Opinion ID: 4533880
Heading Depth: 2
Heading Rank: 2

Heading: Ellis’s Medical History

Text: On February 1, 2012, while undergoing treatment for pneumonia, Ellis experienced severe chest pain as a result of a pulmonary embolism (blood clot in the lungs). He was administered nitroglycerin, but soon afterwards he had an abnormally slow heartbeat, followed by an approximately 24-second heart stoppage. He briefly returned to work after this incident, but his last day of employment with Comcast was February 29, 2012. Ellis submitted a claim for short-term disability benefits, which Liberty approved in March 2012. He reported “poor concentration, dizziness, slowing of physical and mental skills” and was referred to a neurologist in June 2012. Aplt. App., Vol. I at 268. The neurologist who began treating Ellis, Dr. Alan Zacharias, recommended physical and cognitive therapy but also noted that Ellis had an “[u]nremarkable brain MRI,” had no evidence of a primary neuromuscular disease, and was alert and attentive. Id. at 269. Based on this report and documentation from two other providers, Liberty terminated short-term benefits in July 2012. In October 2012, Ellis’s lawyer sent a letter to Liberty asking it to reinstate benefits without a formal appeal. Part of this submission was a neuropsychological evaluation by Dr. Dennis Helffenstein, whom the lawyer had asked to evaluate Ellis. He opined that Ellis’s testing “identified significant cognitive deficits suggesting bilateral frontal and bilateral temporal involvement. The pattern is consistent with cerebral 4 hypoxia[2]. There is absolutely no way Michael could do his job at this time from a cognitive standpoint.” Aplee. Supp. App., Vol. II at 578. Liberty reinstated short-term disability benefits through the maximum duration and advanced the claim for long-termdisability consideration. To assess Ellis’s eligibility for long-term benefits, Liberty’s claim consultant asked Dr. John Crouch and Dr. Gilbert Wager (Liberty’s consulting neuropsychologist and internal-medicine specialist, respectively) to review Ellis’s records. The reports from both doctors expressed doubt that a 24-second heart stoppage could cause cerebral hypoxia or neurological injury. Dr. Wager explained that “[t]his scenario is unlikely, as permanent neurological injury is not a feature of an episode of cardiogenic syncope. In general, it takes about 4 minutes or longer of cerebral anoxia to cause neuronal cell death and permanent neurological damage upon loss of spontaneous circulation.” Aplt. App., Vol. I at 246. Dr. Crouch requested Dr. Helffenstein’s raw data to assess the validity and reliability of Ellis’s claimed cognitive and psychiatric deficits. After receiving the raw data, Dr. Crouch stated in an addendum to his report that “multiple measures of response bias were administered and yield[ed] Normal findings, suggesting that [Ellis’s] impairments [were] valid/reliable.” Id. at 187. Liberty also placed Ellis under 2 According to the National Institute of Neurological Disorders and Stroke, “[c]erebral hypoxia refers to a condition in which there is a decrease of oxygen supply to the brain even though there is adequate blood flow.” National Institute of Health, Cerebral Hypoxia Information Page, https://www.ninds.nih.gov/disorders/all-disorders/cerebralhypoxia-information-page. Possible causes include “cardiac arrest.” Id. 5 surveillance in December 2012; the only video captured of Ellis revealed him “walking in a slow pace while utilizing a cane.” Aplee. Supp. App., Vol. II at 482. Liberty approved long-term benefits in April 2013 but noted that the cause of Ellis’s cognitive impairments was still unclear. In May 2013 Liberty requested updated information from Dr. Dan Hadley, Ellis’s primary-care physician, and Dr. Zacharias, his neurologist. Dr. Hadley completed a restrictions form stating that Ellis could not work in a situation requiring more than 10-20 minutes of minimal concentration. Dr. Zacharias did not specify a work-related restriction and instead signed a restrictions form directing Liberty to “see neuropsych testing that supports his impairment.” Aplt. App., Vol. I at 239. Liberty completed a vocational report in July 2013 that identified several