United States District Court, W.D. Virginia, Danville Division
REPORT AND RECOMMENDATION
JOEL C. HOPPE, Magistrate Judge.
Plaintiff Jamar Davis asks this Court to review the Commissioner of Social Security's ("Commissioner") final decision denying his applications for child's insurance benefits ("CIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-434, 1381-1383f. Davis argues that the Administrative Law Judge ("ALJ") should have given greater weight to an examining physician's medical opinion, did not fully consider Davis's mental limitations, and should have consulted a vocational expert regarding Davis's ability to work rather than relying on the Medical-Vocational Guidelines ("the grids") to direct a finding of "not disabled." ( See generally Pl. Br. 13-21.) He urges the Court to reverse the Commissioner's decision and to award benefits, or to remand his case for further administrative proceedings. ( See Pl. Br. 22.)
This Court has authority to decide Davis's case under 42 U.S.C. §§ 405(g) and 1383(c)(3), and his 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 the Commissioner's final decision is not supported by substantial evidence in the record. First, the ALJ's finding that Davis is "limited to simple and unskilled work" does not reflect the total limiting effects of Davis's mental impairment. Second, the ALJ did not expressly consider the extent, if any, to which Davis's specific cognitive limitations eroded the unskilled occupational base. These are reversible errors. Therefore, I RECOMMEND that the District Court GRANT Davis's Motion for Summary Judgment (ECF No. 12), DENY the Commissioner's Motion for Summary Judgment (ECF No. 17), REVERSE the Commissioner's final decision, and REMAND this case for further proceedings under the fourth sentence of 42 U.S.C. § 405(g).
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 disability benefits. 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. §§ 423(d)(1)(A), 1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a), 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. §§ 404.1520(a)(4), 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 Commissioner to prove that the applicant is not disabled. See id.
II. Procedural History
Davis filed for SSI on October 25, 2010, and for CIB on November 16, 2010, alleging disability beginning October 3, 2009. ( See R. 52, 60.) Davis, who graduated from Halifax County High School with a "Modified Standard" diploma in May 2008, was 19 years old on his alleged onset date and had never worked. (R. 52, 200-07.) He said that he could not work because of "achondroplasia, leg problems, sleep apnea, and asthma." (R. 52.) A state agency twice denied his applications in 2011. (R. 59, 67, 81, 93.)
Davis appeared with counsel at an administrative hearing on June 6, 2012. (R. 12.) He testified as to his symptoms and to the limiting effect of his conditions. (R. 22-43.) No one else testified at Davis's hearing. ( See R. 26.) In a written decision dated June 27, 2012, the ALJ concluded that, based on his age, education, and ability to do "unskilled light work, " Davis was not entitled to disability benefits. (R. 19-20.)
The ALJ first found that Davis had not yet turned 22 years old on his alleged disability-onset date. (R. 14.) He found that Davis suffered from "severe" hypochondroplasia,  borderline intellectual functioning, sleep apnea, and asthma. ( Id. ) None of Davis's severe impairments or combination of impairments met or medically equaled one of the adult impairments listed in the Act's regulations. ( See id. (citing 20 C.F.R. pt. 404, subpt. P, app. 1, pt. A §§ 3.10, 12.05).)
The ALJ next determined that Davis had the residual functional capacity ("RFC") to do "simple and unskilled" light work that involved only occasional climbing, crawling, and kneeling and avoided "concentrated exposure to fumes and odors." (R. 16.)
At Step Four, the ALJ found that Davis had never worked and therefore could not return to a past job or occupation. ( See R. 19.) At Step Five, the ALJ used grid Rule 202.20 as a "framework" for finding Davis "not disabled" because Davis's "additional limitations [had] little or no effect on the occupational base of unskilled light work." ( Id. ) The Appeals Council declined to review the ALJ's decision on June 25, 2013 (R. 1), and this appeal followed.
Davis makes three arguments on appeal. First, he argues that the ALJ should have fully adopted the opinion of consultative examiner Dr. Glen Monteiro, M.D., regarding Davis's physical limitations. (Pl. Br. 13.) Second, Davis argues that the ALJ did not fully incorporate Davis's mental limitations into his final RFC. (Pl. Br. 17.) Third, he argues that the ALJ should have consulted a vocational expert ("VE") about Davis's ability to work rather than relying on the grids to direct a finding of "not disabled." (Pl. Br. 19.)
