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Allen-Young v. Berryhill

United States District Court, D. Delaware

March 15, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.




         Plaintiff Valerie Allen-Young ("Allen-Young") filed this action on August 31, 2017 against the defendant Nancy A. Berryhill, the Acting Commissioner of the Social Security Administration (the "Commissioner"). Allen-Young seeks judicial review pursuant to 42 U.S.C. § 405(g) of the Commissioner's July 3, 2017 final decision, denying Allen-Young's claim for disability insurance benefits ("DIB") under Title II of the Social Security Act (the "Act"), 42 U.S.C. §§ 401-134 and §§ 1381-1383f The court has jurisdiction over the matter pursuant to 42 U.S.C. § 405(g).

         Currently before the court are cross-motions for summary judgment filed by Allen-Young and the Commissioner.[1] (D.I. 13; D.I. 15) Allen-Young asks the court for an immediate award of benefits or, alternatively, to remand her case for further administrative proceedings. (D.I. 14 at 2, 19) The Commissioner requests the court affirm the ALJ's decision. (D.I. 16 at 1-2) For the reasons set forth below, Allen-Young's motion for summary judgment is denied (D.I. 13), and the Commissioner's cross-motion for summary judgment is granted (D.I. 15).[2]


         A. Procedural History

         Allen-Young filed a DIB application on October 31, 2014, [3] claiming a disability onset date of September 25, 2014. (Tr. at 198-199) Her claim was initially denied on December 29, 2014, and denied again after reconsideration on July 27, 2015. (Id. at 116-120, 123-128) Allen-Young then filed a request for a hearing, which occurred on September 21, 2016. (Id. at 49-87) Administrative Law Judge, Jennifer M. Lash (the "ALJ"), issued an unfavorable decision, finding that Allen-Young was not disabled under the Act on February 6, 2017. (Id. at 25-41) The Appeals Council subsequently denied Allen-Young's request for review on July 3, 2017, rendering the ALJ's decision the final decision of the Commissioner. (Id. at 1-6)

         On August 31, 2017, Allen-Young brought a civil action in this court challenging the ALJ's decision. (D.I. 2) On April 16, 2018, Allen-Young filed a motion for summary judgment, and on June 14, 2018, the Commissioner filed a cross-motion for summary judgment. (D.I. 13; D.I. 15)

         B. Medical History

         Allen-Young was born on September 12, 1961, and was 53 years old on her alleged onset date. (Tr. at 51, 55) Allen-Young graduated high school and completed approximately one year of college. (Id. at 56, 220) Allen-Young worked in customer service at Laurel Linen Services in 2001 and as a customer service representative for Quest Diagnostics from 2001 to 2004. (Id. at 59-60, 241) Allen-Young had a temporary position at Kelly Services in 2005, followed by another temporary position at Empyrean Management Group. (Id. at 61) She worked as a church clerk at Alpha Worship Center from June 2006 to October 2006. (Id. at 61-62, 241) She returned to work at Empyrean Management Group from October 2006 to January 2007 and then worked at Aerotek from November 2007 to January 2008. (Id. at 62, 241) Finally, she returned to Alpha Worship Center, where she worked part-time as a church clerk from February 2008 to September 2014. (Id. at 62, 241) At the hearing, Allen-Young testified that she had trouble gaining employment since 2014, when she was fired from Alpha Worship Center for being excessively absent and late from work. (Id. at 53, 290) The ALJ determined that Allen-Young meets the insured status requirements of the Social Security Act through December 31, 2019. (Id. at 27)

         The ALJ concluded that Allen-Young has the following severe impairments: a right knee disorder, disorders of the back, retinopathy with cataracts, congestive heart failure, kidney disease with hyperkalemia, anemia, diabetes mellitus with neuropathy, and morbid obesity. (Id. at 27) The court notes that Allen-Young's medical history is not in dispute.

         1. Right Knee Disorder

         On February 28, 2014, Allen-Young saw Dr. Fletcher, complaining of pains in her left knee after an incident at work where she fell and twisted her left knee when attempting to stand back up. (Id. at 510-511) Dr. Fletcher prescribed an elastic knee brace for her left knee and x-rays of the left knee. (Id. at 511) On July 9, 2014, Allen-Young visited First State Orthopaedics for bilateral knee pain, and Dr. Johnson observed that Allen-Young experienced pain below the patella in her right knee. (Id. at 404) Furthermore, this pain was reportedly worse when bending, moving, sitting, walking, or standing. (Id.) Allen-Young was diagnosed with arthritis in her knees. (Id. at 446)

         Knee pain persisted into 2015 and, in April 2015, Dr. Kalman noted that Allen-Young had osteoarthritis in her right knee. (Id. at 717) He suggested physical therapy, weight loss, and viscosupplementation to alleviate the persistent knee pain. (Id.) Allen-Young started taking Synvisc injections on May 1, 2015. (Id. at 716) By May 8, 2015, she reported more comfortable walking and received her second injection. (Id. at 715) However, by May 13, 2015, she reported knee pain and a "giving way sensation" when walking and climbing stairs. (Id. at 720) She received her third injection on May 22, 2015. (Id. at 714) Dr. Kalman stressed the importance of weight loss and physical therapy for continued improvement. (Id.) He also noted that as long as the injections provide relief, she may continue to receive them every six months. (Id.)

