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Nelson v. Berryhill

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

February 28, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1] Defendant.



         Plaintiff Shellie R. Nelson (“Nelson”), proceeding pro se, challenges the final decision of the Commissioner of Social Security (“Commissioner”) determining that she was not disabled and therefore not eligible for supplemental security income (“SSI”) under the Social Security Act (“Act”). 42 U.S.C. §§ 1381-1383f. Nelson asserts that the Administrative Law Judge (“ALJ”) erred by concluding that she did not have a mental or physical impairment that rendered her disabled under the Act. Specifically, Nelson asserts that her diagnosis of Cowden Syndrome and anxiety are severe impairments that prevent her from working.[3] I conclude that the ALJ failed to properly account for Nelson's moderate impairment with concentration, persistence and pace, and thus the decision is not supported by substantial evidence. Consequently, I DENY the Commissioner's Motion for Summary Judgment, and REVERSE and REMAND this matter for further administrative consideration consistent with this opinion. Dkt. No. 18.


         This court limits its review to a determination of whether substantial evidence supports the Commissioner's conclusion that Nelson failed to demonstrate that she was disabled under the Act.[4] Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001). “Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996) (internal citations and alterations omitted). The final decision of the Commissioner will be affirmed where substantial evidence supports the decision. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990).

         However, remand is appropriate if the ALJ's analysis is so deficient that it “frustrate[s] meaningful review.” Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (noting that “remand is necessary” because the court is “left to guess [at] how the ALJ arrived at his conclusions”); see also Monroe v. Colvin, 826 F.3d. 176, 189 (4th Cir. 2016) (emphasizing that the ALJ must “build an accurate and logical bridge from the evidence to his conclusion” and holding that remand was appropriate when the ALJ failed to make “specific findings” about whether the claimant's limitations would cause him to experience his claimed symptoms during work and if so, how often) (citation omitted). In Mascio and Monroe, the court remanded because the ALJ failed to adequately explain how he arrived at conclusions regarding the claimant's RFC. Mascio, 780 F.3d at 636, Monroe, 826 F.3d. at 189. Similarly, I find that remand is appropriate here because the ALJ's opinion leaves the court to guess at how he reached his conclusions regarding Nelson's RFC.


         Nelson filed for SSI on October 18, 2011, claiming that her disability began on November 4, 2010. R. 266-74. The Commissioner denied the application at the initial and reconsideration levels of administrative review. R. 100-04, 108-10. On December 5, 2013 and April 21, 2014, ALJ Robert S. Habermann held hearings to consider Nelson's disability claim. R. 38-77. Nelson was represented by an attorney at the hearing, which included testimony from vocational expert Gerald Wells. Id.

         On May 1, 2014, the ALJ entered his decision analyzing Nelson's claim under the familiar five-step process[5] and denying her claim for benefits. R. 16-28. The ALJ found that Nelson suffered from the severe impairments of status-post thyroid, renal, and colon cancer; status-post surgeries and residual effects; thyroid disorder, status-post thyroidectomy; ovarian cyst, status-post removal; Cowden syndrome; anxiety disorder; and obesity. R. 18. The ALJ found that these impairments, either individually or in combination, did not meet or medically equal a listed impairment. R. 18-20. The ALJ further found that Nelson retained the RFC to perform light work, except that she can frequently push and pull; cannot climb ladders, ropes, and scaffolds or work around unprotected heights; can occasionally crawl or climb ramps and stairs; and can frequently kneel, crouch, stoop, and balance. R. 20. The ALJ also limited Nelson to unskilled work. Id.

         The ALJ determined that Nelson could not return to her past work of modification dispatcher (R. 26), but that she could perform other work that exists in significant numbers in the national economy, such as office helper, mailroom clerk and dining room attendant. R. 27. Thus the ALJ concluded that Nelson was not disabled. Id. On August 26, 2015 the Appeals Council denied Nelson's request for review (R. 1-4), and this appeal followed.


         Physical Impairments

         Nelson suffers from Cowden Syndrome, a disorder characterized by multiple noncancerous, tumor-like growths and an increased risk of developing certain cancers, including breast cancer, thyroid cancer, cancer of the endometrium, colon cancer, kidney cancer and melanoma. See Genetics Home Reference, a service of the National Library of Medicine, Cowden Syndrome, Nelson has undergone multiple surgeries to remove tumors or polyps, including a tumor from her colon (November 2010), polyps from her colon (June 2011); lesion from her kidney (October 2011); removal of a fallopian tube and ovary (August 2012); and a thyroidectomy (December 2013). Nelson was also diagnosed with polycystic ovarian syndrome in October 2010, and suffers from gastroesophageal reflux disease and chronic obstructive sleep apnea.

         The record contains three medical opinions with regard to Nelson's physical functional capacity. On December 8, 2011, Richard Surrusco, M.D., reviewed Nelson's records and determined that she could perform a range of light work, specifically, lifting 20 pounds occasionally and 10 pounds frequently; standing and walking 4 hours in an 8 hour workday; sitting for 6 hours in an 8 hour workday; unlimited pushing and pulling; occasional climbing ramps and stairs, balancing, stooping, kneeling and crouching, and never crawling or climbing ladders, ropes or scaffolds. R. 82-83. On May 24, 2012, Joseph Duckwall, M.D., reviewed Nelson's records and agreed with Dr. Surrusco's findings. R. 94-95.

         The ALJ gave Drs. Surrusco and Duckwall's opinions “some” weight and adopted their opinions as to Nelson's restrictions on lifting and carrying, but disagreed with their recommended limitations as to Nelson's ability to stand, walk and postural limitations, noting that the medical evidence shows no ...

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