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Moses v. Berryhill

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

May 22, 2017

NANCY A. BERRYHILL, [1] Acting Commissioner of the Social Security Administration, Defendant.


          Cheryl A. Eifert Judge.

         This is an action seeking review of the decision of the Commissioner of the Social Security Administration (hereinafter the “Commissioner”) denying plaintiff's application for supplemental security income (“SSI”) under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383f. This case is presently before the Court on the parties' motions for judgment on the pleadings as articulated in their briefs. (ECF Nos. 11, 12). Both parties have consented in writing to a decision by the United States Magistrate Judge. (ECF Nos. 7, 8). The Court has fully considered the evidence and the arguments of counsel. For the reasons that follow, the Court finds that the decision of the Commissioner is supported by substantial evidence and should be affirmed.

         I. Procedural History

         Plaintiff, Angela Dawn Moses (hereinafter referred to as “Claimant”), completed an application for SSI benefits on August 7, 2012, alleging a disability onset of December 12, 2004[2] due to “Psychological problems, back lumbar problems, ibs [IBS-Irritable Bowel Syndrome], vision, back injury, depression, anxiety, migraines, knee problems, shoulder problems, hands, [and] allergies.” (Tr. at 216). The Social Security Administration (“SSA”) denied the application initially and upon reconsideration. (Tr. at 11). On May 23, 2013, Claimant filed a written request for an administrative hearing, which was held on November 10, 2014 before the Honorable Maria Hodges, Administrative Law Judge (“ALJ”). (Tr. at 31-64). By decision dated November 20, 2014, the ALJ determined that Claimant was not entitled to benefits.[3] (Tr. at 11-25).

         The ALJ's decision became the final decision of the Commissioner on May 20, 2016, when the Appeals Council denied Claimant's request for review. (Tr. at 1-3). On July 21, 2016, Claimant brought the present civil action seeking judicial review of the administrative decision pursuant to 42 U.S.C. § 405(g). (ECF No. 2). The Commissioner filed an Answer and a Transcript of the Proceedings. (ECF Nos. 9, 10). Thereafter, the parties filed their briefs in support of judgment on the pleadings, each requesting relief on her behalf. Consequently, this matter is fully briefed and ready for resolution.

         II. Claimant's Background

         Claimant was 35 years old at the time of the administrative hearing and the ALJ's decision. (Tr. at 36). She has at least high school education and is able to communicate in English. (Tr. at 36, 215, 217). Claimant previously worked as a home health caregiver, cleaner, restaurant worker, and cashier. (Tr. at 38-42, 218).

         III. Summary of ALJ's Findings

         Under 42 U.S.C. § 423(d)(5), a claimant seeking disability benefits has the burden of proving disability, defined as the “inability to engage in any substantial gainful activity by reason of any medically determinable impairment which 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. § 416.920. The first step in the sequence is determining whether a claimant is currently engaged in substantial gainful employment. Id. § 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. § 416.920(c). 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. Id. § 416.920(d). If the impairment does, then the claimant is found disabled and awarded benefits.

         However, if the impairment does not, the adjudicator must determine 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. § 416.920(e). After making this determination, the next step is to ascertain whether the claimant's impairments prevent the performance of past relevant work. Id. § 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 establish, as the final step in the process, that the claimant is able to perform other forms of substantial gainful activity, when considering the claimant's remaining physical and mental capacities, age, education, and prior work experiences. Id. § 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 Social Security Administration (“SSA”) “must follow a special technique at every level in the administrative review.” 20 C.F.R. § 416.920a. First, the SSA evaluates the claimant's pertinent signs, symptoms, and laboratory results to determine whether the claimant has a medically determinable mental impairment. If such impairment exists, the SSA documents its findings. Second, the SSA rates and documents the degree of functional limitation resulting from the impairment according to criteria specified in 20 C.F.R. § 416.920a(c). Third, after rating the degree of functional limitation from the claimant's impairment(s), the SSA determines the severity of the limitation. 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) 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. 20 C.F.R. § 416.920a(d)(1). Fourth, if the claimant's impairment is deemed severe, the SSA 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. 20 C.F.R. § 416.920a(d)(2). Finally, if the SSA finds that the claimant has a severe mental impairment, which neither meets nor equals a listed mental disorder, the SSA assesses the claimant's residual function. 20 C.F.R. § 416.920a(d)(3). The Regulation further specifies how the findings and conclusion reached in applying the technique must be documented at the ALJ and Appeals Council levels as follows:

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. § 416.920a(e)(4).

