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Hilts v. Commissioner of Social Security

United States District Court, W.D. Louisiana, Lafayette Division

January 22, 2019


          JAMES, JUDGE



         Before the Court is an appeal of the Commissioner's finding of non-disability. Considering the administrative record, the briefs of the parties, and the applicable law, it is recommended that the Commissioner's decision be reversed and remanded for further administrative action.

         Administrative Proceedings

         The claimant, Ronald Hilts, fully exhausted his administrative remedies before filing this action in federal court. He filed applications for disability insurance benefits (“DIB”) and supplemental security income benefits (“SSI”), alleging disability beginning on March 20, 2015 due to Graves' Disease and hyperthyroidism.[1] His applications were denied.[2] He requested a hearing, which was held on January 25, 2017 before Administrative Law Judge Robert Grant.[3] The ALJ issued a decision on March 2, 2017, concluding that the claimant was not disabled within the meaning of the Social Security Act from March 20, 2015 through the date of the decision.[4] The claimant requested review of the ALJ's decision, but the Appeals Council found no basis for review.[5] Therefore, the ALJ's decision became the final decision of the Commissioner for the purpose of the Court's review pursuant to 42 U.S.C. § 405(g). The claimant then filed this action seeking review of the Commissioner's decision.

         Summary of Pertinent Facts

         The claimant was born on May 4, 1982.[6] At the time of the ALJ's decision, he was thirty-four years old. He graduated from high school and attended college without obtaining a degree.[7] He has relevant work experience as a fast food shift manager, an immigration transport officer, and a team leader in a home for mentally disabled men.[8] He alleged that he has been disabled since March 20, 2015.[9] In his applications for benefits, he attributed his alleged disability to Graves' Disease and hyperthyroidism.[10] In a function report dated June 8, 2015, he stated that any amount of heat, stress, or even a short walk caused his heart rate to increase to over 150 beats per minute and cause shortness of breath and dizziness.[11] At the hearing, he also testified that he had experienced chronic back pain since two low back surgeries in approximately 2003 or 2004, headaches, and fatigue. In his briefing, he argued that he also has severe congestive heart failure.

         On March 12, 2014, the claimant was examined by Dr. Jade N. Heinen for commercial driver fitness.[12] It was noted that he experienced back pain and had undergone spinal fusion surgery in 2003. Dr. Heinen noted that the claimant took Tylenol for his back pain and that this medication would not affect his driving. Inconsistently, however, Dr. Heinen indicated that the claimant had not undergone previous spine surgery, and had no limitation of motion or tenderness in his spine. Dr. Heinen also indicated that the claimant had no heart murmurs, no extra sounds in his heart, no enlarged heart, no pacemaker, and no implanted defibrillator.

         On July 10, 2014[13] and July 14, 2014, [14] the claimant saw Dr. Jevin Bordelon and Dr. Michael Owens, respectively, in the emergency department of Acadian Medical Center in Eunice, Louisiana, in connection with injuries sustained in a motor vehicle accident. He complained of pain in his back, left lateral anterior chest, left lateral posterior chest and neck. He was diagnosed with myofascial lumbar strain, myofascial cervical strain, and rib contusion. On both occasions, he was given pain medications and released.

         The claimant again saw Dr. Owens in the emergency department of Acadian Medical Center on September 9, 2014 for a rash.[15] It was noted that he was tachycardic, which means that his pulse rate was elevated.

         On March 24, 2015, lateral chest x-rays ordered by Dr. Heinen were normal.[16]

         On April 28, 2015, the claimant saw an endocrinologist, Dr. Daniel G. Stout, on referral from Dr. Heinen for hyperthyroidism.[17] The claimant reported that he had experienced an elevated heart rate since 2012 and was taking propranolol for high blood pressure. According to Dr. Stout, testing had revealed hyperthyroidism as the cause of the claimant's elevated heart rate. Dr. Stout's assessments were abnormal thyroid function study, tachycardia, abnormal liver function study, anemia, fatigue, nausea with vomiting, and tobacco use disorder. He suspected that the claimant had Graves' Disease and planned further evaluation. He suspected that the abnormal liver study and fatigue were related to the hyperthyroidism. He did not know the cause of the anemia, and he recommended that the claimant stop smoking.

