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Nowlin v. Saul

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

October 22, 2019

RICK NOWLIN, o/b/o LINDA NOWLIN, Deceased, Plaintiff,
ANDREW M. SAUL, Commissioner of the Social Security Administration, Defendant.



         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 his favor. (ECF Nos. 15, 16).

         For the following reasons, the undersigned RECOMMENDS that the Court GRANT Plaintiff's motion for judgment on the pleadings to the extent that it requests remand of the Commissioner's decision pursuant to sentence four of 42 U.S.C. § 405(g); DENY Defendant's request to affirm the decision of the Commissioner; REVERSE the final decision of the Commissioner; REMAND this matter pursuant to sentence four of 42 U.S.C. § 405(g) for further administrative proceedings consistent with this PF&R; and DISMISS this case, with prejudice, and remove it from the docket of the Court.

         I. Procedural History

         In November 2015, Plaintiff Linda Joann Nowlin (“Claimant”) filed applications for DIB and SSI, alleging a disability onset date of October 1, 2015 due to acute pancreatitis, hand arthritis, depression, anxiety, high blood pressure, thyroid dysfunction, neck pain, and leg cramps. (Tr. at 212-21, 241). The Social Security Administration (“SSA”) denied Claimant's applications initially and upon reconsideration. (Tr. at 20). Thus, Claimant requested an administrative hearing on her applications for benefits. (Tr. at 53-54). However, Claimant died on January 5, 2018, three weeks before the administrative hearing was scheduled to take place. (Tr. at 234). Accordingly, Claimant's husband, Rick Nowlin (“Substitute Claimant”) was substituted as the party of interest. (Tr. at 201). An administrative hearing was held on January 29, 2018 before the Honorable Melinda Wells, Administrative Law Judge (the “ALJ”). (Tr. at 32-52). By written decision dated April 17, 2018, the ALJ found that Claimant was not disabled as defined by the Social Security Act. (Tr. at 17-31). The ALJ's decision became the final decision of the Commissioner on January 29, 2019 when the Appeals Council denied Claimant's request for review. (Tr. 1-8).

         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 the Administrative Proceedings. (ECF Nos. 8, 9). Claimant filed a Brief in Support of Judgment on the Pleadings, and the Commissioner filed a Brief in Support of Defendant's Decision. (ECF Nos. 15, 16). Consequently, the matter is fully briefed and ready for resolution.

         II. Claimant's Background

         Claimant was 56 years old on her alleged onset date and 59 years old when she died. (Tr. at 234). She completed the twelfth grade, communicated in English, and previously worked as a cook, kitchen helper, and delicatessen manager. (Tr. at 37-38, 49, 240, 242-43).

         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 or her findings. Second, the ALJ rates and documents the degree of functional limitation resulting from the impairment according to criteria specified in 20 C.F.R. §§ 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 four functional areas of understanding, remembering, or applying information; (2) interacting with others; (3) maintaining concentration, persistence, or pace; and (4) adapting or managing oneself 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, 2020. (Tr. at 22, 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 1, 2015, the alleged disability onset date. (Id., Finding No. 2). At the second step of the evaluation, the ALJ found that Claimant's hypertension was a severe impairment. (Tr. at 22-23, Finding No. 3). The ALJ considered Claimant's fecal incontinence, intermittent dysphagia, hypothyroidism, obesity, generalized osteoarthritis, and acute pancreatitis, but found that the impairments were non-severe. (Tr. at 23).

         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 23, Finding No. 4). Accordingly, the ALJ determined that Claimant possessed:

[T]he residual functional capacity to perform medium work as defined in 20 CFR 404.1567(c) and 416.967(c) except she could have occasionally climbed and crawled and frequently balanced, stooped, kneeled and crouched. She would have required to avoid more than occasional exposure to vibration, unprotected heights, and moving machinery. She would have required reasonable access to restroom facilities.

(Tr. at 23-25, Finding No. 5).

         At the fourth step, with the assistance of a vocational expert, the ALJ determined that Claimant was able to perform her past relevant work as a cook, kitchen helper, and deli manager. (Tr. at 25-26, Finding No. 6). Therefore, the ALJ found that Claimant was not disabled as defined in the Social Security Act. (Tr. at 26, Finding No. 7).

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

         Substitute Claimant raises four discernable challenges to the ALJ's decision. First, he argues that the ALJ did not mention or reference Claimant's depression and anxiety, including never determining whether the impairments were severe at step two of the sequential evaluation. (ECF No. 15 at 16). Second, he states that the ALJ “summarily ignored” the opinions of Claimant's treating and examining physicians, including: Jamie Stoner, A.P.R.N.; Leigh Levine, D.O.; Kip Beard, M.D.; Mary Chaney, M.A.; and Clifton Bolinger, M.D. (Id.). Third, Substitute Claimant argues that the ALJ failed to develop the evidence regarding Claimant's pancreatitis, osteoarthritis, thyroid problems, anxiety, depression, insomnia, neck pain, and hand arthritis. (ECF No. 15 at 15). Finally, Substitute Claimant asserts that the ALJ did not consider whether Claimant's combination of impairments met a listing at step three of the sequential evaluation. (Id. at 16-17).

         In response to Substitute Claimant's challenge regarding Claimant's mental impairments, the Commissioner acknowledges that the ALJ did not discuss the consultative mental examination. (ECF No. 16 at 12). However, the Commissioner argues that any error by the ALJ concerning Claimant's anxiety and depression was harmless because the record did not demonstrate that Claimant was significantly limited by a mental impairment. (Id.). Regarding the assertion that the ALJ “summarily ignored” opinions from Claimant's treating and examining providers, the Commissioner argues that the evidence that Substitute Claimant cited was treatment notes, not medical opinions about Claimant's ability to work. (Id. at 10). Further, the Commissioner asserts that the ALJ adequately developed the record and considered Claimant's impairments in combination. (Id. at 10-13).

         V. Relevant Evidence

         The undersigned has reviewed all of the evidence before the Court. The following evidence is most relevant to the issues in dispute.

         A. Treatment Records

         From January 31, 2014 to February 2, 2014, Claimant was treated for acute pancreatitis at St. Mary's Medical Center. (Tr. at 363, 499). When she saw her primary care provider, Nurse Practitioner Stoner, later that year on October 22, 2014, Claimant did not have abdominal tenderness, and her musculoskeletal and neurological examinations were normal. (Tr. at 373). However, Claimant had a depressed mood, and her affect was sad, tearful, and showed worry. (Id.). Nurse Practitioner Stoner diagnosed Claimant with, inter alia, generalized osteoarthritis in multiple sites, persistent insomnia, and generalized anxiety disorder. (Tr. at 374). She prescribed Klonopin in addition to Claimant's current medications of meloxicam and Cymbalta. (Tr. at 372, 374). On October 31, 2014, Nurse Practitioner Stoner additionally prescribed Ambien for Claimant's insomnia and Tramadol for Claimant's pain in her foot and toes. (Tr. at 377-78). Nurse Practitioner Stoner later added Neurontin to Claimant's medication regimen on January 13, 2015, due to Claimant's diagnosed neuropathy. (Tr. at 382-83). Claimant had a depressed and anxious mood with congruent affect at that appointment, although her thought processes and content were unimpaired. (Tr. at 382).

         On May 8, 2015, Claimant followed up with Nurse Practitioner Stoner regarding issues with her thyroid and other chronic conditions. (Tr. at 384). Claimant's mood was euthymic with normal affect, but Nurse Practitioner Stoner still assessed Claimant with persistent insomnia and generalized anxiety disorder. (Tr. at 385-86). Claimant was ...

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