United States District Court, S.D. West Virginia, Charleston 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
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 John T.
Copenhaver, Jr., 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, requesting judgment on the pleadings,
and the Commissioner's brief in support of her decision,
requesting judgment in her favor. (ECF Nos. 17, 18).
undersigned has fully considered the evidence and the
arguments of counsel. For the following reasons, the
undersigned RECOMMENDS that Plaintiff's
request for judgment on the pleadings be
DENIED; the Commissioner's request for
judgment on the pleadings be GRANTED; and
this case be DISMISSED and removed from the
docket of the Court.
August 27, 2013 and January 18, 2014, respectively, Plaintiff
Stanley Thomas Lovejoy, (“Claimant”), filed
applications for SSI and DIB, (Tr. at 224, 231), alleging a
disability onset date of March 1, 2012,  due to “leg
problems, left arm problems, [and] high blood
pressure.” (Tr. at 258). The Social Security
Administration (“SSA”) denied Claimant's
applications initially and upon reconsideration. (Tr. at
115-24, 129-34). Claimant then filed a request for an
administrative hearing, (Tr. at 135), which was held on
January 28, 2016, before the Honorable Tierney Carlos,
Administrative Law Judge (“ALJ”). (Tr. at 45-80).
By written decision dated March 21, 2016, the ALJ found that
Claimant was not disabled as defined by the Social Security
Act. (Tr. at 29-38). The ALJ's decision became the final
decision of the Commissioner on March 16, 2017, when the
Appeals Council denied Claimant's request for review.
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 the
Administrative Proceedings. (ECF Nos. 9, 10). Claimant filed
a Brief in Support of Judgment on the Pleadings, (ECF No.
17), and the Commissioner submitted a Brief in Support of
Defendant's Decision, (ECF No. 18), to which Claimant
filed a reply. (ECF No. 19). Consequently, the matter is
fully briefed and ready for resolution.
was 50 years old at the time he completed the instant
applications for benefits, and 52 years old on the date of
the ALJ's decision. (Tr. at 29, 58, 224, 231). Claimant
left school in the eleventh grade, but subsequently obtained
a mining certification. (Tr. at 59, 259). He communicates in
English and has prior work experience as a laborer and as a
roof bolter in the coal mining industry. (Tr. at 59-61, 259).
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, 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).
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.
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).
case, the ALJ determined as a preliminary matter that
Claimant met the insured status for disability insurance
benefits through June 30, 2015. (Tr. at 31, Finding No. 1).
At the first step of the sequential evaluation, the ALJ
confirmed that Claimant had not engaged in substantial
gainful activity since March 1, 2012, the alleged disability
onset date. (Tr. at 31, Finding No. 2). The ALJ explained
that Claimant had worked after March 1, 2012, but his wages
did not rise to the level necessary to constitute substantial
gainful activity. At the second step of the evaluation, the
ALJ found that Claimant had the following severe impairments:
“degenerative disc disease of the cervical and thoracic
spine, degenerative joint disease of the left knee, and
osteoarthritis of the right knee.” (Tr. at 31-32,
Finding No. 3). The ALJ also considered Claimant's
reports of left shoulder impairment and hypertension, but
found that these conditions were non-severe. Furthermore, the
ALJ evaluated Claimant's report of depression, noting
that this condition was not a medically determinable
impairment, as Claimant had not been diagnosed with
depression and did not testify to having mental health
issues. (Tr. at 32).
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. (Id. at Finding No. 4). Accordingly, he
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 the
claimant could occasionally climb ramps and stairs, balance,
stoop, kneel, crouch, and crawl. The claimant could never
climb ladders, ropes, or scaffolds.
(Tr. at 32-36, Finding No. 5). At the fourth step, the ALJ
determined that Claimant was unable to perform his past
relevant work. (Tr. at 36, Finding No. 6). Therefore, 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 36-37, Finding Nos. 7-10). The ALJ
considered that (1) Claimant was born in 1963, and was 49
years old on the alleged date of disability, which placed him
in the category of an individual closely approaching advanced
age; (2) he had a limited education and could communicate in
English; and (3) transferability of job skills was not an
issue because the Medical-Vocational Rules (the
“Grids”) supported a finding that Claimant was
“not disabled, ” regardless of his transferable
job skills. (Tr. at 36, Finding Nos. 7-9). Taking into
account 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 36-37, Finding No. 10), including
work as a product inspector, laundry worker, and price marker
at the unskilled, light exertional level. (Tr. at 37).
Accordingly, the ALJ concluded that Claimant was not disabled
as defined in the Social Security Act and was not entitled to
benefits. (Tr. at 37-38, Finding No. 11).
Claimant's Challenges to the Commissioner's
asserts that the ALJ erred in two respects. First, Claimant
argues that the ALJ failed to adequately address
Claimant's reliance on a cane to stand and walk.
