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Davis v. Berryhill

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

March 14, 2018

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


          Robert S. Ballou United States Magistrate Judge

         Plaintiff Ricky Lee Davis (“Davis”) filed this action challenging the final decision of the Commissioner of Social Security (“Commissioner”) finding him 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. Davis alleges that the Administrative Law Judge (“ALJ”) erred by failing to properly evaluate the opinion evidence, including opinions of Davis's treating physicians, the independent medical expert, and the state agency doctors. I conclude that the ALJ failed to explain the reasoning for the weights assigned to the physician opinions in the record. Consequently, I DENY the Commissioner's Motion for Summary Judgment (Dkt. No. 20), GRANT in part Davis's Motion for Summary Judgment (Dkt. No. 16) and REVERSE and REMAND this matter for further administrative consideration consistent with this opinion.


         This court limits its review to a determination of whether substantial evidence exists to support the Commissioner's conclusion that Davis failed to demonstrate that he 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).


         Davis filed for SSI and DIB on June 22, 2012, claiming that his disability began on June 30, 2008, due to deteriorating discs in his back and a tumor in his left lung. R. 273, 277, 281, 321. Davis later amended his alleged onset date to March 22, 2012. R. 28. Davis's date last insured was March 31, 2013; thus, he must show that his disability began on or before this date and existed for twelve continuous months to receive DIB. R. 29, 317; 42 U.S.C. §§ 423(a)(1)(A), (c)(1)(B), (d)(1)(A); 20 C.F.R. §§ 404.101(a), 404.131(a). The state agency denied Davis's applications at the initial and reconsideration levels of administrative review.[2] R. 108-16, 117- 25, 128-35, 136-43. On June 23, 2014, ALJ Robert S. Habermann held a hearing to consider Davis's claims for SSI and DIB. R. 56-85. Following the June 2014 hearing, the ALJ reviewed additional records submitted by Davis's attorney, obtained a consultative psychological evaluation and a records review, and then held a second hearing on March 9, 2015. R. 28, 43-55. Counsel represented Davis at both the June 2014 and March 2015 hearings, which included testimony from vocational experts Asheley Wells and Casey Vask. On March 23, 2015, the ALJ entered his decision analyzing Davis's claims under the familiar five-step process[3] and denying his claim for benefits. R. 28-37. The ALJ found that Davis was insured at the time of the disability onset and that he suffered from the severe impairments of chronic lumbar myofascitis and lumbar degenerative disc disease. R. 31. The ALJ determined that these impairments, either individually or in combination, did not meet or medically equal a listed impairment. R. 31. The ALJ specifically considered Listing 1.02 and 1.04. Id.

         The ALJ concluded that Davis retained the residual functional capacity (“RFC”) to perform a limited range of medium work. R. 33. Specifically, the ALJ found that Davis can lift or carry up to 20 pounds continuously and up to 50 pounds occasionally, and can sit for 8 hours and stand and walk for 6 hours in an 8-hour workday. Id. The ALJ further found Davis can continuously balance, operate foot controls and perform manipulative operations, can occasionally crawl, crouch, kneel, stoop, climb ladders or scaffolds, and be exposed to temperature extremes and humidity or wetness, can frequently climb stairs and ramps, and should never be exposed to vibrations. Id.

         The ALJ determined that Davis was unable to perform his past relevant work as a motor vehicle assembler, painter helper, and floor maintenance worker, but that he could perform jobs that exist in significant numbers in the national economy, such as kitchen worker, laundry worker, and food service worker. R. 36-37. Thus, the ALJ concluded that Davis was not disabled. R. 37. Davis appealed the ALJ's decision and the Appeals Council denied his request for review on August 3, 2015. R. 1-4.


         Davis alleges that the ALJ failed to properly evaluate and explain the weight he gave to the contradictory opinion evidence in the record of Davis's treating physician, two consultative physicians and a state agency physician.[4] Davis has a history of low back pain, stemming from back injuries in the 1980s and 1990s. R. 577-78. On March 22, 2012, Davis underwent an MRI of his lumbar spine, which showed stable spondylosis and disc disease including foraminal stenosis at ¶ 4/5 and L5/S1, a central protrusion at ¶ 5/S1 with left central annular fissure, and a chronic L1 compression fracture. R. 643. Davis sought treatment for his low back pain at the Veterans Administration Medical Center (“VAMC”), which included pain medication and epidural steroid injections. R. 575, 579, 660.

         The ALJ reviewed and weighed multiple opinions from medical providers when assessing Davis's RFC. On September 10, 2012, state agency physician Joseph Duckwall, M.D., reviewed Davis's records and determined that he could perform a range of medium work, including lifting/carrying 50 pounds occasionally and 25 pounds frequently; standing/walking 6 hours in an 8 hour day; sitting for 6 hours in an 8 hour workday; occasionally climbing ladders, ropes and scaffolds, and frequently performing all other postural functions. R. 112-14. The ALJ gave “great” weight to the opinion of Dr. Duckwall that Davis can perform medium work; however, the ALJ provided no explanation for his assignment of weight, aside from stating that Dr. Duckwall noted the findings of Davis's March 2012 MRI and that Davis was treated with lumbar injections and nerve blocks. R. 34.

         On June 20, 2014, Robert Stephenson, M.D., performed a consultative examination of Davis. R. 807-10. Davis reported constant low back aching pain, with intermittent sharp pain depending upon activity and positioning. R. 807. He noted increased pain in the low back with prolonged sitting or walking or heavy lifting. Id. Davis denied radicular pain or numbness and weakness in his lower extremities, and denied pain or problems with his neck and upper extremities Id. Upon examination, Davis had a normal gait and full range of motion in his upper extremities and neck. He had a localized muscle spasm in his right lumbar paraspinal muscles with muscle tightness of the left lumbar paraspinal muscles. R. 808. He had limited range of motion of the thoracolumbar and lumbar spine due to pain. Id. Davis had full range of motion of all joints of his lower extremities, and negative straight leg raising. R. 808-809. Dr. Stephenson's impression was chronic low back pain related to underlying lumbar degenerative arthritis with degenerative disc disease throughout. Dr. Stephenson expected Davis's underlying lumbar degenerative arthritis with foraminal stenosis and annular fissuring to gradually worsen over time, and gave him a “fair-poor” prognosis for significant improvement in the future. R. 809.

         Dr. Stephenson determined that Davis could stand/walk for 4 hours in an 8 hour workday; sit for 4 hours in an 8 hour workday; lift/carry 10 pounds frequently and 25 pounds occasionally; occasionally bend, stoop, crouch; and should avoid cold or damp environments and unprotected heights. Id. Dr. Stephenson recommended low back exercises, cessation of smoking, and continued care with his treating physicians. R. 810.

         The ALJ gave Dr. Stephenson's opinion “little” weight, noting that he performed a onetime exam of Davis, at the request of his attorney. R. 34. The ALJ stated, “[t]reating progress notes and objective findings do not support Dr. Stephenson's restrictions for the claimant. For his pain complaints, the claimant receives only conservative treatment. His ...

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