United States District Court, E.D. Virginia, Alexandria Division
REPORT AND RECOMMENDATION
THERESA CARROLL BUCHANAN UNITED STATES MAGISTRATE JUDGE
to the Social Security Act § 205(g), 42 U.S.C. §
405(g), Barbara Williams ("Plaintiff") seeks
judicial review of the final decision of Nancy A. Berryhill
("Defendant"), the Acting Commissioner of Social
Security, denying Plaintiff's claim for Disability
Insurance Benefits ("DIB") pursuant to Title II of
the Social Security Act. On August 14, 2017, the certified
Administrative Record ("R.") was filed under seal,
pursuant to Local Civil Rules 5(B) and 7(C)(1). By October
23, 2017, both parties filed motions for summary judgment
with briefs in support, which are now ripe for
resolution. Pursuant to 28 U.S.C. § 636(b)(1)(B),
the undersigned U.S. Magistrate Judge recommends, for the
following reasons, that Plaintiff's Motion for Summary
Judgment (Dkt. 18) be DENIED and Defendant's Motion for
Summary Judgment (Dkt. 20) be GRANTED.
filed the presently disputed application for DIB on September
10, 2013, alleging disabling conditions of hypertension,
chronic sinusitis, a severe pinched nerve in the neck, severe
lower back pain, a nodule on the thyroid, arthritis in the
neck, the inability to raise the right arm, the inability to
walk or stand for long periods, pain on left side of the
body, and severe weakness, with an alleged onset date
("AOD") of June 7, 2007. (R. at 87-88, 173-74.)
Plaintiff's claims were first denied on March 11, 2014,
then again on reconsideration on May 1, 2014. (Id at
104-09, 111-17.) On May 12, 2014, Plaintiff filed a request
for a hearing in front of an administrative law judge
("ALJ"). (Id. at 135-36.) The hearing was
held in front of ALJ Michael A. Krasnow on May 26, 2016,
during which the testimonies of Plaintiff and vocational
expert James M. Ryan were taken. (Id. at 44-80.) The
ALJ issued his decision denying Plaintiff's claims on
June 29, 2016. (Id. at 30-40.) On August 23, 2016,
Plaintiff requested review of the ALJ's decision to the
Appeals Council for the Office of Disability and Adjudication
and Review ("Appeals Council"). (Id. at
26-28.) The Appeals Council denied Plaintiff s request for
review on December 7, 2016, making the ALJ's decision the
final decision of Defendant. (Id. at 6-8.) Plaintiff
filed her Complaint (Dkt.1) for judicial review of
Defendant's decision on February 8, 2017. After the Court
granted an enlargement of time to answer, Defendant filed her
timely Answer (Dkt. 8) on August 8, 2017. By October 23,
2017, Plaintiff filed her Motion for Summary Judgment (Dkt.
18) and Defendant filed her Motion for Summary Judgment (Dkt.
20). The matter is now ripe for review.
STANDARD OF REVIEW
the Social Security Act, the Court's review of
Defendant's final decision is limited to determining
whether the ALJ's decision applied the correct legal
standard was supported by substantial evidence in the record
and whether the correct legal standard was applied in
evaluating the evidence. 42 U.S.C. § 405(g); Hays v.
Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990).
Substantial evidence is "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 scintilla but less than a
preponderance. Hays, 907 F.2d at 1456. While the
standard is high, where the ALJ's determination is not
supported by substantial evidence on the record, or where the
ALJ has made an error of law, the district court must reverse
the decision. Coffman v. Bowen, 829 F.2d 514, 517
(4th Cir. 1987) .
reviewing for substantial evidence, the Court must examine
the record as a whole, but it may not "undertake to re-
weigh the conflicting evidence, make credibility
determinations, or substitute [its] judgment for that of the
Secretary." Mastro v. Apfel, 270 F.3d 171, 176
(4th Cir. 2001) (citing Craig v. Chater, 76 F.3d at
589 (4th Cir. 1996)). The correct law to be applied includes
the Social Security Act, its implementing regulations, and
controlling case law. See Coffman, 829 F.2d at
517-18. Moreover, relevant law charges Defendant with
evaluating the medical evidence and assessing symptoms,
signs, and medical findings to determine the functional
capacity of a claimant, not the reviewing district court.
