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Elliott v. Berryhill

United States District Court, E.D. Virginia, Richmond Division

July 17, 2017

TEODORA ELLIOTT, pro se Plaintiff,
v.
NANCY A. BERRYHILL, [1] Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION

          David J. Novak United States Magistrate Judge.

         On October 29, 2013, Teodora Elliott ("Plaintiff) applied for Social Security Disability Benefits ("DIB") and, on January 8, 2014, for Supplemental Security Income ("SSI") under the Social Security Act ("Act"), alleging disability from breast cancer, chemotherapy treatment, an abdominal hernia and an aorta aneurysm, with an alleged onset date of October 16, 2013. The Social Security Administration ("SSA") denied Plaintiffs claims both initially and upon reconsideration. Thereafter, an Administrative Law Judge ("ALJ") denied Plaintiffs claims in a written decision and the Appeals Council denied Plaintiffs request for review, rendering the ALJ's decision as the final decision of the Commissioner.

         Plaintiff, now proceeding pro se, seeks judicial review of the ALJ's decision pursuant to 42 U.S.C § 405(g), arguing that the ALJ erred in formulating the residual functional capacity ("RFC"), and that additional evidence warrants remand. (Pl.'s Mot for Summ. J. with a Br. in Support ("Pl.'s Mem.") (ECF No. 12) at 1-2.) This matter now comes before the Court by consent of the parties, pursuant to 28 U.S.C. § 636(c)(1), on the parties' cross-motions for summary judgment, rendering the matter now ripe for review.[2] For the reasons that follow, the Court hereby DENIES Plaintiffs Motion for Summary Judgment (ECF No. 12), GRANTS Defendant's Motion for Summary Judgment (ECF No. 15) and AFFIRMS the final decision of the Commissioner.

         I. PROCEDURAL HISTORY

         On October 29, 2013, Plaintiff filed an application for DIB and, on January 8, 2014, Plaintiff filed an application for SSI with an alleged onset date of October 16, 2013. (R. at 207, 211.) The SSA denied these claims initially on June 20, 2014, and again upon reconsideration on October 6, 2014. (R. at 80, 90.) At Plaintiffs written request, the ALJ held a hearing on March 1, 2016. (R. at 37, 141.) On March 15, 2016, the ALJ issued a written opinion, denying Plaintiffs claims and concluding that Plaintiff did not qualify as disabled under the Act, because she could make successful adjustments to jobs that existed in significant numbers in the national economy. (R. at 29-30.) On June 7, 2016, the Appeals Council denied Plaintiffs request for review, rendering the ALJ's decision as the final decision of the Commissioner subject to review by this Court. (R. at 1-3.)

         II. STANDARD OF REVIEW

         In reviewing the Commissioner's decision to deny benefits, a court "will affirm the [SSA]'s disability determination 'when an ALJ has applied correct legal standards and the ALJ's factual findings are supported by substantial evidence.'" Mascio v. Colvin, 780 F.3d 632, 634 (4th Cir. 2015) (quoting Bird v. Comm V of Soc. Sec. Admin., 699 F.3d 337, 340 (4th Cir. 2012)). Substantial evidence requires more than a scintilla but less than a preponderance, and includes the kind of relevant evidence that a reasonable mind could accept as adequate to support a conclusion. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012); Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). Indeed, "the substantial evidence standard 'presupposes ... a zone of choice within which the decision makers can go either way, without interference by the courts. An administrative decision is not subject to reversal merely because substantial evidence would have supported an opposite decision.'" Dunn v. Colvin, 607 F.App'x 264, 274 (4th Cir. 2015) (quoting Clarke v. Bowen, 843 F.2d 271, 272-73 (8th Cir. 1988)). To determine whether substantial evidence exists, the court must examine the record as a whole, but may not "undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [ALJ]." Hancock, 667 F.3d at 472 (quoting Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005)). In considering the decision of the Commissioner based on the record as a whole, the court must "take into account whatever in the record fairly detracts from its weight." Breeden v. Weinberger, 493 F.2d 1002, 1007 (4th Cir. 1974) (quoting Universal Camera Corp. v. N.L.R.B., 340 U.S. 474, 488 (1951)). The Commissioner's findings as to any fact, if substantial evidence in the record supports the findings, bind the reviewing court to affirm regardless of whether the court disagrees with such findings. Hancock, 667 F.3d at 477. If substantial evidence in the record does not support the ALJ's determination or if the ALJ has made an error of law, the court must reverse the decision. Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).

