Commissioner”) denying her application for Supplemental Security Income (“SSI”).[1] The parties consented to magistrate judge jurisdiction. (Dkt. Entry dated 02/12/18). For the reasons set forth below, the Commissioner's decision is AFFIRMED IN PART AND REVERSED AND REMANDED IN PART.


         On September 16, 2014, Plaintiff filed her application for SSI and DIB alleging a disability onset date of November 15, 2013. [Record (hereinafter “R”) 175-82]. These claims were denied initially on October 9, 2014, and upon reconsideration on February 24, 2015. [R93, 97]. Thereafter, Plaintiff filed a written request for hearing. [R116]. Plaintiff appeared and testified at a hearing before an Administrative Law Judge (“ALJ”) on August 2, 2016, where she was represented by an attorney and amended her alleged onset date to May 25, 2015, thus nullifying her DIB claims. [R33-52]. A vocational expert (“VE”) also testified. [Id.].

         On October 14, 2016, the ALJ denied Plaintiff disability benefits. [R21-27]. Plaintiff then sought review by the Appeals Council, which review was denied on August 5, 2017, making the ALJ's decision the final decision of the Commissioner. [R1-7].

         Plaintiff filed this action on September 29, 2017, seeking review of the Commissioner's decision. [Docs. 1-2, 3]. The answer and transcript were filed on January 19, 2018. [Docs. 6, 7]. On February 19, 2018, Plaintiff filed a brief in support of her petition for review of the Commissioner's decision, [Doc. 11], and on March 21, 2018, the Commissioner filed a response in support of the decision, [Doc. 12], to which Plaintiff replied on March 29, 2018, [Doc. 14]. The matter is now before the Court upon the administrative record, and the parties' pleadings and briefs, [2] and it is accordingly ripe for review pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3).


         Plaintiff claims that the ALJ made the following errors:

1. The ALJ's decision is based upon an error of law in the evaluation of the opinion of treating physician Goins.
2. The ALJ's decision is not supported by substantial evidence because it contains multiple errors of fact and is based on incorrect or inappropriate reasons for discounting Plaintiff's symptoms and limitations.

[Doc. 11 at 8, 12].


         A. Background

         Plaintiff was born in 1965 and was 50 years old on the alleged onset date. [R196]. Plaintiff completed the tenth grade and worked in the past as a babysitter, cafeteria worker, and home health care aide. [R211]. She alleges disability due to due to diabetes, high blood pressure, back pain, depression, pain in her feet, and arthritis. [R210].

         B. Lay Testimony

         Plaintiff testified before the ALJ that she had “a lot of problems[, ]” including visible knots in her right hand and wrist. [R38]. She also complained of pain in her left shoulder and right knee, [R42], with her knee pain being a “10” on the pain scale, [R43]. She testified that she had problems bending and could not stand for long, and difficulty doing household chores in her apartment because her legs regularly swelled and that she needed to elevate them. [R40]. She further testified that her medical providers wanted her to have a cardiac stress test done because they were concerned that she had congestive heart failure, but she could not afford the test.[3] [R41].

         C. Medical Records

         Plaintiff submits that since she has not worked since 2009, [R210], she did not have any income, [R37], and, therefore, her medical treatment consisted of various visits to the emergency room (“ER”) and the limited treatment offered by a charity clinic, Healing Bridge Clinic. [Doc. 11 at 5].

         Plaintiff was seen in the Piedmont Hospital ER on November 12, 2014 for a cough with nausea, vomiting, and headache. [R338]. She returned on Christmas Eve 2014 for a dry cough that began the night before. [R341]. She had an abnormal ECG, [4]with sinus tachycardia, [5] and indications that she had previously suffered a heart attack (“anterior infarction, age undetermined”). [R346]. She returned to the ER in March and April 2015, showing significantly elevated blood sugars. [R354]. An abnormal ECG, with indications of a previous anterior infarction, was again noted. [R357].

