United States District Court, W.D. Virginia, Danville Division
REPORT AND RECOMMENDATION
JOEL C. HOPPE, Magistrate Judge.
Plaintiff Francis Barnwell brought this action for review of the Commissioner of Social Security's ("Commissioner") decision denying his claim for disability insurance benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. §§ 401-434 (the "Act"). On appeal, Barnwell argues that the Commissioner erred in failing to find that he met the listing for chronic pulmonary insufficiency, discounting the opinion of his treating cardiologist Dr. Ajit Chauhan, M.D., and failing to consider the combined effects of his impairments in assessing his residual functional capacity ("RFC"). The Court has jurisdiction pursuant to 42 U.S.C. § 405(g) and this case is before the undersigned magistrate judge by referral pursuant to 28 U.S.C. § 636(b)(1)(B). After carefully reviewing the record, I find that the Commissioner's decision is not supported by substantial evidence and respectfully recommend that the case be remanded for further administrative proceedings.
I. Standard of Review
The Social Security Act authorizes this Court to review the Commissioner's final determination that a person is not entitled to disability benefits. See 42 U.S.C. § 405(g); see also Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). The Court's role, however, is limited-it may not "reweigh conflicting evidence, make credibility determinations, or substitute [its] judgment" for that of agency officials. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Instead, the Court asks only whether substantial evidence supports the ALJ's factual findings and whether the ALJ applied the correct legal standards. Meyer v. Astrue, 662 F.3d 700, 704 (4th Cir. 2011).
"Substantial evidence" means "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). It is "more than a mere scintilla" of evidence, " id., but not necessarily "a large or considerable amount of evidence, " Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence review takes into account the entire record, and not just the evidence cited by the ALJ. See Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984); see also Universal Camera Corp. v. NLRB, 340 U.S. 474, 487-89 (1951). Ultimately, this Court must affirm the ALJ's factual findings if "conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled.'" Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (per curiam) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996) (internal quotation marks omitted)). However, "[a] factual finding by the ALJ is not binding if it was reached by means of an improper standard or misapplication of the law." Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).
A person is "disabled" if he or she is unable engage in "any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or 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); 20 C.F.R. § 404.1505(a). Social Security ALJs follow a five-step process to determine whether an applicant is disabled. The ALJ asks, in sequence, whether the applicant: (1) is working; (2) has a severe impairment; (3) has an impairment that meets or equals an impairment listed in the Act's regulations; (4) can return to her past relevant work based on his or her residual functional capacity; and if not (5) whether he or she can perform other work. See 20 C.F.R. § 404.1520(a)(4); see also Heckler v. Campbell, 461 U.S. 458, 460-462 (1983). The applicant bears the burden of proof at steps one through four. Hancock, 667 F.3d at 472. At step five, the burden shifts to the agency to prove that the applicant is not disabled. See id.
II. Procedural History
Barnwell was born in 1963 (Administrative Record, hereinafter "R." 155), and during the relevant period was considered a "younger" individual under the Act. 20 C.F.R. § 404.1563(b), (c). He has a bachelor's degree and an associate's degree and has worked in several jobs including mental health counselor, case manager, and instructor. (R. 44-45, 185.) In his September 6, 2011, application for DIB, Barnwell alleges that he became disabled on August 25, 2011, due to congestive heart failure, diabetes, and pulmonary fibrosis. (R. 17, 176.) After rejecting Barnwell's application initially and on reconsideration (R. 61-87), the Commissioner convened a hearing before an Administrative Law Judge ("ALJ") at Barnwell's request on October 18, 2012. (R. 40-60.)
On November 30, 2012, the ALJ issued his final decision finding Barnwell not disabled and denying him benefits. (R. 17-39.) The ALJ found that Barnwell had severe chronic heart failure, chronic obstructive pulmonary disease ("COPD"), chronic renal failure, diabetes mellitus with peripheral neuropathy, obstructive sleep apnea, and obesity, but that these impairments did not meet or equal the severity of those listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 19-21.) The ALJ then found that Barnwell retained the capacity to perform sedentary work except that he could stand or walk for only two hours in an eight-hour work day; climb ramps and stairs, balance, stoop, kneel, crouch, and crawl only occasionally; and never climb ladders, ropes, or scaffolds, and he must avoid exposure to fumes, odors, dusts, gases, or poorly ventilated areas. (R. 21.) At step four, he found that Barnwell could perform his past relevant work as a mental health counselor as that job is generally performed in the national economy. (R. 32.) Alternatively, the ALJ found that Barnwell could perform other work existing in significant numbers in the national economy, specifically as a general office clerk and a records clerk. (R. 33.) Accordingly, he found Barnwell not disabled under the Act. (R. 34.)
