United States District Court, W.D. Virginia, Danville Division
ROGER G. HORTON, JR., Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
JOEL C. HOPPE UNITED STATES MAGISTRATE JUDGE
Plaintiff Roger G. Horton, Jr., asks this Court to review the Commissioner of Social Security's ("Commissioner") final decision denying his application for disability insurance benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. §§ 401-434. The case is before me by the parties' consent under 28 U.S.C. § 636(c)(1). ECF No. 7. Having considered the administrative record, the parties' briefs and oral arguments, and the applicable law, I find that substantial evidence supports the Commissioner's decision that Horton is not disabled.
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); Mines 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 Universal Camera Corp. v. NLRB, 340 U.S. 474, 487-89 (1951); Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984). 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); 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); 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
Horton filed an application for DIB on July 12, 2011, alleging disability caused by arthritis, back and hip pain, and diabetes. Administrative Record (“R.”) 67. He claimed that his period of disability began on June 13, 2011, at which time he was 49 years old. Id. Disability Determination Services (“DDS”), the state agency, denied his claim at the initial and reconsideration stages. R. 67-80, 82-96. On September 3, 2013, Horton appeared with counsel at an administrative hearing before ALJ Brian Rippel. R. 29-63. The ALJ heard testimony from Horton, R. 44-54; his mother, Shirley Horton, R. 35-41; and Andrew Beal, a vocational expert (“VE”), R. 54-62.
ALJ Rippel denied Horton’s claim in a written decision issued on September 10, 2013. R. 11-24. He found that Horton had severe impairments of degenerative disc disease, left hand contractures, obesity, affective disorder, substance abuse disorder, attention deficit disorder, and somatoform disorder, but also found that Horton’s impairments of diabetes mellitus and hypertension were nonsevere. R. 13-14. The ALJ then determined that none of Horton’s severe impairments, alone or in combination, met or medically equaled the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1-in particular Listings 1.04 (disorders of the spine), 12.02 (organic mental disorders), 12.04 (affective disorders), 12.07 (somatoform disorders), and 12.09 (substance addiction disorders). R. 14-16.
As to Horton’s residual functional capacity (“RFC”),  the ALJ determined that Horton could perform light work,  with some postural and environmental limitations, and was “limited to work that involves simple, routine, and repetitive tasks, [such as] entry level unskilled work.” R. 16-23. Based on this finding and the testimony of the VE, the ALJ concluded that Horton was unable to perform any of his past relevant work, but could perform other jobs existing in the national economy, including packer, cleaner, and cafeteria attendant. R. 22-24. Therefore, the ALJ concluded that Horton was not disabled. R. 24. The Appeals Council received additional evidence into the record, R. 5, but ultimately declined Horton’s request for review, R. 1-3. This appeal followed.
A. Relevant Treatment Records
Medical evidence in the record before ALJ Rippel shows that from 2004 to 2008, Horton received occasional treatment from Bozenna Liszka, M.D., at Martinsville Family Medical Center, for a variety of medical conditions and symptoms, including diabetes, hepatitis C, anxiety, hypertension, sinus and mouth infection, and upper respiratory illness. R. 295-340. On a few occasions, Horton also reported pain in his finger joints, knees, ankles, right leg, and lower back. R. 311, 333. In April 2008, Andrew Gehrken, M.D., at Piedmont Urology Associates, evaluated Horton for nocturia, which was described as intermittent and mild in intensity. Dr. Gehrken noted that Horton also complained of joint pain from arthritis, lower back pain, and diabetes. R. 365-67.
Beginning in October 2008, Horton received treatment from Maureen Aaron, M.D. R. 239-63. Prior to the alleged onset date, Dr. Aaron noted that Horton performed heavy work, R. 241, and that he had back pain caused by lifting at work, R. 242. Horton took hydrocodone for his back pain and arthritis. R. 250, 254. Dr. Aaron observed that Horton was sometimes noncompliant in performing finger sticks, taking medication, and following medical recommendations as to diet and alcohol and tobacco use. R. 241, 244-45, 249, 258.
