United States District Court, W.D. Virginia, Harrisonburg Division
JOEL C. HOPPE, Magistrate Judge.
Plaintiff Debra Ann Mullenax 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. §§ 401-34, 1381-1383f. On appeal, Mullenax argues that the ALJ erred in weighing her credibility and evaluating the opinions of her treating physicians. The case is before me by the parties' consent under 28 U.S.C. § 636(c)(1). ECF No. 17. Having considered the administrative record, the parties' briefs and oral arguments, and the applicable law, I find that substantial evidence supports the Commissioner's final decision, and it is therefore affirmed.
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), 416.905(a). Social Security ALJ's 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)(4), 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
Mullenax filed for DIB and SSI on March 9, 2011. See Administrative Record ("R.") 10. She was 50 years old, R. 333, and had worked as a restaurant server, R. 359. Mullenax alleged disability because of a brain aneurysm, subarachnoid hemorrhage, high blood pressure, and fibromyalgia. R. 187. A state agency twice denied her applications. R. 10. Mullenax appeared with counsel before ALJ Brian Kilbane for an administrative hearing on December 6, 2012. R. 30-48. Mullenax testified about her medical conditions and the limitations those conditions caused in her daily life activities. R. 33-39. A vocational expert ("VE") also testified about Mullenax's work experience and her ability to return to her past work or to perform other work in the national or local economies. R. 39-46.
The ALJ denied Mullenax's application in a written decision dated January 18, 2013. R. 10-22. ALJ Kilbane first addressed Mullenax's prior applications and the prior decisions against her. R. 10. Mullenax previously filed claims for DIB and SSI on March 13, 2007, and April 30, 2009; these claims were rejected, respectively, by ALJ Charles Boyer on March 17, 2009, R. 117-27, and ALJ Mark O'Hara on January 28, 2011, R. 136-53. Both Mullenax's current claims and her prior claim filed in April 2009 alleged a disability onset date of February 19, 2007. R. 10. ALJ Kilbane found that ALJ O'Hara's determination that Mullenax was not disabled as of January 28, 2011, was determinative of the issue of her disability prior to that date, and he addressed only the period afterwards for her current applications. Id.
ALJ Kilbane found that Mullenax had severe impairments of a back disorder, fibromyalgia, status post 2005 myocardial infarction, and status post 2007 brain aneurysm and hemorrhage. R. 13-14. He determined that these impairments, alone or in combination, did not meet or equal a listing. R. 14-15. The ALJ next determined that Mullenax had the residual functional capacity ("RFC") to perform "light work" except that she "can only occasionally climb, balance, stoop, kneel, crouch, and crawl and he [sic] should avoid all exposure to hazards such as moving machine parts and unprotected heights." R. 15. Relying on the VE's testimony, the ALJ concluded at step four that Mullenax could perform her past relevant work as a restaurant server. R. 33. Again relying on the VE's testimony, the ALJ alternatively found that Mullenax could perform other jobs available in the economy, including housekeeper, cafeteria attendant, and cashier. R. 20-21. He therefore determined that she was not disabled under the Act. R. 21. The Appeals Council declined to review that decision, R. 1-3, and this appeal followed.
Mullenax raises two arguments on appeal. First, she contends that ALJ Kilbane failed to provide specific reasons, supported by the record, for not fully crediting her statements concerning the extent of her limitations. Pl. Br. 5-10, ECF No. 18. Second, she contends that he incorrectly weighed opinions from two of her treating physicians by disregarding their entire statements because a part of each concerned an issue reserved to the commissioner. Id. at 10-12.
A. Relevant Medical Evidence
On March 31, 2011, Mullenax saw Robert G. Kennedy, M.D., for a follow-up appointment concerning her "continued facial numbness, fibromyalgia, hypertension, and anxiety." R. 1921. She had diminished sensation and mild facial weakness on the left side of her face, but had increased movement of it. Id. Her back and shoulder displayed some tenderness, and she had some triggering in two fingers. Id. She complained of pain between her shoulder blades, radiating into her neck, and pain in both hands, worse in the right hand. Id. She also reported increased difficulty with her mood and anxiety and stated that she might be having panic attacks. Id. Dr. Kennedy noted that she was in no real cardiopulmonary distress and found her pleasant, talkative, cooperative, and interactive. Id. He assessed facial numbness, fibromyalgia, hypertension, coronary artery disease status post myocardial infarction, and "anxiety now with marked panic." Id. He also opined that "[g]iven her difficulties with the neurologic symptoms as well as the fibromyalgia... it is unlikely that she will be able to return to work." Id.
On June 14, 2011, Mullenax had a rheumatology follow-up appointment with Matthew S. Hogenmiller, M.D. R. 2236. She reported tight, burning pain of 3 or 4 out of 5 in her shoulders and back. R. 2238. She walked with a normal gait and no assistive devices. Id. Dr. Hogenmiller recorded that she had severe fibromyalgia, cervical spondylosis, and recurrent tenosynovitis for which he did not know the cause. R. 2236. Mullenax declined treatment with a steroid pack because she did not like how they had made her feel, and Dr. Hogenmiller recommended Aleve. Id.
Mullenax returned to Dr. Kennedy on August 8 for a follow-up and evaluation of new chest pain. R. 2280. She reported constant left-side facial numbness; pain in her neck, upper back, and right foot; and aching in her elbows, knees, and ankles. Id. She rated her pain as a 3.5 out of 5. Id. She had increased her oxycodone use to four or five times per day. Id. She reported tightness in her chest and shortness of breath after walking half a block. Id. She also said that her hands and feet go numb and her memory was getting worse. Id. On examination, she had no cardiopulmonary distress, bilateral expiratory wheezes in her lungs, no tremor in her hands, some tenderness across her right big toe, and no swelling or erythema. Id. Dr. Kennedy assessed polyarthralgias, dyspnea related to smoking, and hypertension. Id.
On August 16, Mullenax had a follow-up appointment with Dr. Hogenmiller. R. 2235. She had mild difficulty with her wrist on extension and less swelling from her tenosynovitis than at her last visit. Id.
On August 24, Mullenax reported to cardiologist Masood Ahmed, M.D., per Dr. Kennedy's referral. R. 2269-71. She complained of worsening shortness of breath on exertion and chest discomfort during anxiety attacks. R. 2269. She displayed no obvious orthopnea or ankle swelling and denied any syncope, presyncope, loss of consciousness, significant palpitation, or feelings of tachyarrhythmia or bradyarrhythmia. Id. On examination, Mullenax had no sounds in her lungs; no focal motor or sensory deficits; and no edema or joint deformity, swelling, or tenderness. R. 2270. An electrocardiogram ("ECG") returned normal findings. R. 2271. Dr. Ahmed assessed dypsnea with exertion, no known coronary artery blockage, hypertension dyslipidemia, a prior brain aneurysm, cervical joint degenerative disc disease, and fibromyalgia. Id. He ordered an echocardiogram and stress test and prescribed additional medication to address her blood pressure. Id.
On September 14, Mullenax returned to Dr. Ahmed. R. 2266-68. As part of the history of her present illness, Dr. Ahmed recorded that Mullanex was able to perform her daily activities without any limitation. R. 2266. On examination, there was no evidence of lower extremity edema or any joint deformity or swelling. R. 2267. The echocardiogram was essentially normal, showing no evidence of pulmonary hypertension, no valvular abnormality, and diastolic parameters within the normal range. Id. The stress test was negative for ischemic ECG changes and a myocardial perfusion imaging study showed no ischemia. Id. Dr. Ahmed ...