GILLESPIE v. COMMISSIONER OF SOCIAL SECURITY

CourtDistrict Court, D. New Jersey
DecidedSeptember 2, 2022
Docket3:21-cv-20342
StatusUnknown

This text of GILLESPIE v. COMMISSIONER OF SOCIAL SECURITY (GILLESPIE v. COMMISSIONER OF SOCIAL SECURITY) is published on Counsel Stack Legal Research, covering District Court, D. New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
GILLESPIE v. COMMISSIONER OF SOCIAL SECURITY, (D.N.J. 2022).

Opinion

*NOT FOR PUBLICATION* UNITED STATES DISTRICT COURT DISTRICT OF NEW JERSEY

GIOVANNI GILLESPIE,

Plaintiff, Civil Action No. 21-20342 (FLW)

v. OPINION KILOLO KIJAKAZI, Acting Commissioner of Social Security1,

Defendant.

WOLFSON, Chief Judge: Giovanni G. Gillespie (“Plaintiff”) appeals from the final decision of the Acting Commissioner of Social Security, Kilolo Kijakazi (“Defendant”), denying Plaintiff disability benefits under Title II of the Social Security Act (the “Act”). After reviewing the Administrative Record, the Court finds that the Administrative Law Judge’s (“ALJ”) decision was based on substantial evidence and, accordingly, the ALJ’s decision is AFFIRMED. I. FACTUAL BACKGROUND AND PROCEDURAL HISTORY Plaintiff was born on February 10, 1994, and was 22 years old2 at the alleged disability onset date of January 1, 2017. (Administrative Record (“A.R.”) 28.) Plaintiff completed tenth

1 Kilolo Kijakazi became the Acting Commissioner of Social Security on July 9, 2021. Accordingly, pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, Kilolo Kijakazi is substituted for Andrew Saul as the defendant in this suit. 2 Plaintiff is considered to be a “younger person” because he was under the age of 50 years old when he applied for disability benefits. See 20 CFR 404.1563(c). grade prior to his alleged disability and has prior job experience as a clerk at a jewelry store and convenience stores. (A.R. 328.) Plaintiff alleges the following impairments: fibromyalgia, migraine/cluster headaches, hand and leg tremors, impulse control, bipolar disorder, and anxiety. (A.R. 32, 87, 327.) Plaintiff filed an application for disability benefits on November 14, 2018.

(A.R. 25.) On November 23, 2018, Plaintiff filed an application for supplemental security income. (Id.) Plaintiff’s applications were denied initially on January 25, 2019, and upon reconsideration on June 20, 2019. (Id.) Following these denials, Plaintiff filed a request for a disability benefits hearing. (Id.) On January 25, 2021, Plaintiff attended a telephone hearing and testified before Administrative Law Judge Peter R. Lee (“ALJ”). (Id.) After this hearing, the ALJ issued his decision, finding Plaintiff not disabled under the Act. (A.R. 40.) The Appeals Council denied Plaintiff’s request for review of the ALJ’s decision on September 30, 2021. (A.R. 1-6.) Thereafter, Plaintiff filed the instant appeal on December 3, 2021. (ECF No. 1.) A. Review of the Medical Evidence i. Physical Impairments

The record establishes that prior to the alleged onset date of January 1, 2017, Plaintiff had reported a history of substance abuse that began at age 13. (A.R. 602.) However, as of January 1, 2017, Plaintiff reported no continued drug use. (A.R. 604.) In April 2017, Plaintiff visited neurologist, Dr. Haodong Song, M.D., with complaints of tremors and severe headaches lasting 20-45 minutes, three to four times per day. (A.R. 532.) Dr. Song suspected cluster headaches and prescribed Botox injections, Verapamil, and steroids. (A.R. 532, 568.) The following month, Plaintiff returned to see Dr. Song, because he complained of further migraines despite his prior Botox injection, but noted significant improvement after steroids and verapamil. (A.R. 531.) Dr. Song prescribed another round of Botox injections, and continued Plaintiff’s current dose of steroids and Verapamil. (Id.) In November 2017, Plaintiff went to the Rheumatology Center of New Jersey for alleged myalgias, arthralgias, and joint pain all over with excessive fatigue. Dr. Ahmed Abdel-Megid,

