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Williams v. Berryhill

United States District Court, N.D. Texas, Dallas Division

September 13, 2019


         Consent Case [1]



         Lasonya Cavett Williams (Plaintiff) seeks judicial review of a final decision by the Commissioner of Social Security (Commissioner) denying her claim for a period of disability and disability insurance benefits (DIB) under Title II of the Social Security Act. (See docs. 1; 16.) Based on the relevant filings, evidence, and applicable law, the Commissioner's decision is AFFIRMED.

         I. BACKGROUND

         On February 5, 2015, Plaintiff filed her application for DIB, alleging disability beginning on March 27, 2014. (Id. at 54.)[2] Her claim was denied initially on May 20, 2015, and upon reconsideration on September 27, 2015. (Id. at 77, 82.) On September 28, 2015, Plaintiff requested a hearing before an Administrative Law Judge (ALJ). (Id. at 85-86.) She appeared and testified at a hearing on May 30, 2017. (Id. at 32-53.) On August 28, 2017, the ALJ issued a decision finding her not disabled and denying her claim for benefits. (Id. at 14-31.)

         Plaintiff timely appealed the ALJ's decision to the Appeals Council on September 21, 2017. (Id. at 155-56.) The Appeals Council denied her request for review on June 22, 2018, making the ALJ's decision the final decision of the Commissioner. (Id. at 5-11.) Plaintiff timely appealed the Commissioner's decision under 42 U.S.C. § 405(g). (See doc. 1.)

         A. Age, Education, and Work Experience

         Plaintiff was born on July 28, 1974, and was 42 years old at the time of the hearing, (doc. 12-1 at 35.) She had an eleventh grade education, could communicate in English, and had past relevant work as a school bus driver. (Id. at 36.)

         B. Medical Evidence

         On March 27, 2014, Plaintiff presented to Stanley B. Cohen, M.D., with musculoskeletal complaints. (Id. at 339.) She had pain in her left thigh with numbness and tingling all the way down her left leg that bothered her while driving a bus and sitting for a long period. (Id.) A rheumatologist had seen her and felt that she had fibromyalgia and possibly lupus. (Id.) Her physical examination showed no evidence of synovitis, but she had severe valgum deformity in her knees. (Id. at 341.) Straight leg raising was positive on the left, but Plaintiff had a range of motion that was good in all upper extremity joints, normal in the cervical spine, and excellent in both hips. (Id.) She had a positive Taber Patrick maneuver, and her lower extremities were unremarkable. (Id.) Dr. Cohen assessed her joint pain as potentially a component of sciatica and recommended imaging studies of her spine, left hip, and knees. (Id.) He noted that her lupus was stable with creatinine, and that he had discussed the necessity of weight reduction. (Id.) He was uncertain whether Plaintiff could continue working as a bus driver because of her obesity and "mechanical issues." (Id.)

         The following day, Plaintiff presented to Maria Carmin Perez, M.D., for lupus treatment. (Id. at 300.) Her creatinine was stable, and she had been tolerating her lupus medication. (Id.) She continued to experience left leg pain, but her hyperkaimenia, recurrent skin abscesses, and abdominal pain were noted as resolved. (Id. at 303.) She weighed approximately 287 pounds[3] with a BMI of 56.08, and Dr. Perez discussed weight loss strategies. (Id. at 303-04.)

         On April 1, 2014, Plaintiff underwent MRIs of her lumbar spine and left hip to rule out nerve entrapment and avascular necrosis (AVN). (Id. at 341.) Her lumbar spine showed a 1.8 mm central protrusion with epidural lipomatosis and mild facet hypertrophy at L5-S1, but no significant foraminal narrowing. (Id. at 357.) It also showed minor degenerative disc disease (DDD) and epidural lipomatosis, but was not considered significant by the examining neurologist. (Id. at 333.) Bilateral lower quadrant/pelvic cystic lesions were observed, and a sonographic correlation was recommended for possible adnexal tumors. (Id. at 358-59.) Plaintiffs left hip showed bilateral symmetric avascular nacrosis of the femoral heads without articular surface collapse or disruption, as well as mild left gluteus minimus and medius insertional tendinopathy. (Id. at 359.) It also showed borderline bilateral external iliac symmetric lymphadenophy, and a correlation for systemic cause was recommended. (Id.) A septated left adnexal cystic focus measuring at least 4.2 x 4 cm was observed, and the radiologist opined that stability of this finding could be confirmed through a follow-up pelvic ultrasound. (Id.). A right knee X-ray was unremarkable. (Id. at 356.)