         In this case, the ALJ determined that Claimant satisfied the first inquiry because she had not engaged in substantial gainful activity since August 7, 2012. (Tr. at 13-14, Finding No. 1). Under the second inquiry, the ALJ found that Claimant suffered from the severe impairments of obesity, degenerative disc disease, Irritable Bowel Syndrome (IBS), Bipolar Disorder, Anxiety-related Disorder, and Alcohol Abuse in remission.” (Tr. at 14-15, Finding No. 2). However, the ALJ found that Claimant's impairments of endometriosis, polycystic ovarian syndrome, diabetes mellitus, hypertension, headaches, and vision issues were non-severe. (Tr. at 14-16).

         At the third inquiry, the ALJ concluded that Claimant's impairments did not meet or equal the level of severity of any impairment contained in the Listing. (Tr. at 16-19, Finding No. 3). Consequently, the ALJ determined that Claimant had the RFC to:

[P]erform medium work as defined in 20 CFR 416.967(c) except should never climb ladders, ropes, or scaffolds; can frequently climb ramps/stairs, balance, stoop, kneel or crouch; occasionally crawl; should avoid concentrated exposure to temperature extremes, hazards, and vibration; is limited to understanding, remembering and carrying out simple instructions in a work setting involving occasional interaction with others; and low-stress work, defined as no fast-paced production rate or strict time limits.

(Tr. at 19-23, Finding No. 4). Based upon the RFC assessment, the ALJ determined at the fourth step that Claimant was unable to perform her past relevant work. (Tr. at 23, Finding No. 5). Under the fifth and final inquiry, the ALJ reviewed Claimant's prior work experience, age, and education in combination with her RFC to determine if she would be able to engage in substantial gainful activity. (Tr. at 24, Finding Nos. 6-8). The ALJ considered that (1) Claimant was born in 1979 and was defined as a younger individual; (2) she had at least a high school education and could communicate in English; and (3) transferability of job skills was not material to the disability determination because using the Medical-Vocational Rules supported a finding that the Claimant is “not disabled, ” whether or not the Claimant had transferable job skills. (Id.). Given these factors, Claimant's RFC, and the testimony of a vocational expert, the ALJ determined that Claimant could perform jobs that existed in significant numbers in the national economy. (Tr. at 24-25, Finding No. 9). At the light level, Claimant could work as a garment bagger or hotel maid; and at the medium level, Claimant could work as a laundry worker or night cleaner and at the sedentary level, Claimant could work as an inspector or assembler. (Id.). Therefore, the ALJ concluded that Claimant was not disabled as defined in the Social Security Act. (Tr. at 25 Finding No. 10).

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

         Claimant asserts two challenges to the Commissioner's decision. First, she claims that the ALJ failed to consider the combined effect of Claimant's impairments when determining her RFC. (ECF No. 11 at 4-6). As part of this challenge, Claimant argues that the ALJ erred by finding that Claimant's statements regarding the severity and persistence of her pain, fatigue, and other symptoms were not fully credible. (Id. at 6). According to Claimant, her statements and the objective evidence are mutually supportive of a finding of disability under the Social Security Act; therefore, the statements are entitled to full credibility. Second, Claimant contends that the ALJ's RFC finding is not supported by substantial evidence, because the ALJ's discussion is internally inconsistent. Specifically, Claimant points to the summary RFC finding set forth on page 19 of the transcript, which indicates that Claimant is capable of less than a full range of medium level work, and compares it to a statement in the associated discussion at page 21, which states that Claimant is restricted “to a reduced range of light work.” (Tr. at 21) (emphasis added). Claimant argues that both statements cannot be correct and questions which RFC finding was intended by the ALJ.

         In response to Claimant's criticisms, the Commissioner asserts that the ALJ clearly considered all of Claimant's impairments when analyzing her RFC. (ECF No. 12 at 9-12). The Commissioner argues that the ALJ's comprehensive RFC discussion included an analysis of all of Claimant's functional limitations that were established by the record, and also accounted for all of those limitations in the RFC finding. The Commissioner rejects Claimant's credibility argument, emphasizing that the ALJ provided multiple reasons for discounting the severity of symptoms described by Claimant. (Id. at 10). With respect to Claimant's argument regarding the internal inconsistency of the RFC discussion, the Commissioner apparently misunderstood the argument, because she failed to directly address the discrepancy between the two exertional findings in the RFC section of the written decision. Instead, the Commissioner discusses all of the evidence that supports the ALJ's determination that Claimant could perform a reduced range of medium level work. (Id. at 11-13).