         2. Disorder of the Back

         In March 2014, Allen-Young visited Nephrology Associates following a hospitalization with a urinary tract infection and pyelonephritis. (Id. at 417) Dr. Torregiani noted that Allen-Young had improved, but had "a bit of back pain." (Id.) In February 2016, Allen-Young had an x-ray of her back, which indicated minimal degenerative change at ¶ 4-L5 but prominent aortoiliac arteriosclerotic calcifications. (Id. at 155)

         3. Retinopathy with Cataracts

         On January 2, 2015, Allen-Young visited Eye Physicians & Surgeons, PA, and denied flashers or floaters, but had an instance of a red spot in her vision, which reportedly went away after a few minutes. (Id. at 787) Dr. Glazer-Hockstein recommended that Allen-Young proceed with anti-VEGF injections[4] to prevent vision loss. (Id. at 789) On February 13, 2015, Allen-Young reported more instances of red floaters, and Dr. Glazer-Hockstein noted that she would proceed with Eylea injections. (Id. at 783, 785) By February 24, 2015, she reported stable vision without flashes or floaters. (Id. at 780) This improved vision continued throughout 2015, and Dr. Glazer-Hockstein repeatedly stressed the importance of controlling blood sugar, blood pressure, and cholesterol. (Id. at 776-778, 773-775, 770-772, 766-769, 762-765) On May 19, 2015, after routinely applying anti-VEGF injections, Allen-Young was able to stop injections due to an improved edema. (Id. at 768) On September 15, 2015, Dr. Glazer-Hockstein noted that Allen-Young's diabetic macular edema had resolved, but still suffered with moderate to severe nonproliferative diabetic retinopathy. (Id. at 764-765) On December 15, 2015, Allen-Young reported slightly blurred vision, but no significant change in her vision. (Id. at 760)

         On April 26, 2016, Allen-Young reported seeing a blood spot in her right eye. (Id. at 748) She denied flashers, floaters, or eye trauma. (Id.) Dr. Glazer-Hockstein recommended intravitreal Avastin to prevent vision loss and again reminded Allen-Young that control of her blood sugar is the most effective way to prevent diabetes changes within the eye. (Id. at 756) By August 2016, Dr. Glazer-Hockstein noted Allen-Young's retinopathy was moderately severe but stable. (Id. at 750) Furthermore, Dr. Glazer-Hockstein recommended PRP laser treatment to prevent vision loss. (Id. at 752)

         4.Congestive Heart Failure

         On October 16, 2013, Allen-Young visited Cardiology Physicians P.A. for a follow-up on a recent hospitalization on September 11, 2013, for left upper chest pain. (Id. at 309, 396) Dr. Leidig stated that Allen-Young had been compliant with medication, had an unremarkable stress test, no further discomfort, and no shortness of breath. (Id. at 309) He recommended that Allen-Young lose weight and monitor her blood pressure. (Id. at 470) At a follow-up appointment on April 14, 2014, Dr. Leidig found that her carotid arteries were stable and that there was no evidence of ischemia or congestive heart failure. (Id. at 312-316)

         On December 31, 2014, Allen-Young visited Cardiology Physicians and indicated dyspnea and chest discomfort with exertion, particularly when climbing stairs. (Id. at 673) She experienced left-sided chest pain that radiated down her left arm and chest pressure that lasted a few minutes. (Id.) Her exam showed normal jugular pulses and she was diagnosed with unstable angina. (Id. at 673-675) Jacqueline Warner ("Ms. Warner"), a physician assistant, referred Allen-Young for cardiac catheterization with additional intravenous fluid required post-catheterization. (Id. at 675) Ms. Warner noted that the recorded blood pressure suggested "less than ideal control." (Id.) Ms. Warner stressed the importance of compliance with the prescribed medical therapy, losing weight, and restricting sodium intake. (Id.)

