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Boothe v. Berryhill

United States District Court, W.D. Virginia, Roanoke Division

February 5, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Hon. Glen E. Conrad, Senior United States District Judge

         Plaintiff 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. §§ 416(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).

         The plaintiff, Heather A. Boothe, was born on November 13, 1974, and eventually completed her high school education. She also attended a local community college for a few years, but did not obtain a degree. Ms. Boothe has worked as a cashier and convenience store manager. She last worked on a regular and sustained basis in 2011. On December 28, 2012, Ms. Boothe filed applications for disability insurance benefits and supplemental security income benefits. In filing her current claims, Ms. Boothe alleged that she became disabled for all forms of substantial gainful employment on October 1, 2011, due to diabetes, neuropathy, arthritis of the spine, scoliosis, and heart problems. (Tr. 238). Ms. Boothe now maintains that she has remained disabled to the present time. With respect to her application for disability insurance benefits, the record reveals that Ms. Boothe met the insured status requirements of the Act through the fourth quarter of 2016, but not thereafter. See generally, 42 U.S.C. §§ 416(i) and 423(a). Consequently, plaintiff is entitled to a period of disability and disability insurance benefits only if she has established that she became disabled for all forms of substantial gainful employment on or before December 31, 2016.

         Ms. Boothe's applications were denied upon initial consideration and reconsideration. She then requested and received a de novo hearing and review before an Administrative Law Judge. In an opinion dated December 28, 2015, the Law Judge also determined that Ms. Boothe is not disabled. The Law Judge found that Ms. Boothe suffers from several severe impairments, including obesity, hypertension, degenerative disc disease, osteoarthritis, diabetes, and peripheral neuropathy. (Tr. 22). Nevertheless, the Law Judge determined that Ms. Boothe retains the residual functional capacity to perform a limited range of light exertional activity. More specifically, the Law Judge found that plaintiff is capable of performing "light work, "[1] except that she can only "occasionally operate foot controls, climb, kneel, crawl, and reach overhead, " and can "never climb ladders, ropes, or scaffolds." (Tr. 26). Given such a residual functional capacity, and after considering testimony from a vocational expert, the Law Judge determined that Ms. Boothe remains capable of performing her past relevant work as a cashier or convenience store manager. In the alternative, the Law Judge found that if even if Ms. Boothe is disabled for past relevant work, she retains the capacity to perform other work roles existing in significant number in the national economy. Accordingly, the Law Judge concluded that Ms. Boothe is not disabled, and that she is not entitled to benefits under either federal program. See generally 20 C.F.R. §§ 404.1520(f)-(g) and 416.920(f)-(g).

         Ms. Boothe then sought review by the Social Security Administration's Appeals Council. In connection with her request for review, Ms. Boothe submitted additional evidence to support her claims for benefits. The new evidence included additional treatment records from the Pulaski Free Clinic dated December 3, 2015 through December 22, 2015, as well as an opinion letter from Dr. Robert B. Stephenson, a board certified orthopaedic surgeon who examined Ms. Boothe on February 10, 2016.

         In his opinion letter, Dr. Stephenson noted that Ms. Boothe has "a long history of progressive low back pain" and a "longstanding history of diabetes mellitus, which has been difficult to control." (Tr. 41). The letter indicates that Dr. Stephenson reviewed x-rays of Ms. Boothe's lumbar, cervical, and thoracic spine, taken in 2012 and 2013, which showed "degenerative changes throughout." (Tr. 44). He also reviewed the results of a lumbar MRI scan performed on December 10, 2015, noting as follows:

Review of report today reveals several areas of small/mild disc bulging with osteophytes are noted, especially at the L4-5 level, causing mild spinal stenosis. At ¶ 5-S1, there is a larger disc bulge/osteophyte complex eccentric to the left side with facet hypertrophy causing mild impingement of the exiting L5 nerve root in the left neural foramen.

(Tr. 42). Based on his review of existing medical records and his examination of plaintiff, Dr. Stephenson's diagnostic impression included "chronic back and neck pain related to underlying degenerative changes of the cervical/thoracic/lumbar spine, " "progressive diabetic neuropathy, " and obesity. (Tr. 44). He rated Ms. Boothe's prognosis as "fair to poor, " given the natural history of degenerative changes of the spine, and her difficulty losing weight. (Id.) Dr. Stephenson also provided the following opinions regarding Ms. Boothe's functional limitations:

It is felt that the patient could be expected to sit and/or stand and/or walk up to a maximum of 2 hours each in an 8 hour workday with breaks as needed, including change in position or activity level, as discussed above. Patient has no need for any assistive devices for ambulation. It is felt that the patient could lift and/or carry up to 5 pounds frequently and approximately 10-15 pounds occasionally. The patient would have postural limitations regarding bending, stooping, crouching, etc., which she could do on an occasional basis. The patient could do manipulative activities regarding reaching and pushing and pulling on a nonstrenuous basis without restriction. The patient would have difficulty with repetitive handling, feeling, grasping, and fingering because of her decreased sensation due to diabetic neuropathy in a stocking-glove distribution. The patient should be limited from climbing ladders and also limited to only occasional stair use because of balance problems related to diabetic neuropathy. The patient reports that she typically uses a ramp rather than stairs when available. Patient should avoid exposure to vibration and/or cold because of aggravation of arthritic changes of the spine. For safety reasons, the patient should not engage in activities involving unprotected heights.

(Tr. 44-45).

         The Appeals Council ultimately denied Ms. Boothe's request for review and adopted the Law Judge's opinion as the final decision of the Commissioner. In so doing, the Appeals Council considered the additional treatment records from the Pulaski Free Clinic but found that they did not provide a basis for changing the Law Judge's decision. As for the new opinion letter from Dr. Stephenson, the Appeals Council found that the letter was not chronologically relevant and thus declined to consider it. The Appeals Council commented as follows:

We also looked at a letter from Dr. Robert B. Stephenson, M.D., dated February 10, 2016 (5 pages).... The Administrative Law Judge decided your case through December 28, 2015. This new information is about a later time. Therefore, it does not affect the decision about whether you were disabled beginning on or before December 28, 2015.

(Tr. 2). Having exhausted all available administrative remedies, Ms. Boothe has now appealed to this court.

         While 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. ยงยง 423(d)(2) and 1382c(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 ...

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