United States District Court, W.D. Virginia, Danville Division
IRMA J. DAILEY, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner, Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
JOEL C. HOPPE, Magistrate Judge.
Plaintiff Irma J. Dailey asks this Court to review the Commissioner of Social Security's ("Commissioner") final decision denying her applications for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-422, 1381-1383f. This Court has authority to decide Dailey'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). On appeal, Dailey primarily argues that the Administrative Law Judge erred in finding that some of her impairments were not severe and in assigning no functional limitations to those impairments. See generally Pl. Br. 23-30, ECF No. 13. Having considered the administrative record, the parties' briefs, and the applicable law, I find that substantial evidence supports the Commissioner's final decision that Dailey is not disabled.
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 Administrative Law Judge ("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); 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) (governing claims for DIB), 416.905(a) (governing adult claims for SSI). 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), 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
Dailey protectively filed for DIB and SSI on May 31, 2011. See Administrative Record ("R.") 66, 76. She was 44 years old, id., and had last worked as a part-time companion to her mother, who passed away in April 2009. See R. 227. Dailey alleged disability beginning March 23, 2011, due to a host of medical conditions, including diabetes, hypertension, monocular blindness and blurred vision, carpal tunnel syndrome ("CTS"), back and neck pain, and leg cramps. See R. 223, 227. The state agency twice denied her applications. R. 86-87, 117-18.
Dailey appeared with counsel at a hearing before Administrative Law Judge Marc Mates ("the ALJ" or "ALJ Mates") on July 24, 2012. R. 25. She testified as to many of her alleged impairments and the limitations those impairments caused in her daily activities. See R. 30-39. A vocational expert ("VE") also testified as to Dailey's ability to return to her past work or to perform other work existing in the national and regional economies. See R. 39-43.
In a written decision dated August 31, 2012, ALJ Mates concluded that Dailey was not entitled to disability benefits after March 23, 2011. R. 20. He found that Dailey suffered from three "severe impairments: loss of visual acuity in the right eye, migraines, and osteoarthritis, " R. 13, but that these impairments were not presumptively disabling, R. 15-16. He also found that Dailey's diabetes and thyroid disorder were non-severe impairments because they generally were controlled by medication. See R. 13-14.
ALJ Mates next determined that Dailey had the residual functional capacity ("RFC") to perform a limited range of light work. See R. 16, 19. Specifically, he found that Dailey could (1) occasionally climb ramps and stairs; (2) never climb ladders, ropes, or scaffolds; (3) frequently balance; and (4) occasionally stoop, kneel, crouch, or crawl; but (5) should avoid "concentrated exposure" to noise and "even moderate exposure" to hazards. R. 16.
Relying on the VE's testimony, ALJ Mates concluded that Dailey was not disabled because she could return to her "past relevant work as a companion" as actually or generally performed. R. 18-19. ALJ Mates alternatively concluded that Dailey's age, education, work history, and RFC allowed her to perform other jobs available nationally or in Virginia, such as laundry folder, night cleaner, and office helper. R. 19. The Appeals Council declined to review that decision, R. 1, and this appeal followed.
A. Previous Factual Findings
On March 22, 2011, ALJ Owen found that Dailey had a "history of uncontrolled diabetes mellitus II." R. 54 (citing R. 285, 290-92, 293-95, 297-99, 302-04). A year earlier, Dailey's primary care provider, Dr. Marian Hahesy-Calhoun, M.D., referred Dailey to Dr. Akta Mukherjee, M.D., an endocrinologist, to manage her diabetes. See id. (citing R. 285). Dailey reported that her blood-glucose levels were "up and down" on insulin. R. 285. Dr. Mukherjee diagnosed type II diabetes with neuropathy. She changed Dailey's insulin regimen and counseled her about the roles diet and exercise play in managing diabetes. See R. 54.
Dr. Mukherjee noted that Dailey's blood-glucose levels should stay between 70 and 140 mg/dL and that her A1c should be less than 7%. See id. At the time, Dailey's blood glucose was 151 mg/dL with more than 11% A1c. See R. 285. Dailey's glucose and A1c levels remained high despite multiple medication adjustments between March 2010 and January 2011. See R. 54-56 (citing R. 290-92, 293-95, 297-99, 302-04). She often reported feeling fatigued, dizzy, or nauseous during this time. See R. 53, 286, 293, 297, 302. On January 17, 2011, Dr. Mukherjee also suspected that Dailey had Graves' disease when she reported sudden onset "symptoms of hyperthyroidism" including palpitations, nausea, weakness, and fatigue. See R. 55, 302-08.
Based on evidence available through February 9, 2011, ALJ Owen found that Dailey's diabetes and "hyperactive thyroid" were severe, but not disabling. R. 51, 52, 54-56. He acknowledged that Dailey "experience[d] fatigue despite taking her [insulin] as prescribed, " R. 53, but found that her glucose levels were improving under Dr. Mukherjee's care, R. 58. He also found that Dailey's thyroid medication "appeared to be helping her symptoms" as of her most recent doctor's visit. Id. ALJ Owen found that Dailey had the RFC to perform light work that did not require climbing ropes, ladders, or scaffolds; only occasionally involved stooping, kneeling, crouching, or crawling; and involved at most "moderate exposure to hazards such as machinery and heights." R. 52. Relying on a VE's testimony, ALJ Owen concluded that Dailey was not disabled because she could return to her past work as a cashier in a fast-food restaurant. R. 59.
B. Current Medical Evidence
1. Treatment Records
Dailey continued under Dr. Mukherjee's care from February 2011 to March 2012 during the period relevant to her current applications. See R. 306-09, 438-41, 442-45, 499-502, 504-07, 508-12 (Feb., Apr., June, Aug., Sept. & Nov. 2011); R. 513-16, 518-21 (Feb. & Mar. 2012). Dr. Mukherjee often adjusted Dailey's insulin in an effort to lower her A1c levels. See R. 308, 440, 444, 502, 506-07, 511. Laboratory results show that Dailey's blood-glucose or A1c levels were above target in April, May, August, and November 2011. See R. 369, 442, 472, 475, 504, ...