A. Davis's Physical Capabilities
Agency regulations instruct ALJs to weigh each medical opinion in the record. 20 C.F.R. §§ 404.1527(c), 416.927(c). The regulations classify medical opinions by their source: those from treating sources and those from non-treating sources. See 20 C.F.R. §§ 404.1527(c), 416.927(c). Opinions from non-treating sources are not entitled to any particular weight. See 20 C.F.R. §§ 404.1527(c), 416.927(c). Rather, the ALJ must consider certain factors in determining what weight to give such opinions, including the source's familiarity with the applicant; the weight of the evidence supporting the opinion; the source's medical specialty; and the opinion's consistency with other relevant evidence in the record. See id. Opinions from examining physicians generally are entitled to greater weight than opinions from non-examining physicians, such as state-agency medical reviewers. Radford v. Colvin, 734 F.3d 288, 296 (4th Cir. 2013). Ultimately, though, "the ALJ must consider the opinions received in light of the evidence of record and the ALJ must determine whether the record supports the opinions offered." Stonestreet v. Astrue, 5:12-cv-111, 2014 WL 992098, at *5 (W.D. Va. Mar. 14, 2014.
If the ALJ's final RFC conflicts with a medical-source opinion, he also must explain why that opinion was not adopted in full. Young v. Colvin, 7:12-cv-468, 2014 WL 991712, at *3 (W.D. Va. Mar. 13, 2014) (citing Soc. Sec. R. 96-8p, 1996 WL 374184, at *7 (Jul. 2, 1996)). His "decision must be sufficiently specific to make clear to any subsequent reviewers the weight [he] gave' to the opinion and the reasons for that weight.'" Id. (quoting Soc. Sec. R. 96-2p, 1996 WL 374188, at *5 (Jul. 2, 1996)). As always, the ALJ's choice between conflicting evidence must be supported by substantial evidence in the record. See Johnson, 434 F.3d at 656.
1. Dr. Monteiro's Opinion
The agency arranged for Dr. Monteiro to examine Davis because the medical evidence in Davis's record was insufficient to support a decision on his claim. (R. 54.) At the examination on May 21, 2011, Davis told Dr. Monteiro that he was born with hypochondroplasia and that he suffered "midline lower back pain" after undergoing a procedure "to correct the bilateral bowing of his knees" when he was eight or nine years old. (R. 335.) He said that the pain was particularly bad "after walking more than a mile." ( Id. ) Davis also said that he suffered "bilateral knee pain... with occasional numbness and tingling going towards his back from his knees." ( Id. ) Although he did not use an assistive device to walk, Davis said that he "occasionally" felt unsteady on his feet. ( Id. )
On exam, Dr. Monteiro observed that Davis's "short stature [was] immediately apparent"-the 21-year-old man stood just 4'1½" tall. (R. 337.) Davis exhibited "mild bowing" and reduced range of motion in both knees. His lower and upper extremity strength "appeared to be good" at 4/5, and he had normal range of motion in his ankles. (R. 338.) Davis walked with a "slight limp" favoring his left leg. ( Id. ) He had "normal" range of motion in the left hip but experienced pain in the right hip and groin on internal rotation and abduction. (R. 337.)
Based on his physical exam, Dr. Monteiro opined that Davis could sit for six hours, stand and walk for six hours, and walk for four to six hours in an eight-hour workday. (R. 339.) He based those restrictions on Davis's "chronic bilateral leg problems and his hyperchondroplasia [ sic ] status." ( Id. ) Dr. Monteiro also opined that Davis could lift and carry "5 pounds occasionally and less than 2 pounds frequently." ( Id. ) He based that restriction on Davis's "chronic bilateral leg problems which alter body mechanics and make carrying and handling objects difficult." ( Id. ) Dr. Monteiro noted that Davis "should have some limitations on bending, stooping, and crouching given his chronic back and knee problems, " but he did not specify the extent to which Davis could do these things. ( Id. ) He also said that Davis "may consider" using a single-point cane or a walker to help him ambulate "during acute flare up[s] of the leg pain." ( Id. )
2. State-agency Opinion
State-agency reviewer Dr. Martin Cader, M.D., reviewed the medical evidence in Davis's record in July 2011. (R. 88-90.) Dr. Cader opined that Davis could do "light work" with additional postural and environmental limitations. (R. 92.) Specifically, Dr. Cader found that Davis could: (1) occasionally lift and carry 20 pounds; (2) frequently lift and carry 10 pounds; and (3) sit, stand, and walk for about six hours in an eight-hour workday; but (4) should "avoid concentrated exposure" to respiratory irritants and poor ventilation. (R. 88-90.) He recommended using grid Rule 202.20 as a framework for finding Davis "not disabled" because his "non-exertional limitations [did] not significantly erode the [light] occupational base." (R. 92.)
3. Other Relevant Evidence
The record contains evidence of Davis's physical condition in 2004, 2007, and 2009-2012. ( See R. 33-43, 207, 209-219, 259, 282, 287-88, 299-300, 305-06, 313, 314, 325-33, 335-39, 342.) Davis was a "very active" 14-year-old boy in 2004. (R. 286, 287.) Although he wore knee-high metal prostheses on both legs, Davis did not report any physical limitations related to his achondroplasia, stature, or weight in March 2004. ( See id. ) On the contrary, he ...