Mitchell v. Kijakazi

MATTHEW JOHN MITCHELL, Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant.

No. 4:21-cv-40085-TSH

United States District Court, D. Massachusetts

August 19, 2022

REPORT AND RECOMMENDATION

David H. Hennessy, United States Magistrate Judge

Plaintiff Matthew John Mitchell (“Mitchell”) moves for an order vacating Defendant Acting Commissioner of Social Security's decision (“Commissioner” or “Defendant”) denying his application for Supplemental Security Income (“SSI”) benefits. [Dkt. Nos. 1, 15]. The Commissioner opposes Mitchell's motion and seeks an order affirming her decision denying Mitchell's application. [Dkt. Nos. 11, 17]. District Judge Hillman referred the matter to me on April 12, 2022 for a Report and Recommendation. [Dkt. No. 19].

For the reasons stated below, I hereby RECOMMEND that Mitchell's Motion for Order Reversing the Commissioner's Decision [Dkt. No. 15] be DENIED and Defendant's Motion to Affirm the Decision of the Commissioner [Dkt. No. 17] be GRANTED.

I. BACKGROUND

A. Procedural History

On March 7, 2019, Mitchell filed an application for SSI, alleging he was disabled as of December 31, 2018. [Tr. 16].^[1]The application was initially denied on September 4, 2019, and again on reconsideration on November 21, 2019. [Tr. 93, 106]. Following a hearing held on November 10, 2020 [Tr. 53-82] the administrative law judge (“ALJ”) denied Mitchell's application for benefits on November 25, 2020, finding Mitchell was not disabled. [Tr. 13-30].

On June 4, 2021, the Appeals Council denied Mitchell's request for administrative review, rendering the ALJ's decision final and ripe for judicial review. [Tr. 1-7]. Mitchell filed a complaint in this Court on August 9, 2021, and the Commissioner answered on November 24, 2021. [Dkt. Nos. 1 and 11]. Pursuant to the Court's procedural order [Dkt. No. 7], Mitchell moved to reverse the decision of the Commissioner on March 7, 2022, and the Commissioner cross-moved to affirm its decision on April 8, 2022. [Dkt. Nos. 15 and 17]. On April 21, 2022, Mitchell filed a reply to the Commissioner's motion [Dkt. No. 20], and on April 22, 2022, the Commissioner filed a sur-reply. [Dkt. No. 21].

B. Personal History

Mitchell was 51 years old when he claimed disability. [Tr. 83]. He graduated high school and completed two years of college. [Tr. 202]. Mitchell states in his Disability Report that he was last employed in December 2018, as a driver's helper at a delivery business, a job he held intermittently since December 2014. [Tr. 203]. During that time, Mitchell held various other jobs, such as an auto detailer between February and March 2015, and a dishwasher in July 2017. [Id.]. Mitchell claims he stopped working on December 1, 2018 due to a variety of impairments, including osteoarthritis in the knees, back and hands, hypertension, major depressive disorder (“MDD”), generalized anxiety disorder (“GAD”), and myeloproliferative neoplasms (“MPN”), a form of blood cancer. [Tr. 201; see also Dkt. Nos. 16 at 1; 18 at 3]. However, Mitchell testified during the hearing before the ALJ that since December 2018, he worked at the carwash between July 2019 and February 2020, and worked on a few painting jobs. [Tr. 62].

C. Medical History

On December 3, 2018, Mitchell presented to Carol M. Mathew, M.D., at UMass Memorial Healthcare for leukocytosis and a complaint of high white blood cell count. [Tr. 306]. It appears that as part of Mitchell's “work up” with his primary care physician (“PCP”)-Ishwara Sharma, M.D.-he was found to have an elevated white blood cell count, so “his PCP wanted him to [be] evaluated by hematology.” [Id.]. Dr. Mathew noted that Mitchell had an “abnormal” complete blood count, “showing leukocytosis, left shifted granulocytic lineage, monocytosis, basophilia as well as polycythemia, and erythrocytosis.” [Tr. 311]. Dr. Mathew also noted that these findings “can be seen in a range of conditions,” and need to be confirmed with further evaluations. [Id.]. On December 7, 2018, Dr. Mathew called Mitchell to discuss scheduling lab work “to check for additional abnormalities,” and ordered two additional procedures for Mitchell: a “next generation sequencing” test for possible MPN, and a testing for BCR-ABL. [Id.]. On December 13, 2018, Mitchell underwent both tests, and was positive for MPN. [Tr. 315].

