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Yates v. Commissioner of Social Security

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

February 16, 2018




         Plaintiff Mary Ellen Yates asks this Court to review the Commissioner of Social Security's (“Commissioner”) final decision denying her applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act (the “Act”), 42 U.S.C. §§ 401-434, 1381-1383f. The case is before me by referral under 28 U.S.C. § 636(b)(1)(B). ECF No. 12. Having considered the administrative record, the parties' briefs, and the applicable law, I cannot find that substantial evidence supports the Commissioner's final decision. Accordingly, I recommend that the decision be reversed and the case be remanded under the fourth sentence of 42 U.S.C. § 405(g) to give the Commissioner another opportunity to explain her findings and conclusions.

         I. Standard of Review

         The Social Security Act authorizes this Court to review the Commissioner's final decision that a person is not entitled to disability benefits. 42 U.S.C. §§ 405(g), 1383(c)(3); see also Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). The Court's role, however, is limited-it may not “reweigh conflicting evidence, make credibility determinations, or substitute [its] judgment” for that of agency officials. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Instead, a court reviewing the merits of the Commissioner's final decision asks only whether the Administrative Law Judge (“ALJ”) applied the correct legal standards and whether substantial evidence supports the ALJ's factual findings. Meyer v. Astrue, 662 F.3d 700, 704 (4th Cir. 2011); see Riley v. Apfel, 88 F.Supp.2d 572, 576 (W.D. Va. 2000) (citing Melkonyan v. Sullivan, 501 U.S. 89, 98-100 (1991)).

         “Substantial evidence” means “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 mere scintilla” of evidence, id., but not necessarily “a large or considerable amount of evidence, ” Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence review takes into account the entire record, and not just the evidence cited by the ALJ. See Universal Camera Corp. v. NLRB, 340 U.S. 474, 487-89 (1951); Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984). Ultimately, this Court must affirm the ALJ's factual findings if “conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled.” Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (per curiam) (quoting Craig v. Chater, 76 F.3d 585, 594 (4th Cir. 1996)). However, “[a] factual finding by the ALJ is not binding if it was reached by means of an improper standard or misapplication of the law.” Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).

         A person is “disabled” within the meaning of the Act if he or she is unable to engage in “any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); accord 20 C.F.R. §§ 404.1505(a), 416.905(a). Social Security ALJs follow a five-step process to determine whether a claimant is disabled. The ALJ asks, in sequence, whether the claimant (1) is working; (2) has a severe impairment that satisfies the Act's duration requirement; (3) has an impairment that meets or equals an impairment listed in the Act's regulations; (4) can return to his or her past relevant work based on his or her residual functional capacity; and, if not (5) whether he or she can perform other work. See Heckler v. Campbell, 461 U.S. 458, 460-62 (1983); Lewis v. Berryhill, 858 F.3d 858, 861 (4th Cir. 2017); 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The claimant bears the burden of proof through step four. Lewis, 858 F.3d at 861. At step five, the burden shifts to the agency to prove that the claimant is not disabled. See id.

         II. Procedural History

         Yates filed for DIB and SSI on September 21, 2012, alleging disability because of post-traumatic stress disorder (“PTSD”), borderline split personality disorder, anxiety, and depression. See Administrative Record (“R.”) 71, 84, ECF No. 9-1. She alleged disability as of December 31, 2008, at which time she was twenty-five years old. Id. Disability Determination Services (“DDS”), the state agency, twice rejected Yates's applications. R. 97-98, 124-25. On September 2, 2015, Yates appeared with counsel for an administrative hearing before ALJ H. Munday. R. 45. Yates and a vocational expert (“VE”) testified at the hearing. R. 51-64, 65-69.

         ALJ Munday issued an unfavorable decision on October 15, 2015. R. 16-33. She first found that Yates had not worked since December 31, 2008, and that Yates met the Act's insured status requirements through March 31, 2013.[1] R. 19. At step two, she found that Yates's fibromyalgia, PTSD, major depressive disorder, and borderline personality disorder qualified as “severe” medical impairments. Id. All of Yates's other diagnosed conditions were deemed non-severe impairments.[2] Id. At step three, ALJ Munday found that none of Yates's severe impairments met or medically equaled one of the impairments listed in the Act's regulations. R. 19-21. As part of this analysis, she also found Yates's mental impairments caused “mild restriction[s]” in her daily activities, “moderate difficulties” in social functioning, “moderate difficulties in concentration and persistence[, ] and no significant limitation in pace.” R. 20.

