United States District Court, W.D. Virginia, Harrisonburg Division
BRIAN S. RUSSELL, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner, Social Security Administration, Defendant.
JOEL C. HOPPE, Magistrate Judge.
Plaintiff Brian S. Russell asks this Court to review the Commissioner of Social Security's ("Commissioner") final decision denying his 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. The case is before me by the parties' consent under 28 U.S.C. § 636(c)(1). Having considered the administrative record, the parties' briefs and oral argument, and the applicable law, I find that the Commissioner's final decision is not supported by substantial evidence in the record. The decision is reversed and the case remanded under the fourth sentence of 42 U.S.C. § 405(g).
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)). 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 to 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 claimant 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 claimant is not disabled. See id.
II. Procedural History
Russell filed for DIB and SSI on June 8, 2011. See Administrative Record ("R.") 53, 66. He was 36 years old, R. 53, and had worked most recently as a disassembler at an auto parts shop. R. 199. Russell alleged disability beginning on February 1, 2001, because of scoliosis, herniated discs in his neck and lower back, and Attention Deficit Disorder. R. 168, 178, 224. He met the DIB insured-status requirements through March 31, 2011. R. 84. After a state agency twice denied his applications, R. 65, 98, Russell appeared with counsel at an administrative hearing on May 15, 2013. R. 27. At the hearing, Russell amended his alleged disability onset date to January 1, 2011. R. 30. He testified about his mental and physical conditions and the limitations they placed upon his daily activities. R. 31-45. A vocational expert ("VE") also testified about the nature of Russell's past work and his ability to perform other jobs in the national and local economy. R. 45-51.
The ALJ denied Russell's application in a written decision dated June 21, 2013. R. 13-23. He found that Russell had severe impairments of degenerative disc disease in his lumbar, cervical, and thoracic spine. R. 15. He determined that these impairments, alone and in combination, did not meet or equal a listing. R. 17. The ALJ next determined that Russell had the residual functional capacity ("RFC") to perform light work with some postural restrictions. Id. Relying on the VE's testimony, the ALJ concluded at step four that Russell could return to his past relevant work as an artisan. R. 22. As an alternative finding, the ALJ determined that Russell can perform other jobs that exist in significant numbers in the economy, such as security guard, hand packer, and retail sales clerk. R. 22-23. He therefore determined that Russell was not disabled under the Act. R. 23. The Appeals Council declined to review that decision, R. 1, and this appeal followed.
III. Relevant Medical Evidence
A. Treatment Notes
Russell's medical records indicate that he has a long history of degenerative disc disease in the lumbar, thoracic, and cervical spine, see, e.g., R. 316, 320, 325-28, 356, 429, 498, 529, 543, 607, 612, that has worsened since 2004, see R. 664, 650, 705.
An MRI of Russell's cervical and thoracic spine taken on September 21, 2010, showed degenerative disc disease at C5-C6 and C6-C7, but no evidence of vertebral body fracture or malalignment. R. 664. The reviewing radiologists opined that Russell had mild to moderate central canal stenosis at C6-C7, minimal multilevel degenerative disc disease at the mid-thoracic spine, and posterior bulge and superimposed annular tear at T11-T12 causing minimal central canal narrowing. R. 665.
On October 14, 2010, Russell visited UVA Hospital East for a follow-up appointment and reported that lying flat, bending his neck, and holding extra weight made his pain worse. R. 484. He told Lara Myers, N.P., that "physical therapy had worked for him in the past, " he was currently looking for a physical therapy facility, and he was "not interested in pursuing invasive techniques of treatment." Id.
In March 2011, Russell began treatment at Middlebrook Family Medicine ("Middlebrook"). R. 784. Russell was seen by Kenneth Perkins, P.A., and Cindy Almarode, N.P., during most of these visits, see R. 649-62, 675-702, 732-43, 746-83, but both operated under the supervision of John Marsh, M.D., see, e.g., R. 744 (treatment note from Dr. Marsh), 741-42 (treatment note from Nurse Almarode co-signed by Dr. Marsh).
On March 24, 2011, Russell told Mr. Perkins that he had chronic cervical, thoracic, and lumbar spine pain that had recently started to radiate down his left hip and leg. R. 604. On examination, he had tenderness throughout his spine, with more tenderness at L4-L5 on the left side than the right. Id. He had left-side pain on a straight leg raise test at 20 degrees, and his left leg had decreased quadriceps strength and foot extension compared to his right. Id. Mr. Perkins found no ...