United States District Court, W.D. Virginia, Lynchburg Division
K. MOON UNITED STATES DISTRICT JUDGE
matter is before the Court on the parties’ cross
Motions for Summary Judgment (dkts. 14 and 16), the Report
& Recommendation of United States Magistrate Judge Robert
S. Ballou (dkt. 21, hereinafter “R&R”), and
Plaintiff’s Objections to the R&R (dkt. 22,
hereinafter “Objections to R&R”). Pursuant to
Standing Order 2011-17 and 28 U.S.C. § 636(b)(1)(B), the
Court referred this matter to U.S. Magistrate Judge Ballou
for proposed findings of fact and a recommended disposition.
Judge Ballou filed his R&R, advising this Court to deny
Plaintiff’s Motion for Summary Judgment and grant the
Commissioner’s Motion for Summary Judgment. Plaintiff
timely filed his Objections, obligating the Court to
undertake a de novo review of those portions of the
R&R to which objections were made. See 28 U.S.C.
§ 636(b)(1)(B); Farmer v. McBride, 177 F.
App’x 327, 330 (4th Cir. 2006). For the following
reasons, I will overrule Plaintiff’s Objections and
adopt Judge Ballou’s R&R in full.
October 2010, Thomason visited the Village Family Physicians
complaining of hypertension, headache, and depression. R.
217. At this appointment, Thomason indicated that she had not
had any medication for approximately four days and had been
experiencing increased depression and crying. R. 217. To help
with these problems, the doctor prescribed her four different
types of medication. R. 220.
November and December 2011, Thomason returned to Village
Family Physicians. R. 213. She continued to complain of
hypertension, depression and headaches, along with new
complaints of back and joint pain. R. 213. This examination
revealed that she had pain and spasms in her lower back and
swelling of her knee. R. 211.
August 2012 and January 2013, Thomason once again returned to
Village Family Physicians for medication refills. R. 225,
254. At these appointments, she complained of headaches, back
and joint pain, and an inability to fall asleep. R. 225, 254.
The examination revealed that Thomason was obese, but had
normal posture, muscle tone, and strength in her arms and
legs. R. 227. The mental status exam indicated that she had
appropriate mood and affect, normal judgment and insight, and
could perform basic computations and apply abstract
reasoning. R. 227.
23, 2012, Thomason protectively filed for SSI, claiming that
her disability began on that same day due to back problems,
knee pain, high blood pressure, depression, and migraines. R.
12, 161, 180. The state agency denied Thomason’s
application at the initial and reconsideration levels of
review. R. 60-67, 69-79.
September 2012, Richard J. Milan, Jr., Ph.D., state agency
psychologist, indicated that Thomason’s mental status
examinations were within normal limits and her depression was
controlled with medication. R. 63. Dr. Milan determined that
Thomason “retain[ed] the ability to handle all levels
of work tasks.” R. 63. Similarly, in June 2013, Hillery
Lake, M.D., state agency physician, determined that
Thomason’s mental impairment was non-severe, noting
that Thomason’s mental status exams were normal and she
attended regular education classes in school. R. 74. Two
other state physicians, Dr. Michael Hartman and Dr. Robert
McGuffin, also reviewed the record. Dr. Hartman determined
that Thomason had the ability to perform work at the medium
extertional level, while Dr. McGuffin found that Thomason
could perform a limited range of light work, with postural
limitations due to her knee and back pain. R. 66, 76-77.
15, 2013, Sung-Joon Cho, M.D., performed a medical
consultative evaluation on Thomason. R. 268-71. At this
evaluation, Dr. Cho noted that Thomason had complained of
chronic knee and back pain for approximately ten years, due
to a vehicle accident. Dr. Cho, however, noted that Thomason
walked with “otherwise unremarkable” gait and
without assistance. Dr. Cho also indicated that Thomason had
“some problems with reading.” R. 269.
physical exam revealed that Thomason was 5’3”
tall and weighed 209 pounds. Dr. Cho noted that Thomason was
“limited by her obesity” making it difficult for
her to walk on her tip-toes and squat. R. 269-70. However,
her motor function was a full five out of five in the upper
and lower extremities, with no joint effusion or significant
crepitus in her knee, and no evidence of major inflammation
or instability, and her straight leg test was negative. R.
270. Dr. Cho noted that Thomason had full range of motion
except for lumbar flexion, lumbar extension, and lateral
flexion. R. 270.
found that Thomason’s affect, thought content, and
memory were adequate; however, her general fund of
information was limited and she had difficulty counting in
intervals of three. R. 270. This limitation was consistent
with Thomason dropping out at school at age fourteen due to
pregnancy. R. 46, 270.
end of the examination, Dr. Cho diagnosed Thomason with
obesity, chronic low back pain, degenerative joint disease of
the knee exacerbated by obesity, and illiteracy. R. 270. Dr.
Cho imposed the functional limitations of maximum standing
and walking of two to four hours and maximum lifting of ten
pounds frequently and twenty pounds occasionally. R. 270- 71.
Dr. Cho also noted that Thomason should only occasionally
balance, stop, kneel, crouch, and crawl and should avoid
climbing. R. 271.
The ALJ’s Decision
January 22, 2014, Administrative Law Judge
(“ALJ”) Ann V. Sprague held a hearing to consider
Thomason’s claims for SSI. R. 25-52. Counsel
represented Thomason at the hearing, which included testimony
from vocational expert Robert Jackson. On April 8, 2014, the
ALJ entered her decision analyzing Thomason’s claim.
analyzed Thomason’s claim under the required five-step
inquiry. Walls v. Barnhart, 296 F.3d 287, 290 (4th
Cir. 2002). In this process, the ALJ determines whether: (1)
the claimant is engaged in substantial gainful activity; (2)
the claimant has a medical impairment (or combination of
impairments) that is severe; (3) the claimant’s medical
impairment meets or exceeds the severity of one of the
impairments listed in Appendix I of 20 C.F.R. Part 404,
Subpart P, Appendix 1, and the impairment meets the duration
requirement in 20 C.F.R. §§ 404.1509 and 416.909;
(4) the claimant is able to perform her past relevant work;
and (5) the claimant can perform other specific types of
work. Johnson v. Barnhart, 434 F.3d 650, 653 n.1
(4th Cir. 2005) (citing 20 C.F.R. § 404.1520).
claimant has the burden of production and proof in Steps 1-4.
See Hunter v. Sullivan,993 F.2d 31, 35 (4th Cir.
1992) (per curiam). If the claimant meets that
burden, at Step 5 the burden shifts to the Commissioner
“to produce evidence that other jobs exist in the
national economy that the claimant can perform considering
his age, education, and work experience.” Id.
If a determination of disability can be made at ...