United States District Court, W.D. Virginia, Big Stone Gap Division
RHONDA G. AMAYA, Plaintiff.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
PAMELA MEADE SARGENT, Magistrate Judge.
I. Background and Standard of Review
Plaintiff, Rhonda G. Amaya, ("Amaya"), filed this action challenging the final decision of the Commissioner of Social Security, ("Commissioner"), denying plaintiff's claims for disability insurance benefits, ("DIB"), and supplemental security income, ("SSI"), under the Social Security Act, as amended, ("Act"), 42 U.S.C.A. §§ 423 and 1381 et seq. (West 2011 & West 2012). Jurisdiction of this court is pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). This case is before the undersigned magistrate judge by transfer based on consent of the parties pursuant to 28 U.S.C. § 636(c)(1). Oral argument has not been requested; therefore, the matter is ripe for decision.
The court's review in this case is limited to determining if the factual findings of the Commissioner are supported by substantial evidence and were reached through application of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). Substantial evidence has been defined as "evidence which a reasoning mind would accept as sufficient to support a particular conclusion. It consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance." Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966). "If there is evidence to justify a refusal to direct a verdict were the case before a jury, then there is "substantial evidence."'" Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990) (quoting Laws, 368 F.2d at 642).
The record shows that Amaya protectively filed her applications for SSI and DIB on March 16, 2009, alleging disability as of May 15, 2007,  due to bipolar disorder, anxiety, depression, socio-phobia, heart problems and high blood pressure. (Record ("R."), at 203-08, 232, 245.) The claims were denied initially and upon reconsideration. (R. at 126-31, 133-34, 138-45.) Amaya then requested a hearing before an administrative law judge, ("ALJ"). (R. at 146.) A hearing was held on Amaya's claims on November 16, 2011. (R. at 29-71.) Amaya was represented by counsel at this hearing. (R. at 29.)
By decision dated December 15, 2011, the ALJ denied Amaya's claims. (R. at 14-26.) The ALJ found that Amaya met the disability insured status requirements of the Act for DIB purposes through June 30, 2010. (R. at 16.) The ALJ found that Amaya had not engaged in substantial gainful activity since May 15, 2007, the alleged onset date. (R. at 16.) The ALJ found that the medical evidence established that Amaya had severe impairments, namely affective disorder (bipolar disorder and depression), anxiety disorder, history of drug abuse and obesity, but the ALJ found that Amaya did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. at 16, 18.) The ALJ found that Amaya had the residual functional capacity to perform light work that did not require her to climb ladders, ropes or scaffolds, to be exposed to unprotected heights or more than occasionally climbing ramps or stairs, balancing, stooping, kneeling, crouching, crawling, operating foot controls or reaching. (R. at 20.) The ALJ found that Amaya was able to understand, remember and carry out simple instructions, to make judgments on simple work-related decisions, to interact appropriately with supervisors and co-workers in a routine work setting and to respond to usual work situations and to changes in a routine work setting. (R. at 20.) The ALJ also found that Amaya should be isolated from the public with only occasional supervision and occasional interaction with co-workers. (R. at 20.) The ALJ found that Amaya was unable to perform any of her past relevant work. (R. at 24.) Based on Amaya's age, education, work experience, residual functional capacity and the testimony of a vocational expert, the ALJ found that a significant number of jobs existed in the national economy that Amaya could perform, including jobs as merchandise marker, a machine tender and a checker. (R. at 24-25.) Thus, the ALJ concluded that Amaya was not under a disability as defined by the Act and was not eligible for DIB or SSI benefits. (R. at 25-26.) See 20 C.F.R. §§ 404.1520(g), 416.920(g) (2013).
After the ALJ issued his decision, Amaya pursued her administrative appeals, but the Appeals Council denied her request for review. (R. at 1-4, 10.) Amaya then filed this action seeking review of the ALJ's unfavorable decision, which now stands as the Commissioner's final decision. See 20 C.F.R. §§ 404.981, 416.1481 (2013). This case is before this court on Amaya's motion for summary judgment filed December 23, 2013, and the Commissioner's motion for summary judgment filed January 17, 2014.
Amaya was born in 1964, (R. at 520), which, at the time of the ALJ's decision, classified her as a "younger person" under 20 C.F.R. §§ 404.1563(c), 416.963(c). Amaya graduated from high school and attended two years of college. (R. at 505.) Amaya has past work experience as a licensed practical nurse. (R. at 505.) Amaya testified at her hearing that she quit work in 2007 because "being around the people was causing a lot of panic attacks...." (R. at 39.) Amaya also testified that she began having seizures around this period of time in which she would blackout, and others would say that her body would shake and that she would talk to people who were not there. (R. at 39-40.) Amaya stated that, after one of these seizures, she would be required to lie in bed for a couple of days because she would be sore and groggy. (R. at 40-41.) Amaya stated that these "episodes, " as she called them, have come under control with medication. (R. at 42.) At the time of her hearing, Amaya claimed that she would have two to three episodes per week where she would simply stare until someone touched her. (R. at 42.)