According to Claimant, the record contains substantial
evidence demonstrating his need for a cane. Despite this
evidence, the ALJ never explicitly discussed the issue and
never provided a rationale for rejecting Claimant's
contention that he relied on a cane. Claimant points to the
vocational expert's testimony stating that Claimant would
be unable to perform light exertional work if he required a
cane. Claimant argues that if he is precluded from light
level work, his other vocational factors mandate a finding of
“disabled” under the Grids. For his second
challenge to the decision, Claimant asserts that the ALJ
erred by failing to give controlling weight to the RFC
opinions expressed by his treating physician, Dr. Ira Morris.
response, the Commissioner argues that Claimant is mistaken
in his contention that the ALJ did not consider
Claimant's alleged use of a cane. The Commissioner notes
that the ALJ expressly commented on Claimant's statement
that he needed a cane, and the ALJ made other references to
evidence discussing hand-held assistive devices. However, the
ALJ clearly was not persuaded that Claimant required a cane
to walk and stand, because the evidence did not corroborate
such a scenario. With respect to Dr. Morris's opinions,
the Commissioner cites to the applicable rules and
regulations and maintains that the ALJ followed them to the
letter. The Commissioner indicates that the ALJ provide
multiple reasons for rejecting Dr. Morris's opinions, not
the least of which was the inconsistency between
Claimant's relatively mundane treatment notes and Dr.
Morris's extreme RFC limitations.
Relevant Medical Evidence
undersigned has reviewed all of the evidence before the
Court, including the records of Claimant's health care
examinations, evaluations, and treatment. The relevant
information is summarized as follows:
April 23, 2011, Claimant presented to Boone Memorial
Hospital's emergency room complaining of knee pain. (Tr.
at 413-17). He reported twisting his left knee at work while
carrying a can of oil. A physical examination was performed
and was negative, except for left knee effusion. An x-ray of
Claimant's left knee revealed no evidence of acute
fracture or malalignment. Claimant was diagnosed with left
knee strain; given prescriptions for Naprosyn, a Medrol dose
pak, and Lortab; and was discharged in good condition.
22, 2011, Claimant returned to Boone Memorial Hospital with
complaints of global left knee pain and swelling secondary to
an twisting injury sustained while at work. (Tr. at 406-12).
A physical examination revealed left knee pain and
tenderness. X-rays of Claimant's left knee showed a
cystic lesion on the superior patella; however, no acute
fracture or dislocation was seen. The cyst was well
circumscribed and appeared to be a benign subchondral cyst.
(Tr. at 410). Claimant was diagnosed with left knee strain,
provided prescriptions for Vicodin and Naprosyn, and
discharged home in good condition.
September 1, 2011, Claimant was examined by Nurse
Practitioner (“NP”) Melanie Harper-Allen at Boone
Memorial Hospital's Rural Health Clinic
(“BMHRHC”). (Tr. at 332-33). Claimant complained
of chronic low back pain and right leg pain that had been
present for years. The low back pain was getting
progressively worse, and the leg pain radiated down his leg.
Claimant reported that he was injured in a mining accident
several years earlier and was later “run over by a dump
truck.” (Tr. at 332). Claimant stated that he now
possessed a medical card and wanted an MRI. On examination,
Claimant weighed two hundred fifty pounds, with a height of
six feet, two inches, and had a blood pressure of 148/80. He
had no bowel or bladder loss. NP Harper-Allen assessed
Claimant with lumbosacral neuritis and lumbago. She
prescribed Daypro, Ultram, and Neurontin and ordered x-rays
of Claimant's lumbar spine. (Tr. at 397-98). The x-rays
showed mild to moderate degenerative changes, most noticeable
at ¶ 3-4, but also involving L4 through S1 and T10-12.
In addition, there was possible mild dextroscoliosis of the
lumbar spine, but no evidence of abnormal alignment or
October 6, 2011, Claimant returned to BMHRHC with complaints
of persistent low back pain that was not relieved by the
prescribed medication. (Tr. at 334-35). Claimant also
complained of pain in his right lower extremity. An
examination by Physician's Assistant (“PA”)
Tarah Hagar revealed no somatic dysfunction, pain, or
arthritic changes. Claimant's extremities were negative
for edema, cyanosis, clubbing, and deformities, and his
distal pulses measured �. PA Hagar assessed Claimant with
lumbago and provided prescriptions for Daypro, Neurontin,
Motrin, Prednisone, and Ultram.
October 24, 2011, Claimant presented to Dr. Ira Morris at
Wharton Medical Center with complaints of leg cramps that
were worse in the right leg. (Tr. at 469). Claimant reported
that he had not been getting regular medical care, but
treated with another physician in the past, who prescribed
Neurontin, and this medication was helpful in reducing the
symptoms. Dr. Morris conducted a review of systems, which was
negative except for leg cramps. Claimant's physical
examination findings were normal. Dr. Morris was unsure of
the cause of Claimant's cramps, so he ordered various
diagnostic studies and prescribed Neurontin. (Tr. at 471).
