United States District Court, S.D. West Virginia, Huntington Division
A. Eifert Judge.
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.
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 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. (Tr. at 11-25).
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
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).
Summary of ALJ's Findings
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.
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).
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
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).
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).
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.
Claimant's Challenges to the Commissioner's
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.
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).
Scope of Review
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
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).
Relevant Medical Records
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.
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.
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.
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
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.
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.
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
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. 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.
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.
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
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.
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.
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.
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;