         On May 20, 2014, Plaintiff returned to Dr. Cohen for pain in both her lower back and lumbosacral junction. (Id. at 333.) She weighed approximately 283 pounds with a BMI of 52.60. (Id. at 335.) Dr. Cohen recommended physical therapy and continued weight reduction, and referred her for pain management. (Id. at 336.) He noted that she should remain on short-term disability because her situation prevented her from working as a bus driver. (Id.) On May 28, 2014, Plaintiffs hip X-ray showed mild degenerative changes of the right hip, and her pelvic ultrasound was normal. (Id. at 353-54.)

         From June 2014 through September 2014, Plaintiff completed eleven physical therapy sessions for sacroilitis, trochanteric bursitis, and lumbar radiculopathy. (Id. at 266-67.) Her compliance with physical therapy was noted as "fair"; she discharged herself on September 29, 2014. (Id.)

         On July 3, 2014, Plaintiff saw Dr. Cohen for a follow-up. (Id. at 327.) She weighed 277 pounds with a BMI of 51.49. (Id. at329-30.) She had responded well to epidural steroid injections, and Dr. Cohen opined that the source of her pain appeared to be from her hips and back. (Id. at 329.) Her lupus nephritis (LN) and aseptic necrosis femur (ANF) symptoms were noted as stable, and the results from her musculoskeletal examination remained unchanged. (Id. at 329-30.) Dr. Cohen opined that she should not drive a bus and would be better off in a sedentary job. (Id. at 327.)

         On August 18, 2014, Plaintiff returned to Dr. Perez for a lupus follow-up.(Id. at 287.) Her renal function and creatinine remained stable, but she continued showing proteinuria and hematuria. (Id.) She weighed approximately 273 pounds with a BMI of 53.47. (Id. at 288.)

         At a follow-up with Dr. Cohen on September 2, 2014, Plaintiff reported lower back pain during prolonged sitting or weight bearing. (Id. at 406.) Prior injections provided some relief, but her symptoms returned. (Id.) She did not have any radicular complaints or hip issues, and her weight remained the same. (Id.) Dr. Cohen noted that her DDD was being aggravated by her obesity and severe lumbar lordosis, and recommended core strengthening, another injection, and aggressive weight reduction. (Id. at 409.)

         The following day, Plaintiff presented to Irving Orthopedics and Sports Med (Orthopedics) for evaluation of her bilateral hips. (Id. at 271.) Her bilateral hip pain had started gradually months before, was most severe in the left hip, and would radiate to the lower leg. (Id.) She described it as constant "sharp, aching, and numbness of moderate intensity" that would become more severe with standing and sitting. (Id.) She previously received two left sacroiliac joint injections that had moderately improved her pain, and she was administered another injection. (Id.)

         On September 25, 2014, she returned to Orthopedics with "throbbing" pain in her low back and left leg that she rated as an eight out often, worse than in her previous visit. (Id. at 268.) It was noted that her recent cortisone injection was "not effective," her lumbosacral spine range of motion was "mildly reduced," and her straight leg raise test was positive on the left. (Id. at 268, 270.) She agreed to the recommended lumbar medical branch block injection under fluoroscopy to relieve pain. (Id. at 270.).

         On November 25, 2014, Plaintiff saw Dr. Cohen for a routine appointment. (Id. at317.) She had been in a motor vehicle accident earlier in the month that had aggravated the pain in her cervical and lumbar spine. (Id.) She weighed approximately 266 pounds with a BMI of 49.44. (Id. 317-19.) She denied photosensitivity and did not have eye pain or changes in vision, but reported some episodic paresthesia in her hands that worsened after lying down. (Id. at 317.) Dr. Cohen released Plaintiff back to work despite her being symptomatic, but she stated that she was unable to continue in her current position and would be looking for alternative employment. (Id. at 319.) Plaintiff returned to Dr. Cohen on December 2, 2014; her ANF was considered stable and she was not experiencing significant discomfort. (Id. at 312-14.)

         On February 6, 2015, Plaintiff saw Dr. Perez for her lupus. (Id. at 279.) She continued showing proteinura and hematuria, and reported that she had not been to pain management and was no longer working. (Id. at 280.)

