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Williams v. Berryhill

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

January 18, 2018

BARBARA WILLIAMS, Plaintiff,
v.
NANCY A. BERRYHILL, Defendant.

          REPORT AND RECOMMENDATION

          THERESA CARROLL BUCHANAN UNITED STATES MAGISTRATE JUDGE

         Pursuant 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.[1] 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.

         I. PROCEDURAL BACKGROUND

         Plaintiff 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.

         II. STANDARD OF REVIEW

         Under 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) .

         In 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 decision.

         III. THE ALJ'S FINDINGS OF FACT AND CONCLUSIONS OF LAW

         An ALJ 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.

         At step 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 40.)

         IV. RELEVANT FACTUAL BACKGROUND

         Plaintiff 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.)

         A. Medical Evidence

         The 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.

         1. Before Plaintiff's AOD

         In 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 1141-44.)

         By 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.)

         2. After Plaintiff's AOD and Before Plaintiff's DLI

         In late 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.)

         In 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.)

         In 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.)

         In 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 ...


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