United States District Court, W.D. Virginia, Roanoke Division
EARL N. REDD, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
Glen E. Conrad, Senior United States District Judge
has filed this action challenging the final decision of the
Commissioner of Social Security denying plaintiffs claims for
disability insurance benefits and supplemental security
income benefits under the Social Security Act, as amended, 42
U.S.C. §§ 4l6(i) and 423, and 42 U.S.C. § 1381
et seq., respectively. Jurisdiction of this court is
pursuant to 42 U.S.C. § 405(g) and 42 U.S.C. §
1383(c)(3). As reflected by the memoranda and argument
submitted by the parties, the issues now before the court are
whether the Commissioner's final decision is supported by
substantial evidence, or whether there is "good
cause" to necessitate remanding the case to the
Commissioner for further consideration. See 42
U.S.C. § 405(g).
plaintiff, Earl N. Redd, was born on February 12, 1968, and
eventually completed his high school education. Mr. Redd
previously worked as a commercial cleaner. He stopped working
completely in 2014. On July 23, 2012 and November 20, 2012,
respectively, Mr. Redd filed applications for disability
insurance benefits and supplemental security income benefits.
In filing his current claims, Mr. Redd alleged that he became
disabled for all forms of substantial gainful employment on
October 18, 2010, due to pancreatitis, back pain, and
stuttering. At the time of an administrative hearing on
August 26, 2015, plaintiff amended his applications so as to
reflect an alleged disability onset date of January 9, 2015.
(Tr. 66). Mr. Redd now maintains that he has remained
disabled to the present time. With respect to his application
for disability insurance benefits, the record reveals that
Mr. Redd met the insured status requirements of the Act
through the fourth quarter of 2016, but not thereafter.
See generally, 42 U.S.C. §§ 4l6(i) and
423(a). Consequently, plaintiff is entitled to a period of
disability and disability insurance benefits only if he has
established that he became disabled for all forms of
substantial gainful employment on or before December 31,
Redd's applications were denied upon initial
consideration and reconsideration. He then requested and
received a de novo hearing and review before an
Administrative Law Judge. In an opinion dated October 6,
2015, the Law Judge also determined that Mr. Redd is not
disabled. The Law Judge found that Mr. Redd suffers from
several severe impairments, including "lumbar
strain/lumbago, peripheral artery disease in the right upper
extremity, and chronic obstructive pulmonary disease
(COPD)." (Tr. 43). Nevertheless, the Law Judge
determined that Mr. Redd retains the residual functional
capacity to perform a limited range of light exertional
activity. The Law Judge assessed Mr. Redd's residual
functional capacity as follows:
After careful consideration of the entire record, the
undersigned finds that the claimant has the residual
functional capacity to perform light work as defined in 20
C.F.R. 404.1567(b) and 416.967(b) except he cannot tolerate
exposure to hazards or climbing ladders, ropes, or scaffolds.
He can occasionally handle, finger, and feel with the right
upper extremity. He can tolerate occasional exposure to
pulmonary irritants and chemicals.
(Tr. 44). Given his residual functional capacity, and after
considering Mr. Redd's prior work experience and the
testimony of a vocational expert, the Law Judge determined
that Mr. Redd is unable to perform his past relevant work as
a commercial cleaner. However, the Law Judge found that Mr.
Redd retains sufficient functional capacity to perform
certain light work roles existing in significant number in
the national economy. (Tr. 50). Accordingly, the Law Judge
concluded that Mr. Redd is not disabled, and that he is not
entitled to benefits under either federal program. See
generally, 20 C.F.R. §§ 404.1520(g) and
416.920(g). The Law Judge's opinion was adopted as the
final decision of the Commissioner by the Social Security
Administration's Appeals Council. Having exhausted all
available administrative remedies, Mr. Redd has now appealed
to this court.
plaintiff may be disabled for certain forms of employment,
the crucial factual determination is whether plaintiff is
disabled for all forms of substantial gainful employment.
See 42 U.S.C. §§ 423(d)(2) and l382c(a).
There are four elements of proof which must be considered in
making such an analysis. These elements are summarized as
follows: (1) objective medical facts and clinical findings;
(2) the opinions and conclusions of treating physicians; (3)
subjective evidence of physical manifestations of
impairments, as described through a claimant's testimony;
and (4) the claimant's education, vocational history,
residual skills, and age. Vitek v. Finch, 438 F.2d
1157, 1159-60 (4th Cir. 1971); Underwood v.
Ribicoff, 298 F.2d 850, 851 (4th Cir. 1962).
appeal, Mr. Redd raises several arguments, including that the
Law Judge improperly assessed the medical opinion evidence
and disregarded the treating physician rule in determining
his residual functional capacity. This particular argument
was the subject of supplemental briefing by the parties.
After reviewing the record and considering the parties'
arguments, the court finds "good cause" to remand
the case to the Commissioner for further development and
consideration. See 42 U.S.C. § 405(g).
the regulations setting forth the standards for evaluating
medical opinion evidence, the opinion of a treating physician
is entitled to '"controlling weight' ... so long
as the opinion is 'well-supported by medically acceptable
clinical and laboratory diagnostic techniques and is not
inconsistent with the other substantial evidence in [the
claimant's] case record[.]'" Lewis v.
Berryhill, 858 F.3d 858, 867 (4th Cir. 2017)
(alterations in original) (quoting 20 C.F.R. §§
404.1527(c)(2) and 4l6.927fcY2T); see also Brown v.
