United States District Court, W.D. Virginia, Big Stone Gap Division
MELISSA S. MAYS, Plaintiff
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant
Pamela Meade Sargent United States Magistrate Judge
I. Background and Standard of Review
Plaintiff, Melissa S. Mays, (“Mays”), filed this action challenging the final decision of the Commissioner of Social Security, (“Commissioner”), determining that she was not eligible for disability insurance benefits, (“DIB”), under the Social Security Act, as amended, (“Act”), 42 U.S.C.A. § 423 (West 2011). Jurisdiction of this court is pursuant to 42 U.S.C. § 405(g). This case is before the undersigned magistrate judge by transfer based on consent of the parties pursuant to 28 U.S.C. § 636(c)(1). Oral argument has not been requested; therefore, the matter is ripe for decision.
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 Mays protectively filed an application for DIB on October 21, 2010, alleging disability as of October 9, 2008, due to multiple sclerosis, (“MS”); depression; anxiety; fatigue; and methylenetetrahydrofolate reductase, (“MTHFR”). (Record, (“R.”), at 217-18, 230, 234.) The claim was denied initially and on reconsideration. (R. at 85-87, 91-93, 97-99, 110-14, 116-18.) Mays then requested a hearing before an administrative law judge, (“ALJ”), (R. at 119.) A hearing was held by video conferencing on January 29, 2013, at which Mays was represented by counsel. (R. at 35-55.)
By decision dated February 11, 2013, the ALJ denied Mays’s claim. (R. at 14-24.) The ALJ found that Mays met the nondisability insured status requirements of the Act for DIB purposes through December 31, 2013. (R. at 16.) The ALJ also found that Mays had not engaged in substantial gainful activity since October 9, 2008, her alleged onset date. (R. at 16.) The ALJ found that the medical evidence established that Mays suffered from severe impairments, namely MS; a blood disorder; fatigue; depression; and anxiety, but he found that Mays 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 16.) The ALJ found that Mays had the residual functional capacity to perform light work that did not require more than occasional climbing of ramps and stairs, balancing, stooping, kneeling, crouching, crawling and reaching; that did not require climbing ladders, ropes or scaffolds, concentrated exposure to cold, heat, wetness, humidity and vibration; that did not require moderate exposure to work hazards, fumes, odors, dusts and gases; and that required only one- to two-step job instructions. (R. at 18.) The ALJ found that Mays had no past relevant work. (R. at 22.) Based on Mays’s age, education, work history and residual functional capacity and the testimony of a vocational expert, the ALJ found that jobs existed in significant numbers in the national economy that Mays could perform, including jobs as an usher, a laminating machine operator and a tanning salon attendant. (R. at 23.) Thus, the ALJ found that Mays was not under a disability as defined by the Act and was not eligible for DIB benefits. (R. at 23-24.) See 20 C.F.R. § 404.1520(g) (2015).
After the ALJ issued his decision, Mays pursued her administrative appeals, (R. at 6-9), but the Appeals Council denied her request for review. (R. at 1-4.) Mays 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. § 404.981 (2015). The case is before this court on Mays’s motion for summary judgment filed January 13, 2015, and the Commissioner’s motion for summary judgment filed February 17, 2015.
Mays was born in 1987, (R. at 217), which classifies her as a “younger person” under 20 C.F.R. § 404.1563(c). She has a high school education and completed a few college classes. (R. at 39, 234.) She has past work experience as a secretary, a cook and a cashier. (R. at 40, 235.) She stated that she could not work due to fatigue and pain. (R. at 41.)
Vocational expert, Mark Hileman, also testified at Mays’s hearing. (R. at 49-54.) Hileman classified Mays’s work as a general secretary as sedentary and skilled, and her work as a cook and food service worker as light and semi-skilled. (R. at 51-52.) Hileman was asked to consider a hypothetical individual of Mays’s age, education and work experience, who would be limited to light work that did not require more than occasional climbing of stairs and ramps; balancing, stooping; kneeling; crouching; crawling; and reaching; that did not require her to climb ladders, scaffolds and ropes; that did not require concentrated exposure to cold, heat, wetness, humidity and vibration; that did not require moderate exposure to working hazards, fumes, odors, dusts and gases; and that would require only one-to two-step job instructions. (R. at 52.) Hileman stated that such an individual could not perform Mays’s past work, but could perform other jobs existing in significant numbers in the national economy, including those of an usher, a laminating machine operator and a tanning salon attendant. (R. at 52-53.) Hileman was asked to consider the same individual, but who would have no useful ability to deal with work stresses and to demonstrate reliability, and who would be absent more than three days a month. (R. at 53.) He stated that there would be no jobs available that such an individual could perform. (R. at 53.)
