RIVERA v. COMMISSIONER OF SOCIAL SECURITY

District Court, D. New Jersey·Decided November 4, 2021·No. 3:20-cv-05308·Unknown

Opinion

*NOT FOR PUBLICATION* UNITED STATES DISTRICT COURT DISTRICT OF NEW JERSEY

WANDA I. RIVERA,

Plaintiff, Civil Action No. 20-05308 (FLW)

v. OPINION ANDREW SAUL, Commissioner of Social Security,

Defendant.

WOLFSON, Chief Judge: Wanda Rivera (“Plaintiff”) appeals from the final decision of the Commissioner of Social Security, Andrew Saul (“Defendant”), denying Plaintiff disability benefits under Titles II of the Social Security Act (the “Act”). After reviewing the Administrative Record (“A.R.”), 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, born on August 1, 1962, was 54 years old on December 31, 2016, her date last insured, qualifying her as an individual closely approaching advanced age as defined in the Code of Federal Regulations. (A.R. 35; see 20 C.F.R. §§ 404.1563(d), 416.963(d)). Plaintiff has at least a high school education, and has previously worked as a customer service representative, data entry clerk, and pre-school teacher. (Id.) On September 20, 2016, Plaintiff filed an application for a period of disability and disability insurance benefits under Title II of the Social Security Act, alleging disability as of February 18, 2016, due to high blood pressure, hypothyroidism, depression, anxiety, numbing of the hands/fingers, carpal tunnel syndrome, arthritis, lower back pain, sleep apnea, insomnia, heart valve leakage, chest pain, and fibromyalgia. (A.R. 25, 80-81, 92.) Plaintiff’s application was denied initially, and on reconsideration. (A.R. 135-42.) Plaintiff then requested a hearing with an

ALJ, which was held on December 18, 2018. (A.R. 42-79, 143-44.) On January 15, 2019, the ALJ found Plaintiff was not disabled under the relevant statutes. (A.R. 25-36.) Plaintiff requested review of the ALJ’s decision by the Appeals Council, which was granted on January 9, 2020. (A.R. 217-20.) On March 1, 2020, the Appeals Council adopted the substance of the ALJ’s factual and legal findings,1 and concluded that Plaintiff was not entitled to disability under applicable statutes. (A.R. 1-10.) A. Review of Medical Evidence i. Carpal Tunnel In 2012, Plaintiff underwent left carpal tunnel release surgery for moderately severe carpal tunnel. (A.R. 383, 472-73.) In September 2014, Plaintiff visited Michael T. Lu, M.D., and

complained about right hand numbness and pain that had been ongoing for two to three years. (A.R. 383.) At the visit, Plaintiff explained that she previously had similar symptoms in her left hand, but the left-hand pain had improved after carpal tunnel release. (Id.) Dr. Lu found that palpation of the right wrist revealed tenderness, but otherwise Plaintiff had a normal range of wrist motion, 5/5 wrist strength in all muscle groups, normal sensation and reflexes, and no deformity or other swelling. (A.R. 384.) Further, x-rays revealed no evidence of fracture, bone lesions, or

1 The Appeals Council found and corrected one typographical error in the ALJ’s decision. (A.R. 7-8.) other abnormalities. (Id.) That day, Dr. Lu gave Plaintiff a steroid injection and fitted her with a wrist splint. (Id.) On January 19, 2015, Plaintiff visited Dr. Lu again and complained that although the injection provided her with 1-2 months of symptomatic relief, she now had right hand pain,

numbness, and tingling that was keeping her awake at night. (A.R. 327.) Dr. Lu referred Plaintiff for an NCV/EMG, (A.R. 371), which showed moderate to severe right carpal tunnel syndrome, and mild to moderate left carpal tunnel syndrome. (A.R. 350.) Plaintiff returned to Dr. Lu on June 29, 2015, and Dr. Lu found that non-operative measures had not provided lasting relief, and therefore recommended right carpal tunnel release surgery. (A.R. 323-326.) Plaintiff underwent such surgery on July 23, 2015. (A.R. 331-34.) Two months after surgery, Plaintiff reported that her pain and neurologic symptoms were improving. (A.R. 315.) Dr. Lu told Plaintiff to return if symptoms worsened or failed to improve. (Id.) The record does not indicate that she returned to Dr. Lu. ii. Physical Pain

