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Maynard v. Berryhill

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

April 24, 2018

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


          Cheryl A. Eifert, Judge

         This action seeks a review of the decision of the Commissioner of the Social Security Administration (hereinafter “Commissioner”) denying Plaintiff's application for a period of disability and disability insurance benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 401-433. 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 the parties' motions for judgment on the pleadings as articulated in their briefs. (ECF Nos. 7, 10). For the following reasons, the undersigned respectfully RECOMMENDS that the presiding District Judge GRANT Defendant's Motion for Judgment on the Pleadings, (ECF No. 10); DENY Plaintiff's Motion for Judgment on the Pleadings, (ECF No. 7); AFFIRM the final decision of the Commissioner; and DISMISS this action from the docket of the Court.

         I. Procedural History

         On November 27, 2013, Plaintiff, Harvey Maynard (“Claimant”), completed an application for DIB, alleging a disability onset date of October 25, 2013, due to “neck problems, osteoarthritis [of the] knees, back problems, bursitis of right knee, hiatal hernia, bilateral carpal tunnel syndrome, epicondylitis, rapid heartbeat, gerd [Gastroesophageal Reflux Disease, “GERD”], shortness of breath, hearing loss, tennis elbow in right elbow, high blood pressure [and] slight rupture in groin.” (Tr. at 190, 227). The Social Security Administration (“SSA”) denied Claimant's application initially and upon reconsideration. (Tr. at 109, 121). Claimant filed a request for an administrative hearing, which was held on October 9, 2015, before the Honorable Leslie Weyn, Administrative Law Judge (“ALJ”). (Tr. at 31-81). By written decision dated February 10, 2016, the ALJ found that while Claimant was not disabled prior to July 29, 2015, he became disabled on July 29, 2015 and remained disabled through the date of the decision. (Tr. at 9-21). The ALJ's decision became the final decision of the Commissioner on February 7, 2017, when the Appeals Council denied Claimant's request for review. (Tr. 1-3).

         Claimant timely filed the present civil action seeking judicial review pursuant to 42 U.S.C. § 405(g). (ECF No. 1). The Commissioner filed an Answer and a Transcript of the Administrative Proceedings. (ECF Nos. 5, 6). Both parties filed memoranda in support of judgment on the pleadings, (ECF Nos. 7, 10); consequently, the issues are fully briefed and ready for resolution.

         II. Claimant's Background

         Claimant was 55 years old at the time he filed the instant application for benefits, and 57 years old on the date of the ALJ's decision. (Tr. at 9, 39). He has a high school education and communicates in English. (Tr. at 226, 228). Claimant has prior relevant work experience as a carpenter and laborer. (Tr. at 45-49, 229).

         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, 774 (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. The first step in the sequence is determining whether a claimant is currently engaged in substantial gainful employment. Id. § 404.1520(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). 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). If the impairment does, then the claimant is found disabled and awarded benefits.

         However, if the impairment does not meet or equal a listed impairment, 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. § 404.1520(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). 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, as the fifth and 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. 20 C.F.R. § 404.1520(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).

         Here, the ALJ determined as a preliminary matter that Claimant met the insured status for disability insurance benefits through December 31, 2017. (Tr. at 11, Finding No. 1). At the first step of the sequential evaluation, the ALJ confirmed that Claimant had not engaged in substantial gainful activity since October 25, 2013, the date of the alleged onset of disability. (Id., Finding No. 2). At the second step of the evaluation, the ALJ found that Claimant had the following severe impairments: “degenerative disc disease, bilateral knee arthritis and cardiac dysrhythmias.” (Tr. at 11-12, Finding No. 3). The ALJ considered Claimant's other alleged impairments of hypertension, GERD, inguinal and hiatal hernias, tinnitus, migraine headaches, bilateral carpal tunnel syndrome, right elbow epicondylitis, shortness of breath, actinic keratosis and lentigo, but found them to be non-severe. (Tr. at 12-13, Finding No. 3). Under the third inquiry, the ALJ determined 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 13-14, Finding No. 4). Accordingly, the ALJ considered the evidence as a whole and concluded that prior to July 29, 2015, Claimant possessed:

[T]he residual functional capacity to perform medium work as defined in 20 CFR 404.1567(c) except he can occasionally climb ramps or stairs, never climb ladders, ropes or scaffolds, occasionally stoop, kneel, crouch or crawl, and should avoid concentrated exposure to vibration, moving machinery and unprotected heights.