alternative occupations fitting Ellis’s training, education, experience, and physical capacities. The case manager who completed the report indicated that she was asked to “presume[] sedentary work capacity, and not to include any cognitive and/or mental restrictions and limitations.” Aplee. Supp. App., Vol. II at 455. Liberty also had a threeday surveillance conducted in August 2013, but no clear video of Ellis was obtained. When Liberty asked Dr. Crouch for an updated clinical review of Ellis’s records, he reported in September 2013 that “based on available information, it is unlikely that the claimant could perform the job duties of alternate occupations comparable to his prior job.” Aplt. App., Vol. I at 189. But he said that an independent neuropsychological reevaluation was warranted if one had not been recently performed. Dr. Bob Gant, a neuropsychologist, was retained by an outside vendor at Liberty’s request and evaluated 6 Ellis in October 2013. He determined that Ellis’s neuropsychological test results were invalid because of “[c]lear evidence of symptom exaggeration and suboptimal effort.” Id. at 202. He said: Mr. Ellis reported an unusual and elevated degree of neurological complaints which are likely to be vague and illogical. This was confirmed by other tests utilized during this examination which indicated that the degree of neurologic impairment reported by Mr. Ellis was highly atypical and illogical. Such a presentation includes symptoms that are illogical or inconsistent with symptoms of a bona fide neurologic disorder or they occur very rarely in neurologically impaired patients. Id. at 203–04. Dr. Gant questioned whether Ellis even had cognitive impairment: [W]ithin reasonable medical probability [Ellis] has not suffered cognitive impairment related to the asystole event which lasted 24 seconds on February 1, 2012. In fact, I am not certain that the patient suffers from cognitive impairment. It is likely that elements of secondary gain and/or impairment related to somatic exaggeration is responsible for [his] presentation. Id. at 196. In November 2013, Dr. Crouch reviewed Dr. Gant’s report and stated that the results from Dr. Gant’s evaluation “are insufficient to support the presence of valid/reliable” cognitive impairment. Id. at 194. Dr. Crouch also agreed that it was “medically impossible for a 24 second asystole event to cause cerebral hypoxia.” Id. at 194. Liberty terminated Ellis’s disability benefits in December 2013. Ellis appealed the denial in June 2014. He included as additional evidence in support of his appeal a March 2014 letter from his speech therapist, letters from the Social Security Administration from December 2013 declaring him eligible for disability benefits, and imaging from a Single Photon Emission Completed Tomography (SPECT) 7 scan together with an assessment report interpreting the images. The SPECT scan, which shows blood flow and oxygen perfusion to the brain, was interpreted by Dr. S. Gregory Hipskind, a nuclear neurologist to whom Ellis had been referred by Dr. Helffenstein. He read the scan as abnormal—consistent with “a diffuse, toxic/hypoxic encephalopathic process.” Id. at 220. Dr. Helffenstein had also conducted a second evaluation in May 2014 and his written report, completed in July 2014, later supplemented Ellis’s appeal. The report said that Ellis had demonstrated notable improvement in his results but had “reached maximum medical improvement from a neuropsychological standpoint” and was “totally and permanently disabled from competitive employment.” Id. at 144–45. In September 2014, Liberty had Dr. Timothy Belliveau, another of its consulting neuropsychologists, review Ellis’s medical records and neuropsychological evaluations. Dr. Belliveau opined that the test data from Dr. Helffenstein’s 2012 exam and Dr. Gant’s 2013 exam probably indicated symptom over-reporting. Dr. Belliveau concluded that “[c]onsidered as a whole, and in the context of the claimant’s documented medical history, the neuropsychological test data provide insufficient support for the presence of cognitive or psychological impairment due to a presumed brain injury in February 2012.” Id. at 109. In light of Dr. Belliveau’s review, Liberty upheld its denial.