Amaya testified that, as long as she stayed isolated at home, she could avoid having panic attacks, but she stated that she continued to experience crying spells a couple of times a week. (R. at 43.) Amaya also testified that she used illicit drugs only when she felt stress and panic that she could not otherwise get under control. (R. at 44.) Later in her testimony, however, Amaya stated that she had not used drugs recreationally since her children were born. (R. at 51.) Amaya testified that her children were then 19 and 25 years old. (R. at 52.)
Amaya also testified that she suffered from chronic headaches every day. (R. at 45.) She stated that, at least once a month, her head would hurt so badly that she was forced to go to bed. (R. at 45.) Amaya stated that she slept an average of two hours a night. (R. at 46.) As a result, she stated that she stayed tired. (R. at 46.) Amaya also testified that she previously had injured both of her feet when she stepped off a porch during a seizure. (R. at 47.) She stated that she had continuous pain that made it difficult to stand, walk and get out of bed. (R. at 47.) She stated that her feet and ankles would often swell during the day, which would require her to prop up her feet during the day. (R. at 47.)
Amaya testified that there were days when she did not want to get out of bed or groom herself. (R. at 48-49.) In fact, she testified that she had once stayed in her bedroom for two months straight, leaving only to use the bathroom and get something to drink. (R. at 49.) Amaya stated that her medication was helping her condition, but that she still had a couple of days a month when she did not want to get out of bed. (R. at 49.)
Mark Hileman, a vocational expert, also was present and testified at Amaya's hearing. (R. at 58-70.) He classified Amaya's past work as a children's institution attendant as medium,  semi-skilled work, as a licensed practical nurse as medium, skilled work and as a restaurant hostess as light, semi-skilled work. (R. at 61-62.) The ALJ asked Hileman to consider a hypothetical individual of Amaya's age, education and work experience, who could occasionally lift, carry and push or pull items weighing up to 50 pounds and frequently lift, carry and push or pull items weighing up to 25 pounds, stand and/or walk with normal breaks for a total of about six hours in an eight-hour workday, sit with normal breaks for a total of about six hours in an eight-hour workday, never climb ladders, ropes or scaffolds, could occasionally climb ramps and stairs, frequently balance, stoop, kneel, crouch and crawl and who should avoid all exposure to hazards such as dangerous moving machinery and unprotected heights. (R. at 62-63.) The ALJ also asked Hileman to assume that this individual could occasionally interact with the public, supervisors and her co-workers. (R. at 63.)
Hileman testified that a person with those restrictions could not perform Amaya's past work as a restaurant hostess, but could perform her past work as a children's institution attendant and as a licensed practical nurse. (R. at 63-64.) Hileman did testify that a significant number of jobs existed that such an individual could perform, including jobs as a laundry worker, a hand packager and a merchandise marker. (R. at 64.) Hileman testified that the laundry worker and hand packager jobs were classified as medium, unskilled work and that the merchandise maker job was classified as light, unskilled work. (R. at 64.)
The ALJ asked Hileman to assume the same individual as above, but who was restricted to occasionally lifting and carrying items weighing up to 20 pounds and frequently lifting and carrying item weighing up to 10 pounds, occasionally operating foot controls, with a sit/stand option, occasionally balancing, stooping, kneeling, crouching, crawling and reaching overhead. (R. at 65.) This individual would be able to understand, remember and carry out simple instructions, to make judgments on simple work-related decisions, to interact appropriately with supervisors and co-workers in a routine work setting and to respond to the usual work situations and changes in a work setting, but who would need to be isolated from the public with only occasional supervision and only occasional interaction with co-workers. (R. at 65-66.) Hileman stated that such an individual could not perform any of Amaya's past work and that there would be no jobs available for such an individual. (R. at 67-68.) Hileman stated that, if the sit/stand option was removed, such an individual could perform work as a merchandise marker, a canning machine tender and a checker. (R. at 68-69.) Hileman also testified that if an individual would be absent from work more than three days a month, there would be no jobs available that the individual could perform. (R. at 69-70.)