         The SSA regulations set forth a five-step process that the agency employs to determine whether disability exists. 20 C.F.R. § 416.920(a)(4); see Mascio, 780 F.3d 634-35 (describing the ALJ's five-step sequential evaluation). To summarize, at step one, the ALJ looks at the claimant's current work activity. § 416.920(a)(4)(i). At step two, the ALJ asks whether the claimant's medical impairments meet the regulations' severity and duration requirements. § 416.920(a)(4)(ii). Step three requires the ALJ to determine whether the medical impairments meet or equal an impairment listed in the regulations. § 416.920(a)(4)(iii). Between steps three and four, the ALJ must assess the claimant's RFC, accounting for the most that the claimant can do despite her physical and mental limitations. § 416.945(a). At step four, the ALJ assesses whether the claimant can perform her past work given her RFC. § 416.920(a)(4)(iv). Finally, at step five, the ALJ determines whether the claimant can perform any work existing in the national economy. § 416.920(a)(4)(v).

         III. THE ALJ'S DECISION

         On March 1, 2016, the ALJ held a hearing during which Plaintiff (then-represented by counsel) and a vocational expert testified. (R. at 37-69.) On March 15, 2016, the ALJ issued a written opinion, finding that Plaintiff did not qualify as disabled under the Act. (R. at 29-30.)

         The ALJ followed the five-step evaluation process established by the Act in analyzing Plaintiffs disability claim. (R. at 20-29.) At step one, he found that Plaintiff had not engaged in substantial gainful activity since her alleged onset date. (R. at 21.) At step two, he determined that Plaintiff had the following severe impairments: breast cancer, depressive disorder and anxiety disorder. (R. at 21.) The ALJ concluded at step three that none of these impairments or combination of impairments met or medically equaled the severity of one of the listings. (R. at 22.)

         In assessing Plaintiffs RFC, the ALJ determined that Plaintiff could perform light work with additional limitations. (R. at 23-24.) She could lift and carry ten pounds frequently and twenty pounds occasionally. (R. at 23.) She could sit, stand or walk for six hours in an eight-hour workday. (R. at 23.) Plaintiff could constantly push or pull at the light exertional level. (R. at 23.) Although she could frequently climb stairs and ramps, she could never climb ladders, ropes or scaffolds. (R. at 23-24.) She could frequently balance, stoop, kneel, crouch or crawl. (R. at 24.) Plaintiff could never tolerate exposure to unprotected heights. (R. at 24.) As for her mental RFC, the ALJ limited Plaintiff to understanding, remembering and carrying out short, simple instructions consistent with the performance of unskilled work. (R. at 24.) Plaintiff could tolerate frequent interaction with supervisors and co-workers, but only occasional interaction with the public. (R. at 24.)

         At step four, the ALJ found that Plaintiff could not perform any of her past relevant work. (R. at 28.) Then, at step five, the ALJ determined that Plaintiff could perform jobs that existed in significant numbers in the national economy. (R. at 28.) Therefore, she did not qualify as disabled under the Act. (R. at 29-30.)

         IV. ANALYSIS

         Plaintiff, forty-eight years old at the time of this Opinion, previously worked as an insurance representative and a sales assistant. (R. at 227, 231.) On September 19, 2013, a biopsy revealed that Plaintiff had stage II left breast cancer. (R. at 339.) She applied for Social Security Benefits, alleging disability from stage II breast cancer, chemotherapy treatment, abdominal hernia and aorta aneurysm, with an alleged onset date of October 16, 2013. (R. at 230.) Plaintiffs appeal to this Court challenges the ALJ's RFC assessment.[3] (Pl.'s Mem. at 1-2.) Specifically, she alleges that the ALJ erred in the weight that he assigned Plaintiffs two treating physicians. (Pl.'s Mem. at 1.) Additionally, Plaintiff asks the Court to remand based on new evidence submitted with her motion for summary judgment. (Pl.'s Mem. at 1-2.)

         A. The ALJ Did Not Err in Assigning Weight to Plaintiffs Treating Physicians.

         Plaintiff alleges that the ALJ erroneously weighed the opinions of her treating physicians, resulting in a faulty RFC. (Pl.'s Mem. at 1.) The ALJ gave great weight to the opinion of Attique Samdani, M.D., but little weight to the opinion of Vivian Fernandez, M.D. (R. at 27-28.) Defendant responds that the ALJ properly weighed the medical opinion evidence. (Def.'s Mot. for Summ. J. and Br. in Support ("Def.'s Mem.") (ECF No. 15) at 18.)