A. Medical Records
On November 22, 2010, Barnwell saw Dr. Namrita Baveja, M.D., a nephrologist at Danville Urologic Clinic (R. 1247-48.) Dr. Baveja diagnosed stage 3 chronic kidney disease with glomerular filtration rate of 59. (R. 1248.) He noted that Barnwell's blood pressure was "not at goal, " and that although Barnwell "claim[ed] to have taken his medications this morning, " he admitted "having dietary indiscretion" and not checking his blood sugars daily. ( Id. ) Dr. Baveja emphasized with Barnwell his "risk factors of hypertension and diabetes and their control." ( Id. ) At a follow-up visit on February 15, 2011, Barnwell reported doing well, and Dr. Baveja noted that his creatinine level was stable. (R. 1243.) Dr. Baveja prescribed Tekamlo, discontinued Norvasc (amlodopine), and had Barnwell stop taking potassium gluconate. (R. 1242-43.)
Barnwell saw a neurologist for electromyography ("EMG") testing on December 20, 2010. (R. 328-29.) The exam was "consistent with severe motor sensory neuropathy most likely secondary to... long lasting [diabetes] since age 25." ( Id. )
Barnwell was admitted to the emergency room at Danville Regional Medical Center ("Danville RMC") on March 11, 2011, for recurring episodes of non-exertional chest pain. (R. 412.) His chest pain resolved on its own, and doctors discharged him the following day with a diagnosis of "chest pain, rule out for myocardial infarction" and chronic diastolic heart failure. (R. 412-13.) On March 13, Barnwell was admitted to the emergency room at Morehead Memorial Hospital with complaints of shortness of breath. (R. 252.) An echocardiogram showed "severe concentric LVH with an estimated [ejection fraction] of 55% to 60%" and a "left ventricular diastolic filling pattern consistent with elevated mean left atrial pressure." (R. 252.) A two-day LEXA cardiolite study showed "some equivocal left ventricular perfusion changes." (R. 252.) Barnwell showed no chest pain or electrocardiogram ("EKG") changes during the stress test portion of the study. ( Id. ) He was asymptomatic by March 15 and was discharged that day. (R. 252.) Doctors diagnosed "acute but mild congestive heart failure secondary to diastolic dysfunction." (R. 253.) They started Barnwell on Lopressor, but discontinued Actos "as it can aggravate congestive heart failure." ( Id. ) Barnwell saw Dr. Carl Winfield, M.D., his primary care physician, on March 17, 2011. (R. 290-91.) Dr. Winfield increased Barnwell's Lopressor and asked him to follow up in two months. ( Id. )
Barnwell first saw cardiologist Dr. Chauhan on March 31, 2011, on referral from Dr. Winfield for exertional and non-exertional chest pain. (R. 813-16.) Barnwell reported that he could walk half a mile without difficulty, gets chest pain after walking for an hour, and gets short of breath after walking a quarter mile or climbing a flight and a half of stairs. (R. 813.) Barnwell also complained of fatigue, orthopnea, and nocturia. ( Id. ) Dr. Chauhan noted that Barnwell had a normal echocardiogram and left heart catheterization in 2009, but that his current EKG showed left ventricular hypertrophy with ST segment changes. (R. 815.) Dr. Chauhan arranged for a stress cardiolite and an echocardiogram, gave Barnwell nitroglycerin, and advised him to "go straight to the ER with any further [chest pain]." ( Id. )
Barnwell followed up with Dr. Chauhan on April 14, 2011. (R. 817-19.) He complained of suffering chest pain at rest for 10 to 15 minutes daily, but reported he could walk a quarter of a mile three days per week without difficulty. ( Id. ) Barnwell also complained of orthopnea, swelling in his right foot and non-productive cough, and Dr. Chauhan noted that he showed "NYHA Class 1-2 symptoms." (R. 818.) Dr. Chauhan observed that Barnwell's b-type natriuretic peptide ("BNP") was high at 401, "most likely due to his chronic kidney disease." ( Id. ) Dr. Chauhan also indicated that Barnwell was non-stressable due to his risk for coronary artery disease. ( Id. ) An echocardiogram on April 28, 2011, showed massive left ventricular hypertrophy, trace mitral regurgitation, top normal right ventricular size, and ejection fraction of 55-60%. (R. 833.)