In rendering his decision, the ALJ reviewed records from Dr. Christopher M. Basham, M.D.; Robert S. Spangler, Ed.D., a licensed psychologist; Dr. Noah Kolb, M.D., a neurologist; James Kegley, MS, and Joyce Thompson, FNP, with Wise County Behavioral Health; Dr. Jenell R. Decker, M.D., and Stacey B. Gipe, PA-C, with Medical Associates of Southwest Virginia; Lonesome Pine Hospital; Southwestern Virginia Mental Health Institute; Dr. Kevin Blackwell, D.O.; B. Wayne Lanthorn, Ph.D., a licensed clinical psychologist; Dr. Jo Ann Arey, M.D., with Blue Ridge Health Associates; Dr. Asim Rana, M.D., a psychiatrist with The Center for Behavioral Health; Twin County Regional Hospital; Joseph Leizer, Ph.D., a state agency psychologist; Dr. Michael Hartman, M.D., a state agency physician; Dr. Robert McGuffin, M.D., a state agency physician; and Richard J. Milan, Jr., Ph.D., a state agency psychologist.
Amaya treated with Dr. Jo Ann Arey, M.D., with Blue Ridge Health Associates, from Janaury 2006 to March 2008. (R. at 394-405, 408-28, 430-36, 438-44, 470-72.) Dr. Arey performed a new patient evaluation of Amaya on January 23, 2006. (R. at 394-96.) Amaya told Dr. Arey that she had a "nervous breakdown" when she was 30 years old and had been taking Prozac and Seroquel ever since. (R. at 394.) Amaya told her that she also had been given Xanax in the past, but that she had undergone drug rehabilitation to quit taking Xanax. (R. at 394.) Amaya said that she had suffered a mild heart attack when she was being tapered off Xanax. (R. at 394.) Amaya complained of depression, insomnia, high blood pressure and occasional headaches. (R. at 394.) Dr. Arey's physical examination revealed nothing abnormal other than blood pressure readings of 138/90 and 156/90. (R. at 395.) She noted that Amaya was oriented with no signs of mood, thought or memory difficulty. (R. at 395.)
Amaya returned to see Dr. Arey on February 20, 2006, complaining of depression and years of daily headaches. (R. at 397.) Dr. Arey noted that Amaya's affect was tearful, congruent with her stated mood without signs of thought or memory difficulty. (R. at 398.) She denied any suicidal or homicidal ideations. (R. at 398.) Amaya said that she experienced headaches at least twice a month that required something stronger than over-the-counter medications. (R. at 397.) She stated that her previous physician had given her Vicodin. (R. at 397.) Amaya stated that she was having trouble finding a job and could no longer work as a nurse due to "stress." (R. at 397.) Dr. Arey gave Amaya a prescription for Ultram for her headaches and referred her for counseling. (R. at 397.)
On April 20, 2006, Dr. Arey instructed Amaya that she must be seen on a monthly basis to continue to receive refills of her prescriptions. (R. at 403.) On this occasion, Amaya continued to complain of high blood pressure, "nerves, " and headaches. (R. at 403.) Amaya stated that she was taking up to 10 Tylenol a day for headaches, which she attributed to high blood pressure. (R. at 403.) Amaya stated that she drank three to four caffeinated beverages a day, but denied any use of alcohol or illegal drugs. (R. at 403.) Dr. Arey encouraged Amaya to stop taking the over-the-counter medication for her headaches due to rebound headaches and urged her to taper off caffeine. (R. at 403.) She also recommended a neurological evaluation. (R. at 403.) She wrote Amaya a prescription for Vicodin to use sparingly for only severe headaches. (R. at 403.) Amaya relayed experiencing episodes of depression and said that she had a lot of anger related to her father and the way her life had turned out. (R. at 403.)
On July 19, 2006, Amaya told Dr. Arey that her "nerves" and depression were much better since taking a new job, getting out of the house and making new friends. (R. at 409.) She also stated that she had stopped consuming caffeine, and her headaches had improved. (R. at 409.) Dr. Arey also noted that Amaya's hypertension had improved with a blood pressure reading of 121/76. (R. at 409-10.) Dr. Arey did prescribe 15 Vicodin to use as needed for severe headaches. (R. at 410.)
On July 23, 2006, Amaya presented to the Twin County Regional Hospital emergency department seeking treatment for a headache. (R. at 344-52.) Amaya stated that she had run out of her Vicodin. (R. at 346, 348.) The emergency room physician gave Amaya another prescription for Vicodin. (R. at 347.) On August 15, 2006, Amaya presented to the emergency department with complaints of extremity pain due to lifting at work. (R. at 334-43.) The attending physician diagnosed left rotator cuff strain. (R. at 337.) She was given a Toradol shot and prescriptions for Ultracet and Orudis. (R. at 335, 342.)
