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Caldwell v. Berryhill

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

June 13, 2018

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



         Plaintiff has filed this action challenging the final decision of the Commissioner of Social Security denying plaintiffs claims for disability insurance benefits and supplemental security income benefits under the Social Security Act, as amended, 42 U.S.C. §§ 416(i) and 423, and 42 U.S.C. § 1381 et seq., respectively. Jurisdiction of this court is pursuant to 42 U.S.C. § 405(g) and 42 U.S.C. § 1383(c)(3). This court's review is limited to a determination as to whether there is substantial evidence to support the Commissioner's conclusion that plaintiff failed to meet the requirements for entitlement to benefits under the Act. If such substantial evidence exists, the final decision of the Commissioner must be affirmed. Laws v. Celebrezze, 368 F.2d 640 (4th Cir. 1966). Stated briefly, substantial evidence has been defined as such relevant evidence, considering the record as a whole, as might be found adequate to support a conclusion by a reasonable mind. Richardson v. Perales, 402 U.S. 389, 401 (1971).

         The plaintiff, Lydia I. Caldwell, was born on March 19, 1970, and has received some college education. Ms. Caldwell was previously married and did not work during her marriage. After her divorce, she worked as a waitress and a dishwasher at a restaurant. However, the Law Judge concluded that the plaintiff has no past relevant work for purposes of her applications for benefits. (Tr. 26). The Law Judge found that Ms. Caldwell last worked on a regular and sustained basis in 2011 based on Ms. Caldwell's alleged onset date of April 1, 2011. On September 11, 2012, Ms. Caldwell filed an application for a period of disability and disability insurance benefits, and on October 15, 2012, she filed an application for supplemental security income benefits. Ms. Caldwell alleged disability based on fibromyalgia, osteoporosis, Graves disease, arthritis, incontinence, lower back pain, severe fatigue and weakness, carpal tunnel syndrome, migraines, depression, anxiety disorder, and panic attacks. She now maintains that she has remained disabled to the present time. As to her application for a period of disability and disability insurance benefits, the Law Judge found that Ms. Caldwell met the insured status requirements of the Act at all relevant times. (Tr. 19); see, gen., 42 U.S.C §§ 416(i) and 423(a).

         Ms. Caldwell's applications were denied upon initial consideration and reconsideration. She then requested and received a de novo hearing and review before an Administrative Law Judge. In an opinion dated March 1, 2016, the Law Judge applied the five-step sequential process for evaluating disability claims.[1] 20 C.F.R. §§ 404.1520 and 416.920. The Law Judge found that Ms. Caldwell has not engaged in substantial gainful activity since her alleged onset date of April 1, 2011, [2] and that she suffers from severe impairments including fibromyalgia, Graves ophthalmopathy, degenerative disc disease, osteoporosis, hypothyroidism, stress incontinence, history of bilateral carpal tunnel syndrome, headaches, history of edema, bipolar disorder, and anxiety. The Law Judge then assessed Ms. Caldwell's residual functional capacity as follows:

After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except the claimant can occasionally climb, stoop, kneel, crouch, and crawl. She can perform frequent (but not constant) handling. She could have occasional exposure to excessive noise and vibrations. She would be able to perform simple, routine, unskilled work tasks, which do not require exposure to hazards, allow for regularly scheduled breaks, and have no more than occasional changes in the work setting. She would require no more than occasional interaction with the public.

(Tr. 22). Given this residual functional capacity, and after considering Ms. Caldwell's age, education, and prior work experience, as well as the testimony of a vocational expert, the Law Judge determined that Ms. Caldwell retained sufficient functional capacity to perform certain light work roles existing in significant number in the national economy.[3] (Tr. 26). Accordingly, the Law Judge concluded that Ms. Caldwell has not been disabled since 2011, is not presently disabled, and is not entitled to either disability insurance benefits or supplemental security income benefits. See 20 C.F.R. §§ 404.1520(g) and 416.920(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 administrative remedies, Ms. Caldwell 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) and 1382c(a). 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 constrained to conclude that the Commissioner's final decision is supported by substantial evidence. The Law Judge's opinion reflects a thorough evaluation of Ms. Caldwell's medical records, the relevant medical opinions, Ms. Caldwell's testimony about her impairments, and Ms. Caldwell's characteristics.

         The medical record reveals that Ms. Caldwell received her primary care from Dr. Caren Aaron from the time of her alleged onset date in 2011 through mid-2013, and from Dr. Kimberly A. Dulaney since mid-2013. (Tr. 41). Ms. Caldwell has a history of treatment for Graves disease, degenerative disc disease, fibromyalgia, carpal tunnel syndrome, and stress incontinence. Ms. Caldwell has been advised to treat the symptoms of her Graves disease, a thyroid eye condition, with eye drops and ointment (Tr. 718), and has been directed to take an appropriate dose of her thyroid medication and Potassium (Tr. 1125). In 2015, Dr. Dulaney determined that Ms. Caldwell's thyroid was much improved and almost within the normal range. (Tr. 793). Ms. Caldwell has complained of back pain, but despite some indication of mild multilevel degenerative joint disease, her imaging "was essentially negative." (Tr. 381-83). A 2015 image of Ms. Caldwell's lumbar spine showed that she has normal alignment and normal disc heights and facet joints. (Tr. 1000). Ms. Caldwell has reported some improvement in her pain through the use of pain medication and epidural injections (Tr. 634), and has been advised to perform lower back exercises and aquatic therapy to treat her lower back pain and fibromyalgia (Tr. 967). Ms. Caldwell has also undergone procedures to correct her bilateral carpal tunnel syndrome and did not experience any complications with the procedures. (Tr. 493- 94, 525-26). Additionally, Ms. Caldwell underwent a bladder sling replacement in 2012 for stress urinary incontinence. In 2013, Ms. Caldwell requested another referral to urology because of pain and cramping related to the sling replacement (Tr. 469), but the record does not reflect significant later treatment for this problem.

