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McQuaig v. Berryhill

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

March 28, 2018

DEREK K. MCQUAIG, Plaintiff,
NANCY BERRYHILL, Acting Commissioner of Social Security, Defendant.


          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 claim for a period of disability and disability insurance benefits under the Social Security Act, as amended, 42 U.S.C. §§ 416(i) and 423. Jurisdiction of this court is pursuant to 42 U.S.C. § 405(g). 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, Derek K. McQuaig, was born on October 16, 1966, and eventually completed his high school education. Mr. McQuaig has also completed two years in college and previously worked as a communications engineer. He last worked on a regular and sustained basis in 2008. (Tr. 36). On January 23, 2014, Mr. McQuaig filed an application for a period of disability and disability insurance benefits. The record suggests that an earlier application for such benefits had proven unsuccessful. In filing his most recent claim, Mr. McQuaig alleged that he became disabled for all forms of substantial gainful employment on June 20, 2012, due to hip pain, digestive disorder, hypertension, posttraumatic stress disorder, cervical spine impairment, fibromyalgia, left knee injury, headaches, and chronic obstructive pulmonary disease. He now maintains that he has remained disabled to the present time. The record reveals that Mr. McQuaig met the insured status requirements of the Act through the fourth quarter of 2013, but not thereafter. See gen., 42 U.S.C. §§ 416(i) and 423(a). Consequently, plaintiff is entitled to a period of disability and disability insurance benefits only if he has established that he became disabled for all forms of substantial gainful employment on or before December 31, 2013. See 42 U.S.C. § 423(a).

         Mr. McQuaig's most recent application was denied upon initial consideration and reconsideration. He then requested and received a de novo hearing and review before an Administrative Law Judge. In an opinion dated March 24, 2017, the Law Judge also determined that plaintiff was not disabled. The Law Judge found that Mr. McQuaig suffered from several severe impairments, including bilateral hip avascular and aseptic necrosis with a total right hip replacement; degenerative disc disease; anxiety; knee arthritis; posttraumatic stress disorder; major depressive disorder; and a history of Crohn's disease, colitis, and attention deficit hyperactivity disorder. (Tr. 13). Because of plaintiffs mental and physical impairments, the Law Judge held that plaintiff was disabled for all of his past work roles. (Tr. 23). However, the Law Judge ruled that plaintiff retained sufficient functional capacity for a limited range of sedentary work at all relevant times prior to termination of insured status. The Law Judge assessed plaintiffs residual functional capacity as follows:

After careful consideration of the entire record, the undersigned finds that, through the date last insured of December 31, 2013, the claimant had the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a) with exceptions. The claimant could never climb or crawl, but could occasionally stoop and crouch. He was able to maintain attention and concentration throughout the workday for tasks involving short, simple, and some detailed, but not more complex instructions. The claimant could tolerate occasional interaction with others, but could not interact with large crowds of unfamiliar persons. He required the use of a cane for ambulation beyond fifty feet.

(Tr. 17). Given such a residual functional capacity, and after considering plaintiffs age, education, and prior work experience, as well as testimony from a vocational expert, the Law Judge ruled that Mr. McQuaig retained sufficient functional capacity to perform several specific sedentary work roles existing in significant number in the national economy. (Tr. 24). Accordingly, the Law Judge ultimately concluded that plaintiff was not disabled, and that he is not entitled to a period of disability or disability insurance benefits. See 20 C.F.R. § 404.1520(g). The Law Judge's opinion was adopted as the final decision of the Commissioner by the Social Security Administration's Appeals Council. Having exhausted all available administrative remedies, Mr. McQuaig has now appealed to this court.

         While the plaintiff may be disabled for certain forms of employment, the crucial factual . determination is whether the plaintiff is disabled for all forms of substantial gainful employment. See 42 U.S.C. § 423(d)(2). 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 education, vocational history, residual skills, and age. Vitek v. Finch, 438 F.2d 1157, 1159-60 (4th Cir. 1971); Underwood v. Ribicoff, 298 F.2d 850, 851 (4th Cir. 1962).

         After a review of the record in this case, the court is unable to conclude that the -Commissioner's final decision is supported by substantial evidence. With regard to non-exertional limitations, the court must conclude that the Law Judge did not account for all of the manifestations of plaintiff s conditions in the hypothetical questions put to the vocational expert. Thus, the court finds "good cause" for remand of this case to the Commissioner so that all of plaintiffs work-related limitations can be considered in assessing his capacity for other work roles.

         The medical record confirms that Mr. McQuaig has a history of depression and pain related to physical impairments. On March 28, 2012, Mr. McQuaig established treatment at the Veterans Affairs Medical Center ("VAMC") in Salem, Virginia. (Tr. 608). During that visit, he saw VAMC Physician Assistant Christopher L. Lentz for a general evaluation and Dr. Christina B. Shook for a psychological evaluation. (Tr. 598, 608). Dr. Shook observed that Mr. McQuaig had poor concentration, including during activities such as watching television and reading the newspaper, and that this problem occurred "quite a bit" or more than half of the time. (Tr. 600, 603, 606).

         On November 18, 2014, Lentz and Dr. John F. Gaylord completed a medical source statement for Mr. McQuaig.[1] (Tr. 489). The two providers opined that, as of January 2008, Mr. McQuaig experienced the following limitations: Mr. McQuaig could only lift and carry ten pounds occasionally; required five-minute walking breaks every thirty to sixty minutes; and was limited to less than one hour of sitting and less than one hour of standing or walking in an eight-hour work day. (Tr. 487-88). Finally, they concluded that Mr. McQuaig would be absent from work at least three times a month because of his impairments and that his depression and memory problems affected his ability to work. (Tr. 488-89).

         On March 25, 2016, Dr. Gaylord completed a separate medical source statement setting forth Mr. McQuaig's physical limitations since 2007. (Tr. 617-21). In this statement, Dr. Gaylord concluded that Mr. McQuaig's pain and other symptoms would frequently interfere with Mr. McQuaig's ability to pay attention and concentrate during an eight-hour workday. (Tr. 620).

         On October 18, 2016, Dr. Gaylord and Lentz completed a medical source statement regarding Mr. McQuaig's mental health. (Tr. 1478-81). The statement listed anxiety and depression as Mr. McQuaig's mental health diagnoses. (Tr. 1478). Dr. Gaylord indicated that Mr. McQuaig had experienced the following symptoms since 2008: irritability, social withdrawal or isolation, and intermittent insomnia. (Tr. 1479). According to Dr. Gaylord, Mr. McQuaig experienced no to mild limitations with understanding, remembering, and carrying out simple, one to two step instructions, but experienced moderate difficulty understanding, remembering, and carrying out detailed instructions. (Tr. 1480). While Mr. McQuaig could sustain an ordinary routine without supervision, he had moderate to marked limitations in. maintaining attention and concentration for extended periods, completing a normal workday, and performing work at a consistent pace without rest periods. (Tr. 1480). Finally, Dr. Gaylord . opined that Mr. McQuaig would be absent from work more than three times per month and stated that Mr. McQuaig's symptoms had been present since January 2008. (Tr. 1481).

         In determining Mr. McQuaig's residual functional capacity, the Law Judge did not give controlling weight to any of Dr. Gaylord's opinions. Despite seemingly identifying Dr. Gaylord -as a treating physician, the Law Judge concluded that the medical evidence did not support the limitations identified by Dr. Gaylord. (Tr. 22). As support for that conclusion, the Law Judge cited his analysis regarding the paragraph B criteria. (Tr. 22).

         When the Law Judge discussed the paragraph B criteria, he commented on Mr. McQuaig's limitations regarding ...

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