United States District Court, W.D. Virginia, Danville Division
SANDRA F. PURYEAR, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
REPORT AND RECOMMENDATION
JOEL C. HOPPE, Magistrate Judge.
Plaintiff Sandra Puryear asks this Court to review the Commissioner of Social Security's ("Commissioner") final decision denying her application for disability insurance benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. §§ 401-434, and supplemental security income ("SSI") under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383f. Puryear asserts that the Administrative Law Judge ("ALJ") erred in failing to consider a closed period of disability. This Court has authority to decide Puryear's case under 42 U.S.C. § 405(g), and her case is before me by referral under 28 U.S.C. § 636(b)(1)(B). After considering the administrative record, the parties' briefs, oral arguments, 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); see also 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, and not just the evidence cited by the ALJ. See Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984); see also 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 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); 20 C.F.R. § 404.1505(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. § 404.1520(a)(4); see also 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
Puryear protectively filed for DIB and SSI on October 25, 2011, alleging disability beginning April 30, 2006. Administrative Record ("R.") 20, 188, 192. When she filed her applications, she was 44 years old. R. 188. She had worked as a machine attendant, machine operator, and cook and cashier at a grocery. R. 221. Puryear reported that she was unable to work because of arthritis, diabetes, and high blood pressure. R. 240. A state agency twice denied her application. R. 20.
Puryear appeared with counsel at an administrative hearing on September 4, 2013. R. 41-60. She testified as to her past employment, her symptoms, and the limiting effects of her conditions. R. 45-55. An impartial vocational expert, Barry Hensley, Ed.D., also testified at the hearing. R. 56-59.
In a written decision dated September 27, 2013, the ALJ concluded that Puryear was not disabled. R. 20-33. The ALJ determined that Puryear had not engaged in substantial gainful activity since April 30, 2006. R. 22. He found that Puryear had severe impairments of bilateral knee difficulty, diabetes mellitus, and obesity, none of which met or equaled a listing. R. 22-23. The ALJ determined that Puryear has the residual functional capacity ("RFC") to perform sedentary work as defined in 20 C.F.R. §§ 404.1567(a) and 416.967(a). R. 24. Although the ALJ found that Puryear was not able to perform any past relevant work, he determined that she could perform other work in the national economy. R. 31. Thus, the ALJ found that Puryear was not disabled. R. 33. Puryear sought review by the Appeals Council, which upheld the ALJ's determination. R. 1-3. This appeal followed.
III. Statement of Facts
A. Medical Evidence
Puryear's medical history, as provided for the record, begins on January 8, 2010, when she was seen at Halifax Primary Care, by Arthur Fajardo, M.D. She appeared healthy, looked well, and her diabetes was under control. R. 359-60. Dr. Fajardo made similar findings on June 24, 2010. R. 356-57.
On September 9, 2010, Puryear went to Halifax Primary Care for pre-knee replacement operation clearance after laboratory tests showed that she had low potassium. R. 352. She told Venkat Neelagiri, M.D., that she had left sided knee joint pain from severe degenerative joint disease. R. 352-53.
On October 22, 2010, Puryear had X-rays taken of her lower extremities. The images of her left leg showed severe medial compartment osteoarthritic change with severe joint space narrowing, moderate osteophyte formation, and mild lateral subluxation of the proximal tibia relative to the distal femur. Moderate osteophytic changes were also present in the patellofemoral compartment of the left knee. The images showed no sign of significant joint effusion or other acute process. R. 401.
On November 9, 2010, Puryear was examined by Dr. Neelagiri. Puryear said that an orthopedist, on second opinion, had advised that she did not need knee replacement surgery because her degenerative joint disease was not severe enough. She complained of back stiffness and pain and left knee pain. Dr. Neelagiri's physical examination showed normal range of motion and no joint tenderness in her hips, knees, or ankles. Her gait was normal. She had no joint laxity, muscle weakness in her extremities, or decreased muscle tone. Her knee reflex was normal. R. 346-50.
On January 7, 2011, Puryear had a follow up examination with Dr. Neelagiri. She reported experiencing occasional left low back pain that did not radiate. On examination, Dr. Neelagiri found no lumbar paraspinal spasm or tenderness. Her straight leg raise testing was negative bilaterally, deep tendon reflexes were 2 bilaterally and equal, strength was full in all four extremities, and knee reflex was normal. Puryear's diabetes and hypertension remained controlled. R. 341-43. Dr. Neelagiri made similar findings in April 2011. See R. 334-38.
On April 8, 2011, Puryear was seen at VCU Health System/MCV Hospitals & Physicians, by Jason Hull, M.D., for left medial compartment knee arthritis. Dr. Hull noted that prior X-rays had shown significant narrowing of the medial compartment, especially on the PA flexion view. Puryear had received an injection in October 2010, which she said provided approximately five months of good relief, but she experienced rapid return of symptoms with medial knee pain. Physical examination revealed an antalgic gait on the left side. Puryear had pain-free motion of the left hip and was mildly tender over the left trochanteric bursa. She had varus posture to the left knee with partial correct and medial compartment tenderness. Dr. Hull gave her another cortisone injection. R. 368-69; 396-97.
On September 2, 2011, Puryear had imaging taken of her lower extremities. Kevin Hoover, M.D., reviewed the images, compared them to images taken in 2010, and assessed progressive knee osteoarthritis, which was severe in the medial compartment. R. 400.
On October 12, 2011, Puryear visited Dr. Neelagiri for a six-month follow-up. On exam, Dr. Neelagiri found no lumbar paraspinal spasm or tenderness, negative bilateral straight leg raise testing, normal deep tendon reflexes, and full strength in all four extremities. Puryear had mild tenderness in her knee joints and ...