M.D., noted that Plaintiff’s physical examination was “completely negative,” and assessed Plaintiff with “joint disorder, unspecified.” (A.R. 445.) Dr. Abdel-Megid suspected that Plaintiff’s reported depression / anxiety and medication use could be the underlying reason for his alleged arthralgias and myalgias. (Id.) That same month, Plaintiff also went to the Emergency Room at CentraState complaining of aches and pains all over the body. (A.R. 437.) At the emergency room, workup was done that suggested high Creatine Kinase (CK) levels, and Plaintiff was admitted for management of rhabdomyolysis. (Id.) Plaintiff received aggressive IV fluids and his headache medications were continued. (Id.) Although Dr. Rupa Panchal, MD., suggested that Plaintiff remain in the hospital pending further reduced CK levels, Plaintiff insisted on discharge and was released with

instructions to follow up with his rheumatologist. (Id.) At a follow-up appointment with Dr. Abdel-Megid in early December 2017, Plaintiff reiterated complaints of joint pains and fatigue. (A.R. 447.) However, Dr. Abdel-Megid found no active joint swellings or active synovitis to suggest any underlying connective tissue diseases or inflammatory arthritis. (A.R. 450.) Moreover, Plaintiff’s physical exam was negative. (Id.) On October 19, 2018, Plaintiff reported a headache lasting three days at a wellness visit with primary care physician, Dr. Vanessa Abrina, M.D. (A.R. 483.) Plaintiff’s general objective exam was unremarkable, and Dr. Abrina noted that Plaintiff was awake, alert, not in distress, and ambulatory. (A.R. 484.) Dr. Abrina assessed Plaintiff with fibromyalgia and migraines, and prescribed an antibiotic. (Id.) At a follow-up appointment in November 2018, Plaintiff alleged daily migraine headaches and fatigue. (A.R. 482.) His exam, however, was unremarkable. (Id.) Plaintiff also saw Dr. Song for treatment for his headaches and fibromyalgia on three occasions in 2018, and on multiple occasions in 2019, during which Dr. Song noted improvement

with Botox, Verapamil, Neurontin. (A.R. 521, 523, 525, 527, 562-63, 568, 570.) On January 3, 2018, Plaintiff also had a “normal awake and drowsy routine EEG.” (A.R. 571.) At an appointment with Dr. Abrina in May 2019, Plaintiff stated that his migraine had improved with his current medications and medical marijuana. (A.R. 572.) In September 2019, Plaintiff underwent an MRI of the brain. (A.R. 661.) The MRI was unremarkable. The following month, in October 2019, Plaintiff had a cervical MRI which was “normal.” (A.R. 662.) In February 2020, Plaintiff was diagnosed with rheumatoid arthritis (RA) following immunology testing. (A.R. 653.) However, in June 2020, Plaintiff had a low Vectra score of 25 indicating a “low risk of radiographic progression.” (A.R. 635, 655.) In July 2020, Plaintiff’s

Vectra score increased to 36, a score within the moderate range associated with “limited risk for radiographic progression.” (A.R. 657.) In November 2020, Plaintiff returned to Dr. Song with complaints of cognitive symptoms, including worsening memory, in addition to headache. (A.R. 685.) Dr. Song opined that these symptoms were likely secondary and related to mood disturbance and medication side effects. (Id.) Although Dr. Song noted that further adjustment of medication was likely necessary, he continued Plaintiff’s prescriptions and Botox regimen. (A.R. 687) ii. Mental Impairments Plaintiff also alleges disability due to several mental health conditions. In April 2017, Plaintiff had a verbal altercation with his mother, and police transported him to CentraState Medical Center for a psychiatric evaluation. (A.R. 421, 425.) There, he complained of depression

and insomnia that worsened since his wedding in February 2017. (A.R. 421, 425.) A mental health assessment revealed depressed and irritable mood, as well as signs of hopelessness, but otherwise indicated normal attention span, memory, orientation, speech, and judgment. Plaintiff’s attitude was guarded, but friendly. (A.R. 427.) Plaintiff also denied delusions, hallucinations, and suicidal ideations. (A.R.

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GILLESPIE v. COMMISSIONER OF SOCIAL SECURITY, Counsel Stack Legal Research, https://law.counselstack.com/opinion/gillespie-v-commissioner-of-social-security-njd-2022.