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Smith-Williams v. Berryhill

United States District Court, S.D. West Virginia, Charleston Division

April 6, 2017

TERRIE LYNN SMITH-WILLIAMS, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, [1]Defendant.

          PROPOSED FINDINGS AND RECOMMENDATIONS

          CHERYL A. EIFERT UNITED STATES DISTRICT JUDGE.

         This action seeks a review of the decision of the Commissioner of the Social Security Administration (hereinafter “Commissioner”) denying Plaintiff's applications for a period of disability and disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-433, 1381-1383f. The matter is assigned to the Honorable John T. Copenhaver, Jr., United States District Judge, and was referred to the undersigned United States Magistrate Judge by standing order for submission of proposed findings of fact and recommendations for disposition pursuant to 28 U.S.C. § 636(b)(1)(B). Presently pending before the Court are Plaintiff's Brief in Support of Judgment on the Pleadings and the Commissioner's Brief in Support of Defendant's Decision, requesting judgment in her favor. (ECF Nos. 12, 13).

         Having fully considered the record and the arguments of the parties, the undersigned United States Magistrate Judge respectfully RECOMMENDS that Plaintiff's request for judgment on the pleadings be DENIED, the Commissioner's request for judgment on the pleadings be GRANTED, the Commissioner's decision be AFFIRMED, and that this case be DISMISSED and removed from the docket of the Court.

         I. Procedural History

         On July 30, 2013 and May 28, 2014, respectively, Plaintiff Terrie Lynn Smith-Williams (“Claimant”), completed applications for DIB and SSI, alleging a disability onset date of January 1, 1994, [2] (Tr. at 215, 218), due to “Riters [sic] syndrome, chronic pain, Autoimmune Disorders, Uveitis, Vision Problems, Balance Problems, Numbness in face, Diverticulosis, Anxiety, Depression, Attention Deficit Disorder (“ADD”), Fibromyalgia, Arthritis [and] Endometriosis.” (Tr. at 256). The Social Security Administration (“SSA”) denied Claimant's applications initially and upon reconsideration. (Tr. at 104, 110). Claimant filed a request for an administrative hearing, which was held on April 1, 2015 before the Honorable Scott Johnson, Administrative Law Judge (“ALJ”). (Tr. at 34-81). By written decision dated April 14, 2015, the ALJ found that Claimant was not disabled as defined in the Social Security Act. (Tr. at 15-28). The ALJ's decision became the final decision of the Commissioner on December 28, 2015, when the Appeals Council denied Claimant's request for review. (Tr. at 5-7).

         Claimant timely filed the present civil action seeking judicial review pursuant to 42 U.S.C. § 405(g). (ECF No. 2). The Commissioner subsequently filed an Answer opposing Claimant's complaint and a Transcript of Proceedings. (ECF Nos. 8, 9). Claimant then filed a Brief in Support of Judgment on the Pleadings. (ECF No. 12). In response, the Commissioner filed a Brief in Support of Defendant's Decision, (ECF No. 13), to which Claimant filed a Reply. (ECF No. 14). Consequently, the matter is fully briefed and ready for resolution.

         II. Claimant's Background

         Claimant was 50 years old at the time of the alleged onset of disability and 57 years old at the time of the ALJ's decision. (Tr. at 15, 38). She has at least a high school education and communicates in English. (Tr. at 43, 255). Claimant previously worked as a caregiver, daycare provider, medical assistant, and bank teller. (Tr. at 44-49, 258).

         III. Summary of ALJ's Decision

         Under 42 U.S.C. § 423(d)(5), a claimant seeking disability benefits has the burden of proving a disability. See Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972). A disability is defined as the “inability to engage in any substantial gainful activity by reason of any medically determinable impairment which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A).

         The Social Security regulations establish a five-step sequential evaluation process for the adjudication of disability claims. If an individual is found “not disabled” at any step of the process, further inquiry is unnecessary and benefits are denied. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The first step in the sequence is determining whether a claimant is currently engaged in substantial gainful employment. Id. §§ 404.1520(b), 416.920(b). If the claimant is not, then the second step requires a determination of whether the claimant suffers from a severe impairment. Id. §§ 404.1520(c), 416.920(c). A severe impairment is one that “significantly limits [a claimant's] physical or mental ability to do basic work activities.” Id. If severe impairment is present, the third inquiry is whether this impairment meets or equals any of the impairments listed in Appendix 1 to Subpart P of the Administrative Regulations No. 4 (the “Listing”). Id. §§ 404.1520(d), 416.920(d). If so, then the claimant is found disabled and awarded benefits.

         However, if the impairment does not meet or equal a listed impairment, the adjudicator must assess the claimant's residual functional capacity (“RFC”), which is the measure of the claimant's ability to engage in substantial gainful activity despite the limitations of his or her impairments. Id. §§ 404.1520(e), 416.920(e). After making this determination, the fourth step is to ascertain whether the claimant's impairments prevent the performance of past relevant work. Id. §§ 404.1520(f), 416.920(f). If the impairments do prevent the performance of past relevant work, then the claimant has established a prima facie case of disability, and the burden shifts to the Commissioner to demonstrate, in the fifth and final step of the process, that the claimant is able to perform other forms of substantial gainful activity, given the claimant's remaining physical and mental capacities, age, education, and prior work experiences. 20 C.F.R. §§ 404.1520(g), 416.920(g); see also McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983). The Commissioner must establish two things: (1) that the claimant, considering his or her age, education, skills, work experience, and physical shortcomings has the capacity to perform an alternative job, and (2) that this specific job exists in significant numbers in the national economy. McLamore v. Weinberger, 538 F.2d 572, 574 (4th Cir. 1976).

