United States District Court, W.D. Virginia, Harrisonburg Division
C. HOPPE UNITED STATES MAGISTRATE JUDGE
Sonja Marie Musser asks this Court to review the Commissioner
of Social Security's (“Commissioner”) final
decision denying her application for disability insurance
benefits (“DIB”) under Title II of the Social
Security Act (the “Act”), 42 U.S.C. §§
401-434. The case is before me by the parties' consent
under 28 U.S.C. § 636(c)(1). Having considered the
administrative record, the parties' briefs and oral
arguments, and the applicable law, I find that substantial
evidence supports the Commissioner's decision.
Standard of Review
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).
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).
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); 20
C.F.R. § 404.1505(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). 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.
filed for DIB on May 31, 2012, alleging disability caused by
anxiety, fibromyalgia, refractive trochanteric bursitis,
ulnar neuropathy, and depression beginning on March 1, 2011,
at which time she was forty-one years old. Administrative
Record (“R.”) 77, ECF No. 9. Disability
Determination Services (“DDS”), the state agency,
denied her claim at the initial, R. 77-88, and
reconsideration stages, R. 90-105. On September 11, 2014,
Musser appeared with counsel at an administrative hearing
before ALJ Marc Mates and testified about her impairments,
past work, and daily activities. R. 35-76. A vocational
expert (“VE”) also testified about Musser's
past work and her ability to do other jobs in the national
and local economies. R. 71-75.
November 10, 2014, ALJ Mates issued a written decision
denying Musser's DIB application. R. 12-26. He determined
that she had not engaged in substantial gainful activity
since March 1, 2011. R. 14. He then found that Musser had
severe impairments of fibromyalgia, trochanteric bursitis,
and obesity. Id. All other conditions, including her
dry eyes, bilateral ulnar neuropathies, mouth lesions, stage
I endometriosis, and depression, were deemed non-severe. R.
14-17. None of these impairments, alone or in combination,
met or medically equaled the severity of one of the listed
impairments. R. 17. As to Musser's residual functional
capacity (“RFC”),  ALJ Mates determined that she
could perform a range of sedentary work in that she could
lift and carry twenty pounds occasionally and ten pounds
frequently; stand and walk for four hours and sit for six
hours in an eight-hour workday; occasionally balance and
stoop; never climb ladders, ropes, or scaffolds; and
occasionally reach overhead and push and pull with the upper
extremities bilaterally. Id. She also should avoid
exposure to workplace hazards, such as unprotected heights
and dangerous moving machinery. Id. Musser could not
perform her past relevant work as a college professor. R. 24.
She could, however, perform other jobs, including general
office clerk, receptionist, inspector/grader, and assembler,
that existed in significant numbers in the national and local
economies. R. 24-25. Therefore, ALJ Mates concluded that
Musser was not disabled. R. 26. The Appeals Council denied
Musser's request for review, R. 1- 4, and this appeal
frames the issues of her appeal as “[w]hether the ALJ
committed error by failing to follow Social Security Ruling
12-2p and by misstating the medical evidence of
record.” Pl.'s Br. 2, ECF No. 12. The crux of this
challenge concerns ALJ Mates's RFC determination,
particularly as to his assessment of Musser's
fibromyalgia and evaluation of her subjective statements
about her symptoms. Musser also disputes the weight the ALJ
assigned to the opinion of her treating physician, contending
that it should have been afforded controlling weight,
id. at 4-5, and she asserts that ALJ Mates erred at
step two by finding that she did not have a severe eye
impairment, id. at 5-6. Musser's arguments are
Severe Eye Impairment
Facts and Testimony
did not allege disability because of an eye-related
impairment in her initial DIB application. R. 77. She did,
however, note some problems with her vision in her function
reports submitted as part of her application for benefits,
stating that her blurry vision made it difficult to read and
that she regularly used prescription glasses. See R.
264, 266, 295, 301. She then testified at the administrative
hearing that she experienced dry eyes as a side effect of
some of her medications. R. 61. She stated that John Stathos,
M.D., her ophthalmologist, put punctal plugs in her eyes,
which “helped amazingly” at first. Id.
The plugs eventually began to cause severe irritation by
rubbing against her corneas, so Dr. Stathos removed them. R.
62. Musser noted that she began using Restasis eye drops,
which also helped, although not as much as the plugs.
visited Dr. Stathos annually for eye treatment from 2011
through 2013. On February 3, 2011, Musser complained of
blurry vision, but her visual acuity with correction was
20/25 in the right eye and 20/20 in the left eye. R. 371.
Dr. Stathos indicated that she had a congenital cataract in
the right eye and instructed her to return in one year. R.
372. On February 9, 2012, Musser reported worsening vision,
both up close and at a distance, in both eyes. R. 373. She
also noted that she occasionally saw floaters and experienced
a glare. Id. Her visual acuity with correction was
20/40 in the right eye and 20/25 in the left eye.
Id. Dr. Stathos increased her prescription strength,
ordered her prescription bifocals, and instructed her to
return in a year. R. 373-74. During a visit in 2013, Musser
explained that she had not been able to wear her contact
lenses for a month and a half because of dryness. R. 734. She
had trouble with reading- although Dr. Stathos noted she took
her glasses off to read-and sometimes she could not see the
closed captioning on the television. Id. Her visual
acuity with correction was 20/30- on the right and 20/25 on
the left. Id. Dr. Stathos again noted that Musser
had a congenital cataract in the right eye and instructed her
to follow up in one year. R. 735. Musser returned on December
19, requesting punctal plugs. R. 762. Her visual acuity with
correction was 20/25 on the right and 20/20 on the left.
Id. Dr. Stathos scheduled her to return in ten days
to receive the plugs. R. 763. On March 7, 2014, Musser
followed up with continued complaints of dryness. R. 758. She
had been using Restasis, which helped, but she still had
blurred vision daily and experienced floaters and an
“awful glare.” Id. Her visual acuity
with correction was 20/25 on the right and 20/20 on the left,
and she had a moderately deep tear lake. Id. Dr.
Stathos continued her on Restasis and advised her to keep her
scheduled appointment. R. 759. Musser followed up with Dr.
Stathos on July 8 and reported having pain after using
Restasis drops. R. 792. She still experienced glare and
dryness that prevented her from wearing contact lenses, but
she had no new floaters. Id. Her visual acuity with
correction was 20/20 in both eyes. Id. Dr. Stathos
continued her on Restasis and instructed her to follow up in
a year. R. 793.
two, the ALJ determines whether a claimant has a
“severe medically determinable physical or mental
impairment . . . or combination of impairments.” 20
C.F.R. § 404.1520(a)(4)(ii).
[A]n impairment or combination of impairments is considered
“severe” if it significantly limits an
individual's physical or mental abilities to do basic
work activities; an impairment(s) that is “not
severe” must be a slight abnormality (or a combination
of slight abnormalities) that ...