See Hays, 907 F.2d at 1456-57. With this standard in
mind, the Court evaluates the ALJ's findings and
THE ALJ'S FINDINGS OF FACT AND CONCLUSIONS OF
is required to employ a five-step sequential evaluation in
every Social Security disability claim analysis to determine
a claimant's eligibility. The Court examines this
five-step process on appeal to determine whether the correct
legal standards were applied in this case, and whether
Defendant's resulting decision is supported by
substantial evidence in the record. 20 C.F.R. §§
404.1520, 416.920. In accordance with the five-step
sequential analysis, the ALJ made the following findings of
fact and conclusions of law.
one of the sequential evaluation, the ALJ found that
Plaintiff has not engaged in substantial gainful activity
from June 7, 2007, Plaintiff's AOD, to December 31, 2012,
the date Plaintiff last met the insured status requirements
of the Social Security Act, also known as the date of last
insured ("DLI"). (R. at 35.) At step two of the
sequential evaluation, the ALJ found that Plaintiff had the
following medically determinable impairments through her DLI:
essential hypertension, sinusitis, obesity, seborrheic
keratosis, and metrorrhagia. (Id.) However, the ALJ
found that Plaintiff did not have a severe impairment or
combination of impairments that significantly limited the
ability to perform basic work-related activities for twelve
consecutive months. (Id.) Therefore, the ALJ
determined that Plaintiff was not disabled as defined by the
Social Security Act from her AOD to her DLI. (Id. at
RELEVANT FACTUAL BACKGROUND
was 54 years old when she testified before the ALJ.
(Id. at 50.) Plaintiff ended school in the ninth
grade, but later earned a GED and completed cosmetology
school. (Id. at 53, 88.) Plaintiff's work
history included jobs in fast food restaurants, a grocery
store, and a carpet plant. (Id. at 89, 202-09.)
Plaintiff generally claimed that injuries from car accidents
and the aftermath of a sinus surgery have left her unable to
work. (Id. at 48-49.) Plaintiff claimed the
resultant pain from the accidents and surgery has worn down
her body and has made it impossible for her body to function.
(Id. at 47-48, 57, 73.)
record contains eight years of Plaintiff's medical
records, which cover distinct time frames. The first time
frame is before June 7, 2007: the time before Plaintiff's
AOD. The second time frame is from June 7, 2007, to December
31, 2012: the time between Plaintiff's AOD and
Plaintiff's DLL The third time frame is after December
31, 2012: the time after Plaintiff's DLL The medical
records from each time frame are described below.
Before Plaintiff's AOD
September 1999, Plaintiff exhibited pain in her back and
muscle spasms in her back and on her sides. (Id. at
1109, 1117, 1121.) In January 2000, Plaintiff had a knot in
her back and was having muscle spasms. (Id. at 1110,
1122.) In October 2000, Plaintiff exhibited pain in her lower
back and abdomen. (Id. at 1111, 1124.) In March
2002, Plaintiff exhibited pain in her lower back.
(Id. at 1113, 1123.) In January 2006, an x-ray of
Plaintiff's chest revealed no evidence of disease.
(Id. at 1136.) Later in January 2006, Plaintiff
reported a headache and pain in her leg. (Id. at
September 2006, Plaintiff reported being pain free.
(Id. at 658, 1102.) In November 2006, Plaintiff
reported mild pain from coughing at night. (Id. at
656, 1100.) In December 2006, Plaintiff reported severe
headache pain. (Id. at 653-55, 1097-99.) In March
2007, Plaintiff was noted as pain free. (Id. at 651,
1095.) Later in March 2007, Plaintiff reported a sore throat
and neck pain. (Id. at 347, 351.) Due to her neck
pain, Plaintiff had imaging completed of her neck, which
revealed normal tissues. (Id. at 1139-40.) In April
2007, Plaintiff was twice noted as pain free. (Id.
at 645, 648, 1089, 1092.)