         V. Scope of Review

         The issue before this Court is whether the final decision of the Commissioner denying Claimant's application for benefits is supported by substantial evidence. In Blalock v. Richardson, the Fourth Circuit Court of Appeals defined substantial evidence as:

Evidence which a reasoning mind would accept as sufficient to support a particular conclusion. It consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance. If there is evidence to justify a refusal to direct a verdict were the case before a jury, then there is “substantial evidence.”

483 F.2d 773, 776 (4th Cir. 1972) (quoting Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966)). Additionally, the Commissioner, not the court, is charged with resolving conflicts in the evidence. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990). The Court will not re-weigh conflicting evidence, make credibility determinations, or substitute its judgment for that of the Commissioner. Id. Instead, the Court's duty is limited in scope; it must adhere to its “traditional function” and “scrutinize the record as a whole to determine whether the conclusions reached are rational.” Oppenheim v. Finch, 495 F.2d 396, 397 (4th Cir. 1974). Thus, the ultimate question for the Court is not whether the Claimant is disabled, but whether the decision of the Commissioner that the Claimant is not disabled is well-grounded in the evidence, bearing in mind that “[w]here conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the responsibility for that decision falls on the [Commissioner].” Walker v. Bowen, 834 F.2d 635, 640 (7th Cir. 1987).

         VI. Relevant Medical Records

         The Court has reviewed the Transcript of Proceedings in its entirety, including the medical records in evidence, and summarizes below Claimant's medical treatment and evaluations to the extent that they are relevant to the issues in dispute.

         A. Treatment Records

         On April 28, 2011, Claimant was examined by Ricardo Roa, M.D., in preparation for nasal septoplasty, endoscopy, tonsillectomy, and adenoidectomy. (Tr. at 302-04). Claimant's current medical issues included adenoid hypertrophy, benign neoplasm of the soft palate, deviated nasal septum, hypertrophied nasal turbinate, sinusitis, and tonsillar hypertrophy. Her past medical history included arthritis, depression with anxiety, otitis media, and sinusitis. Claimant presented with normal mood and affect. A CT scan of the sinuses taken on March 21 revealed minimal mucosal thickening of the right maxillary and left sphenoid air cells with minimal leftward deviation of the nasal septum. A CT scan of the neck showed a subtle polypoid nodule projecting from the soft palate just to the right of the midline that might represent a superficial mucosal inclusion cyst. There appeared a possible cementoma near the first maxillary molar. The surgery was performed on May 4, 2011. (Tr. at 298-300). The post-operative diagnosis included lesion of the palate, chronic tonsillitis, adenotonsillar hypertrophy, chronic sinusitis, nasal obstruction, nasal septal deviation, bilateral inferior turbinate hypertrophy, and failure of medical management.

         On August 25, 2011, Claimant presented to her primary care physician, Daniel Whitmore, D.O., with complaints of fatigue and persistent low back pain for the past two to three years. (Tr. at 410). Claimant reported that she took Tylenol and Motrin for pain, and they provided some relief. On examination, Claimant weighed two hundred twenty-nine pounds with a blood pressure of 127/84. Claimant was alert and had an appropriate mood. Her physical examination was otherwise unremarkable, except for some pain elicited on palpation of her dorsolumbar spine and paraspinal muscles. She did not have evidence of scoliosis, and her straight leg raise was negative. Claimant was assessed with lumbago and was told to lose weight. She was also assessed with fatigue due to weight gain and depression, although Dr. Whitmore felt Claimant's depression was under control with Celexa and hydroxyzine. Dr. Whitmore ordered x-rays of Claimant's thoracic and lumbar spine that were performed on August 29, 2011. (Tr. at 421). The thoracic spine x-ray demonstrated normal spinal alignment with no evidence of acute fracture and well-preserved vertebral body heights and disc spaces. The lumbar spine x-ray showed Grade I anterolisthesis of the L5-S1, secondary to bilateral pars defects; however, no acute fracture was seen.

         Claimant returned to Dr. Whitmore on September 22, 2011 informing him that she had undergone physical therapy and chiropractic care for back pain that gave her very little relief. Nonetheless, Claimant advised Dr. Whitmore that she was no longer having back pain. (Tr. at 409). Claimant was assessed with resolved back pain and encouraged to lose weight and go for daily walks.