March 16, 2012, Claimant returned to Dr. Morris after
suffering a back and upper leg strain at work the previous
night. (Tr. at 472). Claimant stated that he needed “a
night off work.” (Id.). Claimant's lumbar
spine was tender to palpation at ¶ 5, and he had a
positive straight leg raising test bilaterally. Claimant was
given a prescription of Robaxin.
presented to Boone Memorial Hospital's emergency room on
April 12, 2012 with complaints of right leg pain due to a
work injury that occurred two weeks earlier. (Tr. at 387-96).
Claimant added that he had twisted his right leg earlier in
the day, which had increased his leg pain. Claimant was
ambulatory and his physical examination was largely normal,
although he had back tenderness and decreased range of
motion, tenderness to internal rotation, and decreased
function of the right leg. X-rays of Claimant's hip,
femur, and back were ordered. (Tr. at 391-92). The x-rays of
his hip showed mild enthesopathic change (a disorder of
muscle or ligament); an incidental benign primary bone tumor
involving the proximal aspect of the right femur that was
probably not of clinical significance; and no evidence of
acute fractures, dislocations, malalignment, or bony
abnormalities. X-rays of the right femur revealed a 4mm
radiopaque foreign body proximal to the mid right thigh, but
no evidence of acute fracture or malalignment. X-rays of
Claimant's lumbar spine were negative for acute fractures
or malalignment, but showed moderate degenerative changes at
¶ 3-S1 and a transitional vertebra at ¶ 5. Claimant
was diagnosed with lumbar and groin strain, given
prescriptions and a three-day work excuse, and was discharged
in fair condition.
returned to Boone Memorial Hospital's emergency room on
May 1, 2012 complaining of right upper leg pain. (Tr. at
384-86). Claimant reported that he had been injured at work
two weeks earlier, came to the emergency room, and was
referred to a specialist, but had not yet seen the
specialist. Claimant denied having trouble weight-bearing,
and his physical examination was unremarkable. He was
diagnosed with lumbar and groin strain; provided with
prescriptions for Motrin, Flexeril, and Lortab; and given an
excuse advising him to stay off work for two days.
19, 2012, Claimant presented to Boone Memorial Hospital's
emergency room for syncopal episodes, weakness, and
lightheadedness that occurred the prior day. (Tr. at 374-83).
Claimant surmised that his symptoms were caused by
hypertension, indicating that he had taken blood pressure
medication provided by a friend. Claimant's physical
examination was unremarkable, except for low blood pressure,
and he appeared to be in no acute distress. Claimant was
“talking to all nurses, asking questions, very
talkative.” (Tr. at 375). An EKG reflected a borderline
left axis deviation, and a tilt table test was positive. A CT
scan of Claimant's head and brain showed a normal brain
and skull, but moderate sinusitis in the right sphenoid
sinus. The emergency room physician recommended admission to
the hospital for further work-up; however, Claimant declined
and asked to be discharged. He was diagnosed with hypotension
and weakness and was released in fair, but stable, condition.
Claimant was instructed to see his primary care physician.
9, 2012, Claimant was again seen in the emergency room at
Boone Memorial Hospital for complaints of left shoulder pain.
(Tr. at 368-73). Claimant described rolling off a bench onto
his left shoulder. A physical examination showed good range
of motion without any obvious signs of injury. Claimant's
neurological examination was normal, and he had no weakness
of the extremities. The hospital records document that
Claimant was under arrest at the time of the visit and
refused to have an x-ray. Accordingly, he was discharged to
police custody in good condition.
following month, on August 4, 2012, Claimant returned to
Boone Memorial Hospital's emergency room complaining of
chronic pain in the right leg and left arm. (Tr. at 362-67).
A physical examination revealed a mass in the left mid
humerus. However, Claimant's neurovascular examination
was normal, and he had no deformity, swelling, or range of
motion deficit. The emergency room staff noted that Claimant
had been in the emergency room on “several occasions
but does not follow-up with [recommended] specialist.”
(Tr. at 364). Claimant was diagnosed with chronic pain and
bicep tendon rupture. He was discharged in good condition.
January 30, 2013, Claimant presented to Sriramloo Kesari,
M.D., for Suboxone treatment. (Tr. at 420-21). Claimant
traced his drug use history to 1995. He reported having been
arrested in the past and charged with delivery of a
controlled substance, for which he was placed on probation.
Claimant admitted that he started “looking for a doctor
to supply his drug habit” and “doctor
shopped” to get medications. (Tr. at 420). Claimant
reported that, other than his drug habit, “he [was] a
healthy man.” (Id.). Claimant advised that he
needed to continue taking Suboxone, because without it, he
would not be able to do his daily work at home or on the job.
He was administered a toxicology screening test, which was
negative for all substances except Suboxone, and his physical
examination was unremarkable. Claimant was diagnosed with
substance dependence and provided an induction of Suboxone.
He was advised to ...