Barnwell saw pulmonologist Dr. Thomas O'Neill, M.D., on May 12, 2011, for shortness of breath that had increased significantly over the past four months. (R. 763-65.) A chest x-ray was "basically normal" except for moderate cardiomegaly. (R. 762.) In a walking oximetry test, Barnwell was able to walk 520 feet in 6 minutes, and his oxygen saturation remained above 93%. (R. 764, 793.) Spirometry showed FVC of 2.25 L (58% predicted) and FEV1 of 1.98 L (64% predicted). (R. 800.) Barnwell did show "significant severe decrease in diffusion capacity, " with diffusing capacity for carbon monoxide ("DLCO") of 38% predicted. (R. 764, 802.) Dr. O'Neill noted no evidence of obstructive process and sent Barnwell for a lung CT scan and methacholine challenge. (R. 764.)
On May 20, 2011, Dr. O'Neill noted that Barnwell was "feeling poorly" and had "a low grade fever" with "productive significant discolored sputum." (R. 790.) Arterial blood gas tests showed a PO2 (partial pressure of oxygen) of 65 mmHg and a PCO2 (partial pressure of carbon dioxide) of 32 mmHg, both below normal. (R. 795.) Dr. O'Neill diagnosed "dyspnea, class 5 at present, both cardiac and pulmonary" and "acute sinotracheitis, question pneumonia without obstruction" and sent Barnwell to the emergency room. (R. 791.) Doctors at Danville RMC noted Barnwell to be in "mild respiratory distress" with sharp chest pain "rating a 5 out of 10." (R. 344.) They diuresed him with Lasix and administered doxycycline and Rochepin for possible bronchitis. ( Id. ) Barnwell was discharged on May 22 with a 7-day prescription for doxycycline. (R. 344, 346.) On discharge, doctors indicated a diagnosis of "Acute [COPD] exacerbation" as well as "acute on chronic congestive heart failure exacerbation." (R. 344.)
On June 21, 2011, Barnwell followed up with Dr. Chauhan. (R. 820-22.) Barnwell told Dr. Chauhan that he had no routine exercise regiment and would get short of breath after walking one block. (R. 820.) Dr. Chauhan noted that Barnwell "is not in heart failure." (R. 821.) He gave Barnwell three clonidine to reduce his blood pressure and also prescribed a TTS patch. ( Id. )
Barnwell returned to the Danville RMC emergency room on July 11, 2011, complaining of shortness of breath. (R. 341.) A right-sided heart catheterization showed "what appears to be pulmonary venous hypertension with elevated wedge pressure of , moderate-severe pulmonary mean pressure of 42, with normal pulmonary vascular resistance of 2.97 Wood units." (R. 341, 602-05.) These results indicated moderately severe pulmonary hypertension. (R. 603.) An echocardiogram showed "left ventricular hypertrophy, left atrial enlargement, trace pericardial effusion with an ejection fraction of 55%, mild mitral regurgitation, [and] right ventricular asystolic pressure... estimated to be around 30." (R. 341.) A chest x-ray showed "increased interstitial changes [and] mild adenopathy, suggestive of possible underlying sarcoid." (R. 605, 616-17.) A progress note dated July 12 states that Barnwell has "fairly severe hypertension with medication noncompliance" and suggests that Barnwell's medication "should be adjusted to decrease his wedge pressure, " which should result in "significant improvement in his respiratory status." (R. 605.) Barnwell was discharged on July 13 with a primary diagnosis of pulmonary hypertension, a prescription for Norvasc, and instructions to follow a "low-sodium, diabetic diet." (R. 341-42.) The discharge note states that Barnwell "could be considered high risk for re-admission due to noncompliance with diabetes as well as hypertension medications." (R. 342.)
Later that day, Barnwell was readmitted to Danville RMC "for shortness of breath and likely congestive heart failure." (R. 579.) A chest CT scan showed an increased pleural effusion ( i.e., excess fluid build-up around the lungs). (R. 579, 614-15.) "Aggressive diuresis with intravenous Lasix" caused the fluid to dissipate and "greatly" improved Barnwell's shortness of breath. (R. 579, 594.) Doctors "kept [Barnwell] for several days" to try to lower his blood pressure, which initially proved difficult. ( Id. ) An echocardiogram on July 19 showed "right ventricular dilation, which is old, " "mild... pulmonary regurgitation with blunted PR slope... consistent with pulmonary hypertension, " and right ventricular systolic pressure increased to 44 from 30 eight days earlier. (R. 589-90.) Barnwell was discharged on July 20 with "much more acceptable blood pressure, " "normal baseline breathing function, " and "markedly decreased" lower leg edema. (R. 579-80.) Doctors increased his Lasix, stopped his Norvasc "in the setting of congestive heart failure, " and prescribed Coreg and hydralazine. (R. 580.)
