United States District Court, Western District of Virginia, Danville Division
REPORT AND RECOMMENDATION
Joel C. Hoppe United States Magistrate Judge
Plaintiff Cherran Carter 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. Carter asserts that the Administrative Law Judge (“ALJ”) erred in determining that she did not have a severe impairment or combination of impairments. She asks the Court to reverse the Commissioner’s decision and to award benefits or remand her case for further administrative proceedings.
This Court has authority to decide Carter’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. 12. After considering 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); 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, not just the evidence cited by the ALJ. See Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984); 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); 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
Carter protectively filed for SSI on October 21, 2010. Administrative Record (“R.”) 43. She was 58 years old and had not worked since November 22, 1992. R. 43, 128. Carter claimed disability onset date of July 15, 2010, because of arthritis in her knees, diabetes, hypertension, and back pain. R. 43, 45. A state agency denied her application initially and upon reconsideration. R. 12.
Carter appeared with counsel at an administrative hearing on October 13, 2011. R. 24. She testified to her alleged impairments and the limitations they placed upon her daily activities. R. 31–42. A vocational expert was present, but the ALJ determined that he did not need to hear further testimony. R. 40.
In a written decision dated February 29, 2012, the ALJ found that Carter was not disabled under the Act. R. 12–18. He found that she had not engaged in substantial gainful activity since her application date and that she suffered from five medically determinable impairments: “dysfunction of her knees, diabetes mellitus, hypertension, obesity, and back pain.” R. 14. He then found that neither Carter’s individual impairments nor their combination constituted a “severe” impairment. Id. The ALJ also discredited Carter’s statements concerning the intensity, persistence, and limiting effects of her impairments to the extent that they contradicted a finding that she did not suffer from a severe impairment or combination of impairments. R. 17. He therefore determined Carter was not disabled and denied her application. R. 18. The Appeals Council declined to review the ALJ’s decision on July 19, 2013, and this appeal followed. R. 1.
Carter asserts that the ALJ erred in determining that she did not have a severe impairment or combination of impairments. Pl. Br. 16, ECF No. 16. Specifically, she argues that her bilateral knee condition and obesity were severe, the ALJ improperly discounted her complaints of pain and limitations, and the ALJ failed to consider the combined effect of her limitations, especially her obesity. Id. at 12–17.
A. Relevant evidence
1. Medical Evidence
Carter’s medical record begins with a series of handwritten treatment notes from her primary care physician, Dr. Tomas M. Alabanza, M.D. See R. 155–71. These are largely indecipherable. The notes do reveal that Carter saw Dr. Alabanza once for muscle spasms in her back on May 25, 2011, R. 170, and five times for knee pain between December 2009 and August 2011, R. 155, 160, 161, 167, 169. During the same period, Dr. Alabanza’s notes include a diagnosis of degenerative arthritis in one or both of her knees six times, R. 155, 160, 161, 165, 169, 171, and of osteoarthritis in one or both of her knees three times, R. 167, 169, 170. Additional legible statements include a note from August 13, 2010, that Ibuprofen did not help alleviate Carter’s pain, R. 155, and two notes mentioning Carter’s meniscus in relation to her arthritis, from December 15, 2009, R. 161, and April 15, 2010, R. 160.
Dr. Alabanza ordered an X-ray of Carter’s knees, which was performed on December 6, 2010. R. 162–63. Carter’s left knee showed “mild medial and patellofemoral joint osteoarthrosis with a slight amount of osteopenia.” R. 162. Carter’s right knee showed “mild medial and patellofemoral joint osteoarthrosis, ” “small joint effusion, ” and ...