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Mejia v. Astrue

June 28, 2010


The opinion of the court was delivered by: Andrew J. Peck, United States Magistrate Judge


Pro se plaintiff Joseph Mejia brings this action pursuant to § 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), challenging the final decision of the Commissioner of Social Security ("the Commissioner") denying Mejia Disability Insurance Benefits and Supplemental Security Income Benefits. (Dkt. No. 2: Compl.) The Commissioner has moved for judgment on the pleadings pursuant to Fed. R. Civ. P. 12(c). (Dkt. No. 13: Am. Notice of Motion.) The parties have consented to decision of this case by a Magistrate Judge pursuant to 28 U.S.C. § 636(c). (Dkt. No. 6.)

For the reasons set forth below, the Commissioner's motion for judgment on the pleadings is GRANTED.


Procedural Background

On November 2, 2007, Mejia applied for both Social Security Disability Insurance Benefits and Supplemental Security Income Benefits, alleging that he was disabled since October 16, 2007. (See Dkt. No. 11: Administrative Record Filed by the Comm'r ("R") 74-78, 98.) In his application, Mejia claimed to suffer from "heart failure" and "high blood pressure." (R. 28, 98; Dkt. No. 2: Compl. ¶ 4.) On March 12, 2008, the Social Security Administration ("SSA") conducted an initial review of Mejia's claim and found that he was not disabled. (R. 40-43.) On May 13, 2008, Mejia requested an administrative hearing. (R. 45-46, 191-92.)

Administrative Law Judge ("ALJ") Robin J. Arzt conducted a hearing on May 14, 2009. (R. 23-38.) Mejia appeared at the hearing without an attorney. (R. 23, 25-26.) On May 28, 2009, ALJ Arzt issued a written decision finding that Mejia was not disabled. (R. 6-22.) ALJ Arzt's decision became the Commissioner's final decision when the Appeals Council denied Mejia's request for review on September 2, 2009. (R. 1-3.)

The issue before the Court is whether the Commissioner's decision, that Mejia was not disabled between October 16, 2007 and May 28, 2009, is supported by substantial evidence. The Court finds that it was.

Non-Medical Evidence

Mejia was born on March 18, 1960 and was forty-seven years old at the alleged onset of his disability. (R. 28.) Mejia attended high school until the eleventh grade; he does not have a GED. (R. 29, 118.) Between 1999 and 2007, Mejia held a number of jobs, including mail room clerk and radio dispatcher. (R. 29, 101-05, 114.) Mejia's longest running and most relevant position was as a supervisory shipping and receiving clerk for a production editing company. (R. 29-32, 101-02.) During his seven years with the company, Mejia engaged in semi-skilled, exertionally heavy labor, lifting and transferring boxes weighing 50 to 100 pounds each. (R. 29-31, 102, 114.) Mejia also had limited supervisory duties over two other clerks in his department. (R. 30, 102, 114.) The company terminated Mejia when it went out of business on August 13, 2007, and Mejia has been unemployed ever since. (R. 29, 32, 113.)

In October 2007, Mejia's dentist took Mejia's blood pressure and discovered that it was elevated. (R. 32, 148.) After an electrocardiogram, the dentist referred Mejia to Dr. Michael Huber for further testing. (R. 28, 32, 141, 148-49.) According to Mejia, Dr. Huber stated that despite "good" arteries, Mejia's heart was "messed up" because it was "bigger than it's supposed to be." (R. 35-36.) Mejia testified that Dr. Huber diagnosed him with "heart failure" resulting from his "ingrown heart." (R. 35.)

In his November 2007 application for Social Security Disability Benefits, Mejia identified his daily activities as reading, watching television, attending doctors' appointments, caring for his personal hygiene, cleaning and ironing. (R. 91-94, 128.) Mejia spent thirty to sixty minutes cooking each day (R. 92), and spent forty-five minutes shopping at least once a month (R. 94). Mejia left his apartment daily and could walk up to thirty blocks. (R. 93-94, 96.) His social activities, which included playing cards, listening to music and attending church once a week, were unchanged. (R. 95, 174.) Indeed, the only activity Mejia stated that he was unable to do following his diagnosis was "work." (R. 91.)