On August 16, 2006, Dr. Arey saw Amaya for complaints of a sprain/strain of her left shoulder. (R. at 412.) Amaya stated that she had filled in as a dishwasher at her job, which had required lifting a large rack of glasses and dishes repetitively over her head. (R. at 412.) Amaya said that she had received a Toradol shot the night before in the hospital emergency department, and it had helped. (R. at 412.) Dr. Arey noted mild soreness and pain upon movement in Amaya's shoulder, with normal strength and sensation in both arms. (R. at 413.) Dr. Arey prescribed Mobic for shoulder pain and told Amaya that she might use her Vicodin sparingly. (R. at 412.) Dr. Arey released Amaya to return to light-duty work pending her next doctor's appointment. (R. at 412.)
Amaya returned for follow-up on her shoulder injury on August 29, 2006. (R. at 414.) Amaya stated that she worked light-duty only one day before she was placed by her employer back in the dishwashing position, resulting in pain in both shoulders. (R. at 414.) Dr. Arey stated that Amaya should not work again until September 4, 2006. (R. at 414.) She gave Amaya a Toradol injection and told her to take Aleve and Vicodin sparingly for pain. (R. at 414.)
Amaya again sought treatment at the Twin County Regional Hospital emergency department on September 23, 2006, for complaints of being sore all over due to a motor vehicle accident. (R. at 322-32.) The attending physician diagnosed cervical strain. (R. at 325.) Amaya was given prescriptions for Flexeril and Naprosyn. (R. at 331.)
Amaya was upset when she returned to see Dr. Arey on September 28, 2006, explaining that she had been in three motor vehicle accidents, totaling all three vehicles, in a 24-hour period recently. (R. at 420.) Dr. Arey noted that Amaya was very anxious and tearful. (R. at 419.) Amaya stated that the first accident was the result of another driver pulling out in front of her vehicle. (R. at 420.) She stated that she experienced blackout spells during the other two accidents. (R. at 420.) Amaya stated that she suffered a cervical sprain with neck discomfort as a result of these accidents. (R. at 420.) Amaya denied taking excessive medication or running out of any of her medications prior to these blackouts. (R. at 420.) Although Amaya denied using any illegal drugs, she admitted that she would sometimes "get Percocet of the street" for her headaches. (R. at 420.) Dr. Arey stated that Amaya had suffered some "absence-type spells" in the past with no evidence of seizure activity. (R. at 420.) Dr. Arey instructed Amaya not to drive and arranged an appointment with a neurologist. (R. at 419.) Dr. Arey also gave Amaya a prescription for Percocet. (R. at 420.)
Amaya returned on October 1, 2006, and saw Dr. Robert Pryor, M.D., complaining of pain all over and headache. (R. at 422.) Amaya claimed that she was taking Percocet every four hours for pain with only partial relief and that she could not sleep because of the pain. (R. at 422.) Dr. Pryor noted an abrasion on Amaya's left neck from a "seatbelt burn" and blisters on both feet. (R. at 422.) Amaya stated that the blisters on her feet were from where she "walked the streets for 3 days before I came to." (R. at 422.) Dr. Pryor stated that her complaints of myalgias were not unexpected after a significant motor vehicle accident, but he did note that Amaya had made numerous previous requests for narcotics in the past. (R. at 422.) Nonetheless, Dr. Pryor gave Amaya prescriptions for Percocet and Flexeril. (R. at 422.)
Amaya returned to the Twin County Regional Hospital on October 5, 2006, stating that she was out of her pain medication. (R. at 312-21.) Amaya requested a prescription for Percocet, but was discharged with a prescription for Ultram. (R. at 320.)
When Amaya returned to see Dr. Arey on December 12, 2006, she told Dr. Arey that she had not kept her referral to a neurologist because she had decided that her Seroquel prescription was the cause of her blackouts and that she had discontinued taking it. (R. at 426.) Amaya explained that about a month previous she had stopped taking all of her medications. (R. at 426.) After about a week, she decided that she needed to take her blood pressure medicine because her blood pressure was rising, and she was having headaches. (R. at 426.) Amaya said that she went back on all of her medicine except for the Seroquel and that she increased her Klonopin dose from twice a day to three times a day without consulting any physician. (R. at 426.) Amaya stated that she had not experienced any feelings of "being outside her body" since stopping the Seroquel. (R. at 426.) Amaya stated that she was back at work part-time. (R. at 426.) Dr. Arey advised Amaya that it was dangerous to stop her medications without consulting a physician, and referred Amaya to a psychiatrist for adjustment of her medications for bipolar disorder. (R. at 426.) Dr. Arey again referred Amaya to a neurologist to evaluate her bouts of syncope. (R. at 426.)
Amaya returned to see Dr. Arey on January 23, 2007, stating that she had not seen a psychiatrist because of her lack of insurance. (R. at 433.) Amaya stated that she was taking her medications as prescribed. (R. at 433.) She said that her depression was better, although she still experienced some mood swings. (R. at 433.) Amaya stated that she had an appointment scheduled for the next day with a neurologist to evaluate her headaches, and she requested a prescription for additional ...