United States District Court, S.D. West Virginia, Huntington Division
PROPOSED FINDINGS AND RECOMMENDATIONS
A. EIFERT, UNITED STATES MAGISTRATE JUDGE
action seeks a review of the decision of the Commissioner of
the Social Security Administration (hereinafter
âCommissionerâ) denying Plaintiff's applications for a
period of disability and disability insurance benefits
(âDIBâ) and supplemental security income (âSSIâ) under Titles
II and XVI of the Social Security Act, 42 U.S.C. Â§Â§ 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. Â§
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).
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
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).
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.
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,
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).
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).
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).
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).
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).
Claimant's Challenge to the Commissioner's
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).
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
undersigned has reviewed all of the evidence before the
Court. The following evidence is most relevant to the issues
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).
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 ...