         A visit on May 10, 2015 for cough, chest tightness, and fluid retention revealed bilateral lower extremity edema.[6] [R364]. Her ECG was again abnormal. [R368]. Differential diagnoses included “acute coronary syndrome (“ACS”), [7] decompensated heart failure, pulmonary embolism, pneumonia, chronic obstructive pulmonary disease (“COPD”), asthma, bronchitis, influenza, anxiety, malignancy[.]” [R366]. She returned nine days later with complaints of back pain and an x-ray of her thoracic spine revealed multi-level degenerative disc changes. [R378].

         On May 26, 2015, Plaintiff presented to the Healing Bridge Clinic where she was treated for right shoulder impingement and right knee pain. [R405]. She returned on August 13, 2015 complaining of a two-year history of pain in her feet, wrist, and back. [R388]. On November 5, 2015, she was evaluated for right knee pain, bilateral upper and lower extremity neuropathy, and a ganglion cyst[8] on her right wrist. [R382].

         On May 26, 2016, Maurice Goins, M.D., the orthopedist who treated Plaintiff at the clinic, completed a pain questionnaire, in which he indicated that he first examined Plaintiff August 13, 2015 and again on May 26, 2016. [R397-99]. Dr. Goins noted that Plaintiff had an onset of right knee pain and left shoulder pain three years ago which caused constant, severe pain. [R397]. He noted painful range of motion on exam and diffuse intermittent edema. [Id.]. It was his opinion that Plaintiff would need to lie down for a minimum of two hours during the normal working day; would need to elevate her feet on a daily basis; and he concluded that she was not physically capable of performing even sedentary work on a full-time basis. [R399]. There were no other opinions from examining physicians in the record and no consultative examinations were ordered.

         D. Vocational-Expert Testimony

         The ALJ asked the VE if Plaintiff could perform her past work (as babysitter, cafeteria worker, and health aid) if she could occasionally lift 20 pounds; frequently lift 10 pounds; stand and sit for six hour in an eight-hour workday; occasionally or frequently, kneel, crouch, crawl, stoop, balance, and take stairs; never use ladders; occasionally be exposed to heights and moving parts and reach overhead with her non- (last visited 3/6/19).

         dominant arm. [R49]. The VE responded that she could not perform her past work with those limitations, but that sufficient jobs existed in the national economy that Plaintiff could perform, such as laundry worker (DOT #361.687-014, 400, 000 positions nationally), housekeeper (DOT #302.685-010, 800, 000 positions nationally), or office helper (DOT #239.567-010, 90, 000 positions nationally). [R49-50].


         The ALJ made the following findings of fact:

1. The claimant meets the insured status requirements of the Social Security Act through December 31, 2014.
2. The claimant has not engaged in substantial gainful activity since May 27, 2015, the alleged onset date (20 CFR 416.971 et seq.).
3. The claimant has the following severe impairments: degenerative disc disease, right knee, left shoulder pain, diabetes mellitus, and obesity (5'0”, 267 pounds, BMI of 52.1) ([20 CFR] 416.920(c)).
. . .
4. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 416.920(d), 416.925, and 416.926).
. . .
5. The claimant has the residual functional capacity to perform light work as defined in 20 CFR 416.967(b) except she can occasionally lift 20 pounds, frequently lift 10 pounds, and stand, sit, and walk for six hours out of an 8-hour day. She can never climb ladders, occasionally climb stairs, stoop, balance, kneel, crouch, and crawl, occasionally reach overhead with the left upper extremity, and tolerate occasionally exposure to hazards.[]
. . .
6. The claimant is unable to perform any past relevant work (20 CFR 416.965).
. . .
7. The claimant was born on May 27, 1965 and was 50 years old, which is defined as an individual approaching advanced age, on the alleged disability onset date (20 CFR 416.963).
8. The claimant has a limited education and can communicate in English (20 CFR 416.964).
9. Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant in “not disabled, ” whether or not the claimant has transferable job skills (See SSR 82-41 and 20 CFR Part 404, Subpart P, Appendix 2).
10. Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant ...

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