United States District Court, D. Arizona
BRIDGET S. BADE, District Judge.
Laurie Sue Tejeda (Plaintiff) seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner), denying her application for disability insurance benefits under the Social Security Act (the Act). The parties have consented to proceed before a United States Magistrate Judge pursuant to 28 U.S.C. § 636(b) and have filed briefs in accordance with Local Rule of Civil Procedure 16.1. For the following reasons, the Court reverses the Commissioner's determination and remands for an award of benefits.
I. Procedural Background
On April 15, 2009, Plaintiff applied for disability insurance benefits and supplemental security income under Titles II and XVI of the Act. 42 U.S.C. §§ 401-34 (2012). (Tr. 30.) Plaintiff alleged that she had been disabled since April 9, 2009. ( Id. ) After the Social Security Administration (SSA) denied Plaintiff's initial application and her request for reconsideration, she requested a hearing before an administrative law judge (ALJ). After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 30-38.) This decision became the final decision of the Commissioner when the Social Security Administration Appeals Council denied Plaintiff's request for review. (Tr. 1); see 20 C.F.R. § 404.981 (2013) (explaining the effect of a disposition by the Appeals Council.) Plaintiff now seeks judicial review of this decision pursuant to 42 U.S.C. § 405(g).
II. Medical Record
The record before the Court establishes the following history of diagnosis and treatment related to Plaintiff's physical health. The record also includes opinions from State Agency Physicians who either examined Plaintiff or reviewed the medical records, but who did not provide treatment. Although some of the history of Plaintiff's heart condition pre-dates the alleged onset date of her disability, the Court discusses these records as necessary to provide context for Plaintiff's current claims.
A. Medical Records before the April 9, 2009 Disability Onset Date
During the summer of 2008, Plaintiff had regular episodes of syncope (fainting), including one episode that resulted in a car accident. (Tr. 282.) In July 2008, Wilber Su, M.D., a cardiologist, implanted a cardiac monitor to assess Plaintiff's episodes of syncope. (Tr. 284-85.) Later that month, he observed that the monitor showed several episodes of dangerously accelerated heart rates. (Tr. 271-72.) He admitted Plaintiff to the hospital, where doctor's noted an ejection fraction of forty percent. (Tr. 271-72.) Dr. Su performed an ablation procedure and implanted a cardiac defibrillator. (Tr. 271-76.) At that time, he noted that Plaintiff had an increased risk of sudden cardiac death due to tachycardia. (Tr. 274.) Dr. Su cleared Plaintiff for discharge on July 25, 2008. (Tr. 271.) At that time, he diagnosed Plaintiff with a trial fibrillation and supraventricular tachycardia status post AV node ablation, congestive heart failure, fluid overload, dyspnea, and chronic pain syndrome. (Tr. 271-72.) Among other medications, Dr. Su prescribed an "ACE inhibitor" because Plaintiff's ejection fraction was forty percent. (Tr. 272.) An echocardiogram on August 10, 2008 revealed a left ventricle ejection fraction of forty-eight percent, severe left atrial enlargement, mild mitral regurgitation with mitral annular calcification, mild tricuspid regurgitation, and grade 1 LV diastolic dysfunction suggestive of impaired relaxation. (Tr. 318.)
B. Medical Records after the April 9, 2009 Disability Onset Date
On April 10, 2009, Plaintiff was admitted to Banner Good Samaritan Medical Center complaining that her implanted defibrillator had shocked her the previous night. (Tr. 322.) Plaintiff reported to Claudia Dima, M.D., that before the shock she felt lightheaded and "she felt something was not right in her chest." (Tr. 322.) Dr. Dima described the defibrillator shock as "appropriate" because Plaintiff had ventricular fibrillation. Dr. Dima diagnosed Plaintiff with "[m]ultiple episodes of nonsustained ventricular tachycardia, probably [due to a] ventricular tachycardia storm, " cardiomyopathy, abnormal TSH, and history of atrial fibrillation status post ablation. (Tr. 322-23, 329-31.) Dr. Dima noted Plaintiff's only medication at the time was Lasix. She planned to contact Dr. Su to see if Plaintiff could start taking a "beta blocker and ACE inhibitors for her cardiomyopathy." (Tr. 323.) On April 13, 2009, an echocardiogram showed that Plaintiff had a left ventricular ejection fraction of forty-five to fifty percent. (Tr. 325-26.) In mid-April 2009, an Agency employee interviewing Plaintiff in connection with her disability claim observed that Plaintiff appeared short of breath. (Tr. 212.)
