United States District Court, S.D. West Virginia, Huntington Division
PROPOSED FINDINGS AND RECOMMENDATIONS
A. Eifert, Judge
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.
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).
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.
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).
Summary of ALJ's Decision
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).
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.
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.
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
[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).
Claimant's Challenge to the Commissioner's
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).
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.
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.
the undersigned has reviewed all of the evidence of record,
only the evidence most relevant to the disputed issues is
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).
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
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
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.
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.
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.
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 ...