         After step three of the sequential analysis, but before deciding whether a claimant can perform past relevant work at step four, the ALJ must determine the claimant's RFC. 20 C.F.R. §§ 404.1520(e)-(f), 404.1545(a)(1), 416.920(e)-(f), 416.945(a)(1). In analyzing claimant's abilities, an ALJ must first assess the nature and extent of the claimant's physical and mental limitations and then determine the claimant's RFC for work activity on a regular and continuing basis. §§ 404.1545(b), 416.945(b). The RFC must incorporate impairments supported by the objective medical evidence in the record, as well as those impairments that have basis in the claimant's credible complaints. Carter v. Astrue, 2011 WL 2688975, at *3 (E.D. Va. June 23, 2011); accord §§ 404.1545(e), 416.945(e).

         To determine which impairments to incorporate, the ALJ must analyze the claimant's provided medical records and any medical evidence resulting from consultative examinations and ordered medical expert evaluations. §§ 404.1512(a)-(e), 404.1527, 416.912(a)-(e), 416.927. When the record contains a number of different medical opinions, including those from Plaintiffs treating sources, consultative examiners, or other sources that show consistency with each other, then the ALJ makes a determination based on that evidence. §§ 404.1520b(a), 416.920b(a). If, however, the medical opinions conflict internally with each other or other evidence, the ALJ must evaluate the opinions and assign them respective weight to properly analyze the evidence involved. §§ 404.1520b(b), 404.1527(c)(2)-(6), (e), 416.920(b), 416.927(c)(2)-(6), (e).

         The ALJ must evaluate and assign weight to every medical opinion, regardless of its source. §§ 404.1527(c), 416.927(c). In doing so, he considers the following factors: (1) examining relationship; (2) treatment relationship; (3) supportability from objective medical evidence; (4) consistency; and, (5) specialization. §§ 404.1527(c)(1)-(5), 416.927(c)(1)-(5). Courts generally should not disturb an ALJ's decision as to the weight afforded a medical opinion absent some indication that the ALJ "dredged up specious inconsistences." Dunn, 607 F.App'x at 267 (citing Scivally v. Sullivan, 966 F.2d 1070, 1077 (7th Cir. 1992)). Indeed, a reviewing court should leave untouched an ALJ's decision regarding weight afforded a medical opinion unless the ALJ failed to give a sufficient reason for the weight afforded. Id.

         i. The ALJ Did Not Err by Giving Great Weight to Dr. Samdani's Opinion.

         Plaintiff first takes issue with the ALJ's assignment of great weight to Dr. Samdani's opinion. (Pl.'s Mem. at 1.) Dr. Samdani opined that Plaintiff could not perform strenuous activity, but that she could carry out light or sedentary work. (R. at 371, 423, 495.) The ALJ gave this opinion great weight, because it comported with the evidence in the record, including examination findings. (R. at 27.) Substantial evidence in the form of Dr. Samdani's examination findings, the other objective medical evidence and Plaintiffs daily activities supports the ALJ's decision.

         Dr. Samdani's opinion comports with his own examination findings, supporting the ALJ's decision. On November 26, 2013, Plaintiff presented to Dr. Samdani at Virginia Cancer Institute following her breast cancer diagnosis. (R. at 378.) Plaintiff had no specific symptoms and denied any abnormalities on review. (R. at 378-79.) For example, she denied headaches, blurred vision, nausea, joint pain and excessive fatigue. (R. at 379.) She also denied insomnia, depression and mood swings. (R. at 379.) Dr. Samdani noted that the evidence did not demonstrate any metastatic disease. (R. at 378.) On examination, Plaintiff exhibited a normal range of motion with no tenderness, swelling or obvious weakness. (R. at 380.) Plaintiff displayed a normal gait without any sensory or motor deficits. (R. at 380.)

         On January 8, 2014, Plaintiff again presented to Dr. Samdani. (R. at 370.) Dr. Samdani noted that Plaintiff looked clinically stable and that she had responded well to chemotherapy. (R. at 373.) On examination, Plaintiff had normal findings, including no joint pain, swelling, redness, decreased range of motion or obvious weakness. (R. at 372.) Additionally, Plaintiff exhibited a normal gait and no sensory or motor deficits. (R. at 372.) Plaintiff denied any headaches, blurred vision, insomnia, depression or mood swings. (R. at 371.)

         During each of Plaintiff s visits through March 19, 2014, Dr. Samdani made similarly unremarkable findings. She looked clinically stable and responded well to chemotherapy. (R. at 373, 374, 381, 496, 499.) On exam, Plaintiff had normal findings, including no joint pain, swelling, redness, decreased range of motion or obvious weakness. (R. at 371, 375, 379, 494, 498, 504.) Plaintiff exhibited a normal gait with no sensory or motor deficits. (R. at 372, ...


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