(Tr. at 14-19, Finding No. 5). However, beginning on July 29, 2015, Claimant's RFC was reduced to light level exertional work with the same postural and environmental limitations listed above. (Tr. at 19-20, Finding No. 6). At the fourth step of the sequential process, the ALJ consulted with a vocational expert (“VE”) to assess Claimant's ability to perform past relevant work. The ALJ determined that prior to July 29, 2015, Claimant was capable of performing past relevant work as a supervisor/carpenter foreman, as this work did not require the performance of work-related activities precluded by Claimant's RFC. (Tr. 20, Finding No. 7). In contrast, beginning on July 29, 2015, the Claimant's reduction to light level work prevented him from performing the duties of a supervisor/carpenter foreman. (Tr. at 20-21, Finding No. 8). Therefore, the ALJ proceeded to the fifth and final inquiry to determine if there was other work that Claimant could perform despite his limitations. With input from the VE, the ALJ considered that (1) Claimant was an individual of advanced age on July 29, 2015; (2) he had at least a high school education and could communicate in English; and (3) the skills he acquired as carpenter would not transfer to any jobs at the light or sedentary exertional level. (Tr. at 21, Finding Nos. 9-11). The ALJ consulted the Medical-Vocational Guidelines and determined that, even if Claimant were capable of doing a full range of light work, Rule 202.06 directed a finding of “disabled.” (Id., Finding No. 12). Therefore, the ALJ found that Claimant was not disabled prior to July 29, 2015, but became disabled on July 29, 2015. (Tr. at 21-22, Finding No. 13).

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

         Claimant raises two challenges to the Commissioner's decision. First, he claims that the ALJ erred by failing to properly weigh the opinions of three medical sources, Dr. Gale-Dyer, Dr. Chaney, and Dr. Larry Perry. (ECF No. 7 at 9-11). According to Claimant, the ALJ rejected valid opinions related to Claimant's exertional limitations, which led the ALJ to incorrectly conclude that Claimant could perform medium level work prior to July 29, 2015. Second, Claimant asserts that the ALJ failed to adequately consider the combined effects of Claimant's impairments. (Id. at 12-13). Claimant contends that the “overwhelming and uncontradicted” medical evidence confirms that his combined impairments prevent him from working a full eight-hour day. (Id. at 13).

         In response, the Commissioner argues that the ALJ provided good reasons for rejecting the medical source opinions of Drs. Gale-Dyer, Chaney, and Perry. With respect to Dr. Gale-Dyer, the Commissioner claims that Dr. Gale-Dyer's opinions were contrary to his own medical findings; specifically, he opined that Claimant should not perform heavy lifting or postural activities, yet documented that Claimant had a full range of motion, normal joints, normal gait, normal muscle strength, and no obvious abnormalities. (ECF No. 10 at 14-15). Similarly, the Commissioner notes that Dr. Chaney's opinions, which were expressed on a check-box form without any accompanying explanation, were inconsistent with the findings of Claimant's other examiners and treaters. (Id. at 11-12). Lastly, the Commissioner points out that Dr. Larry Perry, a chiropractor, is not an acceptable medical source. Moreover, he only treated Claimant for spine-related complaints, which limited his knowledge of Claimant's other impairments. Lastly, Dr. Perry's opinions were contained on a check-box form, with little explanation or support. (Id. at 13-14). The Commissioner contends that, given the obvious weaknesses of the opinions offered by these three medical sources, the ALJ appropriately rejected them.

         As to the second challenge, the Commissioner disagrees with Claimant's contention that the ALJ failed to consider the synergistic effect of Claimant's impairments. The Commissioner asserts that the ALJ conducted a thorough RFC assessment, which included an analysis of the functional effects of each of Claimant's impairments. As a result, the RFC finding reflected all of the physical limitations flowing from Claimant's medical conditions. (Id. at 19-20).

         V. Relevant Evidence

         While the undersigned has reviewed all of the evidence of record, only the evidence most relevant to the disputed issues is summarized below:

         A. Treatment Records

         On August 23, 2013, Claimant was examined by Michael Kilkenny, M.D., at St. Mary's Family Care. (Tr. at 381-390). Claimant reported a history of dyspnea on exertion, with heart palpitations and chest pain, for the past two years that had gotten progressively worse. Claimant told Dr. Kilkenny that the chest pain seemed to occur when he was at rest as opposed to when he was at work, and although the pattern of episodes happened during rest, the symptoms seemed to be relieved with less exertion. Claimant also reported generalized muscle cramps, numbness in both hands, and diarrhea. (Tr. at 383). On examination, Claimant's heart rate and rhythm were normal; his lungs were clear; there was no edema noted; and his abdomen appeared normal. Dr. Kilkenny diagnosed Claimant with chest pain, palpitations, and dyspnea on exertion. Laboratory tests were ordered. An EKG was performed, which was normal. (Tr. at 387). Claimant was advised to modify his activities pending the results of a stress test. (Tr. at 384).

         Claimant was seen at St. Mary's Medical Center on September 11, 2013 to undergo an exercise electrocardiogram. (Tr. at 324-25, 378-79). Treadmill exercise testing and a bubble study revealed normal findings after maximum exercise, with normal left ventricular systolic function. Claimant denied chest pain during the testing, and the target heart rate was achieved. His stress EKG was normal; the baseline showed no regional wall motion abnormalities; and, at peak stress, there were no regional wall motion abnormalities. His estimated left ventricular ejection fraction ranged from 55% to 60%. He had no stress arrhythmias or conduction abnormalities.

