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Spurlock v. Berryhill

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

April 2, 2018

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


          Chery A. Eifert, United States Magistrate 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 Robert C. Chambers, 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. 9, 10).

         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 March 16, 2012, Plaintiff Lester Lee Spurlock (“Claimant”), completed applications for DIB and SSI, alleging a disability onset date of July 2, 2009[1] due to “back injury can't sit or stand, walk for long periods; high blood pressure; problem with throat; carpal tunnel in hands; tendonitis shoulders; and heart problems.” (Tr. at 284-92, 330). The Social Security Administration (“SSA”) denied Claimant's applications initially and upon reconsideration. (Tr. at 156-61, 166-68, 173-75). Claimant filed a request for an administrative hearing, which was held on April 3, 2014 before the Honorable Edward E. Evans, Administrative Law Judge. (Tr. at 34-83). By written decision dated April 30, 2014, the ALJ found that Claimant was not disabled as defined in the Social Security Act. (Tr. at 130-51). Claimant filed a request for review with the Appeals Council and the case was remanded by order dated December 1, 2015. (Tr. at 152-55). On remand, the case was assigned to the Honorable Robert B. Bowling, Administrative Law Judge (the “ALJ”). Claimant submitted additional evidence and a hearing was held on July 26, 2016. (Tr. at 84-125). By written decision dated August 19, 2016, the ALJ found that Claimant was not disabled as defined in the Social Security Act. (Tr. at 15-33). The ALJ's decision became the final decision of the Commissioner on February 2, 2017, when the Appeals Council denied Claimant's request for review. (Tr. at 1-6).

         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. 7, 8). Claimant then filed a Brief in Support of Judgment on the Pleadings. (ECF No. 9). In response, the Commissioner filed a Brief in Support of Defendant's Decision. (ECF No. 10). Consequently, the matter is fully briefed and ready for resolution.

         II. Claimant's Background

         Claimant was 37 years old at the time of his alleged onset of disability and 44 years old at the time of the ALJ's decision. Claimant completed the ninth grade in high school and received his commercial driver's license and herbicide applicator license, which he renewed every two years. (Tr. at 47, 91). He previously worked as an herbicide sprayer, electrician helper, and garbage truck driver and collector. (Tr. at 76).

         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 disability insurance benefits through December 31, 2015. (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 the alleged onset date, July 2, 2009. (Tr. at 18, Finding No. 2). At the second step of the evaluation, the ALJ found that Claimant had the following severe impairments: “disorders of the spine and peripheral neuropathy of [the] left leg.” (Tr. at 18, 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 21, Finding No. 4). Accordingly, the ALJ determined that Claimant possessed:

[T]he residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except stand and walk six hours in an eight hour workday; sit six hours in an eight hour workday; needs a sit or stand option on a 30 minute basis; never climb ladders, ropes, or scaffolds; occasionally climb ramps and stairs; occasionally stoop, kneel, crouch, and crawl; should avoid concentrated exposure to extreme cold and hazards such as the use of moving machinery, and unprotected heights.

         (Tr. at 21, Finding No. 5). At the fourth step, the ALJ found that Claimant was unable to perform any past relevant work. (Tr. at 25, Finding No. 6). Under the fifth and final inquiry, the ALJ reviewed Claimant's past work experience, age, and education in combination with his RFC to determine his ability to engage in substantial gainful activity. (Tr. at 26, Finding Nos. 7-10). The ALJ considered that (1) Claimant was born in 1971 and was defined as a younger individual on the alleged disability onset date; (2) he had a limited education and could communicate in English; and (3) transferability of job skills was not material to the disability determination because the Medical-Vocational Rules supported a finding that Claimant was “not disabled, ” regardless of whether his job skills were transferable. (Tr. at 26, Finding Nos. 7-9). 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 26-27, Finding No. 10), including work as a routing clerk or price marker at the light exertional level or an inspector at the sedentary exertional level. (Tr. at 26-27). Therefore, the ALJ concluded that Claimant was not disabled as defined in the Social Security Act, and thus, he was not entitled to benefits. (Tr. at 27, Finding No. 11).

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

         Claimant argues that the Commissioner's decision is unsupported by substantial evidence because the ALJ failed to follow the directive of the Appeals Council to clarify on remand the severity and functional impacts of his back impairment and depression. (ECF No. 9). Claimant states that the ALJ's findings that his back impairment was mild and required only conservative treatment and his depression was not a medically determinable condition failed to properly evaluate the new medical evidence that he submitted and were contrary to the totality of the record. Further, Claimant argues that the ALJ erred in not obtaining additional medical information from experts, such as consultative examinations or medical interrogatories, which Claimant contends were “envisioned” by the Appeals Council's remand order.

         In response, the Commissioner argues that the ALJ properly evaluated Claimant's back impairment and depression and weighed the opinion evidence. (ECF No. 10). Further, the Commissioner asserts that Claimant's argument that the Appeals Council's order “envisioned” that the ALJ would obtain an additional consultative examination or medical interrogatories is belied by the fact that the Appeals Council did not expressly order such additional evidence and Claimant raised this issue in his second appeal to the Appeals Council and the Appeals Council denied his request for review. (Id.).

         V. Relevant Evidence

         The undersigned has considered all of the evidence of record, including documentation of medical examinations, treatment, evaluations, and statements. The information most relevant to Claimant's challenge is summarized as follows.

         A. Treatment Records

         On April 24, 2007, Claimant presented to the Now Care Center at Huntington Internal Medicine Group (“HIMG”) complaining of low back pain. (Tr. at 742). He related that he did not have a primary care provider and initially hurt his back by lifting something heavy while working in June 2006. (Id.). He stated that he did not have any issues until he recently went to St. Mary's Medical Center (“SMMC”) and was determined to have a collapsed vertebrae. (Id.). He was given medications and a referral to an orthopedist. Claimant reported that he took the medications prescribed by SMMC and felt better; therefore, he did not immediately follow up with Scott Orthopedics. By the time he decided to go, the referral was no longer valid. (Id.). Claimant was prescribed Motrin and Flexeril at HIMG and again referred to Scott Orthopedics. (Tr. at 743).

         On November 19, 2008, Claimant presented as a new patient to Myron A. Lewis, M.D., at HIMG. (Tr. at 478). Claimant stated that he worked at Asplundh, [2] which required a lot of heavy lifting. (Id.). Claimant reported that he injured his thoracic spine two or three years earlier lifting a heavy object and more recently injured his low back. He now had low back pain radiating into his left thigh. (Id.). Dr. Lewis diagnosed Claimant with lumbar radiculitis, scheduled him for a MRI, and prescribed a Medrol Dosepak and Lortab. (Tr. at 479). Claimant's MRI was taken on November 25, 2008. (Tr. at 480-81). It showed some degenerative changes in Claimant's lower dorsal and lumbar spine, which were most ...

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