After Plaintiff's AOD and Before Plaintiff's
June 2007, Plaintiff was noted as pain free. (Id. at
643, 1087.) In November 2007, Plaintiff was noted as pain
free. (Id. at 638, 1082.) In December 2007,
Plaintiff was noted as pain free. (Id. at 634,
1078.) In November 2008, Plaintiff was noted as pain free.
(Id. at 629, 1073.) In August 2009, Plaintiff
reported ear pain, a sore throat, and a respiratory
infection. (Id. at 338.) In October 2009, Plaintiff
twice reported ear pain, a sore threat, and a respiratory
infection. (Id. at 334-35, 342-43.) In April 2009,
Plaintiff was twice noted as pain free. (Id. at
621-25, 1065-69.) In June 2009, Plaintiff was noted as having
ear blockage but was pain free. (Id. at 618, 1062.)
In August 2009, Plaintiff was noted as pain free.
(Id. at 615, 1059.) In November 2009, Plaintiff
reported a sinus infection, but was noted as pain free.
(Id. at 610, 1054.)
February 2010, Plaintiff reported sinus problems but was
noted as pain free with no abnormalities in the neck or
elsewhere. (Id. at 608, 1052.) In March 2010,
Plaintiff was noted as pain free. (Id. at 605,
1049.) In April 2010, Plaintiff was noted as pain free.
(Id. at 601, 1045.) In May 2010, Plaintiff was twice
noted as pain free. (Id. at 589, 595, 719, 1033,
1039.) In July 2010, Plaintiff complained of earaches and
sinus problems, and Plaintiff had severe pain that was
limited to her earaches. (Id. at 583, 1027.) Later
in July 2010, Plaintiff was noted as pain free. (Id.
at 580, 1024.) In August 2010, Plaintiff reported recurrent
sinus problems, a physical review of Plaintiff revealed no
abnormalities and that neck movement did not cause Plaintiff
neck pain, and Plaintiff was noted as pain free,
(Id. at 574-75, 709, 711, 1018-19.) Also in August,
an imaging report revealed that Plaintiff had acute
sinusitis. (Id. at 400, 786.) In October 2010,
Plaintiff reported recurrent sinus problems along with a sore
throat that caused her moderate pain, and a physical review
of Plaintiff revealed no abnormalities and revealed that neck
movement did not cause Plaintiff neck pain. (Id. at
568-69, 1012-13.) In November 2010, Plaintiff underwent an
operative procedure to address her sinus problems, and the
procedure resulted in no noted complications. (Id.
at 707-08.) Later in November 2010, Plaintiff reported
recurrent sinus problems and was noted as pain free.
(Id. at 563, 1007.) In December 2010, Plaintiff was
noted as pain free. (Id. at 560, 1004.)
January 2011, Plaintiff reported recurrent sinus problems and
was noted as pain free. (Id. at 556, 1000.) In April
2011, Plaintiff was noted as pain free. (Id. at 553,
704-05, 997.) In June 2011, Plaintiff was noted as pain free.
(Id. at 550, 994.) In October 2011, Plaintiff was
noted as pain free. (Id. at 546, 990.)
February 2012, Plaintiff reported cellulitis in her foot and
was noted pain free. (Id. at 542-43, 986-87.) In
June 2012, Plaintiff reported headaches and sinus problems,
but was also noted as pain free. (Id. at 539, 983.)
In October 2012, Plaintiff reported ear and nasal congestion
but was noted as pain free, and a physical review of
Plaintiff did not reveal any abnormalities. at (Id.
533, 535, 977, 979, 1115, 1150.) In November 2012, Plaintiff
was noted as not having any severe pain. (Id. at
530, 974.) Later in November 2012, Plaintiff reported sinus
problems and headaches with moderate pain limited to her
headache. (Id. at 525-26, 969-70, 1116, 1137.) Even
later in November 2012, Plaintiff reported sinus problems and
nasal passage blockage, with moderate pain in her throat ...