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Vaughn v. Berryhill

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

August 14, 2017

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


          Pamela Meade Sargent, United States Magistrate Judge

         I. Background and Standard of Review

         Plaintiff, Billy Joe Vaughn, Jr., (“Vaughn”), filed this action challenging the final decision of the Commissioner of Social Security, (“Commissioner”), denying his 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 Vaughn filed applications for DIB and SSI on December 15, 2010, alleging disability as of June 15, 2008. (Record, (“R.”), at 221-22, 229-37.) The claims were denied initially and on reconsideration. (R. at 72-84, 86-98, 100-14, 116-30, 132-34, 140-44, 146-51, 153-55.) Vaughn requested a hearing before an administrative law judge, (“ALJ”), which was held on January 15, 2013. (R. at 34-71, 156-57.) By decision dated February 1, 2013, an ALJ denied Vaughn's claims. (R. at 20-28.) The Appeals Council thereafter denied Vaughn's request for review. (R. at 1-3.) Vaughn appealed the denial of benefits to this court. On the Commissioner's motion, this court remanded Vaughn's claims to the Commissioner for further development on October 23, 2014. See Vaughn v. Colvin, Civil Action No. 2:14cv00010 (W.D. Va. Oct. 23, 2014). On remand, the ALJ held another hearing on August 6, 2015, at which Vaughn was represented by counsel. (R. at 513-49.)

         By decision dated August 14, 2015, the ALJ again denied Vaughn's claims. (R. at 491-505.) The ALJ found that Vaughn met the nondisability insured status requirements of the Act for DIB purposes through December 31, 2013. (R. at 494.) The ALJ found that Vaughn had not engaged in substantial gainful activity since June 15, 2008, the alleged onset date. (R. at 494.) The ALJ found that the medical evidence established that Vaughn had severe impairments, namely degenerative disc disease and spondylosis of the cervical spine with radiculopathy into the right upper extremity, right shoulder bursitis and chronic low back pain, but he found that Vaughn 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 494-97.) The ALJ found that Vaughn had the residual functional capacity to perform sedentary work, except that he could lift and carry items weighing up to 20 pounds occasionally and 10 pounds frequently, [2] that he must be allowed position changes between sitting and standing every 20 minutes, that he cannot perform more than occasional climbing of ramps and stairs, kneeling, crawling, crouching, balancing and stooping and that he cannot climb ladders, ropes or scaffolds or work in concentrated exposure to cold, wetness, unprotected heights and hazards. (R. at 497-503.) The ALJ found that Vaughn was unable to perform his past relevant work. (R. at 503.) Based on Vaughn'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 Vaughn could perform, including jobs as an addresser, a packing machine operator and a sorter. (R. at 503-04.) Thus, the ALJ concluded that Vaughn was not under a disability as defined by the Act, and was not eligible for DIB or SSI benefits. (R. at 504-05.) See 20 C.F.R. §§ 404.1520(g) 416.920(g) (2016).

         After the ALJ issued his decision, Vaughn pursued his administrative appeals, (R. at 478-79, 487), but the Appeals Council denied his request for review. (R. at 471-74.) Vaughn 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 Vaughn's motion for summary judgment filed October 27, 2016, and the Commissioner's motion for summary judgment filed December 30, 2016.

         II. Facts

         Vaughn was born in 1972, (R. at 519), which classifies him as a “younger person” under 20 C.F.R. §§ 404.1563(c), 416.963(c). Vaughn has a seventh-grade education and past relevant work as roof bolter in an underground coal mine. (R. at 519.) Vaughn testified that he has not worked since 2008. (R. at 519.) At his January 15, 2013, hearing, Vaughn testified that he suffered from constant pain that improved some when he took his pain medication. (R. at 631.) He complained that his pain medication made him drowsy. (R. at 636.) Vaughn said that he experienced neck pain that ran down his right arm. (R. at 636-37.) Vaughn also claimed that he had no strength to grip anything with his right hand. (R. at 637-38.)

         Medical expert Dr. Anthony E. Francis, M.D., an orthopedic surgeon, testified at Vaughn's August 2015 hearing. (R. at 521-38.) Based on his review of the medical evidence, Dr. Francis testified:

The pathology that we have here would be some degenerative disk disease of the lumbar and cervical spine, with an intermittent radiculopathy. Now, the problem … with radiculopathy, especially looking at them over an extended period of time, is that the radiculopathy may be, or usually is, acute at some point, meaning severely impairing due to pain, weakness, all the other things that go along with the radiculopathy.
Most radiculopathies are going to clear up. You know, if you don't do anything, they'll clear up….
But most of them, especially in a younger patient, are going to clear up and either go completely away, or just become sort of a nuisance instead of a significantly impairing problem, and that may be what we have here.

(R. at 528-29.)

         In rendering his decision, the ALJ reviewed records from Wellmont Lonesome Pine Hospital; Lee Regional Medical Center; Blue Ridge Neuroscience Center, P.C.; Wellmont Rehabilitation Services; Jonesville Rural Health Clinic; Dr. Kevin Blackwell, D.O.; Medical Associates of Jonesville; Stone Mountain Health Clinic, St. Charles; Simpson Clinic; Eugenie Hamilton, Ph.D.; and Dr. Richard Surrusco, M.D..

         On October 14, 2010, Vaughn was seen at the emergency department at Lonesome Pine Hospital for neck pain radiating into his right shoulder and arm. (R. at 337.) Vaughn denied any recent injury or repetitive motion. (R. at 337.) A physical examination revealed normal range of motion in Vaughn's neck. (R. at 338.) No sensory or motor loss was noted. (R. at 338.) A CT scan of Vaughn's cervical spine revealed mild to moderate degenerative disc changes at the C4-5 and C5-6 levels. (R. at 339, 364.) X-rays of his cervical spine showed degenerative disc changes at the C5-6 and C6-7 levels with loss of cervical curvature due to muscle spasm of the neck. (R. at 361.) Vaughn's was diagnosed with cervical radiculopathy. (R. at 338.) Vaughn returned to the emergency department at Lonesome Pine Hospital ...

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