In January 2008, however, Mejia began experiencing shortness of breath, which prevented him from walking more than one and one half blocks, standing for more than twenty minutes and carrying a gallon of milk one block. (R. 27, 33, 36-37.) His shortness of breath also routinely interfered with his sleep. (R. 27, 33.) Mejia further testified that, although he experienced periodic chest pain prior to October 2007, the chest pains became more severe following his diagnosis, occurring at least once a week and lasting for up to 45 minutes. (R. 34-35.) Although Mejia experienced back pain when he bent over, he could sit, squat and use fine motor skills without incurring any symptoms. (R.37.)

Mejia testified that Dr. Huber prescribed Lipitor and other medication to "keep [Mejia's] arteries clean" and prevent him from "catching a stroke." (R. 36.) Mejia reported that the medications improved his condition and did not produce any adverse side effects. (R, 35.) His symptoms, however, did not abate. (R. 35.)

Medical Evidence

Treating Physicians

Mejia's dentist conducted a physical examination in preparation for a tooth extraction and found that Mejia's blood pressure was elevated to 181/108. (R. 148.) The dentist referred Mejia to BronxCare Ogden Family Medical Center ("BronxCare"), where a physical examination performed on October 12, 2007 revealed that Mejia's blood pressure was 170/100. (R. 148.) The BronxCare examining physician diagnosed Mejia with "new onset hypertension" and prescribed a treatment regimen of hydrochlorothiazide and aspirin. (R. 148-49.) An EKG performed at Bronx Lebanon Hospital on October 12, 2007, the same day as Mejia's physical examination, showed normal sinus rhythm, possible left atrial enlargement, left ventricular hypertrophy and a possible inferior infarct of undetermined age.*fn1 (R. 118, 140, 149, 163-64.)

During a follow-up appointment at BronxCare on October 17, 2007, Dr. Virginia Martinez noted that Mejia had responded to medication, because his blood pressure had dropped to 141/94. (R. 146.) Dr. Martinez also determined that Mejia's LDL cholesterol levels were elevated and prescribed Lipitor, exercise and dietary changes. (R. 117, 127,132-33,138,146-47, 159.) After clearing him for the dental procedure, Dr. Martinez referred Mejia to Dr. Huber at Bronx Lebanon Hospital for further tests. (R. 141, 147.)

On October 25, 2007, Mejia had an echocardiogram, which revealed a left atrium size of 3.8cm, a septal wall thickness of 1.7cm, a left ventricular end diastolic dimension of 5.6cm and a ventricular posterior wall thickness of 1.7cm. (R. 186.) Dr. Huber reviewed the results and determined that the echocardiogram showed a borderline dilated left ventricle with "eccentric left ventricular hypertrophy," moderate diffuse systolic dysfunction and an ejection fraction*fn2 of thirty-five to forty percent. (R. 186.) Although the echocardiogram also revealed "some evidence of abnormal diastolic relaxation," Dr. Huber deemed the results otherwise "unremarkable." (R. 186.)

On November 20, 2007, Mejia underwent both a cardiac perfusion test*fn3/ and a nuclear exercise stress test at Bronx Lebanon Hospital. (R. 187-90.) During the exercise stress test, Mejia exercised to a maximum of 13.5 METs*fn4 (R. 187-88), which was within normal or "[f]unctional [c]lass" I limits.*fn5 See American Medical Association, Guides to the Evaluation of Permanent Impairment at 171. The test also showed "[n]ormal" myocardial perfusion as well as a "[n]ormal" heart rate and blood pressure response. (R. 189.) Nevertheless, the doctor who performed the test characterized the results as "[a]bnormal" because the stress test revealed moderate left ventricular dysfunction and global hypokinesis. (R. 189.)

In an April 28, 2008 letter concerning Mejia's diagnosis, Dr. Huber stated that Mejia had "congestive heart failure" and "severe LV [left ventricular] dysfunction." (R. 185.) Dr. Huber classified Mejia's symptoms as New York Heart Association ("NYHA") Class II, meaning that he had a slight, mild limitation of activity and was comfortable with rest or with mild exertion.*fn6 (R. 185.) Dr. Huber opined that Mejia's Class II symptoms would improve with medication. (R. 185.)

In a May 6, 2009 follow-up letter, Dr. Huber re-classified Mejia's diagnosis as a "cardiomyopathy, which is idiopathic but possibly hypertensive in origin."*fn7 (R. 194.) Dr. Huber noted that although Mejia's hypertension had responded favorably to the prescribed medications (Avalide, Carvedilol and Lipitor) (R. 117, 174), his Class II symptoms persisted (R. 194). Dr. Huber opined that Mejia would need medication for the "foreseeable future" and should refrain from work entailing "strenuous exertion." (R. 194.)