         When a claimant alleges a mental impairment, the SSA “must follow a special technique at each level in the administrative review process, ” including the review performed by the ALJ. 20 C.F.R. §§ 404.1520a(a), 416.920a(a). Under this technique, the ALJ first evaluates the claimant's pertinent signs, symptoms, and laboratory results to determine whether the claimant has a medically determinable mental impairment. Id. §§ 404.1520a(b), 416.920a(b). If an impairment exists, the ALJ documents his findings. Second, the ALJ rates and documents the degree of functional limitation resulting from the impairment according to criteria specified in Id. §§ 404.1520a(c), 416.920a(c). Third, after rating the degree of functional limitation from the claimant's impairment(s), the ALJ determines the severity of the limitation. Id. §§ 404.1520a(d), 416.920a(d). A rating of “none” or “mild” in the first three functional areas (activities of daily living, social functioning, and concentration, persistence or pace) and “none” in the fourth (episodes of decompensation of extended duration) will result in a finding that the impairment is not severe unless the evidence indicates that there is more than minimal limitation in the claimant's ability to do basic work activities. Id. §§ 404.1520a(d)(1), 416.920a(d)(1). Fourth, if the claimant's impairment is deemed severe, the ALJ compares the medical findings about the severe impairment and the rating and degree and functional limitation to the criteria of the appropriate listed mental disorder to determine if the severe impairment meets or is equal to a listed mental disorder. Id. §§ 404.1520a(d)(2), 416.920a(d)(2). Finally, if the ALJ finds that the claimant has a severe mental impairment, which neither meets nor equals a listed mental disorder, the ALJ assesses the claimant's residual mental functional capacity. Id. §§ 404.1520a(d)(3), 416.920a(d)(3). The regulations further specify how the findings and conclusion reached in applying the technique must be documented by the ALJ, stating:

The decision must show the significant history, including examination and laboratory findings, the functional limitations that were considered in reaching a conclusion about the severity of the mental impairment(s). The decision must include a specific finding as to the degree of limitation in each functional areas described in paragraph (c) of this section.

20 C.F.R. §§ 404.1520a(e)(4), 416.920a(e)(4).

         Here, the ALJ determined as a preliminary matter that Claimant met the insured status for DIB through June 30, 2010. (Tr. at 17, Finding No. 1). At the first step of the sequential evaluation, the ALJ found that Claimant had not engaged in substantial gainful activity since February 22, 2008. (Tr. at 17, Finding No. 2). At the second step of the evaluation, the ALJ found that Claimant had the following severe impairments: “diverticulosis, gastroparesis, fibromyalgia syndrome affecting the hands, wrists, knees, and ankles, cervical spondylosis, and asthma.” (Tr. at 17-18, Finding No. 3). The ALJ considered and found non-severe Claimant's carpal tunnel syndrome, right rotator cuff tear, Reiter's syndrome, uveitis, degenerative disc disease of the spine, endometriosis, anxiety, depression, and ADD. (Tr. at 18-20, Finding No. 3).

         Under the third inquiry, the ALJ found that Claimant did not have an impairment or combination of impairments that met or medically equaled any of the impairments contained in the Listing. (Tr. at 20-21 Finding No. 4). Accordingly, the ALJ determined that Claimant possessed:

[T]he residual functional capacity to perform medium work as defined in 20 CFR 404.1567(c) and 416.967(c) with lifting/carrying of 50 pounds occasionally and 25 pounds frequently; sitting for six hours; standing/walking six hours; and pushing/pulling within the lifting/carrying restrictions of medium exertion. She can frequently perform reaching in all directions (including overhead), handling, and fingering with the bilateral upper extremities. She can frequently perform climbing of ramps and stairs but only occasionally perform climbing of ladders, ropes, or scaffolds. She can frequently perform balancing, stooping, kneeling, and crouching. She can occasionally perform crawling. She should avoid concentrated exposure to hazards such as unprotected heights and moving mechanical parts, dust, odors, fumes, gases, pulmonary irritants, chemicals, poorly ventilated areas, extreme cold, extreme heat, and excessive vibration.

(Tr. at 21-26, Finding No. 5). At the fourth step, with the assistance of a vocational expert (“VE”), the ALJ determined that Claimant was able to perform past relevant work as a childcare provider and medical assistant. (Tr. at 26-27, Finding No. 6). Therefore, the ALJ found that Claimant was not disabled as defined in the Social Security Act, and was not entitled to benefits. (Tr. at 27, Finding No. 7).

         IV. Claimant's Challenges to the Commissioner's Decision

         Claimant raises two challenges to the Commissioner's decision, which both concern the ALJ's RFC finding. First, Claimant contends that the ALJ failed to include any limitations in Claimant's RFC to account for her digestive issues and fibromyalgia, nor did he adequately explain his decision to not include further limitations, thereby frustrating meaningful review. (ECF No. 12 at 8-10). Second, Claimant argues that the ALJ failed to consider her non-severe impairments in making his RFC finding. (Id. at 10).

         In response to Claimant's assertions of error, the Commissioner argues that the ALJ considered the combined, synergistic effect of Claimant's impairments, both severe and non-severe, in assessing Claimant's RFC. (ECF No. 13 at 16-20).

         V. Relevant Medical Evidence

         The undersigned has reviewed all of the evidence before the Court. The medical records and opinion evidence most relevant to this PF & R are summarized as follows.

         A. ...


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