United States District Court, W.D. Virginia, Big Stone Gap Division
PAMELA MEADE SARGENT, Magistrate Judge.
I. Background and Standard of Review
Plaintiff, Teresa Morangello Hunley, ("Hunley"), filed this action challenging the final decision of the Commissioner of Social Security, ("Commissioner"), determining that she was not eligible for supplemental security income, ("SSI"), under the Social Security Act, as amended, ("Act"), 42 U.S.C.A. § 1381 et seq . (West 2012). Jurisdiction of this court is pursuant to 42 U.S.C. § 1383(c)(3). This case is before the undersigned magistrate judge upon transfer by consent of the parties pursuant to 28 U.S.C. § 636(c)(1).
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 Hunley protectively filed her application for SSI on February 26, 2009, alleging disability as of January 21, 2009,  due to hearing loss, unsteady balance, back and knee problems, migraine headaches, depression and anxiety. (Record, ("R."), at 279-81, 293, 297, 323.) The claim was denied initially and on reconsideration. (R. at 199-201, 205-07, 210-11, 213-15, 217-19.) Hunley then requested a hearing before an administrative law judge, ("ALJ"). (R. at 220-21.) The hearing was held on September 29, 2011, at which Hunley was represented by counsel. (R. at 129-68.)
By decision dated October 20, 2011, the ALJ denied Hunley's claim. (R. at 112-22.) The ALJ found that Hunley had not engaged in substantial gainful activity since February 26, 2009, the date of her application. (R. at 115.) The ALJ determined that the medical evidence established that Hunley suffered from severe impairments, including recurrent subluxation/dislocation of the patella status-post arthroscopy, sensory/conductive and sensorineural hearing loss, asthma, mild degenerative disc disease of the lumbar spine, depression, anxiety and headaches, but she found that Hunley did not have an impairment or combination of impairments listed at or medically equal to one listed at 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. at 115-16.) The ALJ found that Hunley had the residual functional capacity to perform simple, routine, repetitive light work that did not require more than limited pushing/pulling with the lower extremities, that did not require crawling, climbing ladders, ropes or scaffolds, working on vibrating surfaces, at unprotected heights, near hazardous machinery, exposure to excessively loud background noise or interaction with the general public and that did not require more than occasional balancing, stooping, kneeling, crouching or climbing of ramps and stairs. (R. at 116-17.) The ALJ found that Hunley was unable to perform her past relevant work. (R. at 121.) Based on Hunley's age, education, work history and residual functional capacity and the testimony of a vocational expert, the ALJ found that Hunley could perform other jobs existing in significant numbers in the national economy, including jobs as a merchandise marker, a laundry worker and a housekeeper. (R. at 121-22.) Therefore, the ALJ found that Hunley was not under a disability as defined under the Act and was not eligible for benefits. (R. at 122.) See 20 C.F.R. § 416.920(g) (2014).
After the ALJ issued her decision, Hunley pursued her administrative appeals, but the Appeals Council denied her request for review. (R. at 1-5.) Hunley 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. § 416.1481 (2014). The case is before this court on Hunley's motion for summary judgment filed May 7, 2014, and the Commissioner's motion for summary judgment filed July 14, 2014.
Hunley was born in 1967, (R. at 137, 279), which classifies her as a "younger person" under 20 C.F.R. § 416.963(c). Hunley has two years of college with certification as a paralegal, and she has vocational training in data processing. (R. at 137-38, 303.) Hunley has past work as a fast food worker. (R. at 157, 298.) Hunley testified that she experienced three panic attacks a week. (R. at 144.) She stated that she could stand and/or sit for up to 15 minutes without interruption. (R. at 149.) Hunley stated that she could lift items weighing up to 10 pounds. (R. at 149-50.) She stated that she could walk 100 yards without interruption. (R. at 150.)
Mark Heileman, a vocational expert, also was present and testified at Hunley's hearing. (R. at 156-64.) Heileman was asked to consider an individual who had the residual functional capacity to perform simple, routine, repetitive light work that required no more than occasional climbing of ramps and stairs; balancing; kneeling; stooping; and crouching, that did not require crawling or working around concentrated exposure to extreme temperatures; excess humidity; pollutants; irritants; hazardous machinery; unprotected heights; vibrating surfaces; or excessively loud background noises, and that did not require climbing ladders, ropes or scaffolds or interacting with the general public. (R. at 157-58.) Heileman stated that such an individual could not perform Hunley's past relevant work. (R. at 158.) Heileman was asked if other work existed that an individual of Hunley's age, education and past work experience, who was limited as indicated in the previous hypothetical, could perform. (R. at 158.) He stated that there was a significant number of jobs that existed that such an individual could perform, including jobs as a merchandise marker, a housekeeping cleaner and a laundry worker. (R. at 158.) Heileman was asked to consider a hypothetical individual who was limited as indicated by the assessment dated September 20, 2011, completed by Dr. Nazia I. Shehzad, M.D. (R. at 159, 864-66.) He stated that there would be no jobs available that such an individual could perform. (R. at 159-60.) Heileman was asked to consider a hypothetical individual with the limitations indicated by the assessments dated November 30, 2009, and July 23, 2011, completed by Robert S. Spangler, Ed.D., a licensed psychologist. (R. at 160, 729-31, 853-55.) He stated that there would be no jobs available that such an individual could perform. (R. at 160-62.) Heileman was asked to consider a hypothetical individual with the limitations indicated by the assessment dated March 27, 2009, completed by Dr. Uzma Ehtesham, M.D. (R. at 162-63, 669-71.) He stated that there would be no jobs available that such an individual could perform. (R. at 163.) Heileman was then asked to consider a hypothetical individual with the limitations indicated by the assessment of Dr. Jill Couch, D.O., dated June 7, 2007. (R. at 163-64, 473-74.) He stated that there would be no jobs available that such an individual could perform. (R. at 164.)