         On May 18, 2015, Roberta Herman, M.D., a state agency medical consultant (SAMC), reviewed Plaintiffs medical records as part of her disability determination. (Id. at 54.) She identified Plaintiff s medically determinable impairments as DDD and systemic lupus erythematosus (SLE), but noted that a consultative examination was not required. (Id. at 56.) While partially credible, she found that "the statements made by the claimant regarding symptom-related functional limitations and restrictions cannot reasonably be accepted as consistent with the objective medical evidence and other evidence in the case record." (Id. at 56-57.) She assessed Plaintiff as having the physical residual functional capacity (RFC) to lift/carry and push/pull 20 pounds occasionally and 10 pounds frequently, stand and/or walk for 2 hours, and sit for 6 hours in an 8-hour workday. (Id. at 57-58.) She identified no postural, manipulative, visual, communicative, or environmental limitations. (Id. at 58.) Dr. Herman found that Plaintiff was not disabled, and her RFC demonstrated the maximum sustained work capability for sedentary work. (Id. at 59-60.) Amita Hedge, M.D., reviewed and affirmed Dr. Herman's assessment on August 19, 2015. (Id. at 62-69.)

         On September 14, 2015, Plaintiff saw Dr. Perez for a routine appointment. (Id. at 466.) She continued showing proteinuria and hematuria, and was still experiencing joint pain. (Id. at 467.) She was off steroids and had been unable to see Dr. Cohen for her SLE because she did not have insurance. (Id.) She weighed approximately 252 pounds[4] with a BMI of 49.22; her eyes were normal. (Id. 467-68.)

         On September 29, 2015, Plaintiff was seen by a physician assistant (PA) at Parkland Hospital (Parkland). (Id. at 560.) She reported a "band-like" headache for three days, myalgias (or muscles aches), and tingling in the toes with constant pain. (Id.) The PA noted that her generalized myalgias were typical to her lupus pain, but she had been out of her lupus medication for 4 months. (Id.) Plaintiff reported bilateral eye pain with hard red nodules, and that her "eye doctor" advised her to use a warm compress.[5] (Id. at 561.) She was referred to a primary care physician who would organize a follow-up with a rheumatologist and nephrologist treatment and provide her with her medications. (Id. at 563.)

         On November 12, 2015, Plaintiff returned to Parkland to establish care for her SLE and lupus nephritis (LN). (Id. at 589.) She had recently been diagnosed with Shingles and had a rash that was still painful but less erythematous. (Id.) She reported occasional sharp stabbing and shooting pains in her bilateral toes that worsened upon standing and walking. (Id. at589.) She would sit to improve her pain, and had to limit her ibuprofen intake due to her LN. (Id.) Plaintiff denied any current arthralgias or myalgias, but complained of persistent lower back pain that was exacerbated by activity. (Id.) She weighed approximately 246 pounds with a BMI of 48.3. (Id. at 591.) The examining physician noted that Plaintiff s SLE and LN was currently a "quiet disease [with] no flare up," and her coronary artery disease (CAD) appeared normal with no signs of clinical heart failure and a normal cardiovascular (CV) exam. (Id. at 592.) She was advised to lose weight and to continue taking the medication prescribed for her shingles, neuropathic pain, CAD, SLE, LN, and hypertension. (Id. at 592-93.)

         On January 21, 2016, Plaintiff saw Dr. Perez and reported ankle and back pain, but no arthralgias, joint swelling, or joint stiffness was observed. (Id. at 472-74.) She weighed approximately 256 pounds with a BMI of 50.02. (Id. at 474.) She was still unable to see Dr. Cohen due to insurance issues, but stated she would establish care for her SLE with another rheumatologist the following week. (Id. at 475.) She was instructed to continue losing weight and to follow a low sodium diet. (Id.)

         On February 26, 2016, Plaintiff returned to Dr. Perez, complaining of back and arm pain. (Id. at 480.) There were no significant changes in her weight and BMI, and her renal function was "stable with same proteinuria." (Id.) She did not report any problems with her eyes, and they showed no erythema, swelling, or discharge with equal, round, and active pupils. (Id. at 481.) On July 11, 2016, Plaintiff returned to Dr. Perez with back and joint pain and some tingling in her lower extremities. (Id. at 488.) Her weight and BMI increased to approximately 266 pounds[6] and 51.95 respectively, but she was noted as being otherwise stable. (Id. at 488-89.)

