United States District Court, W.D. Virginia, Roanoke Division
S. Ballou United States Magistrate Judge
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.
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. 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.
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. 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 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.
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.
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.
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. 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.
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.
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.
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.
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 ...