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Smith v. Colvin

United States District Court, W.D. Virginia, Big Stone Gap Division

February 10, 2017

THERESA GUINN SMITH, Plaintiff
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant

          MEMORANDUM OPINION

          Pamela Meade Sargent United States Magistrate Judge.

         I. Background and Standard of Review

         Plaintiff, Theresa Guinn Smith, (“Smith”), filed this action challenging the final decision of the Commissioner of Social Security, (“Commissioner”), denying her claims for disability insurance benefits, (“DIB”), and supplemental security income, (“SSI”), under the Social Security Act, as amended, (“Act”), 42 U.S.C.A. §§ 423 and 1381 et seq. (West 2011 & West 2012). Jurisdiction of this court is pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). This case is before the undersigned magistrate judge upon transfer by consent of the parties pursuant to 28 U.S.C. § 636(c)(1). Neither party has requested oral argument; therefore, this case 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 Smith protectively filed her applications for DIB and SSI on January 30, 2014, alleging disability as of January 1, 2013, due to disc degeneration in her back and neck; depression; anxiety; panic attacks; bulging discs; suicidal ideation; and diabetes mellitus. (Record, (“R.”), at 9, 243-46, 257-64, 271.) The claims were denied initially and upon reconsideration. (R. at 124-26, 131, 133-35, 137-42, 144-46.) Smith then requested a hearing before an administrative law judge, (“ALJ”). (R. at 147.) A video hearing was held on May 19, 2015, at which Smith was represented by counsel. (R. at 29-59.)

         By decision dated June 12, 2015, the ALJ denied Smith’s claims. (R. at 9-23.) The ALJ found that Smith met the nondisability insured status requirements of the Act for DIB purposes through December 31, 2017. (R. at 11.) The ALJ found that Smith had not engaged in substantial gainful activity since January 1, 2013, the alleged onset date.[1] (R. at 11.) The ALJ found that the medical evidence established that Smith had severe impairments, namely cervical and lumbar spine degenerative disc disease; mild to moderate hearing loss; diabetes mellitus; fibromyalgia; restless leg syndrome; carpal tunnel syndrome with normal nerve conduction studies and EMG; depressive disorder; and anxiety disorder, but she found that Smith did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. at 12.) The ALJ found that Smith had the residual functional capacity to perform simple, repetitive, unskilled, light work[2] that did not require more than occasional pushing and pulling, climbing of ramps and stairs, balancing, kneeling, stooping, crouching and crawling; that did not require more than frequent overhead reaching, handling, feeling and fingering; that did not require her to work around concentrated exposure to extreme temperatures; that did not expose her to hazardous machinery, unprotected heights, excessively loud background noise, climbing of ladders, ropes or scaffolds and vibrating surfaces; and that did not require more than occasional interaction with the general public. (R. at 15.) The ALJ found that Smith was unable to perform her past relevant work. (R. at 21.) Based on Smith’s age, education, work history and residual functional capacity and the testimony of a vocational expert, the ALJ found that a significant number of other jobs existed in the national economy that Smith could perform, including jobs as a nonpostal mail clerk, an order clerk and an office helper. (R. at 21-22.) Thus, the ALJ concluded that Smith was not under a disability as defined by the Act, and was not eligible for DIB or SSI benefits. (R. at 22-23.) See 20 C.F.R. §§ 404.1520(g) 416.920(g) (2016).

         After the ALJ issued her decision, Smith pursued her administrative appeals, (R. at 5), but the Appeals Council denied her request for review. (R. at 1-3.) Smith 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, 416.1481 (2016). This case is before this court on Smith’s motion for summary judgment filed March 2, 2016, and the Commissioner’s motion for summary judgment filed April 4, 2016.