         ALJ Munday next evaluated Yates's residual functional capacity (“RFC”) based on all of her medical impairments. See R. 22-31. The ALJ determined that Yates could perform “medium work”[3] and “simple routine tasks involving no more than simple, short instructions and simple work-related decisions with few workplace changes” and “occasionally interact with the general public and co-workers, ” but she could not “work in close proximity to others (defined as no teamwork or interdependence required).” R. 21. This RFC ruled out Yates's return to her past work. R. 31-32. Finally, based on her RFC finding and the VE's testimony, ALJ Munday concluded that Yates was not disabled during the relevant period because she still could perform certain widely available “medium, unskilled” occupations such as packer, cleaner, and inspector/grader. R. 32-33. The Appeals Council denied Yates's request for review, R. 1-5, and this appeal followed.

         III. Discussion

         Yates makes two overarching arguments on appeal. First, she argues that ALJ Munday ignored evidence of her diagnosed migraine headaches and joint hypermobility syndrome when evaluating the severity of her medical impairments at step two and “failed to consider” those conditions when assessing her physical RFC. See Pl.'s Br. 11-13, 17. This argument merits only a brief discussion because, as the Commissioner correctly points out, Yates does not suggest ALJ Munday overlooked any impairment-related functional limitations that might have changed the outcome in this case. See Id. at 11-13; Def.'s Br. 12-13, ECF No. 19.

         Second, Yates argues that ALJ Munday did not explain how her mental RFC determination-i.e., that Yates was limited to “simple routine tasks involving no more than simple, short instructions and simple work-related decisions with few workplace changes, ” occasional interaction with the general public and coworkers, and no jobs requiring teamwork or “interdependence”-reflected her step-three finding that Yates had moderate difficulties maintaining concentration and persistence. Pl.'s Br. 13, 15. The Commissioner responds that ALJ Munday explained how “she arrived at the specific concentration, persistence, or pace limitations constituting her RFC” determination, Def.'s Br. 18, and reasonably relied on medical opinions that Yates could perform simple, routine tasks despite her mental impairments. See Id. at 15-17, 18-19. Yates has the better position on this issue. “Given the depth and ambivalence of the [current] record, ” however, I find that the Commissioner should have another opportunity to explain her findings and conclusions.[4] Radford v. Colvin, 734 F.3d 288, 296 (4th Cir. 2013).

         A. Non-Severe Impairments

         At step two, the ALJ determines whether the claimant has a “severe” medically determinable physical or mental impairment or combination of impairments. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). An impairment or combination of impairments “is considered ‘severe' if it significantly limits an individual's physical or mental abilities to do basic work activities.” SSR 96-3p, 1996 WL 374181, at *1 (July 2, 1996). Conversely, an impairment or combination of impairments is “considered . . . ‘not severe' only if it is a slight abnormality which has such a minimal effect on the individual, ” Evans v. Heckler, 734 F.2d 1012, 1014 (4th Cir. 1984) (emphasis omitted), that it does not meaningfully impair his or her functional ability to perform basic work activities, SSR 96-3p, 1996 WL 374181, at *2. See also Felton-Miller v. Astrue, 459 Fed.Appx. 226, 229-30 (4th Cir. 2011) (per curiam) (“[M]edical conditions alone do not entitle a claimant to disability benefits; ‘[t]here must be a showing of related functional loss.'” (quoting Gross v. Heckler, 785 F.2d 1163, 1166 (4th Cir. 1986))). “Basic work activities” are the “abilities and aptitudes necessary to do most jobs, ” such as standing, walking, and lifting, or responding to other people, exercising judgment, and dealing with normal workplace situations. 20 C.F.R. §§ 404.1521(b), 416.921(b) (2015).

         Yates asserts that ALJ Munday committed reversible error by “fail[ing] to assess” her joint hypermobility syndrome and by never “mention[ing] the word ‘migraine'” when evaluating her physical impairments. Pl.'s Br. 12, 13. Critically, however, Yates does not identify any specific error in ALJ Munday's finding that, with the exception of fibromyalgia, PTSD, major depressive disorder, and borderline personality disorder, all of Yates's other diagnosed conditions, “considered singly and in combination, ” were non-severe impairments at least in part because they “did not result in any continuous . . . functional limitations” affecting her ability to do basic work activities. See R. 19. For example, although Yates faults ALJ Munday for not mentioning a July 30, 2015 comment by Jeffrey Potter, M.D., that Yates exhibited hypermobility at the elbows, two finger joints, knees, and ankles, Pl.'s Br. 12 (citing R. 1095-99), she does not identify any “related functional loss” that ALJ Munday supposedly overlooked, Felton-Miller, 459 Fed.Appx. at 230; Gross, 785 F.2d at 1166. Nor does she identify any functional limitations associated with the “complaints of migraines” that appear in the medical record. Pl.'s Br. 12-13.