         Claimant returned to Dr. Kilkenny on October 1, 2013, reporting an ongoing sensation of “heaviness” in his chest. He also complained of having two or three episodes of visual field loss and mild confusion, which lasted anywhere from “minutes to hours.” (Tr. at 395-98). Claimant admitted additional symptoms of chest pain, palpitations, shortness of breath, headache, and numbness. He informed Dr. Kilkenny that during a recent stress echocardiogram, he was told by the technician that he had a small hole in his heart; however, Dr. Kilkenny reviewed the stress echocardiogram report and noted that no such finding had been recorded. On examination, Claimant was alert and oriented. His heart rate and rhythm were normal, with no murmur. His lungs were clear to auscultation, and his gait and stance were normal. Dr. Kilkenny diagnosed Claimant with chest pain and transient ischemic attack. Dr. Kilkenny advised Claimant to continue his current medication (Famotidine) and referred him for a cardiology consultation.

         The following week, on October 8, Claimant was examined by Mark Studeny, M.D., a local cardiologist. (Tr. at 375-77). Claimant complained of constant chest pressure, shortness of breath, and a sensation that his heart was “racing” on exertion; however, his physical examination was unremarkable. Dr. Studeny diagnosed Claimant with shortness of breath, palpitations, and chest pain. He prescribed Metoprolol for Claimant and advised him to return in one month.

         Claimant was examined by Luis Bolano, M.D., on November 11, 2013 for complaints of pain, numbness, weakness, and tingling in both hands, right worse than left. (Tr. at 320-22). Claimant rated his pain as seven out of ten during the day and ten at night, indicating that the pain woke him up at night. Claimant added that driving or holding a coffee cup caused numbness in his hands. (Id.). He reported that for the past two years, he had experienced weakness of his grip (right hand dominant), weakness in his hand and forearm, and numbness and tingling in his right hand. A review of systems was described as “general health-benign, ” with no elicited complaints of chest pain, shortness of breath, abdominal pain, blurred or double vision. On examination, Claimant had a normal gait, and his peripheral pulses were normal bilaterally. Palpation of his right elbow elicited tenderness at the lateral epicondyle. Passive range of motion caused pain, and pain was also present with active resisted wrist extension. Claimant's long finger test produced posterior pain in the lateral epicondyle, and a tennis elbow test was positive. However, intrinsic function was normal and light touch sensation was intact. An inspection of Claimant's hands revealed positive Tinels carpal canal, Phalens, and compression carpal canal. Dr. Bolano diagnosed Claimant with carpal tunnel syndrome and lateral epicondylitis. Claimant received an injection of Kenalog and lidocaine in the lateral epicondyle right elbow. Dr. Bolano also scheduled right carpal tunnel release surgery.

         On November 12, 2013, Claimant was seen by Kyle Hegg, M.D., for complaints of bilateral knee pain, right knee worse than the left knee, with an occasional sensation that his legs were going to “give away.” (Tr. at 311-12, 318-19). Claimant also had difficulty squatting and rising from a seated position. Claimant stated that his knees had bothered him for approximately two years ago, but they were getting progressively worse. He indicated that Aleve was somewhat helpful in reducing his pain and stretching also helped lessen his symptoms. Claimant could not identify any factors that exacerbated the symptoms. Other than the knee symptoms, Claimant's review of systems was negative. He denied smoking and recreational drug use. Claimant stated that he lived with his wife and was retired from the carpenter's local union. On examination, Claimant appeared healthy, with a normal gait and symmetrical peripheral pulses. His knees had normal alignment with no evidence of effusion. A McMurray test was negative bilaterally, although Claimant had some tenderness on the right side during the testing. His knee ligaments were stable, and his neurologic examination was normal. X-rays were taken of Claimant's knees, which showed mild proximal patellar spurring, left greater than right; there also appeared to be questionable bilateral medial narrowing. Dr. Hegg diagnosed Claimant with osteoarthritis of the knees. Dr. Hegg recorded that both clinical and x-ray results showed arthritic changes, but no strong meniscal signs. Dr. Hegg discussed different treatment options with Claimant, including steroid injections, which Claimant opted to undergo. He was told to eat healthy, exercise, and follow up in six weeks.

         Claimant returned to Dr. Studeny on November 19, 2013 with complaints of dyspnea; however, he did not tire easily, nor did he have any dizziness, fainting, or chest pain. (Tr. at 372-74). Claimant told Dr. Studeny that he recently retired from the construction business, adding that throughout his career, he had been exposed to various chemical hazards. A physical examination was unremarkable. Dr. Studeny diagnosed Claimant with shortness of breath and palpitations. The palpitations improved with ...

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