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Ball v. Commissioner of Social Security

United States District Court, S.D. Ohio, Eastern Division

July 15, 2019

RACHEL R. BALL, Plaintiff,




         Plaintiff, Rachel R. Ball, brings this action under 42 U.S.C. § 405(g) for review of a final decision of the Commissioner of Social Security (“Commissioner”) denying her application for Social Security Supplemental Security Income benefits (“SSI”). This matter is before the United States Magistrate Judge for a Report and Recommendation on Plaintiff's Statement of Errors (ECF No. 9), the Commissioner's Memorandum in Opposition (ECF No. 15), Plaintiff's Reply (ECF No. 16), and the administrative record (ECF No. 8). For the reasons that follow, it is RECOMMENDED that the decision of the Commissioner be REVERSED and that this action be REMANDED under Sentence Four of § 405(g).

         I. BACKGROUND

         Plaintiff protectively filed her application for benefits in August 2014, alleging that she has been disabled since April 29, 2005, due to rejection of her heart transplant and brain damage caused from her heart stopping. (R. at 153-60, 171.) Plaintiff's application was denied initially and upon reconsideration. Plaintiff sought a de novo hearing before an administrative law judge. (R. at 117-19.) Administrative Law Judge Jeannine Lesperance (“ALJ”) held a hearing on March 28, 2017, at which Plaintiff, who was represented by counsel, appeared and testified. (R. at 35-77.) On August 2, 2017, the ALJ issued a decision finding that Plaintiff was not disabled within the meaning of the Social Security Act. (R. at 15-26.) On February 22, 2018, the Appeals Council denied Plaintiff's request for review and adopted the ALJ's decision as the Commissioner's final decision. (R. at 1-6.) Plaintiff then timely commenced the instant action.


         At the administrative hearing, Plaintiff testified that she lived with her 5-year-old son. (R. at 40.) She is able to drive and has a driver's license. (R. at 41.) However, her father drove her to the hearing and drives her to doctor's appointments because she “get[s] confused[.]” (R. at 42.) Plaintiff graduated from high school, and she went to college for “a few months.” (Id.) She previously worked part-time in several restaurants while she was in high school, but she has not worked since 2005. (R. at 42-44.) Plaintiff testified that she is unable to work because she is unable to stand for “even 20 minutes, ” “a lot of things I don't understand, ” and “I'm not good with people [] skills.” (R. at 45.)

         Plaintiff explained that while some of her medical records indicate that she was walking three miles a day and running after her son, this was only for a period of time when she was getting better. (R. at 45-46.) She started trying to walk because she was told she needed a new heart and the doctors wouldn't consider surgery unless she lost weight. (R. at 46.) At the time of the hearing, she weighed approximately 186 pounds, she has previously weighed as much as 230 pounds. (Id.) She lost the weight over a period of five years. (Id.)

         When discussing her activities of daily living, Plaintiff testified that she has a case manager who assists her in understanding her mail and paying her bills. (R. at 48.) A friend helps her care for her pets. (Id.) Plaintiff is able to do “routine things” such as shopping, and taking care of basic household tasks such as cooking and cleaning. (Id.) Plaintiff writes down her appointments so that she does not forget them. (R. at 49.) Socially, she visits friends and they watch movies together. (Id.)


         Upon referral for a repeat neuropsychological evaluation by John Kovalchin, M.D., to document her neuropsychological functioning and to assist with clinical management, Plaintiff presented for evaluation and testing on three occasions in April and July 2014. (R. at 228-34). Both Amery Treble-Barna, M.A., a psychology intern with the Pediatric Neuropsychology Program, and Jennifer Cass, Ph.D., ABPP/CN, Pediatric Neuropsychologist, signed the neuropsychological evaluation (“the neuropsychological evaluation”). (R. at 233-34.)

         According to the neuropsychological evaluation, Plaintiff experienced cognitive impairments relating to her cardiac arrest in 2000 and subsequent heart transplant in 2005. (R. at 229.) Psychosocial history was remarkable for mood difficulties and several significant stressors. (Id.) Plaintiff reported feelings of depression and anxiety. (Id.) Plaintiff has two close friends but spends most of her time at home. (Id.)

         Plaintiff was tested on three occasions, including two during hospitalizations for inpatient medical procedures and once as an outpatient. (R. at 230.) During the inpatient testing sessions, “Plaintiff had difficulty concentrating, was drowsy, and fell asleep during both testing sessions” and had to schedule an outpatient appointment to complete testing. (Id.) Testing results revealed overall cognitive ability in the low-average range on the WASI-II, with a full-scale score of 82, around the tenth percentile. (Id.) Verbal comprehension and perceptual reasoning indices were in the low average range with standard scores of 89 (25th percentile) and 80 (10th percentile). (Id.) Plaintiff demonstrated significant impairments in verbal learning and memory, and improved right hand motor functioning. (R. at 230-31.)

         Plaintiff's neuropsychological profile places her at risk for academic, vocational, and adaptive difficulties. (R. at 232.) She may have difficulty acquiring new skills, performing skills independently, learning and recalling new information, and communicating her understanding. (Id.) Because of her difficulties with executive functions, she may have a hard time getting started on tasks, and struggle to complete her work in a systematic and efficient manner. (Id.) Plaintiff's work may be slow or impulsive, disorganized, or of inconsistent quality and her slower processing would likely interfere with her ability to complete tasks efficiently. (Id.) Without some level of support, Plaintiff may have difficulty maintaining employment. (Id.)

         The neuropsychological evaluation opined that Plaintiff is likely to function best in a consistent, highly structured work environment in which she has an individual supervisor/mentor who can monitor her performance and offer support. (R. at 232-33.) Plaintiff would benefit from cues and ongoing monitoring to ensure that she ...

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