         On July 18, 2016, Plaintiff presented to rheumatology at Parkland to establish care for her SLE. (Id. at 605.) She reported body aches, pains "jumping all over [her] body," fatigue, and difficulty with getting off the couch and driving, but her kidneys felt unaffected. (Id. at 607.) Her eyes were positive for blurry vision and negative for irritation and redness, and she denied photosensitivity or dry eyes. (Id. at 607-08.) She once lost eyesight in her right eye in 1998, but the cause was unclear. (Id. at 607.) Plaintiff had arthralgias of the shoulders, lower back, and hips, pain in the legs and knees, and some discomfort of the ankles and toes. (Id. at 607.) She weighed approximately 263 pounds, and her musculoskeletal examination was unremarkable. (Id. at 609.) The examining physician's assessment was "SLE with mildly active disease at present," "Lupus nephritis with CKD stage 3b with currently stable renal function," and fibromyalgia was "contributing to much of her current symptoms." (Id. at 609-10.) Exercise was recommended, and she was referred to ophthalmology for a baseline eye examination. (Id. at 610.)

         On November 14, 2016, Plaintiff returned to Dr. Perez and was primarily concerned with her weight gain. (Id. at 495.) She weighed approximately 262 pounds[7] with a BMI of 51.21. (Id. at 499.) Her renal function was noted as stable with minimal proteinuria. (Id. at 495.) Dr. Perez found "no erythema, swelling or discharge" of her eyes and noted that the pupils were equal, round and reactive to light. (Id. at 496.) It was noted that she had missed her last rheumatology appointment at Parkland. (Id.)

         On December 12, 2016, Plaintiff went to Parkland for a routine appointment; she weighed approximately 277 pounds. (Id. at 616.) She had lower back pain, bilateral hip and ankle pain, and numbness in both arms and legs, and complained that "[p]ain just travel[ed] through [her] body." (Id. at 617.) Ibuprofen was no longer effective, and her pain was sometimes so severe that she was unable to even brush the side of her body with a sheet. (Id.) She did not know if the cause of pain was fibromyalgia or lupus, but her prior "lupus attacks" had caused her chest pain. (Id.) Plaintiff was reportedly unable to be active because she was "in too much pain," but admitted that she drank "a lot of Dr. Pepper and other regular sodas," ate "a lot of fried food," and frequently went out to eat. (Id.) The examining physician noted that "sometimes there is no treatment for fibromyalgia despite [] best efforts," and advised her to "work on losing weight" by "cutting down on regular sodas and eat[ing] 1 less fried meal per week," eating a healthy and balanced diet, and exercising 15 to 30 minutes for 3 to 5 times a week "or as tolerated." (Id. at 620, 622.)

         On March 7, 2017, Plaintiff returned to Parkland and reported that she hurt her thumb "playing around." (Id. at 633.) She had been diagnosed with a strain and wore a wristband that made her wrist feel better. (Id.) She weighed approximately 292 pounds with a BMI of 57.2, was noted to have gained over 30 pounds in less than a year, and was morbidly obese, but "continue[d] to drink regular sodas, eat fried foods, and eat out." (Id. at 632-33.) Her lupus nephritis was stable, but her urinary protein/creatinine ratio was elevated. (Id. at 635.) Plaintiff reported being told that she had DDD with possible spinal stenosis, but the examining physician observed no radicular symptoms. (Id.) She was urged to lose weight, particularly since she had "gained almost 50 lbs in [the] past 2 years." (Id.)

         On March 14, 2017, Plaintiff presented to rheumatology at Parkland for a follow-up. (Id. at 641.) She reported chronic hip, back, and joint pain that she attributed to the deterioration of her hip bone from chronic steroid use. (Id. at 642.) It was noted that her "generalized pain [was] secondary to fibromyalgia," and that she should continue taking her prescribed medication for it. (Id. at 641.) She weighed approximately 292 pounds, and her musculoskeletal examination showed tenderness and normal range of motion of the upper and lower extremities. (Id. at 643-44.) Her eyes were "positive for blurred vision" and "negative for phobophobia," and she was again referred to ophthalmology for a baseline eye examination. (Id. at 642, 644.) Her chest X-ray was unremarkable and showed no acute cardiopulmonary disease. (Id. at 679.) Her lumbar spine X-ray showed diminutive or absent ribs at T12, and L5 partially sacralized on the left with a pseudarthrosis potentially symptomatic. (Id. at 680.) The vertebral body heights were maintained with no subluxation, and there was mild facet arthrosis at multiple levels. (Id.)

         C. Hearing

         On May 30, 2017, Plaintiff and a vocational expert (VE) testified at a hearing before the ALJ. (Id. at 32-53.) Plaintiff ...

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