Over the years, Plaintiff was examined for various physical impairments. At a thyroid evaluation on June 2, 2015, Plaintiff complained of bone achiness, and stated she had a history of arthritis. (A.R. 309.) But, the evaluation found that Plaintiff was in good health and negative for arthritis, body aches, tingling, and numbness. (A.R. 307.) At a neurology appointment on August 29, 2015, Plaintiff denied fibromyalgia, bone pain, or foot inflammation. (A.R. 462.) Upon examination, Plaintiff had a normal gait, 5/5 strength in the upper and lower extremities, no truncal ataxia, normal muscle tone, and full range of motion and no tenderness in the neck. (A.R. 463.) At December 2015 and January 2016 neurology appointments, Plaintiff had a normal gait and deep tendon reflexes, good muscle strength and tone, she denied bone pain, and had no focal motor, sensory, or neurologic deficits. (A.R. 465-68.) On September 21, 2016, Plaintiff visited Dr. Lucyamma Thalody, M.D., with complaints of fatigue, depression, and blood pressure issues. (A.R. 561.) At the appointment, Plaintiff

reported no localized weakness, tingling, numbness, or gait disturbance; Plaintiff’s neurological exam showed no focal deficits on her motor or sensory exam, and Dr. Thalody found no muscle wasting. (A.R. 562-63.) Dr. Thalody advised Plaintiff to have a urinalysis, administered a B12 shot, and told her to return in four weeks. (A.R. 563.) In October 2016, Plaintiff returned and stated she had aches and pains all over her body. (A.R. 558.) After examination, Dr. Thalody’s impression was that Plaintiff’s symptoms were in line with fibromyalgia. (A.R. 560.) Plaintiff received another B12 shot. (Id.) In November 2016, Plaintiff saw Dr. Thalody again, complaining of aches and pains all over her body, joint pain, and arthritic pain in her fingers. (A.R. 591.) Dr. Thalody advised her to go to a vascular doctor due to her leg cramps and leg pain, and then administered another B12 shot. (A.R. 593.) Dr. Thalody also recommended another urinalysis

and told Plaintiff to come back in two weeks. (A.R. 593.) Two weeks later, in December 2016, Plaintiff returned to Dr. Thalody and reported feeling fairly good, aside from her urinary problems. (A.R. 588.) Plaintiff reported no muscle pain or swelling, and had no obvious muscle wasting. (A.R. 589-90.) iii. Hypertension Plaintiff was diagnosed with high blood pressure and hypertensive heart disease on February 17, 2016. (A.R. 483-84.) That day, Plaintiff was treated at Union County Cardiology Associates, P.A., for chest pressure with no associated dyspnea, but dyspnea on exertion from walking a flight of stairs or less than one block. (A.R. 483.) Plaintiff’s blood pressure was 140/92, and she noted that her blood pressure was not optimally controlled. (Id.) An EKG revealed a normal sinus rhythm, and Plaintiff was recommended for an echocardiogram and a stress test. (A.R. 484.) On March 4, 2016, Plaintiff underwent an exercise stress test according to the Bruce protocol, but the test was terminated after 6 minutes due to fatigue. (A.R. 479.) The test found

negative exercise stress test for coronary artery ischemia, limited exercise capacity for her age, dyspnea on moderate exertion, and hypertensive response to exercise. (A.R. 480.) Plaintiff also had an echocardiogram that day, which found normal left ventricle systolic function, mild concentric left ventricular hypertrophy, left ventricular ejection fraction of 60%, evidence of impaired ventricular relaxation suggestive of stage 1 diastolic dysfunction. (A.R.

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RIVERA v. COMMISSIONER OF SOCIAL SECURITY, (D.N.J. 2021).

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