         Ms. Caldwell's medical record also indicates that she has been diagnosed with bipolar disorder and has reported feelings of depression and anxiety. Dr. Aaron noted that Ms. Caldwell reported an inability to leave her apartment except to attend medical appointments or go to the grocery store as well as irritability, panic attacks, and fatigue. (Tr. 628-29). While receiving treatment from Dr. Aaron, Ms. Caldwell took medication for her anxiety. (See Tr. 622, 626). However, Dr. Aaron's records also reflect periods in which Ms. Caldwell appeared to have a good mood, good affect, and no signs of anxiety or depression. (Tr. 616, 630, 633, 694). In 2015, Dr. Dulaney observed that Ms. Caldwell expressed some difficulty with concentration, restless sleep, paranoia, and irritability. (Tr. 781, 1020). Ms. Caldwell also briefly received care at the Center for Emotional Care in 2015. There, the psychiatrist's report noted that Ms. Caldwell attended weekly therapy sessions and had a history of taking medications for anxiety, depression, and bipolar disorder. (Tr. 1049-50). Although Ms. Caldwell had described her concentration as "off to Dr. Dulaney (Tr. 781), the psychiatrist's report described Ms. Caldwell as having a good affect, good memory, and "good attention and concentration" (Tr. 1049). Ms. Caldwell reported to Dr. Dulaney that she experienced some improvement in her mental health symptoms with medication and counseling. (Tr. 998).

         In addition to the medical record, the Law Judge considered the opinions of the state agency consultants and Ms. Caldwell's treating physician, Dr. Aaron. The state agency consultants opined that Ms. Caldwell could perform light work with certain conditions and was moderately limited in her ability to maintain attention and concentration for extended periods, but "would be able to meet the basic mental demands of competitive work on a sustained basis." (Tr. 104-08, 120-28). A state agency consultant explained that although Ms. Caldwell experiences stress and worry, her mental status exams fall within normal limits, she takes medication to manage symptoms, and she has the ability to complete household activities and go to the store and medical appointments. (Tr. 127). The consultant opined that Ms. Caldwell fears crowds but can otherwise maintain socially appropriate behavior as demonstrated by her socialization with her daughter and endeavors outside the home. (Tr. 128). The consultant recognized that Ms. Caldwell had not received any "significant psychiatric care" since her initial filing and had "not been hospitalized or received intensive inpatient or outpatient psychiatric care." (Tr. 128). The consultant concluded that Ms. Caldwell "remains capable of simple, routine work." (Tr. 128). However, one of the plaintiffs treating physicians, Dr. Aaron, opined that Ms. Caldwell is disabled due to a combination of physical and emotional causes. (Tr. 630, 643, 667, 682). The Law Judge determined that Ms. Caldwell's complaints and Dr. Aaron's notes based on those complaints were not entirely consistent with the overall medical evidence, which was reviewed by the state agency consultants. The court believes that substantial evidence supports the Law Judge's reliance on the state agency consultants' opinions, inasmuch as the court agrees that these opinions are consistent with the objective findings in the record.

         Through his consideration of the state agency reports, the court believes that the Law Judge was able to properly consider the synergistic effect of all of plaintiffs physical and emotional problems. Stated differently, the court believes that, in this case, the state agency reports provide substantial evidence for the Law Judge's disposition.

         The Law Judge did not give significant weight to Dr. Aaron's opinions that Ms. Caldwell was unable to seek or maintain employment because of back pain, reduced stamina, depression, and incontinence; that Ms. Caldwell was disabled; or that Ms. Caldwell's activities of daily living were markedly limited because of Ms. Caldwell's difficulty with completing tasks. (Tr. 630, 643, 667, 682). Dr. Aaron assumed that Ms. Caldwell was "medically compliant." (Tr. 630). To the extent Dr. Aaron opined that Ms. Caldwell was disabled, the Law Judge rejected the opinion as encroaching on a judgment reserved for the Commissioner. (Tr. 25). The Law Judge accorded reduced weight to the remainder of Dr. Aaron's opinions because she largely relied on Ms. Caldwell's subjective complaints, which the Law Judge did not find entirely credible, and her opinions conflicted with the objective medical evidence in the record. (Tr. 25).

         The Law Judge did not fully credit the subjective complaints of Ms. Caldwell because of her limited work history and history of drug and alcohol abuse. (Tr. 25). Ms. Caldwell testified at the administrative hearing that she experiences approximately three migraines a month, joint pain, pain in her hands, nausea, diarrhea, difficulty sitting for more than 15 to 20 minutes, difficulty standing for more than 10 to 15 minutes, feelings of fatigue due to her thyroid condition and medication, blurred vision, trouble holding objects, difficulty concentrating, and three to four panic attacks a week. (Tr. 50-62). In finding Ms. Caldwell's statements to be of limited credibility, the Law Judge observed that Ms. Caldwell filed for disability as early as 2005, but continued to work for several years after 2005 and even continued to work in an informal manner after the alleged onset date for her instant applications for benefits. (Tr. 25). The Law Judge further observed that Ms. Caldwell did not use her prescription drugs as prescribed, took non-prescribed and illegal drugs, and has not yet secured treatment for her drug use. (Tr. 45, 48, 60, 731). A few weeks after being confronted about her use of controlled and illegal drugs (Tr. 731), Ms. Caldwell arrived at the emergency room and was found to be intoxicated following a night of drinking with her boyfriend (Tr. ...

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