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Howells v. Berryhill

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

March 31, 2017



          Joel C. Hoppe United States Magistrate Judge

         Plaintiff Alyssa Clare Howells 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 (the “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). ECF No. 8. Having considered the administrative record, the parties' briefs and oral arguments, and the applicable law, I find that the Commissioner's decision is supported by substantial evidence.

         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

         Howells applied for DIB and SSI on November 9, 2011, alleging disability caused by bronchiolitis obliterans, [1] depression, anxiety, and psoriatic arthritis. Administrative Record (“R.”) 96, 107, ECF No. 12. At the time of her alleged onset date of March 15, 2011, she was twenty-eight years old. Id. Disability Determination Services (“DDS”), the state agency, denied her claims at the initial and reconsideration stages. R. 96-117, 120-47. On February 28, 2014, Howells appeared with counsel at an administrative hearing before ALJ Mark A. O'Hara, at which time the ALJ heard testimony from Howells and Robert Jackson, a vocational expert (“VE”). R. 39-95.

         ALJ O'Hara denied Howells's claims in a written decision issued on April 15, 2014. R. 8-33. He found that Howells had severe impairments of obesity, bronchiolitis obliterans, asthma, spine disorder, and psoriatic arthritis. R. 11. He determined, however, that the other impairments established in the record, including Vitamin D deficiency, polycystic ovary syndrome, history of right shoulder fracture status post surgery, and Howells's mental impairments, were nonsevere, and that none of her impairments, alone or in combination, met or medically equaled the severity of a listed impairment. R. 11-14.

         As to Howells's residual functional capacity (“RFC”), [2] the ALJ found that she could perform light work, [3] further limited to six hours of sitting and four hours of standing or walking in an eight-hour day; unlimited balancing; frequent stooping, kneeling, crouching, and climbing of stairs or ramps; occasional crawling and climbing of ladders, ropes, or scaffolds; and avoiding even moderate exposure to respiratory irritants. R. 14-31. Based on this RFC and the VE's testimony, the ALJ found that Howells could not return to her past relevant work, but could perform other work existing in the national and regional economies, including light jobs such as non-USPS mail clerk and counter rental clerk, as well as sedentary[4] jobs such as inspector/grader and assembler. R. 31-32. He therefore concluded that Howells was not disabled. R. 33. The Appeals Council denied Howells's request for review, R. 1-3, and this appeal followed.

         III. Discussion

         Howells contends that the ALJ erred by failing to assess whether her documented history of migraine headaches constituted a severe impairment and, accordingly, whether additional limitations should have been included in her RFC. Pl. Br. 4-16, ECF No. 16.[5] In addition, she argues that the ALJ improperly weighed the opinion of one of her treating physicians when assessing her RFC. Id. at 16-37.

         A. Migraine Headaches

         1. Relevant Evidence

         The record documents Howells's complaints of migraines as far back as April 27, 2008, at which time she reported to the University of Virginia (“UVA”) hospital with what she described as the “worst headache of her life.” R. 533-34. Howells stated that she had woken up with a headache the night of April 23, gone to the UVA Emergency Department the following day, and was treated with Benadryl and Toradol, which resolved the headache for a few hours before it returned and persisted for the next several days. Id. Associated symptoms included photophobia, phonophobia, nausea, blurred vision, generalized fatigue, and difficulty with word finding. R. 534. Imaging and test results were all normal, and she was discharged with instructions to follow up with outpatient treatment. R. 530. She returned to UVA on June 3, stating that her headache had not abated since her discharge, and she was treated with several courses of IV dihydroergotamine (“DHE”), which completely relieved her symptoms. R. 530- 32.

         Howells reported to the UVA Emergency Department again on May 5, 2010, complaining of a particularly severe migraine headache accompanied by nausea, phonophobia, photophobia, and visual disturbances. R. 511-19. She stated that she typically got one to two headaches per month and that they usually responded to Imitrex. R. 517. Doctors noted that her previous workup for pseudotumor cerebri was negative. Id. On examination, neurological signs were all normal. R. 518. She was treated with a combination of IV medications and discharged in stable condition. R. 514.

         On December 6, 2011, Howells visited with Bryan Cupka, M.D., a neurologist at UVA, for follow-up treatment of her headaches. R. 542-46.[6] She reported that she had been experiencing daily headaches since she started taking Humira for her arthritis a month earlier. R. 542-43. Howells described these headaches as dull, lasting less than the whole day, and not accompanied by her typical migrainous symptoms. R. 543. She also explained that her migraines had become more frequent: they used to occur once per month, but she now experienced them once per week, although Imitrex relieved her symptoms four out of five times. Id. On examination, Dr. Cupka noted right greater than left anisocoria; decreased sensation on the left in the V1-V3 distribution, first and second digits, and upper arm; and resting tremor worse with intention in her bilateral hands. R. 544-45. Other signs were normal, however, including intact extraocular movements, visual fields full to confrontation, no signs of increased intracranial pressure, no dysarthria, full strength and reflexes in all extremities, and normal coordination and gait. Id. An MRI of her brain, taken several days later, showed no evidence of intracranial abnormality. R. 636.

         Dr. Cupka opined that Howells's migraines were likely exacerbated by recent stress, and he noted that at baseline she kept these under good control by taking Topamax regularly and Imitrex at the onset of her headaches. R. 545. He added a prescription for tizanidine to improve her sleep and relieve the tension component of her headaches. Id. He also assessed that Howells's daily headaches could be caused by Humira. Id. This opinion seemed to be validated when, at a January 23, 2012, visit with Janet Lewis, M.D., her rheumatologist at UVA, Howells reported that she had stopped taking Humira about one month earlier and her daily headaches had since resolved. R. 655.

         Howells returned to Dr. Cupka on March 29 for follow-up. R. 852-55. She again reported that her daily headaches went away after discontinuing Humira, and she stated that she still experienced three to four migraines per month, which would normally responded to Imitrex, but could last for two days on the rare occasions that medication did not work. R. 852. She had no side effects from Topamax. Id. She also reported that she had begun experiencing new visual disturbances, which she did not feel were similar to her migraines, and “spells” involving whole-body tremors. R. 852-53. Her neurological examination was fully normal except for bilateral hand tremor with holding her arms out, which improved with intention. R. 854-55. Dr. Cupka reiterated that Howells's migraines appeared to be under good control and stated that she could increase her dose of Topamax if they got worse. R. 855. As to her tremors, Dr. Cupka expressed skepticism that these had a neurological basis, but rather that they may be an exaggerated physiological tremor related to Howells's anxiety, medications, or other illnesses. Id. He was uncertain of the etiology of Howells's visual changes, but noted that they seemed separate from her migraines. Id.

         Howells next visited the UVA Neurology Clinic on September 13 and was evaluated by Stephen Donahue, M.D. R. 782-84. Dr. Donahue noted that Howells's episodic migraines were well controlled by Topamax and that when these occurred (which she said happened once per week), Imitrex “wipe[d] her headaches out 95% of the time.” R. 782. Howells expressed concern that Topamax could be causing her to experience word-finding difficulties, but she was not interested in discontinuing this medication because it was so helpful in controlling her headaches. Id. On examination, her neurological signs were fully normal. R. 783-84. Dr. Donahue continued Howells's medications, stating that Topamax was effective as a preventive agent and ...

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