During a May 2009 appointment, Plaintiff told Dr. Su that she had "felt well since hospital discharge" and denied any "other" complaints. (Tr. 403.) Information retrieved from Plaintiff's defibrillator showed "a very short burst of supraventricular arrhythmia, " but "nothing sustained." (Tr. 403.) On examination, Plaintiff had a regular heart rate with no significant murmurs. ( Id. ) On May 11, 2009, Dr. Su signed a letter stating that Plaintiff was "permanently disabled" and could not work. (Tr. 337.) He opined that "[d]ue to her extensive cardiac condition, " Plaintiff could not "tolerate even simple tasks that would cause exertion such as standing, sitting, lifting, walking, pushing or pulling." ( Id. )
On June 2, 2009, Plaintiff had a follow-up visit with Dr. Su for her cardiomyopathy. (Tr. 402.) Plaintiff reported that her defibrillator had not discharged since April 2009. She "denie[d] any symptomology, palpitations, or chest pain." ( Id. ) Dr. Su noted that Plaintiff had chronic dyspnea with "no change from her baseline." ( Id. ) Dr. Su diagnosed Plaintiff with cardiomyopathy with an ejection fraction of forty to forty-five percent, congenital heart disease, mitral valve endocarditis status post mitral valve repair, hypertension, and a history of atrial fibrillation status post ablation. ( Id. )
On August 13, 2009, William Chaffee, M.D., examined Plaintiff in connection with her application for disability benefits. (Tr. 347.) Dr. Chaffee diagnosed her with cardiomyopathy with recurrent supraventricular tachycardia, morbid obesity, and "suspected depression." (Tr. 350.) Plaintiff reported that she lived with her sister, performed light housework, and could walk half a block. (Tr. 347-48.) On examination, Dr. Chaffee found a regular heart rhythm, with no murmur or gallop. (Tr. 349.) He opined that Plaintiff could stand/walk two to six hours in an eight-hour day, and sit six to eight hours in an eight-hour day. (Tr. 350.) However, he explained that Plaintiff's "functional status [was] difficult to determine during the brief examination. More objective evidence such as a cardiac stress test or other studies to evaluate her cardiac function would be helpful." (Tr. 352.)
In September 2009, state agency physician Erika Wavak, M.D., reviewed the record and agreed with Dr. Chaffee's general opinion that Plaintiff had abilities consistent with a range of light work. However, she found that Plaintiff should only occasionally reach overhead with her left arm and should never climb ladders, ropes, or scaffolds. (Tr. 374-81); see 20 C.F.R. § 404.1567(b) (defining light work). Dr. Wavak observed that Plaintiff apparently was not taking cardiac medication when her defibrillator discharged in April 2009, and that Plaintiff's most recent ejection fraction was forty-five to fifty percent. (Tr. 381.)
On November 10, 2009, Dr. Su completed a Medical Assessment of Ability to do Work-Related Physical Activities. (Tr. 382.) He opined that Plaintiff could sit less than two hours in an eight-hour work day, stand/walk less than two hours in an eight-hour work day, and could lift/carry less than ten pounds. ( Id. ) He further noted that Plaintiff's "fatigue, dizziness, CHF [congestive heart failure], and cardiomyopathy" limited her ability to sustain work activity for eight hours a day, five days a week. (Tr. 383.)
On November 16, 2009, Plaintiff saw Dr. Su at follow-up appointment for atrial fibrillation, cardiomyopathy, and defibrillator placement. (Tr. 400-01.) Dr. Su noted that Plaintiff had "been somewhat lost to follow up in the past six months." (Tr. 401.) He noted that Plaintiff "clinically has been feeling well and has no complaints." (Tr. 400.) He also noted that Plaintiff reported that "her heart failure symptoms [had] done much better, " and that she "now has Class 2 heart failure symptoms." ( Id. ) Dr. Su noted that Plaintiff had permanent atrial fibrillation and required permanent Coumadin therapy. (Tr. 401.) An echocardiogram revealed an estimated left ventricular ejection fraction of fifty-six percent, along with enlarged left and right atrial sizes. (Tr. 404.)
In January 2010, state agency physician Terry Ostrowski, M.D., reviewed the record and opined that Plaintiff had abilities consistent with light work, with no manipulative limitations. (Tr. 386-93.) Dr. Ostrowski found that Plaintiff could stand/walk about six hours in an eight-hour day. (Tr. 387.) Dr. Ostrowski rejected examining physician Dr. Chaffee's stand/walk limit in view of Plaintiff's fifty percent ejection fraction. (Tr. 392.) In February 2010, Dr. Su signed a letter about ...