United States District Court, W.D. Virginia, Roanoke Division
DEREK K. MCQUAIG, Plaintiff,
NANCY BERRYHILL, Acting Commissioner of Social Security, Defendant.
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).
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).
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
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).
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.
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).
November 18, 2014, Lentz and Dr. John F. Gaylord completed a
medical source statement for Mr. McQuaig. (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).
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).
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.
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).
the Law Judge discussed the paragraph B criteria, he
commented on Mr. McQuaig's limitations regarding