Consultative Physicians

On January 10, 2008, consulting physician Dr. David Guttman examined Mejia. (R. 174-77.) Dr. Guttman's report stated that Mejia did not exhibit any "acute distress" and could get on and off the exam table and rise from a chair without any assistance or difficulty. (R. 175.) Despite a slightly elevated blood pressure of 142/102, Dr. Guttman noted that Mejia's exam showed an otherwise "[r]egular" heart rhythm and a normal point of maximal impulse ("PMI") in the left fifth intercostal space at the midclavicular line. (R. 175.) The examination did not reveal any audible heart "murmur, gallop or rub." (R. 175.) Musculoskeletal tests confirmed that Mejia's ability to perform fine manual manipulation was normal. (R. 175-76.) Based on Mejia's medical history, Dr. Guttman diagnosed Mejia with hypertension and congestive heart failure, but concluded that his physical examination was otherwise within normal limits. (R. 176.) Dr. Guttman designated Mejia's prognosis as "[f]air." (R. 176.)

On March 11, 2008, consultative Physician Dr. D. Zanni performed a Residual Functional Capacity Assessment of Mejia based on his medical records. (R. 178-83.) Dr. Zanni concluded that Mejia could occasionally lift or carry 20 pounds and frequently lift or carry 10 pounds. (R. 179.) Dr. Zanni also concluded that Mejia could stand or walk for 6 hours in an 8 hour workday and sit for 6 hours in an 8 hour workday. (R. 179.) The factual basis for Dr. Zanni's conclusions was that Mejia's blood pressure was 142/102, and Mejia has "increased left ventricular mass. Moderately reduced systolic function. Ejection fraction 35-40%. . . . [N]o chest pains. . . . He has no shortness of breath. He is able to walk six blocks or 1 flight of stairs." (R. 179.) Dr. Zanni concluded that based on the information in his file, Mejia "has a moderately determinable impairment [that] limits [Mejia] to light [work]." (R. 181.)

The ALJ's Decision

In a decision dated May 28, 2009, ALJ Arzt denied Mejia's application for Disability Insurance Benefits and Supplemental Security Income Benefits for the period from October 16, 2007 to May 28, 2009. (R. 6-22.)

ALJ Arzt reviewed Mejia's claim of disability resulting from hypertension and heart failure, considering both Mejia's testimony and medical records. (R. 11-14.) ALJ Arzt concluded that Mejia suffered from both hypertension and "controlled congestive heart failure from idiopathic v. hypertensive cardiomyopathy." (R. 11.) Although Mejia's "medically determinable impairments reasonably could be expected to produce some of the alleged symptoms and limitations," ALJ Arzt found that Mejia's testimony concerning the "intensity, persistence and limiting effects of these symptoms . . . [was] not entirely supported by the record." (R. 13.)

With these considerations in mind, ALJ Arzt applied the appropriate five step legal analysis (R. 10-11) as follows: At the first step, ALJ Arzt found that Mejia had not "engaged in substantial gainful activity since October 16, 2007, the alleged disability onset date." (R. 11.) At the second step, ALJ Arzt found that Mejia's congestive heart failure and hypertension "cause more than a minimal limitation [on his] ability to perform basic work related activities." (R. 11.) At the third step, ALJ Arzt found that Mejia's impairments do not "meet[] or medically equal[] one of the impairments listed in 20 CFR Part 404, Subpart P, Appendix 1." (R. 11.) At the fourth step, ALJ Arzt determined that Mejia has the residual functional capacity to "occasionally lift and carry up to twenty pounds at a time, frequently lift and carry up to ten pounds at a time, walk and stand up to six hours out of an eight hour day, push and pull light weight objects, and occasionally bend and stoop." (R. 12.) Based on Dr. Huber's determination that Mejia has Class II symptoms and should avoid "strenuous exertion," ALJ Arzt found that Mejia can perform "sedentary" or "light"work.*fn8

(R. 12-13.) Because Mejia's "past relevant work" as a shipping and handling clerk required "exertionally heavy work," ALJ Artzt found that it exceeded Mejia's residual functional capacity.

(R. 13-14.) At the fifth and final step, ALJ Arzt utilized the Grid and concluded that based on Mejia's "age, education, past relevant work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that [Mejia] can perform." (R. 14.) Accordingly, ALJ Arzt found that Mejia was "not disabled" from October 16, 2007 through May 28, 2009, and therefore was not entitled to receive disability benefits. (R. 14-15.)


I. THE ...

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