         On January 8, 2015, Allen-Young visited the emergency room for chest pain. (Id. at 925) On February 2, 2015, Allen-Young visited the emergency room again for worsening shortness of breath. (Id. at 592-599) Allen-Young was diagnosed with chronic heart failure, bilateral edema, and morbid obesity. (Id.) An x-ray performed on February 2, 2015 documented central vascular congestion with mild background pulmonary edema. (Id. at 598) On February 17, 2015, Dr. Leidig reported that Allen-Young denied having any chest pains and that there was no evidence of heart attack. (Id. at 670-671) On April 1, 2015, Allen-Young denied orthopnea, chest pain, palpitations, near syncope or syncope, but felt fatigued. (Id. at 667-669) Her blood pressure was very close to her goal pressure. (Id. at 669)

         On April 19, 2016, Allen-Young denied chest pains and Dr. Leidig found no evidence of congestive heart failure or active ischemia. (Id. at 910) However, on April 30, 2016, Allen-Young reported a nagging, burning chest pain and was hospitalized. (Id. at 876) Dr. Subbiah noted this was an atypical chest pain. (Id. at 884) Allen-Young continued to report chest pains during and after her hospitalization. (Id. at 1253, 1278) At a follow-up appointment on May 11, 2016, Dr. Witt assessed Allen-Young for congestive heart failure. (Id. at 1305-1306)

         5. Kidney Disease with Hyperkalemia

         On February 18, 2014, Dr. Fletcher noted that Allen-Young had stage III chronic kidney disease with minimal proteinuria and hypothesized that this was not related to her diabetes. (Id. at 552) On February 19, 2014, Dr. Cicone confirmed Dr. Fletcher's assessment and also did not believe that Allen-Young's kidney disease was due to her diabetes. (Id. at 389) A CAT scan of her abdomen revealed right asymmetric perirenal and proximal periureteral stranding. (Id.) On February 24, 2014, Allen-Young visited Dr. Fletcher with complaints of abdominal pain. (Id. at 513-514) On March 18, 2014, Dr. Frick recorded Allen-Young's report of a lump in her stomach, and noted abdominal pain in the right upper quadrant. (Id. at 503-504) Dr. Leidig also noted Allen-Young's intermittent abdominal pain, and recommended an abdominal exploration. (Id. at 312) On April 24, 2014, Dr. Cardenas performed a surgical excision of the mass in her stomach. (Id. at 1243-1244) On October 28, 2014, Dr. Fletcher noted mild to moderate epigastric tenderness in her abdomen. (Id. at 582)

         On February 16, 2015, Allen-Young visited Tamara J. Newell, CGNP ("Ms. Newell") for a follow-up on her chronic kidney disease. (Id. at 612) Ms. Newell noted that Allen-Young's renal function was stable to slowly progressive. (Id. at 614) Allen-Young was informed of the importance of sugar control to prevent the progression of her renal disease and was encouraged to implement a low sodium diet. (Id.) On March 12, 2015, Allen-Young's creatinine levels were reportedly stable. (Id. at 627) On March 30, 2015, Allen-Young visited Ms. Newell, who noted that her renal function as stable to slowly progressive. (Id. at 618) They had a lengthy discussion regarding "slowing the progression of kidney disease, focusing on blood pressure, blood sugar, weight loss and proteinuric control." (Id.) On May 15, 2015, Allen-Young visited Dr. Torregiani and recounted that she was losing weight with her husband and had a period of worsened edema that had since improved. (Id. at 711) Her renal function was stable to slowly progressive and her creatinine level was close to her baseline. (Id. at 712)

         On August 26, 2015, Dr. Witt analyzed Allen-Young's renal sonography and noted left simple renal cysts, but otherwise was within normal limits. (Id. at 737) On October 26, 2015, Allen-Young continued to report abdominal pain but denied shortness of breath. (Id. at 724) On April 4, 2016, Dr. Goral opined that Allen-Young was not a suitable kidney transplant candidate because her BMI was over 40. (Id. at 742) They discussed her BMI in detail and the preference of transplantation over dialysis. (Id. at 743) On April 5, 2016, Dr. Witt noted that Allen-Young needed to lose sixty pounds before being placed on the kidney transplant list. (Id. at 1308)

         6. Anemia

         On September 11, 2013, Dr. Kharidi noted that Allen-Young had normocrytic anemia "likely secondary to her chronic kidney disease and chronic disease in general." (Id. at 399) By November 21, 2014, Dr. Torregiani noted that her anemia was controlled. (Id. at 430) On March 30, 2015, Ms. Newell observed that Allen-Young had a history of iron deficiency and recommended checking anemia indices at her next visit. (Id. at 618) On May 15, 2015, Dr. Torregiani noted that while Allen-Young had a history of iron deficiency, her hemoglobin was slowly decreasing and her iron stores were pending. (Id. at 712)

         7. Morbid Obesity

         At the time of application, Allen-Young was 5 feet, 8 inches tall and weighed 315 pounds. (Id. at 33) She therefore had a body mass index ("BMI") of 47.9.[5] (Id.) Allen-Young, despite ...

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