         “[T]here is no rigid requirement that the ALJ specifically refer to every piece of evidence in [her] decision” so long as it is clear the “decision was based on the entire record” and the ALJ's factual findings are supported by substantial evidence. Reid v. Comm'r of Soc. Sec., 769 F.3d 861, 865 (4th Cir. 2014) (quoting Dyer v. Barnhart, 395 F.3d 1205, 1211 (11th Cir. 2005) (per curiam)). ALJ Munday's discussion of Yates's physical impairments satisfied these standards. Indeed, she cited Dr. Potter's essentially normal findings on the July 30 physical exam, as well as his recommendation that Yates manage her pain with medications and “regular physical activity, ” to help support her finding that Yates's muscle and joint pain was not as debilitating as alleged. R. 28 (citing R. 1094-95, 1097, 1099). She also mentioned that Dr. Potter's exam “findings were consistent with hypermobility syndrome and associated fibromyalgia, ” id., and she explained why Yates's complaints of back and knee pain, combined with “limited” and “mild” abnormal findings on physical exams and X-rays, supported her finding that fibromyalgia reduced Yates's physical capacity to work even though a DDS physician opined she had “no severe physical impairment, ” R. 30 (citing R. 103, 115-16, 632, 668, 673). Thus, Yates has not shown that ALJ Munday either “ignored” her joint hypermobility syndrome, Pl.'s Br. 12, or overlooked evidence showing the impairment caused specific functional limitations that might have changed the outcome of her disability claim. Reid, 769 F.3d at 865; see also Vitrano v. Colvin, No. 6:14cv51, 2016 WL 1032888, at *2 (W.D. Va. Mar. 14, 2016) (“[A]ny error by the ALJ at step two is harmless if the ALJ considers the effects of all of [the claimant's] impairments in the subsequent steps.”).

         Although ALJ Munday did not mention that Yates sometimes reported migraine headaches or that her family physician Larry Smith, M.D., occasionally prescribed a “migraine prophylaxis, ” see, e.g., R. 54, 622-24, 627-29, 643, she acknowledged that Yates reported having headaches, R. 23, and stated that she considered “the entire record” before making her factual findings, R. 18. See also R. 22-23, 25 (citing R. 53-54, 358-60, 622-24, 627-29, 643). There is no indication that Yates ever attributed specific functional limitations to migraine headaches. R. 54, 622, 627, 643. On March 18, 2013, for example, she told Dr. Smith that she was “currently able to do activities of daily living without limitation” even though she suffered “intense” migraines marked by “some nausea” and “increased sensitivity to light and sound” two or three times a week. R. 622. She also said her migraines were “less frequent” on topiramate, id., but Dr. Smith told her to stop taking that medication because she was pregnant, R. 624. Yates repeatedly denied suffering from headaches and visual disturbances after this date. R. 653 (Aug. 2013), 1074 (Feb. 2015), 1066 (Mar. 2015), 1057 (Apr. 2015), 1053 (May 2015), 1038 (June 2015). Considering Yates's infrequent report of migraines and the absence of evidence showing any related functional limitations, ALJ Munday's failure to specifically discuss this medical condition almost certainly would not have changed the outcome of her disability claim. Cf. Felton-Miller, 459 Fed.Appx. at 229 (“Felton-Miller's sarcoidosis diagnosis, without more, does not establish that she suffers from any particular symptoms or limitations.”). Nonetheless, should the case be remanded for further proceedings, as I recommend, the next ALJ's decision must make clear that he or she considered all of Yates's medically determinable impairments reflected in the record. See 20 C.F.R. §§ 404.1523, 404.1545, 416.923, 416.945; 96-3p, 1996 WL 374181, at *1-2.

         B. Mental RFC Assessment

         Yates next challenges ALJ Munday's assessment of her RFC, particularly as it relates to her ability to pay attention and stay on task in the workplace. See Pl.'s Br. 13-17. A claimant's RFC represents her “maximum remaining ability to do sustained work activities in an ordinary work setting on a regular and continuing basis”[5] despite her medical impairments. SSR 96-8p, 1996 WL 374184, at *2 (emphasis omitted) (July 2, 1996); see 20 C.F.R. §§ 404.1545, 416.945. It is a factual finding “made by the Commissioner based on all the relevant evidence in the [claimant's] record, ” Felton-Miller, 459 Fed.Appx. at 230-31, and it must reflect the combined functionally limiting effects of impairments that are supported by the medical evidence or the claimant's credible symptoms, see Mascio, 780 F.3d at 640. The ALJ's RFC assessment must “include a narrative discussion describing” how medical facts and nonmedical evidence “support[] each conclusion, ” Mascio, 780 F.3d at 636, and explaining why she discounted any “obviously probative” conflicting evidence, Arnold v. Sec'y of Health, Educ. & Welfare, 567 F.2d 258, 259 (4th Cir. 1977). The ALJ must also “build an accurate and logical bridge from the evidence to [her] conclusion, ” Monroe v. Colvin, 826 F.3d 176, 189 (4th Cir. 2016) (quoting Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. ...

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