         On May 1, 2015, [18] the claimant was seen by Dr. Randy Miller in the emergency room at Acadian Medical Center. Upon arrival at the hospital, the claimant had chest pain, heart palpitations, and a headache. A CT scan of his head and brain was normal. A chest x-ray showed cardiomegaly, an abnormal enlargement of the heart. He was diagnosed with a thyroid storm, which is a life-threatening health condition associated with untreated or undertreated hyperthyroidism characterized by the individual's heart rate, blood pressure, and body temperature soaring to dangerously high levels.[19] He was placed on Coreg instead of propranolol and started on Lopressor and propylthiouracil.

         On May 13, 2015, [20] the claimant again presented at the emergency department of Acadian Medical Center with complaints of chest pain. An EKG was abnormal, revealing an atrial flutter. A chest x-ray showed mild cardiomegaly with no acute pulmonary process or significant change from the prior examination. Dr. Miller and Dr. Stout were consulted, and the claimant was transferred to University Hospital and Clinics (“UHC”) in Lafayette, Louisiana, where he could be seen by Dr. Stout. However, the record contains no indication that the claimant was seen at UHC on that date.

         On June 2, 2015, [21] the claimant saw Dr. Heinen again. His chief complaints were headaches and weight loss, which Dr. Heinen noted were likely the result of his hyperthyroidism. Dr. Heinen noted that she had referred the claimant to an endocrinologist but the claimant had no insurance and could not afford to see the specialist. Dr. Heinen's assessments were hyperthyroidism, dysuria, microcytic anemia, headache, and chlamydial infection.

         On November 10, 2015, the claimant was seen at UHC with diagnoses of altered mental state, deep venous thrombosis, hepatic injury, lactic acidosis, metabolic acidosis, swelling of left upper extremity, and thyroid storm.[22] Future appointments were scheduled with the medicine clinic, the endocrine clinic, the ENT clinic, and the cardiology clinic.

         A transthoracic echocardiography report from a study conducted on February 19, 2016 at UHC showed congestive heart failure. The left ventricular ejection fraction was 37%, the left ventricular size was moderately increased, the right ventricle cavity was mildly enlarged, there was trace aortic regurgitation present, and trace to mild mitral regurgitation.

         On March 4, 2016, the claimant was seen in the internal medicine clinic at UHC.[23] He was diagnosed with hyperthyroidism, atrial flutter, valvular regurgitation, and chronic congestive heart failure. His medications were acetaminophen, carvedilol, lisinopril, methimazole, Topamax, Coumadin, and warfarin.

         The claimant followed up at UHC's internal medicine clinic on June 13, 2016.[24] He also complained of swelling on both sides of his neck, causing some swallowing problems. It was noted that he had improved since the last visit, his medications were adjusted, and he was to be referred for surgery as soon as his thyroid lab work normalized.

         On August 26, 2016, the claimant again followed up at the internal medicine clinic at UHC. He had been taken off thyroid medication about one and a half months previously and was having more headaches as well as a decreased appetite.

         On September 12, 2016, the claimant again followed up at UHC's internal medicine clinic.[25] His problems were hyperthyroidism and systolic heart failure. His medications were Coreg, Lisinopril, and Methimazole. Further testing was scheduled.

         Although the record does not contain an operative report, there is evidence that the claimant underwent thyroidectomy surgery on November 18, 2016 and was discharged from UHC on November 20, 2016.[26] On November 23, 2016, [27] he saw Dr. Bradley J. Chastant in the UHC East Clinic for a post-operative visit. It was noted that he underwent the thyroidectomy on November 18, 2016, was doing well, and had a good voice. He was to return in two weeks for a wound check, continue taking Synthroid, and follow up with regard to his Coumadin prescription. His medications were acetaminophen, calcium carbonate, Coreg, Keflex, Lovenox, Nexium, Synthroid, Lisinopril, and Warfarin.

         The claimant saw Dr. Chastant again on December 7, 2016.[28] He was to keep his Coumadin clinic appointment, decrease the Synthroid dosage if feeling anxious or getting little sleep, see his primary care physician for his rash, and return in four weeks after testing of his thyroid hormone levels.