         II. Facts

         Smith was born in 1961, (R. at 34, 243, 257), which, at the time of the ALJ’s decision, classified her as a “person closely approaching advanced age” under 20 C.F.R. §§ 404.1563(d), 416.963(d). Smith has a high school education and some college education and past work experience as a certified nursing assistant and a personal care attendant. (R. at 34-36, 272.) Smith testified that she suffered from emotional problems due to the death of two children and the death of her husband and only sister. (R. at 34.) She stated that she lost one child due to crib death and that her 17-year-old child was killed by a drunk driver. (R. at 34.) Smith stated that she could stand up to 25 minutes without interruption; walk 12 feet without interruption; and sit up to an hour and a half without interruption. (R. at 37.) She stated that she helped her 12-year-old son with his homework. (R. at 38.)

         Barry Hensley, a vocational expert, also was present and testified at Smith’s hearing. (R. at 52-58.) Hensley was asked to consider a hypothetical individual of Smith’s age, education and work history, who would be limited to simple, repetitive, unskilled, light work that did not require more than occasional pushing and pulling, climbing of ramps and stairs, balancing, kneeling, stooping, crouching and crawling; that did not require more than frequent overhead reaching, handling, feeling and fingering; that did not require her to work around concentrated exposure to extreme temperatures; that did not expose her to hazardous machinery, unprotected heights, extensive background noise, climbing of ladders, ropes or scaffolds and vibrating surfaces; and that did not require more than occasional interaction with the general public. (R. at 54-55.) Hensley stated that the individual could not perform Smith’s past relevant work, but that there were other jobs existing in significant numbers in the national economy that such an individual could perform, including those of a nonpostal mail clerk, an order clerk and an office helper. (R. at 55-56.) Hensley was asked to consider the same individual, but who would be limited to only occasional reaching. (R. at 56.) He stated that there would be jobs available that such an individual could perform, including jobs as an order clerk, a nonpostal mail clerk and a materials handler, packer and sealer. (R. at 56.) Hensley stated that, if the individual would be absent from work approximately two days a month on a consistent basis, there would be no jobs available that such an individual could perform. (R. at 57.) He stated that, should the individual be off-task up to 33 percent of the workday, there would be no jobs available that such an individual could perform. (R. at 58.)

         In rendering her decision, the ALJ reviewed records from Joseph Leizer, Ph.D., a state agency psychologist; Dr. William Rutherford, Jr., M.D., a state agency physician; Dr. Hillery Lake, M.D., a state agency physician; Dr. Bert Spetzler, M.D., a state agency physician; Kelli Keller, B.S., a counselor; Frontier Health; Dr. Aimee Coleman, M.D.; Holston Valley Hospital Medical Center; Dr. Linda Gemayel, M.S.; Woodridge Hospital; Dr. Todd A. Cassel, M.D.; and Sabrina Mitchell, F.N.P., a family nurse practitioner.

         The record shows that Smith received treatment from Dr. Todd A. Cassel, M.D., and Sabrina Mitchell, F.N.P., from September 26, 2011, through April 21, 2014, for carpal tunnel syndrome; diabetes mellitus type II; hyperlipidemia; cervical radiculitis; bone loss; neck sprain; neck pain; low back pain; edema; fatigue; fibromyalgia; restless leg syndrome; tendonitis; depression; and anxiety. (R. at 432-509.) On September 26, 2011, Smith reported that her mood was controlled with medication. (R. at 504.) She denied depression and anxiety. (R. at 505.) On February 6, 2012, Smith reported that she stopped taking her medications. (R. at 499.) On August 1, 2012, x-rays of Smith’s cervical spine showed spondylosis, degenerative disc disease and neural foraminal narrowing. (R. at 419.) X-rays of Smith’s lumbar spine showed minimal to mild spondylosis with normal alignment and no fracture, subluxation or bony destruction. (R. at 419.) On October 5, 2012, a cervical MRI showed mild spondylosis, minimal disc space narrowing and no spinal cord compression. (R. at 415-16.) On November 28, 2012, electrodiagnostic testing of the left upper extremity was normal with no evidence of radiculopathy or neuropathy. (R. at 412-14.)

