United States District Court, W.D. Virginia, Danville Division
REPORT AND RECOMMENDATION
JOEL C. HOPPE, Magistrate Judge.
Plaintiff Nancy Sydnor asks this Court to review the Commissioner of Social Security's ("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. This Court has authority to decide Sydnor'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. 15. After reviewing the administrative record, the parties' briefs, and the applicable law, I find that the Commissioner's decision is not supported by substantial evidence in the record. Therefore, I recommend that this Court reverse the Commissioner's final decision and remand the case for further administrative proceedings.
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); 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); 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
Sydnor previously filed for SSI and disability insurance benefits ("DIB") on March 16, 2006, alleging disability beginning February 8, 1999. On her alleged onset date, Sydnor was a 37-year-old college graduate who had recently left her job in an elementary school. See Administrative Record ("R.") 68, 73. Sydnor collected Worker's Compensation for an unspecified injury from December 1999 through March 2001. She underwent fusion surgery on her lumbar spine in December 2000. R. 72. Sydnor reported that she did not try to find a less physically demanding job when she depleted her Worker's Compensation because she was depressed. R. 68.
In a written decision dated April 27, 2007, ALJ Mancuso found that Sydnor had a severe spinal disorder and a severe affective disorder. See R. 66-67, 70-73. ALJ Mancuso determined that, although Sydnor could not return to her past work, she could perform certain sedentary jobs. See R. 67, 74-75. On appeal, the presiding district judge in the present case affirmed the Commissioner's decision. See Sydnor v. Comm'r of Soc. Sec., No. 4:09-cv-25, 2010 WL 1257749, at *1 (W.D. Va. Mar. 26, 2010).
Sydnor protectively filed the present SSI application in late July 2010. See R. 40, 25-26. She was 49 years old and had not worked since February 8, 1999, due to chronic back pain, "failed syndrome, " and arthritis throughout her body. R. 158. A state agency denied Sydnor's application initially and upon reconsideration. R. 39, 50.
Sydnor appeared with counsel at an administrative hearing before ALJ Drew Swank ("the ALJ" or "ALJ Swank") on June 6, 2012. R. 20. She testified as to her back pain, the limits that pain had on her daily activities, and her inability to get free or low-cost healthcare in recent years. See generally R. 30-37. No one else testified at Sydnor's hearing.
In a written decision dated June 20, 2012, the ALJ found that Sydnor suffered from a severe "spine disorder, status post a... lumbar fusion and laminectomy." R. 11. He noted that this impairment limited Sydnor's "ability to lift and carry heavy objects" and to engage in postural activities, but that it did not meet or medically equal the criteria for a presumptively disabling spine disorder listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 § 1.04. R. 11-12.
The ALJ next determined that Sydnor had the residual functional capacity ("RFC") to perform light work with only occasional balancing, stooping, kneeling, crouching, crawling, and climbing stairs, ramps, ropes, ladders, or scaffolds. R. 12. At step four, he concluded that Sydnor could return to her past work as a physical education instructor in an elementary school as that job is "generally performed." R. 16. Thus, he determined that Sydnor was not disabled for the period relevant to her application, which she filed on July 22, 2010. Id. ALJ Swank did not make an alternative finding whether Sydnor could perform other work that existed in the national economy given her age,  education, work history, and RFC. See id. The Appeals Council declined to review the ALJ's decision on July 17, 2013, R. 1, and this appeal followed.
III. Statement of Facts
The record contains almost no medical evidence of Sydnor's physical condition after April 27, 2007. Sydnor reported receiving treatment for "chronic back pain" at Danville Pain Referral Center ("DPRC") from 2006 to 2009. R. 161. The state agency requested medical records from DPRC dated after July 1, 2009, but none existed. R. 225. In June 2012, Sydnor testified that she had not received any medical care since July 22, 2010. R. 25-26. Sydnor has repeatedly said that she does not have medical insurance, cannot afford to pay for services out of pocket, and does not have access to free healthcare. See R. 35, 37, 162, 184, 236. Thus, she could not produce any recent treatment records to support her SSI application.
A. Current Medical Evidence
The state agency ordered x-rays of Sydnor's right hand and lumbar spine on April 19, 2011. See R. 230-31. The hand x-ray showed "no significant abnormalities involving the bones or soft tissues." R. 231. The spine x-ray showed posterior hardware fusion with pedicular screws, paraspinal rods, and a bone cage between L5 and L6 with "apparent anterior osseous fusion." R. 230. Sydnor's lumbar vertebral body heights were preserved and there was no evidence of spondylolisthesis or endplate spurring. See id. The reviewing radiologist, Dr. Arash Chehrazi, M.D., noted his impression as: "L5-L6 posterior hardware fusion and L5 laminectomy without evidence of complication." Id.
The state agency also arranged for Dr. Glen Monteiro, M.D., to examine Sydnor on May 24, 2011. Sydnor told Dr. Monteiro that she first experienced lower back pain in 1998 while working as a physical education instructor. R. 233. A school doctor diagnosed low back strain at that time. Sydnor went back to work but "started experiencing lower midline lumbar back pain for the next five months." Id. She returned to the school doctor for an x-ray, which revealed a herniated disc at L4-L5. Sydnor had back surgery in 2000 that, combined with rehabilitation, relieved her pain for six months. See id.
Sydnor told Dr. Monteiro that she saw "multiple specialists who recommended physical therapy and... pain management for one year." R. 234. She underwent a "hardware block procedure, " but was otherwise "unable to follow up with appropriate pain management [due to] lack of financial resources and no medical insurance." R. 236. Dr. Monteiro noted that these treatments occurred after Sydnor moved to Virginia, R. 234, but the record does not reveal when this move took place, see R. 34-35. Sydnor told Dr. Monteiro that her low back pain occasionally radiates to her left foot and is worse while bending forward, twisting, standing, or sitting for long periods. R. 234. Sydnor reported that she could tend to her personal needs, but had trouble putting on socks and shoes. She did not take any pain medications in May 2011. Id.
On exam, Dr. Monteiro observed that Sydnor walked with a normal gait, could walk on her toes and heels, and did not use an assistive device to ambulate. R. 235. She had full strength and normal sensation in her lower extremities, and her straight-leg tests were negative. R. 236. She had normal range of motion in her hips and ankles. R. 235. Sydnor's upper-extremity strength was 4/5 bilaterally with normal sensation. R. 236. Dr. Monteiro observed that Sydnor's thoracolumbar range of motion was "restricted" at extension to 5 degrees, flexion to 60 degrees, and lateral flexion to 10 degrees bilaterally. R. 235, 236. "No other joint involvement... or deformity of the other joints was noted" on this exam. R. 236. Dr. Monteiro diagnosed "failed back syndrome." R. 236
Based on these findings, Dr. Monteiro opined that Sydnor could sit, stand, and walk for four hours during an eight-hour workday; occasionally lift and carry eight pounds; and frequently lift and carry fewer than four pounds. R. 236. He based these restrictions on Sydnor's "altered body mechanics secondary to the chronic low back pain." Id. Dr. Monteiro opined that Sydnor "should have limitations with stooping, crouching, [and] bending given her chronic back pain, " but he did not specify the extent to which she could do those ...