Horton’s visits with Dr. Aaron prior to the alleged onset date were infrequent. There is no evidence of any treatment between February 2010, R. 239-41, and November 2010, R. 258-62; the record is silent again between December 2010, R. 256-57, and June 2011, when Horton reported a skin condition on his right arm that was subsequently diagnosed as dermatophytosis, R. 255, 343. After being treated for this condition, Horton was cleared to return to work on June 13, 2011-his alleged onset date. R. 264. After the alleged onset date, Horton did not receive treatment again until May 7, 2012, when he reported back to Dr. Aaron. She stated that Horton’s health was poor because of his lifestyle, including his smoking and past alcohol use, and that he still did not check his finger sticks. Horton reported chronic back pain and parasthesias down his legs, and he complained that he had difficulty sleeping through the night. R. 291.
On July 5, 2012, Horton went to James Kramer, M.D., with Murphy/Wainer Orthopedic Specialists, for an initial evaluation regarding the pain in his lower back and left hand. Horton reported that he injured his back at work during the early 1980s and had suffered from chronic intermittent, but persistent, pain since that time. He stated that he had been told at one point that he had arthritis in his spine. Examination of the lumbar spine showed mildly diminished forward bending by 10-15% with pain, mildly diminished extension with pain, normal side bending, no midline tenderness, and mild diffuse paralumbar or quadratus spasm with no SI dysfunction. There was no pelvic obliquity and each hip was unremarkable. Straight leg raise tests were negative bilaterally. Imaging showed markedly diminished disc space height at L5-S1. Dr. Kramer diagnosed degenerative disc disorder at L5-S1 with chronic mechanical low back pain. He told Horton that this would cause long-term symptoms with a lifting disability and a certain amount of chronic pain, and he opined that the only definitive solution would be a lumbar fusion. R. 292.
Horton also explained to Dr. Kramer that he injured his left hand in a separate workplace accident and had since suffered from significant and worsening pain and stiffness in that hand, particularly in the ring finger and little finger. Examination of the left hand showed evidence of a Dupuytren contracture with tenderness to palpation and noticeable flexor tenosynovial thickening to the fourth and fifth digit. The fifth digit was fixed at the PIP joint and had 45 degrees of movement at the MCP joint. The fourth digit was fixed 15 degrees at the PIP joint. Phalen’s and Tinel’s signs were negative. Imaging showed no underlying bony abnormalities. Dr. Kramer could not offer much to Horton with regard to his hand condition. He recommended that Horton consider hand surgery consultation if he wanted to proceed with further proactive therapeutic intervention. Id.
Horton returned to Dr. Aaron on July 31 with continued complaints of back pain radiating down his legs. He reported getting some help from a back brace, but claimed that it had been stolen and he had not gotten another one. Horton stated that he could not do much at home, although at times he could help in the yard for a short while. He also told Dr. Aaron that Dr. Kramer had told him his disc was “shot.” R. 289. On November 1, 2012, Horton was examined by John Favero, D.O. Dr. Favero noted that Horton complied with his medication for cholesterol and anxiety and that he checked his blood sugar daily. He characterized Horton’s anxiety symptoms as mild and his mood status as controlled. Dr. Favero also observed that Horton’s back pain was moderate, controlled, aggravated by movement, and alleviated by Lortab. Horton expressed that he was not interested in weaning off of narcotics. Physical examination findings were unremarkable. Dr. Favero counseled Horton on diet and exercise and advised him to return as needed or in three to four months. R. 344-46.
Horton returned to Dr. Favero on February 27, 2013. The report from this visit addresses Horton’s hypertension, high cholesterol, and diabetes, as well as a rash on his right forearm, but says nothing with regard to Horton’s chronic pain symptoms or anxiety. Physical examination was unremarkable aside from the rash on Horton’s forearm. Horton acknowledged smoking and drinking fourteen to twenty alcoholic drinks per week. R. 351-56. Horton’s next visit with Dr. Favero was on April 26. Dr. Favero noted that Horton’s back pain was stable, moderate in intensity, and aggravated by movement. Horton continued to claim that he benefited from narcotic medications and did not wish to be weaned off of them. Findings on physical examination were again unremarkable. R. 357-60. Imaging of Horton’s hand conducted on May 1, 2013, showed no abnormalities. R. 362.
B. Opinion Evidence