On January 7, 2019, Sonali R. Harchandani, M.D., examined Mitchell's test results and found that Mitchell likely had essential thrombocytosis, though he was asymptomatic, and presented “a low risk MPN.” [Tr. 316]. Dr. Harchandani recommended that Mitchell make lifestyle modifications and take a low dose of aspirin to reduce his risk of thrombotic events, and referred Mitchell to “transfusion medicine for consideration of phlebotomy[.]” [Id.]. Mitchell was seen by Yong Zhao, M.D., later that same day, on Dr. Harchandani's referral, for evaluation of “management of polycythemia by therapeutic phlebotomy.” [Tr. 317]. Dr. Zhao noted that Mitchell “feels well today without any complaints.” [Id.]. During his physical examination with Dr. Zhao, Mitchell presented normal strength, sensation, and reflexes, and denied having any headache, dizziness, focal weakness, syncope, seizure, paresthesia or dysesthesia, or any emotional problems, anxiety or depression. [Tr. 318-19]. Dr. Zhao recommended that Mitchell begin therapeutic phlebotomy to manage his MPN and keep hematocrit levels below 42 percent, in order to prevent thrombotic and vascular complications. [Tr. 319]. Mitchell provided “informed consent” to begin this treatment. [Id.].

In follow-up appointments, Mitchell reported continuing to feel well without severe symptoms. During a January 28, 2019, transfusion follow-up, Shi Bai, M.D., noted that Mitchell reported “feel[ing] well today without any complaints.” [Tr. 320]. Mitchell “noted some headache next day after phlebotomy, which resolved without any specific treatment.” [Id.]. Mitchell reported no fevers, night sweats, weight loss, visual disturbances, tinnitus, hearing loss, ulcers, dental problems, chest pain, respiratory symptoms, gastrointestinal issues, and otherwise no acute abnormalities. [Tr. 321]. A month later, on February 25, 2019, during a “lab review and follow up” for his MPN, Mitchell reported some knee and leg pain, for which he was taking Aleve, but “[o]therwise he [was] doing well” with the phlebotomy. [Tr. 323]. Mitchell reported no other acute abnormalities such as difficulty breathing or uncontrolled pain; his mood was reported as appropriate, and he appeared to be seated comfortably. [Tr. 323-24].

On April 8, 2019, Mitchell presented to Dr. Mathew for an MPN follow-up. [Tr. 328]. Dr. Mathew noted that Mitchell had been undergoing phlebotomy every month to treat his polycythemia, and Mitchell reported tolerating his treatment “fine,” though he was “having frequent headaches that are throbbing, predominantly on the front of the head.” [Id.]. Mitchell stated that his vision was worse and he felt fatigued, though his appetite was “fair.” [Id.]. Dr. Mathew recommended to Mitchell that he continue with his treatment of aspirin and phlebotomy and “emphasized smoking cessation[.]” [Tr. 332]. Dr. Mathew also prescribed Mitchell hydroxyurea, an oral chemotherapy treatment, and a blood count check in two weeks. [Id.]. Dr. Zhao also saw Mitchell on April 8, 2019, “for further evaluation and management” of his MPN. [Tr. 333]. Dr. Zhao found that Mitchell's hematocrit level was at 47.8 percent, though “the goal [was] to keep [Mitchell's] hematocrit less than 45%.” [Tr. 336]. Subsequent to this finding, Mitchell was administered another phlebotomy. [Id.]. Dr. Zhao also found that Mitchell had significant blood pressure difference between his two arms and relayed this information to Dr. Mathew and Dr. Sharma. [Id.]. Dr. Zhao reported that Dr. Sharma said he will contact Mitchell to schedule further evaluation. [Id.].

Mitchell presented to Dr. Sharma's office on April 16, 2019, for consultation regarding the unequal arm pressures. [Tr. 362]. Dr. Sharma was not in the office, but his associate conducted a physical exam and found that Mitchell likely had a left subclavian stenosis. [Tr. 363]. Dr. Sharma's office then made a “[v]ascular referral” to “UMass for intervention consideration,” and scheduled Mitchell for a follow-up two weeks later. [Id.]. On April 22, 2019, Mitchell presented to Eric G. Bluemn, M.D., at UMass for evaluation of the unequal bilateral blood pressures. [Tr. 437-38]. Mitchell reported “no symptoms in the left arm” and “never” having “any issues with weakness or cramping[.]” [Tr. 438]. Mitchell also denied “any episodes of lightheadedness or syncope while using his arms.” [Id.]. Dr. Bluemn informed Mitchell that this condition was “not dangerous” and would “not need any surgical intervention” unless Mitchell developed worsening symptoms. [Tr. 440]. Dr. Bluemn recommended that Mitchell continue blood pressure medication, and “strongly advised tobacco cessation.” [Id.].

On April 29, 2019, during a regular follow-up with Dr. Mathew Mitchell reported that he felt miserable, dizzy, and his headaches had not let up, possibly because he was “withdrawing from caffeine.” [Tr. 441]. Mitchell further reported that his “anxiety” was “through the roof” and he had not been able to see Dr. Sharma, who was in China. [Id.]. However, Mitchell stated that he was “tolerating the hydroxyurea well,” denied having any “GI [gastrointestinal] upset, nausea, vomiting, [or] diarrhea,” and his abdominal tests were normal. [Tr. 441-42]. Mitchell stated he was having a “hard time financially” because he was “missing work” to attend all his appointments. [Id.]. Dr. Mathew found that Mitchell had an elevated hematocrit of 52, but Mitchell did...