Comm'r Soc. Sec, 873 F.3d 251, 268-69 (4th Cir.
2017). When the Law Judge does not give controlling weight to
a treating physician's opinion, the Law Judge must
consider a nonexclusive list of factors to determine what
weight to give the opinion of the treating physician and all
other medical opinions in the record. Johnson v.
Barnhart, 434 F.3d 650, 654 (4th Cir. 2005); see
also 20 C.F.R. §§ 404.1527(c) and 416.927(c)
(listing the factors to be considered). The Law Judge must
also provide "good reasons in [his] notice of
determination or decision for the weight [he] give[s] [the]
treating source's medical opinion." 20 C.F.R.
§§ 404.1527(c)(2) and 416.927(c)(2); see
also SSR 96-8p, 1996 SSR LEXIS 5 (July 2, 1996)
("If the [residual functional capacity] assessment
conflicts with an opinion from a medical source, the [Law
Judge] must explain why the opinion was not adopted.").
Unless the Law Judge "explicitly indicates the weight
given to all of the relevant evidence, " a reviewing
court cannot determine whether the Law Judge's findings
are supported by substantial evidence. Gordon v.
Schweiker, 725 F.2d 231, 235 (4th Cir.
1984s); see also Monroe v. Colvin, 826
F.3d 176, 189 (4th Cir. 2016) ("We have held that
'[a] necessary predicate to engaging in substantial
evidence review is a record of the basis for the ALJ's
ruling, ' including 'a discussion of which evidence
the ALJ found credible and why, and specific application of
the pertinent legal requirements to the record
evidence.'") (quoting Radford v. Colvin,
734 F.3d 288, 295 (4th Cir. 2013)).
case, the record reveals that Mr. Redd began to experience
pain and numbness in his right wrist and arm in January of
2013, when he was hospitalized for three days and diagnosed
with deep vein thrombosis of the upper extremity. (Tr.
532-33). That same year, Mr. Redd injured his back while
unloading a truck at work. (Tr. 663). Mr. Redd subsequently
sought treatment for back pain and pain and numbness in his
right upper extremity on multiple occasions. (Tr. 575, 631,
743, 758, 833, 860, 868, 877, 886, 915, 928, 959, 982). One
of Mr. Redd's treating physicians was Andrew M. Walters,
M.D., a physician at Carilion Clinic Family Medicine
-Roanoke/Salem, where Mr. Redd was treated for diagnoses of
chronic lower back pain and chronic right wrist pain. On July
23, 2015, Dr. Walters completed an assessment of Mr.
Redd's physical capabilities. Dr. Walters opined that Mr.
Redd can stand or walk for two hours at a time and for a
total of five hours in an eight-hour workday; that he can sit
for three hours at a time and for a total of five hours in an
eight-hour workday; and that he can frequently lift up to ten
pounds and occasionally lift up to fifteen pounds. (Tr. 819).
Dr. Walters further opined that Mr. Redd cannot use his right
hand for simple grasping or fine manipulation, and that he
"requires opportunities beyond normal workbreaks during
an 8 hour day to lie down to rest or be inactive for a
certain period as he finds necessary." (Tr. 819).
determining Mr. Redd's residual functional capacity, the
Law Judge did not discuss or assign weight to all of Dr.
Walters' opinions. Instead, after recounting Dr.
Walters' assessment, the Law Judge summarily stated as
follows: "The undersigned accords some weight to [Dr.
Walters'] opinion to the extent that it recognizes the
claimant's capacity for a range of light exertional work
activity." (Tr. 48). Notably, the Law Judge did not
address, much less provide "good reasons" for
rejecting, Dr. Walters' opinion regarding plaintiffs
inability to use his right hand for grasping or fine
manipulation, or Dr. Walters' opinion that the plaintiff
would require extra breaks to lie down or rest during an
eight-hour workday. 20 C.F.R. §§ 404.1527(c)(2) and
416.927(c)(2). Because these opinions were inconsistent with
the Law Judge's determination of plaintiffs residual
functional capacity, the Law Judge was required to explain
why the opinions were not adopted. See SSR 96-8p, 1996 SSR
LEXIS 5 (July 2, 1996). In the absence of such explanation,
the court is unable to determine whether the Law Judge's
decision is supported by substantial evidence. See
Monroe, 826 F.3d at 191 (observing that neither the
appellate court nor the district court can undertake a
meaningful substantial-evidence review unless a Law Judge
adequately explains his reasons for the differing weights
assigned to medical opinions); see also Bogley v.
Berrvhill, No. 16-2381, 2017 U.S. App. LEXIS 25144, at
*3 (4th Cir. Dec. 13, 2017) (concluding that it was "not
possible ... to conduct meaningful appellate review of the
ALJ's decision, " since "the ALJ did not
discuss or assign weight to all of the opinions of [the
claimant's] treating physician . . . and these opinions
were inconsistent with the ALJ's determination of [the
claimant's] residual functional capacity").
Accordingly, remand is appropriate.
reasons stated, the court finds "good cause" to
remand the case to the Commissioner for further development
and consideration. If the Commissioner is unable to decide
this case in plaintiffs favor on the basis of the existing
record, the Commissioner will conduct a supplemental
administrative hearing at which both sides will be allowed to
present additional evidence and argument. An appropriate
order of remand will be entered this day.
Clerk is directed to send certified copies of this memorandum