Reyes v. Berryhill

          REPORT AND RECOMMENDATION

          Robert S. Ballou, United States Magistrate Judge

         Plaintiff Alicia M. Reyes filed this action challenging the final decision of the Commissioner of Social Security (“Commissioner”) finding her not disabled and therefore ineligible for supplemental security income (“SSI”), and disability insurance benefits (“DIB”) under the Social Security Act (“Act”). 42 U.S.C. §§ 401-433, 1381-1383f. Reyes alleges that the Administrative Law Judge (“ALJ”) erred by failing to properly (1) determine her RFC, including evaluating the consultative examiner's opinion, Reyes's ability to handle and finger objects, and conduct a function by function analysis; and (2) evaluate her credibility. I conclude that substantial evidence supports the Commissioner's decision in all respects. Accordingly, I RECOMMEND DENYING Reyes's Motion for Summary Judgment (Dkt. No. 14) and GRANTING the Commissioner's Motion for Summary Judgment. (Dkt. No. 16).

         STANDARD OF REVIEW

         This court limits its review to a determination of whether substantial evidence exists to support the Commissioner's conclusion that Reyes failed to demonstrate that she was disabled under the Act.^[1] Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001). “Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996) (internal citations and alterations omitted). The final decision of the Commissioner will be affirmed where substantial evidence supports the decision. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990).

         CLAIM HISTORY

         Reyes filed for SSI and DIB on August 2, 2012, claiming her disability began on June 13, 2012 due to tremors, chronic obstructive pulmonary disease (“COPD”), asthma, sleep apnea, and nerve damage.^[2] R. 53, 335, 342, 365, 368. The state agency denied Reyes's applications at the initial and reconsideration levels of administrative review. R. 150-62, 163-75, 179-94, 195-210. On June 26, 2014, ALJ Jeffrey Schueller held a hearing to consider Reyes's claims for DIB and SSI. R. 108-38. At this hearing, Reyes requested a consultative evaluation and, following the evaluation, a supplemental hearing took place on December 4, 2014. R. 70-99. Reyes was represented by counsel at both the June and December hearings, which included testimony from vocational experts Asheley Wells and Mark Hileman, respectively.

         On January 30, 2015, the ALJ entered his decision analyzing Reyes's claims under the familiar five-step process^[3] and denying her claim for benefits. R. 53-63. The ALJ found that Reyes was insured at the time of the alleged disability onset^[4] and that she suffered from the severe impairments of de Quervain's disease, essential tremor, COPD/asthma, obesity, GERD, sciatica, and plantar fasciitis.^[5] R. 55. The ALJ determined that these impairments, either individually or in combination, did not meet or equal a listed impairment. R. 60. The ALJ concluded that Reyes retained the residual functional capacity (“RFC”) to perform a limited range of light work. R. 60. Specifically, the ALJ found that Reyes can frequently balance, push/pull, stoop, kneel, crouch, and handle objects, can occasionally crawl, climb ramps and stairs, and finger objects, but can never climb ladders, ropes, or scaffolds, and should avoid concentrated exposure to cold, heat, wetness, humidity, vibrations, odors, fumes, irritating particulates, chemicals, and hazards. Id. The ALJ determined that Reyes was unable to perform her past relevant work as a telephone representative, front desk clerk, and sales clerk, but that she could perform other jobs that exist in significant numbers in the national economy, such as usher, gate guard, and furniture clerk. R. 61-62. Reyes appealed the ALJ's decision and the Appeals Council denied her request for review on May 27, 2016. R. 1-4.

         ANALYSIS

         A. Relevant Medical History

         (1) Tremor

         In August 2012, Reyes saw Joseph M. Ferrara, M.D. at Roanoke Neurology for evaluation of a tremor, which Reyes reported began sometime in early childhood. R. 481. Dr. Ferrara noted that the tremor is most pronounced in Reyes's hands, with the left hand more affected than the right hand, and at times involves her head. R. 482. Dr. Ferrara advised that Reyes undergo an occupational therapy assessment to explore adaptive measures to allow her to perform her activities of daily living with less difficulty, as well as possible vocational rehabilitation. R. 484. Reyes had follow up appointments with Dr. Ferrara in October 2012 and February, May, and November 2013, and November 2014, where Dr. Ferrara noted that Reyes left hand tremor was persistent during activities, but absent during rest, was aggravated by strenuous activity, hunger, fatigue, and her prescribed medication for obstructive pulmonary disease^[6] (Albuterol), and was not responding to the pharmaceutical drugs prescribed. R. 482, 956, 962, 975, 983, 1555.

         In September 2012, Reyes saw Amy Conforti, OTR, for occupational therapy, on referral from Drs. Ferrara and Robert E. Cassidy, M.D., and Ms. Conforti recommended custom orthotics.^[7] R. 862, 864. Reyes returned for two follow-up visits in September and October, 2012; however, she failed to show for her scheduled appointment on October 12. R. 875-79.

         (2) Back Pain

         Reyes saw her family doctor Catherine Rea, M.D. in April 2014, complaining of worsening back pain and leg numbness. R. 1407. An x-ray of her lumbar spine in June 2014 was normal. R. 1618. On July 14, 2014, Reyes saw Richard Weiss, M.D., M.B.A. for an evaluation of her back pain. R. 1422. On examination, she had lumbar tenderness, no swelling, normal muscle strength, negative straight leg raise, normal gate, and decreased reflexes and sensation. R. 1426- 27. Dr. Weiss diagnosed Reyes with mild spondylosis deformans of the lumbar spine, and referred her to physical therapy. R. 1427-28. In August 2014, Reyes presented for a physical therapy evaluation. R. 1447. However, Reyes was discharged from physical therapy when she failed to attend any of her subsequent scheduled appointments. R 1454-55.

         (3) Anxiety

         Reyes saw Laura B. Cieraszynski, D.O. in September 2012, complaining of worsening anxiety following the birth of her child two months previously. R. 835. The record indicates that Reyes “reports no help at home, leading to an inability to get away or relax.” Id. In February 2014, Reyes underwent a psychiatric evaluation at Advanced Telepsychiatry, Inc., and was assessed with panic disorder and panic attacks. R. 1326. At a follow-up visit In March 2014, ...