         The following month, on October 27, 2011, Claimant presented to Robert Lowe, M.D., with complaints of pain from her “neck to her tail, ” causing her legs to give out and go numb. (Tr. at 369-71). Claimant described the back pain as radiating into the neck area, bilateral hips and legs along with numbness and tingling in the arms, legs, and feet. She also complained of bowel and bladder issues, as well as urinary tract infections. Claimant reported having ongoing back pain for several years that began when she injured her back lifting a 15-pound bucket at work. Claimant denied dizziness, abdominal pain, blurred vision, or bleeding. A review of systems was determined to be within normal limits.

         On examination, Claimant measured five feet, seven inches in height and weighed two hundred twenty-eight pounds. She was pale and walked with a limp, but could bear weight equally. Claimant flexed forward eighty degrees and could lateral bend twenty-five degrees; however, her extension was stiff. Her reflexes appeared intact at the knees and ankles, and her toe extensors were strong. Straight leg raise while seated measured ninety degrees bilaterally, and while supine, measured eighty degrees bilaterally. Sensation appeared less in the right leg; however, there was no dermatome pattern. Dr. Lowe thought he would find a stocking pattern, which he did, but to a lesser degree. There were no real trigger points located in Claimant's back. Her thigh and calve circumferences were symmetrical. Dr. Lowe opined that Claimant had L5-S1 25% spondylolisthesis. Although Dr. Lowe could not visualize this on plain x-rays, he observed that Claimant moved at ¶ 5-S1 and the disc heights were subtly increased in height, which was compatible with a potential mal-absorption syndrome that could explain her head to toe pain. Claimant was diagnosed with spondylolisthesis and low back pain. For treatment, Dr. Lowe prescribed a lumbosacral support brace, as he did not elicit any physical findings that warranted surgical intervention. Dr. Lowe felt a positive Knudsen sign at ¶ 5-S1 with disc degeneration and narrowing of the disc might also be a source of the back pain. Dr. Lowe did not believe Claimant's back pain would be altered by more conditioning; however, he would consider physical therapy for Claimant in the future.

         Claimant returned to Dr. Lowe on November 17, 2011. (Tr. at 367-68). Laboratory reports revealed that Claimant had a low level of Vitamin D. Claimant continued to complain of constant neck and back pain causing her legs to give out and go numb. Claimant also reported bowel issues; however, she had never received medical treatment for this, and a review of systems was negative for abdominal pain, nausea, or vomiting. Claimant's gastrointestinal system was noted to be within normal limits. Her physical examination was also normal. Claimant was prescribed Vitamin D and instructed to return in six months.

         Claimant presented to Sanjay Masilamani, M.D., on December 5, 2011 with complaints of anxiety and depression. (Tr. at 391-96). Claimant reported that her psychological symptoms began in her twenties and were related to family issues. She had never seen a psychiatrist, but she had previously received counseling. Claimant began drinking alcohol in her teens, causing her to build up a tolerance; however, Claimant reported that she no longer drank alcohol and had not done so for over three years. Claimant described her symptoms as mania, not being able to sleep, elevated energy, racing thoughts, irritability, fatigue, muscle aches, and agoraphobia. Claimant was being prescribed Celexa and hydroxyzine, noting these medications were helpful, but her insurance no longer covered them. On examination, Claimant was cooperative with good eye contact, normal speech, and no evidence of psychomotor agitation. She showed logical and coherent thought processes. Her affect appeared restricted; her mood was irritable and depressed; and her judgment and insight were limited. Claimant was assessed with bipolar disorder, type 1; generalized anxiety disorder; full, sustained remission of alcohol abuse; and agoraphobia without history of panic disorder. Dr. Masilamani felt that borderline intellectual functioning versus mental retardation should also be ruled out. He gave Claimant a Global Assessment of Functioning (“GAF”) score of 65-70.[4] He documented that Claimant was having a difficult time dealing with the loss of family members, but she was not suicidal at the time. Dr. Masilamani talked to Claimant about following up with a therapist in addition to providing her with a prescription for Lamictal. Claimant was advised to return in one month.

         Claimant presented to Dr. Masilamani on January 16, 2012 reporting no side effects from her medication. Since increasing her dosage of Lamictal, her irritability had slightly improved. (Tr. at 389-90). Dr. Masilamani recorded that Claimant was wearing a back brace, was cooperative, and showed no sign of psychomotor agitation. However, her mood was “jumpy” and her affect was slightly restricted. Claimant did say she had met with a therapist, Jessica Williams, and felt it was very helpful. Claimant demonstrated normal speech, logical thought processes, and fair insight and judgment. Dr. Masilamani increased the dosage of Lamictal in addition to scheduling Claimant for more therapy with Ms. Williams. As Claimant complained of sleep issues, her hydroxyzine dosage was increased.

