United States District Court, W.D. Virginia, Harrisonburg Division
C. Hoppe United States Magistrate Judge
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.
Standard of Review
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).
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).
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.
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.
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"),  the ALJ found that she could perform
sedentary work 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.
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
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,
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. 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.
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 ...