         On January 25, 2017, the claimant testified at a hearing regarding his symptoms, impairments, and medical treatment. He stated that his thyroid condition causes headaches, fluctuations in appetite, fatigue, and a racing heart. He testified that his heart starts racing when he gets overheated, walks fast, or bends down and comes back up quickly. He stated that he had two back surgeries in approximately 2003 or 2004 - a discectomy and a fusion - and continues to have low back pain without radiation. He stated that the medication he takes causes drowsiness. While he admitted that his fatigue fluctuates somewhat, he estimated that he has three to four bad days per week. He attributes the fatigue to his thyroid condition and his medication. He said: “if I don't take my medicine it can harm me and if I do take my medicine I'll just sleep my day away.”[29]

         The claimant now seeks reversal of the Commissioner's adverse ruling.


         A. Standard of Review

         Judicial review of the Commissioner's denial of disability benefits is limited to determining whether substantial evidence supports the decision and whether the proper legal standards were used in evaluating the evidence.[30] “Substantial evidence is more than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”[31] Substantial evidence “must do more than create a suspicion of the existence of the fact to be established, but ‘no substantial evidence' will only be found when there is a ‘conspicuous absence of credible choices' or ‘no contrary medical evidence.'”[32]

         If the Commissioner's findings are supported by substantial evidence, they are conclusive and must be affirmed.[33] In reviewing the Commissioner's findings, a court must carefully examine the entire record, but refrain from reweighing the evidence or substituting its judgment for that of the Commissioner.[34] Conflicts in the evidence[35] and credibility assessments[36] are for the Commissioner to resolve, not the courts. Four elements of proof are weighed by the courts in determining if substantial evidence supports the Commissioner's determination: (1) objective medical facts, (2) diagnoses and opinions of treating and examining physicians, (3) the claimant's subjective evidence of pain and disability, and (4) the claimant's age, education, and work experience.[37]

         B. Entitlement to Benefits

         The Disability Insurance Benefit (“DIB”) program provides income to individuals who are forced into involuntary, premature retirement, provided they are both insured and disabled, regardless of indigence.[38] Every individual who meets certain income and resource requirements, has filed an application for benefits, and is determined to be disabled is eligible to receive Supplemental Security Income (“SSI”) benefits.[39]

         A person is disabled “if he is unable 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 twelve months.”[40] A claimant is disabled only if his physical or mental impairment or impairments are so severe that he is unable to not only do his previous work, but cannot, considering his age, education, and work experience, participate in any other kind of substantial gainful work which exists in significant numbers in the national economy, regardless of whether such work exists in the area in which the claimant lives, whether a specific job vacancy exists, or whether the claimant would be hired if he applied for work.[41]

         C. Evaluation Process and Burden of Proof

         A sequential five-step inquiry is used to determine whether a claimant is disabled. This process requires the ALJ to determine whether the claimant (1) is currently working; (2) has a severe impairment; (3) has an impairment listed in or medically equivalent to those in 20 C.F.R. Part 404, Subpart P, Appendix 1; (4) is able to do the kind of work he did in the past; and (5) can perform any other work.[42]

         Before going from step three to step four, the Commissioner evaluates the claimant's residual functional capacity[43] by determining the most the claimant can still do despite his physical and mental limitations based on all relevant evidence in the record.[44] The claimant's residual functional capacity is used at the fourth step to determine if he can still do his past relevant work and at the fifth step to determine whether he can adjust to any other type of work.[45]

         The claimant bears the burden of proof on the first four steps. At the fifth step, however, the Commissioner bears the burden of showing that the claimant can perform other substantial work in the national economy.[46] This burden may be satisfied by reference to the Medical-Vocational Guidelines of the regulations, by expert vocational testimony, or by other similar evidence.[47] If the Commissioner makes the necessary showing at step five, the burden shifts back to the claimant to rebut this finding.[48] “A finding that a claimant is disabled or is not disabled at any point in the five-step review is conclusive and terminates the analysis.”[49]

         D. The ALJ's Findings and Conclusions

         In this case, the ALJ determined, at step one, that the claimant has not engaged in substantial gainful activity since March 20, 2015. This finding is supported by substantial evidence in the record.

         At step two, the ALJ found that the claimant has the following severe impairments: thyroid disease, cardiac arrhythmia, and lumbar degenerative disc disease. status/post lumbar fusion. This finding is supported by substantial evidence in the record. However, the claimant contends that his congestive heart failure should also have been determined to be a severe impairment.

         At step three, the ALJ found that the claimant has no impairment or combination of impairments that meets or medically equals the severity of a listed ...

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