         Claimant was examined by Ben Edwards, M.D., on February 1, 2012, for complaints of pelvic discomfort. (Tr. at 320-24). On a review of symptoms, Claimant denied having fatigue, malaise, headache, gastrointestinal issues, genitourinary complaints, endocrine abnormalities, or psychological distress. (Tr. at 322). Her physical examination was entirely normal. Claimant weighed two hundred forty-seven pounds, and her blood pressure was 122/80. Claimant displayed a euthymic mood, appearing alert and in no distress. Upon examination, Claimant had no abdominal tenderness; her bladder, urethra and uterus were normal. Claimant was assessed with candida albecans vaginitis, vaginal candidiasis, and contraceptive management. Claimant was provided prescriptions for Enpresse and Fluconazole.

         On February 16, 2012, Claimant returned to Dr. Masilamani reporting that the increase in Lamictal helped stabilize her mood. (Tr. at 386-88). Overall Claimant believed she was “functioning better.” Her issues with sleep were improved with hydroxyzine. Claimant described a slightly depressed mood, which she attributed to a recent loss of family members, although she reported she was coping well. Claimant had met with Ms. Williams and used some of the therapist's ideas of how to change things at Claimant's home, such as re-arranging the furniture in her and her daughter's rooms. Claimant's assessment was unchanged, and her medication regimen remained the same, as it appeared to be controlling her symptoms.

         On March 14, 2012, Claimant presented to St. Mary's Medical Center after having been assaulted by a family member. (Tr. at 338-47). Claimant complained of moderate pain caused by blows to her head. Although she did not lose consciousness, Claimant felt “dazed.” In addition, Claimant complained of a headache and nausea, but no numbness, loss of vision, dizziness, hearing loss, chest pain, difficulty breathing, weakness, abdominal pain or vomiting. On examination, her right temple was moderately tender and mildly swollen; however, there was no Battle's sign and no “raccoon” eyes. Claimant's neck was supple, non-tender, and displayed normal range of motion. Claimant had mild, soft tissue tenderness in the right and left lower lumbar area. The remainder of her examination was unremarkable. A CT scan of Claimant's head revealed a nearly total opacified left maxillary sinus, but no traumatic findings were seen. (Tr. at 344). An x-ray of the lumbar spine revealed an L5 spondylolysis with grade 1 spondylolistheses at ¶ 5-S1. This finding had not changed since September 2009 when a prior film was performed. The remainder of the findings were unremarkable. (Tr. at 343). Claimant was assessed with minor closed head injury resulting from a physical assault and sinusitis. Claimant was provided ibuprofen, Augmentin, and Ultram, advised to apply ice to the head injury, and told to drink fluids. Claimant was discharged in good condition.

         Claimant returned to Holzer Clinic on March 29, 2012 for evaluation of her sinuses. (Tr. at 358-61). She complained of nasal congestion, postnasal drainage, frontal headache, and pain in both ears. Claimant also reported decreased bilateral hearing as well as yellow drainage noting the pain was constant and dull both inside and behind her ears. On examination, Claimant presented with normal mood and affect. There was sinus tenderness upon palpation in the bilateral maxillary regions. Otoscopy of the ears showed normal auditory canals and tympanic membranes with ETD bilaterally. Claimant was assessed with postnasal drip, Eustachian tube dysfunction, allergic rhinitis, laryngitis, and pharyngitis. Claimant was provided prescriptions for Zithromax, Astepro, and a Medrol Pak, in addition to a recommendation of daily use of nasal wash and Alkalol.

         On April 9, 2012, Claimant returned to Dr. Masilamani. (Tr. at 384-85). Claimant told Dr. Masilamani that she felt depressed, rating her depression as four out of ten but overall, she continued to “function fair.” Claimant expressed having difficulties with her sister and complained that she could not visit her mother's house as often because of her sister's presence there. She complained of headaches and reported to Dr. Masilamani that she had been involved in a physical altercation with her sister. Claimant was sleeping more, but her appetite was decreased. On examination, Claimant made good eye contact, was cooperative, and had no psychomotor agitation. Her mood was somewhat depressed, and her affect was restricted. Claimant had limited judgment and insight; however, her thought processes were logical, linear, and coherent. Claimant was assessed with bipolar disorder, type 1; ...

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