United States District Court, W.D. Virginia, Danville Division
GALE E. BOLDEN, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner, Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
JOEL C. HOPPE, Magistrate Judge.
Plaintiff Gale Bolden asks this Court to review the Commissioner of Social Security's (the "Commissioner") final decision denying her application for supplemental security income ("SSI") under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383f. Bolden primarily objects to the Commissioner's conclusion that she can perform "light" work, including her past work as a Certified Nursing Assistant. She urges the Court to reverse the Commissioner's decision and award benefits, or to remand her case for further administrative proceedings. This Court has authority to decide Bolden's case under 42 U.S.C. §§ 405(g) and 1383(c)(3), and her case is before me by referral under 28 U.S.C. § 636(b)(1)(B) (ECF No. 16).
After reviewing the administrative record, the parties' briefs, and the applicable law, I find that substantial evidence supports the Administrative Law Judge's ("ALJ") final decision that Bolden is not disabled. Therefore, I recommend that the Court affirm the Commissioner's decision.
I. Standard of Review
The Social Security Act authorizes this Court to review the Commissioner's final decision that a person is not entitled to supplemental security income. See 42 U.S.C. §§ 405(g), 1383(c)(3); 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 the ALJ applied the correct legal standards and whether substantial evidence supports the ALJ's factual findings. 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. § 1382c(a)(3)(A); 20 C.F.R. § 416.905(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 his or 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. § 416.920(a)(4); see also Heckler v. Campbell, 461 U.S. 458, 460-62 (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
Bolden filed this SSI application on November 15, 2011. (R. 68.) She was 52 years old, had at least a twelfth grade education, and once worked as a Certified Nursing Assistant ("CNA"). ( See R. 68, 72; see also R. 38.) Bolden alleged that she could not work anymore because of an injured rotator cuff, "congestive heart failure, [a] broke[n] disc in [her] back, [a] bulging disc, a pinched nerve in [her] neck causing her to drop things, and hypertension (uncontrolled)." (R. 243, 68.) A state agency denied her application initially and upon reconsideration. (R. 79, 90.)
Bolden appeared with counsel at an administrative hearing before an ALJ on December 4, 2012. (R. 33.) She testified as to her past work, her current impairments, and the limits those impairments had on her daily activities. ( See generally R. 37-54.) A Vocational Expert ("VE") also testified as to Bolden's past work and to the type of jobs that she could still perform given her age, education, work history, and limitations. ( See generally R. 52-61.)
In a written decision dated March 14, 2013, the ALJ found that Bolden was not disabled after November 15, 2011. (R. 28.) The ALJ found that Bolden suffered from "severe" degenerative disc disease, "right shoulder difficulty, " and hypertension. (R. 21.) Although Bolden alleged "left shoulder problems and hand grip problems, " the ALJ found that those impairments were "non-severe" because they did not cause "functional limitations lasting or expected to last [for] a continuous period of at least 12 months." ( Id. ) He also found that Bolden's mood disorder was a "non-severe" impairment because it did not significantly limit her ability to perform basic work activities. (R. 21-22.) None of Bolden's severe impairments, or combination of impairments, met or medically equaled one of the impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 22-23.)
The ALJ next determined that Bolden had the residual functional capacity ("RFC") to do a limited range of "light work" with occasional overhead reaching and "less than frequent" stooping or balancing as long as she avoided "concentrated exposure to hazards." (R. 23; see also R. 27.) At step four, the ALJ concluded that Bolden could return to her past work as a CNA as she actually performed it because, according to the VE's testimony, Bolden "performed this job at the light exertional level." (R. 26-27.) Alternatively, the ALJ found at step five that Bolden could perform other light duty occupations that existed in the national economy, such as unarmed security guard, retail salesperson, and parking lot attendant. (R. 27.) The Appeals Council declined to review the ALJ's decision (R. 1), and this appeal followed.
