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Campbell v. Colvin

United States District Court, W.D. Virginia, Harrisonburg Division

September 30, 2016

CAROLYN W. COLVIN Acting Commissioner, Social Security Administration Defendant.


          Joel C. Hoppe United States Magistrate Judge

         Plaintiff Kathy Lynn Campbell asks this Court to review the Commissioner of Social Security's ("Commissioner") final decision denying her 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. §§ 401-434, 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 arguments, and the applicable law, I find that the Commissioner's decision is not supported by substantial evidence and that the case must be remanded 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); 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 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), 1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a), 416.905(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 Heckler v. Campbell, 461 U.S. 458, 460-62 (1983); 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). 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

         Campbell applied for DIB and SSI in February 2011, alleging disability caused by fibromyalgia and hypermobile joints, with pain in her back, legs, arms, thighs, and left foot. Administrative Record ("R.") 101, 111, ECF No. 10. She initially claimed that her disability began on December 31, 2007, R. 102, 112, but she later amended her alleged onset date to August 28, 2010, R. 35-36, at which time she was twenty-nine years old, R. 23. Disability Determination Services ("DDS"), the state agency, denied her claim at the initial and reconsideration stages. R. 101-20, 123-42. Following an administrative hearing, R. 31-62, ALJ Drew Swank denied Campbell's claim in a written decision issued on June 29, 2012. R. 148-57. The Appeals Council found that ALJ Swank's decision contained multiple errors, however, and remanded Campbell's claim for a new hearing. R. 163-65.

         On March 14, 2014, Campbell appeared with counsel at a hearing before ALJ Brian Rippel. R. 63-100. ALJ Rippel issued a written decision denying Campbell's claim on March 25, 2014. R. 12-24. He found that Campbell had severe impairments of fibromyalgia and degenerative disc disease, but also found that her medically determinable mental impairment of depression was non-severe. R. 14-16. He next determined that none of Campbell's impairments, alone or in combination, met or medically equaled a listed impairment. As to Campbell's residual functional capacity ("RFC"), [1] the ALJ found that she could perform sedentary work[2] with occasional balancing, stooping, and climbing ramps and stairs; never crouching, crawling, or climbing ladders, ropes, or scaffolds; and an option to alternate between sitting and standing. R. 16-23. Based on this RFC finding and the testimony of a vocational expert ("VE"), the ALJ determined that Campbell could not perform her past relevant work as a car detailer, but could perform other work existing in the national and regional economies; therefore, he concluded that she was not disabled. R. 23-24. The Appeals Council denied Campbell's request for review, R. 1-3, and this appeal followed.

         III. Discussion

         On appeal, Campbell argues that the ALJ erred in analyzing and weighing the medical opinion evidence. PI. Br. 4-7, ECF No. 14. Because the ALJ's analysis of the opinions is not supported by substantial evidence, this case must be remanded. A. Medical Opinions

         1. Dr. Elsea

         Richard Elsea, M.D., Campbell's primary care physician, treated Campbell for a variety of ailments beginning in July 2009. R. 498. Campbell first complained to Dr. Elsea about chronic pain symptoms in September 2009, informing him that she had pain in her neck and down through her mid-thoracic area that made it difficult for her to move her head. R. 498. Beginning in February 2010, Campbell complained to Dr. Elsea of intense pain in her lower back, abdomen, and legs. R. 481, 483, 486-87, 498. Although Dr. Elsea initially thought that Campbell's pain might be related to a problem with a disc, R. 498, imaging of Campbell's lower back showed only mild scoliosis and degenerative changes, with no obvious nerve impingement, spondylolisthesis, or spondylosis, R. 484, 528, 538. Dr. Elsea also considered that Campbell's pain could have been caused by pressure from a palpable mass located in the sacral area. R. 481, 483, 486-87. Campbell underwent surgery to remove the mass in April 2010, R. 532, 534, but this did not provide long-term relief, and Campbell's symptoms returned by August 2010, R. 478-79, 481.

         Over the course of his treatment relationship with Campbell, Dr. Elsea observed that she exhibited a significant amount of tenderness to palpation in her back, pelvis, buttocks, and hips. R. 479, 481, 486.[3] Dr. Elsea also noted that Campbell had hypermobile joints and opined that this may have been the result of Ehlers-Danlos syndrome, a congenital condition, which could have contributed to Campbell's pain. R. 479, 481, 483, 486-87, 502. Findings on physical examination were otherwise unremarkable, with normal range of motion and gait, full strength and reflexes in the extremities, and negative straight leg raise testing. R. 479, 483, 486; see also R. 463, 510-11, 513, 515, 531, 538 (noting similar findings by other physicians). At a visit in October 2011, Dr. Elsea acknowledged that Campbell "clearly meets all criteria with respect to severe fibromyalgia, which markedly limits her, " and he also continued to suspect some type of neuropathic pain adjacent to the sacroiliac joint. R. 592. He noted that she had difficulty lying down, sitting, or walking for long periods of time and that her pain medication provided no relief. Id.

         Dr. Elsea completed a physical RFC questionnaire on October 23, 2011. R. 588-91. He noted that Campbell suffered from fibromyalgia and hypermobile joints and that her prognosis was poor. R. 588. Dr. Elsea stated that Campbell had diffuse, severe pain, was extremely fatigued, and had difficulty walking for more than a block without assistance. Id. He stated that Campbell was not a malingerer and that emotional ...

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