Barnwell followed up with Dr. O'Neill on July 27, 2011. (R. 781-84.) Dr. O'Neill noted that Barnwell missed an appointment at UVA and that a hospital pulmonologist thought that most of Barnwell's pulmonary problems were secondary to his cardiac or renal conditions. (R. 781-82.) Dr. O'Neill indicated that he agreed with this assessment. (R. 783.) On August 2, Barnwell complained of increased dyspnea, and Dr. O'Neill noted markedly decreased air entry. (R. 776-80.) An arterial blood gas test showed a lower than normal pO2 result of 68 mmHg on room air. (R. 794.) Dr. O'Neill diagnosed "multi-factoral" dyspnea of at least class 4 and chronic hypoxemia. (R. 777.)
On August 24, 2011, Dr. O'Neill noted that Barnwell was "feeling poorly" and that his chest showed markedly decreased air entry. (R. 771-75.) Later that day, Barnwell reported that he was feeling worse, and Dr. O'Neill told him to go to the Danville RMC emergency room where he was admitted with shortness of breath on exertion. (R. 773, 1040.) An echocardiogram showed "right ventricular systolic pressure of 51 with right ventricular dilation, concentric left ventricular hypertrophy, ejection fraction of 55%, left atrial enlargement of 4.8, mild mitral regurgitation, [and] mild to moderate tricuspid regurgitation. ( Id. ) A chest CT scan showed nonspecific "diffuse ground glass attenuation throughout the lungs" suggestive of "mild pulmonary edema." ( Id. ) Doctors attempted to diurese Barnwell with Lasix, but stopped when his creatinine increased. ( Id. ) A doctor noted "the complexity of [Barnwell's] case and the fine balance between obstructive sleep apnea, pulmonary hypertension, and kidney disease." ( Id. ) Barnwell's creatinine returned to baseline on Lasix 40 mg every other day, and he was discharged on August 28 with a primary diagnosis of "dyspnea on exertion, likely multifactorial including diastolic congestive heart failure, acute, as well as obstructive sleep apnea." ( Id. ) Barnwell was instructed to restrict his salt and fluid intake and was set up with supplemental oxygen to use at home. (R. 1041.)
On September 3, 2011, Barnwell returned to Danville RMC complaining of increasing shortness of breath and leg swelling. (R. 498.) At the hospital, Barnwell was diuresed, and his shortness of breath improved. (R. 495.) He was discharged on September 5 with a primary diagnosis of "dyspnea, likely secondary to acute exacerbation of diastolic heart failure." ( Id. ) Doctors noted that Barnwell "does seem to be noncompliant with his medications." (R. 496.)
On September 6, 2011, Barnwell followed up with Dr. O'Neill, who advised him to see a specialist at Duke University Hospital ("Duke"). (R. 766-70.) On September 13, Barnwell saw Dr. Terry Fortin, M.D., at Duke. A pulmonary function test showed Barnwell's FVC at 1.72 L (35% predicted), his FEV1 at 1.40 L (36% predicted) and his DLCO at 11.7 mL/mmHg/min (40% predicted). (R. 808.) These results were noted to be consistent with "severe restrictive lung disease" and "substantially reduced" diffusion capacity. ( Id. ) Dr. Fortin also reviewed Barnwell's existing test results, which led her to conclude that he had "secondary pulmonary hypertension and not pulmonary arterial hypertension." (R. 810.) Dr. Fortin noted that elevated right-sided pressures from a recent catheterization "show[ed] diastolic heart failure." (R. 811.) She noted that his CT scans did not "look classic for sarcoid, " which concerned her because it suggested that fluid in Barnwell's lungs was "related to heart failure." ( Id. ) Dr. Fortin was also concerned by Barnwell's need for oxygen, which he had started using recently, and "other findings, " including his low DLCO. ( Id. )
Summarizing Barnwell's history of present illness, Dr. Fortin noted that "things really seem[ed] to worsen in spring of 2011, " and she observed that Barnwell "is markedly limited in his activity level and that has been worsening" and that "[h]e is on reasonable medicines for his diastolic dysfunction." (R. 810.) Dr. Fortin stressed to Barnwell the importance of using his CPAP and losing weight. (R. 811.) Because his blood pressure was "inadequately controlled, " Dr. Fortin gave him prescriptions for hydralazine and a higher dose of carvedilol. ( Id. )
Barnwell followed up with Dr. Chauhan on September 29, 2011. (R. 823-25.) Barnwell reported that, since spring, he would become short of breath after walking half a block. (R. 823.) He complained of increasing shortness of breath over the past couple of days to the point where he could walk only five to ten feet before getting short of breath. ( Id. ) He also noted worsening swelling in his feet and ...