A. Medical Records
Bolden's medical records reveal a history of back pain, shoulder pain, and degenerative changes in her spine and right shoulder. In July 2006, for example, Bolden had an MRI of her lumbar spine after reporting to the emergency department with back pain. (R. 436-37.) The MRI revealed "intervertebral disc narrowing... particularly at L2-L3 and to a lesser extent at L4-L5." (R. 436.) There was a "mild to moderate circumferential disc bulge" at L2-L3 and L4-L5. (R. 437.) The left neural forminal opening at L4-L5 also was "partially narrowed by disc material and spurring." ( Id. ) The reviewing physician noted that the degenerative changes at L4-L5 may indicate "slight infraction of the nerve root, " and he recommended an ultrasound for further evaluation. ( Id. ) X-rays taken on October 5, 2006, of Bolden's right knee showed mild arthritic changes. (R. 428-29.)
On August 26, 2011, Bolden reported to the emergency department complaining of "a sharp, shooting pain in [her] back down [the] left leg causing her to fall." (R. 318.) On exam, Dr. Jonathan Logan, M.D., observed that Bolden's back was tender with palpable spasms bilaterally. (R. 319.) She had "normal, full, active" range of motion in all extremities. ( Id. ) Dr. Logan prescribed pain medications and muscle relaxants and instructed Bolden to visit her primary care provider. (R. 320.)
On January 6, 2012, the rescue squad delivered Bolden to the emergency department where she complained of a persistent "moderate right frontal headache" and muscle spasms in her lower back. (R. 878.) On exam, Bolden's back was non-tender and no muscle spasms were noted. ( See R. 882.) She was prescribed muscle relaxants and instructed to contact her primary care provider in the next few days. (R. 886.)
On January 11, 2012, Bolden reported to the emergency department complaining of "horrible pain" in her upper back. (R. 980.) She described the pain as 8/10, "crampy, " and intermittent. ( Id. ) Dr. Rebecca Kirsch, D.O., offered to admit Bolden for further observation, but Bolden insisted that she wanted to go home. (R. 981.) Dr. Kirsch diagnosed "back pain ? [of unknown] etiology" and discharged Bolden home with pain medications and instructions to visit her primary care provider. ( See R. 983, 984.) She also recommended that Bolden "exercise [her] abdominal muscles to help strengthen [her] back." (R. 984.)
Bolden first complained of shoulder pain and difficulty lifting her right arm on January 31, 2012. ( See R. 903.) Bolden informed the attending physician that she "ha[d] been dropping things with her right arm for about a year now and was told that it could be a pinched nerve problem." (R. 906.) She also said that the pain "seem[ed] to radiate to her back." ( Id. ) On exam, Dr. Fredrick Odoo, M.D., noted that Bolden's "right shoulder region [was] diffusely tender" with "limited" range of motion in the right arm. ( Id. ) Her back was not tender to palpation, and she had full strength and intact sensation in all extremities. ( See id. )
An x-ray of Bolden's right shoulder taken the same day revealed "mild degenerative arthritis of the acromioclavicular joint." (R. 911.) An x-ray of her spine confirmed multilevel degenerative osteoarthritis, including "narrowing at the L2-L3 disc interspace, " but no spondylolysis or spondylolisthesis. (R. 912.) Left-sided disc protrusion at C5-C6 was noted. (R. 915.) Dr. Odoo "suspected [an] injury to the rotator cuff, " but he did not recommend any particular course of treatment. (R. 918.) He prescribed pain medications, instructed Bolden to contact her primary care provider, and discharged her home in "stable and improved" condition. (R. 916, 922.)
On March 21, 2012, Bolden reported to the emergency department with "chest pain continuous for the past 2 days that started in her left upper chest area and radiates down her left arm and into her left back." (R. 949.) On exam, Nurse Karin Hall, C.N.P., observed that Bolden had normal range of motion in three extremities, but that she was unable to lift her left arm above her head "due to pain in [the] left upper chest and left arm area with movement." ( Id. ) Bolden was prescribed pain medications, instructed to contact her primary care provider, and discharged home in "stable and improved" condition. (R. 954.)