In rendering his decision, the ALJ reviewed medical records from Wise County Public Schools; Louis Perrott, Ph.D., a state agency psychologist; Dr. Richard Surrusco, M.D., a state agency physician; Howard S. Leizer, Ph.D., a state agency psychologist; Dr. Michael Hartman, M.D., a state agency physician; Holston Valley Hospital; Mountain View Regional Medical Center; Wise Medical Group; April Stidham, F.N.P., a family nurse practitioner; Medical Associates of Southwest Virginia; Associated Neurologists of Kingsport; Robert S. Spangler, Ed.D., a licensed psychologist; Dr. Michelle L. Brewer, M.D., a neurologist; Dr. Victoria Grady, M.D.; Dr. Shawn Christopher Smith, D.O.; Dr. Souhail Shamiyeh, M.D.; Dr. Felix E. Shepard, Jr., M.D.; Norton Community Hospital; and Susan Myers, L.C.S.W., a licensed clinical social worker.
On January 10, 2007, Dr. Michelle L. Brewer, M.D., a neurologist, reported that Mays was alert and oriented, she had fluent speech, intact memory and good fund of knowledge. (R. at 637-39.) Mays’s visual fields were full to confrontation. (R. at 638.) Sensory, motor and cerebellar examinations were intact, as was her gait. (R. at 638.) Dr. Brewer diagnosed MS with positive oligoclonal bands, elevated cerebrospinal fluid with white matter lesions and an enhancing lesion in the brainstem, as well as possible venous angioma. (R. at 638.)
The record shows that Mays was treated by Dr. Souhail Shamiyeh, M.D., and April Stidham, F.N.P., a family nurse practitioner, from 2008 through 2012 for complaints of kidney stones; MS; MTHFR; anxiety; panic attacks; and shoulder pain. (R. at 351-417, 469-94, 642-64.) On December 13, 2011, Mays reported that her MS was doing well and that her symptoms of depression and anxiety were controlled with medication. (R. at 660.) On June 13, 2012, Mays reported that her symptoms of anxiety were “mild.” (R. at 642.) She reported “good” symptom control with medication. (R. at 642.) Dr. Shamiyeh noted that Mays’s examination was normal. (R. at 643-44.)
On October 7, 2010, Dr. Douglas A. Wright, M.D., a neurologist, examined Mays. (R. at 447-51.) Mays complained of an allergic reaction to her MS medication. (R. at 447-48.) She reported intermittent migraine headaches, anxiety and depression. (R. at 448.) Dr. Wright reported that Mays’s examination was normal. (R. at 448-50.) Mays was oriented; her recent and remote memory were normal; her attention span and concentration were normal; her language was normal; and her fund of knowledge was normal. (R. at 449.) No major anxiety was noted. (R. at 449.) Mays reported that she had no complications with regard to MTHFR, and that she was doing well on medication. (R. at 447.) Dr. Wright opined that Mays’s MS was stable. (R. at 447.) On October 30, 2007, an MRI of Mays’s head showed MS without any new symptoms. (R. at 370.) On August 29, 2008, an MRI of Mays’s brain showed that most of the previous lesions had improved, but there was a new left frontal white matter lesion and two small lesions noted at the bilateral brachium pontis. (R. at 365.) On November 13, 2008, an abdominal sonogram showed bilateral kidney stones. (R. at 358-59.) On July 31, 2009, an MRI of Mays’s brain showed white matter lesions involving both cerebral hemispheres consistent with MS; the left white matter lesion showed slight progression; the left frontal coronal radiata lesion showed improvement; and the left frontal periventricular lesion showed interval progression. (R. at 356-57.) On March 7, ...