         On January 7, 2013, Smith reported that she was “working hard.” (R. at 481.) Examination of Smith’s neck was benign, and no back or other musculoskeletal abnormalities were noted. (R. at 483.) On February 11, 2013, Smith reported that medication helped her back pain, and aside from some slight swelling in her neck and thyroid, no abnormalities were noted. (R. at 479-80.) In May and June 2013, Dr. Cassel documented benign examination findings. (R. at 468, 472.) A June 20, 2013, bone density scan showed that Smith had not lost any significant height since age 18 and that her bone mineral density was in the low normal to osteopenic range. (R. at 408.) On September 10, 2013, Smith’s neck was normal and supple, her thyroid unremarkable, and she had nontender muscles with full range of motion. (R. at 461.) On September 10 and 16, 2013, Smith’s back was unremarkable, and she had full range of motion without pain, no edema, normal strength, 2 reflexes and a normal gait. (R. at 457, 461-62.) It was reported that Smith’s anxiety was stable, and exercise was encouraged. (R. at 458.) On November 4, 2013, Smith had slight tenderness with movement in her neck and mild para lumbar pain with trigger areas. (R. at 452.) A trigger point injection was provided. (R. at 453.)

         On January 27, 2014, Dr. Cassel reported that Smith was alert and oriented; she had tenderness, tension and knots in the trapezius muscles and slight tenderness with movement. (R. at 449.) Smith received an injection. (R. at 450.) On April 4, 2014, Smith complained of back, neck and shoulder pain. (R. at 447.) On examination, she had tenderness in the trapezius muscle and the medial scapular areas and tightness in the paraspinal muscle. (R. at 447.) A trigger point injection was given. (R. at 447.) On April 21, 2014, Smith complained of panic attacks and back and shoulder pain. (R. at 443.) Dr. Cassel reported that Smith was alert and oriented. (R. at 443.) Her examination was normal with the exception of tenderness in her trapezius muscle with limited range of motion. (R. at 443.) On June 5, 2014, Smith related frequent headaches for three weeks. (R. at 571.) She had tenderness on examination, and was given a trigger point injection. (R. at 571.) On September 2, 2014, Dr. Cassel wrote a letter to the Virginia Department for Aging and Rehabilitative Services, wherein he stated that Smith was unable to work for more than a couple of hours due to multiple trigger points, muscle fatigue and regional pain problems. (R. at 579.) He did not assess any specific functional limitations or abilities in this letter. (R. at 579.)

         On January 27, 2015, Dr. Cassel completed a Physical Residual Functional Capacity Questionnaire, indicating that Smith was diagnosed with depressive disorder; perhaps a personality disorder; myositis;[3] and chronic back pain. (R. at 807-11.) He noted that Smith’s ability for attention and concentration would frequently interfere with her ability to perform simple work tasks. (R. at 808.) Dr. Cassel reported that Smith could tolerate low-stress jobs. (R. at 808.) He opined that Smith could walk up to two hours in an eight-hour workday and that she could walk up to 10 city blocks without interruption; sit up to four hours in an eight-hour workday and do so for up to one hour without interruption; and stand for up two hours in an eight-hour workday and do so for up to 30 minutes without interruption. (R. at 808-09.) Dr. Cassel opined that Smith would need to walk around for five minutes every hour. (R. at 809.) He found that Smith did not require a job that permitted her to shift positions at will from sitting, standing or walking. (R. at 809.) He reported that Smith occasionally would need to take a few minutes for an unscheduled break. (R. at 809.) Dr. Cassel opined that Smith could frequently lift and carry items weighing less than 10 pounds; occasionally lift and carry items weighing up to 10 pounds; and rarely lift and carry items weighing up to 20 pounds. (R. at 809.) He noted that Smith occasionally could look down, turn her head right or left and look up and frequently hold her head in static position. (R. at 810.) He reported that Smith could occasionally twist and rarely stoop, crouch/squat and climb ladders and stairs. (R. at 810.) Dr. Cassel noted that Smith would be absent from work about one day a month. (R. at 810.)

         On May 29, 2015, Dr. Cassel wrote a “To Whom It May Concern” letter, wherein he stated that Smith was disabled from work due to accumulating difficulties associated with ...


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