Bolden returned to the emergency department on March 26, 2012, complaining of chest pain unabated by prescription strength medication. (R. 943.) The attending physician, Dr. Siddarth Khanna, M.D., noted that he "would like to find out if the patient is chronically using opiates, given the fact that she is requiring high doses of medication to control her pain." (R. 944.) Dr. Khanna admitted Bolden to the hospital to "rule out acute coronary syndrome" as the source of her chest pain. ( Id. ) She was discharged the next day after being diagnosed with "chest pain, possibly secondary to gastroesophegal reflux." (R. 942.) Treatment notes do not document that Bolden complained of any musculoskeletal discomfort during this visit. ( See R. 942-44.)
On April 3, 2012, Bolden appeared at her primary care provider's office with her left arm in a sling. (R. 1031.) She reported a recent injury to her left shoulder and an inability to grip with her left hand. ( Id. ) Nurse Shannon Runion, F.N.P., observed "pain with palpation and movement of the left shoulder" and "pain with palpation of [the] posterior neck and essentially [the] entire back and paraspinal musculature." ( Id. ) Bolden requested "an increase to stronger pain medication, " and Nurse Runion switched Bolden from Lortab to Percocet. (R. 1031, 1032.) She instructed Bolden to "not obtain narcotic[s] from other clinics/providers" except in an emergency, to use Flexeril at bedtime, and to treat her pain with massage and heat. (R. 1032.)
On July 23, 2012, Bolden reported to the emergency department complaining of left shoulder pain "from an old rotator cuff injury" and back pain "from an old bulging disc." (R. 965.) Bolden said that she had run out of her pain medication and was unable to see her primary care provider because she did not have health insurance. (R. 967.) On exam, Justin Gambini, P.A., observed full range of motion in all extremities. (R. 968.) His examination of Bolden's right shoulder was "normal": she had good abduction adduction, normal muscle strength, and no significant joint laxity. ( Id. ) She experienced "pain with ROM [range of motion] with abduction of the left shoulder past 50 degrees." ( Id. ) Gambini also noted pain over the lower spine, but no trigger points or muscle spasms. ( Id. ) He diagnosed chronic back and shoulder joint pain. (R. 968, 976.) Bolden was prescribed pain medications and instructed to follow up with her primary care provider. ( See id. )
On September 9, 2012, Bolden reported to the emergency department complaining of "back pain that caused her to fall." (R. 1102.) She said that she had experienced "even worse back pain bilateral across [the] lumbar spine" since falling the day before. ( Id. ) On exam, Dr. Logan observed that Bolden was "tender all across lumbar spine into [the] sacrum" and that she "jump[ed] to light touch." (R. 1103.) He did not note any palpable muscle spasms. ( See id. ) Bolden had "normal, active, full" range of motion without point tenderness in her neck and all extremities. ( Id. ) Dr. Logan ordered x-rays of Bolden's pelvis, which showed "degenerative changes about the hips, slightly more pronounced on the left" side. (R. 1104.) He prescribed pain medications, instructed Bolden to follow up with her primary care provider, and discharged her home by herself in "stable" condition. (R. 1103, 1105.)
On September 20, 2012, Bolden reported to the emergency department complaining of pain in her neck and right shoulder. (R. 1069.) She also complained of extreme drowsiness and lethargy, which at least one provider personally observed. (R. 1072.) On exam, William Singleton, P.A., noted "normal, active, full" range of motion without tenderness in Bolden's neck and all extremities. (R. 1073.) Multiple x-rays taken that day showed "at most mild narrowing" and "degenerative changes with spondylosis" at C5-C6 bilaterally, as well as osteoarthritis in the right shoulder. (R. 1078.) Noting similar results from x-rays taken in January 2012, the reviewing physician reported that these arthritic changes "can be associated with rotator cuff disease" and suggested that an MRI would be useful for further evaluation. (R. 1078, 1170.)
Bolden was also admitted to the hospital to monitor her fatigue and bradycardia. ( See R. 1079.) Consulting cardiologist Dr. Girish Purohit, M.D., observed that Bolden's primary problem "seem[ed] to be chronic pain of musculoskeletal etiology." (R. 1042.) He also noted that Bolden had "generalized osteoarthritis everywhere and it seems to be quite incapacitating." ( Id. ) On exam, Dr. Purohit observed that Bolden was "in significant pain" and experienced "tenderness to palpation over the cervical spine." ( ...