In rendering her decision, the ALJ reviewed records from Lee County Schools; Sabrina Mitchell, F.N.P., a family nurse practitioner; Dr. J. William Boyle, III, M.D.; Indian Path Medical Center; Wellmont Rehabilitation Services; Dr. Nazia I. Shehzad, M.D.; Howard S. Leizer, Ph.D., a state agency psychologist; Dr. Robert McGuffin, M.D., a state agency physician; Julie Jennings, Ph.D., a state agency psychologist; Dr. Michael Hartman, M.D., a state agency physician; Norton Community Hospital; Dr. S. C. Kotay, M.D.; Sullivan Digestive Center; Dr. L. Del Bailey, M.D.; Pikeville Neurology Clinic & Diagnostic Center; Dr. Laurent J. Legault, M.D.; Dr. Sai P. Gutti, M.D.; Robert S. Spangler, Ed.D., a licensed psychologist; Dr. Uzma Ehtesham, M.D.; Holston Valley Medical Center; Dr. Jeffrey T. Hunt, M.D.; Stone Mountain Health Services; University of Virginia Health Services; Lonesome Pine Hospital; Lee Regional Medical Center; ETSU Family Physicians of Kingsport; Frontier Health; and State of Tennessee Department of Mental Health and Developmental Disabilities. Hunley's attorney submitted additional medical records from Dr. Shehzad to the Appeals Council.
Hunley was treated by Dr. Sai P. Gutti, M.D., a pain specialist, from July 2007 through December 2009 for lower back pain. (R. at 446-48, 517-20, 688-98, 701-11, 713-19.) Dr. Gutti diagnosed low back pain, lower extremity radiculitis and bilateral sacroiliitis. (R. at 688-93, 702.) On April 7, 2009, an MRI of Hunley's lumbar spine was normal. (R. at 697-98.) Hunley underwent bilateral sacroiliac joint injections in July and October 2009, and he reported a good response. (R. at 701, 713, 715, 718.) On October 27, 2009, Hunley reported that her residual pain was tolerable with medication, and her activities of daily living had improved. (R. at 714.)
Hunley treated with Dr. Uzma Ehtesham, M.D., for depression and anxiety from October 23, 2007, through February 1, 2010. (R. at 521-22, 672-84, 746-55.) On October 30, 2007, Dr. Ehtesham noted that Hunley was depressed and anxious, but her appearance was normal, her thought process linear, and her thought content was unremarkable. (R. at 521.) Hunley reported that her symptoms of depression improved on medications. (R. at 521.) On November 13, 2008, Hunley reported that her symptoms of depression had worsened. (R. at 647.) Dr. Ehtesham diagnosed major depressive disorder and generalized anxiety disorder. (R. at 652.) Dr. Ehtesham assessed Hunley's then-current Global Assessment of Functioning, ("GAF"),  score at 60. (R. at 652.) On December 2, 2008, Hunley reported that she was doing fairly well, stating that her mood swings and anger were less. (R. at 645-46.) Dr. Ehtesham assessed Hunley's anxiety and depression on a scale of one to 10 and concluded that her anxiety ranked at level three, and her depression ranked at six. (R. at 645.) Dr. Ehtesham noted that Hunley was anxious and displayed fair insight and intact judgment. (R. at 645.)
On March 27, 2009, Dr. Ehtesham completed a mental assessment indicating that Hunley had an unsatisfactory ability to understand and remember simple instructions and to interact appropriately with the public and supervisors. (R. at 669-71.) Dr. Ehtesham indicated that Hunley had no useful ability to carry out simple instructions, to make judgments on simple work-related decisions, to understand, remember and carry out complex instructions, to make judgments on complex work-related decisions, to interact appropriately with co-workers and to respond appropriately to usual work situations and to changes in routine work settings. (R. at 669-70.) Dr. Ehtesham reported that Hunley was permanently disabled. (R. at 671.)
On May 1, 2009, Dr. Ehtesham completed a Mental Status Evaluation Form indicating that Hunley's depression had worsened and, as a result, her relationships with family and friends had decreased. (R. at 672-76.) Hunley's mood was noted as sad, her memory had decreased, and she experienced hallucinations when under stress. (R. at 673.) Hunley had decreased concentration, and her judgment and fund of knowledge were deemed fair. (R. at 674.) Dr. Ehtesham opined that Hunley was unstable when under stress. (R. at 674.) On December 31, 2009, Dr. Ehtesham completed a medical evaluation for Lee County Department of Social Services indicating that Hunley was unable to participate in employment and training activities in any capacity as a result of her anger problems, and the expected duration of incapacity was 90 days. (R. at 733-34.) Dr. Ehtesham diagnosed major depressive disorder, single episode, severe, without psychotic behavior; and generalized anxiety disorder. (R. at 734.) It also was noted that Hunley's condition hindered her ability to care for her children. (R. at 734.) Also, on December 31, 2009, Hunley reported that her anger and depression were less, and her sleep was improving. (R. at 748.) Dr. Ehtesham rated Hunley's anxiety level at three out of 10. (R. at 746.) Hunley's insight was fair, and her judgment intact. (R. at 748.) On February 1, 2010, Hunley reported that her depression was improving, and her anxiety was lessening. (R. at 746.)
Dr. Ehtesham completed a mental assessment indicating that Hunley was seriously limited in her ability to understand, remember and carry out simple instructions and to interact appropriately with the public. (R. at 803-05.) Dr. Ehtesham reported that Hunley had no useful ability to make judgments on simple work-related decisions, to understand, remember and carry out complex instructions, to make judgments on complex work-related decisions, to interact appropriately with supervisors and co-workers and to respond appropriately to usual work ...