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Young v. Berryhill

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

June 15, 2018

ANGELA M. YOUNG, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION

          HON. 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 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, Angela M. Young, was born on March 14, 1969, and eventually completed her high school education. Ms. Young has been employed as a cashier, office clerk, assistant manager/dispatcher, and receptionist. She last worked on a regular and sustained basis in December of 2010, when her and her husband's company went out of business. (Tr. 61). On November 7, 2012, Ms. Young filed applications for disability insurance benefits and supplemental security income benefits. In filing her current claims, Ms. Young alleged that she became disabled for all forms of substantial gainful employment on June 1, 2012, due to depression, anxiety, fibromyalgia, diverticulosis, and fatigue. (Tr. 331, 365). Ms. Young now maintains that she has remained disabled to the present time. With respect to her application for disability insurance benefits, the record reveals that Ms. Young met the insured status requirements of the Act through the fourth quarter of 2015, but not thereafter. See generally, 42 U.S.C. §§ 416(i) and 423(a). Consequently, plaintiff is entitled to a period of disability and disability insurance benefits only if she has established that she became disabled for all forms of substantial gainful employment on or before December 31, 2015.

         Ms. Young'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 May 4, 2016, the Law Judge also determined, after applying the five-step sequential evaluation process, that Ms. Young is not disabled. See 20 C.F.R. §§ 404.1520 and 416.920.[1] The Law Judge found that Ms. Young suffers from several severe impairments, including major depressive disorder with melancholic features, anxiety disorder, alcohol dependence, dysthymic disorder, fibromyalgia, thoracolumbar strain, and lumbago, but that none of the conditions satisfy the requirements of a listed impairment. (Tr. 22.) The Law Judge then assessed Ms. Young'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 exertion work with lifting and carrying 20 pounds occasionally and 10 pounds frequently, standing and walking six hours of an eight-hour workday and sitting six hours of an eight-hour workday. She can never climb ladders, ropes, and scaffolds or crawl and can occasionally climb ramps and stairs, kneel, crouch, and stoop/bend. The claimant is [to] avoid more than occasional exposure to vibration and all exposure to hazards. She can only perform simple, easy to learn, job instructions consistent with unskilled work, with no more than occasional interaction with the public and coworkers.

(Tr. 26). Given such a residual functional capacity, and after considering testimony from a vocational expert, the Law Judge determined that Ms. Young is unable to perform any of her past relevant work. (Tr. 30). However, the Law Judge found that Ms. Young retains sufficient functional capacity to perform other work roles existing in significant number in the national economy. (Tr. 30-31). Accordingly, the Law Judge concluded that Ms. Young is not disabled, and that she is not entitled to benefits under either federal program. See generally 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 available administrative remedies, Ms. Young has now appealed to this court.

         While plaintiff may be disabled for certain forms of employment, the crucial factual determination is whether 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. Young's medical problems and the extent to which they affect her ability to work. Although Ms. Young suffers from a combination of physical and emotional impairments, substantial evidence supports the Law Judge's determination that she retains the residual functional capacity to perform a limited range of light work.

         Turning first to the plaintiffs physical impairments, the record reveals that Ms. Young has a history of musculoskeletal complaints. In September of 2012, her primary care physician, Dr. Bonnie Culkin, prescribed Tramadol for back pain. (Tr. 439). Ms. Young continued to complain of muscle pain in May of 2013. (Tr. 545). Dr. Culkin diagnosed Ms. Young with unspecified myalgia and myositis for which she again prescribed Tramadol. (Tr. 547). During a subsequent "well woman exam" on October 28, 2013, Ms. Young continued to complain of back pain but exhibited normal range of motion in her head and neck, as well as in her upper and lower extremities. (Tr. 539-40). Her muscle strength, gait, coordination, and deep tendon reflexes were also normal. (Tr. 540). On June 26, 2014, Ms. Young presented with back pain and exhibited tenderness along the lumbar spine. (Tr. 584-85). However, her straight leg raise test was normal, her deep tendon reflexes were intact, and she exhibited normal motor strength. (Tr. 585). Dr. Culkin added a diagnosis of lumbago and prescribed Soma as needed for muscle spasms. (Tr. 586). That same month, Ms. Young presented to an urgent care facility with complaints of back pain. (Tr. 596). Ms. Young reported that she had injured her lower back while lifting one of her grandchildren. Although Ms. Young appeared to be "uncomfortable, " her physical examination revealed "no spinal tenderness, " normal motor strength, and "normoactive" reflexes. (Tr. 598). The examining physician diagnosed her with lumbrosacral radiculitis and prescribed Norco as needed for pain. (Tr. 598).

         At the administrative hearing held on January 14, 2016, Ms. Young testified that she experiences radiating pain in her legs and sides. (Tr. 79-80). She estimated that she can sit for approximately thirty to forty-five minutes before needing to stand and move, and that she can only stand for approximately five to ten minutes before "everything hurts" and she becomes "lightheaded." (Tr. 88-89). Plaintiff further testified that she takes a nap once a day, and that the naps last between two and three hours. (Tr. 89). Although plaintiff acknowledged that she occasionally watches her three young grandchildren for several hours at a time, she testified that she usually naps as soon as they leave and that "everything hurts" for several days thereafter. (Tr. 86, 87, 90).

         After considering all of the evidence of record, the Law Judge determined that Ms. Young's physical impairments are not so severe as to prevent performance of lighter forms of work activity. In making this determination, the Law Judge found that Ms. Young's allegations of disabling physical limitations are not entirely credible. The Law Judge noted that the plaintiffs treatment records do not support her allegations regarding the need for daily naps, and that the clinical evaluations discussed above include relatively benign objective findings. The Law Judge emphasized that while the medical records reflect consistent complaints of pain, particularly in the plaintiffs back, the findings on examination were generally limited to tenderness and did not reveal signs of more severe abnormalities or defects, such as reduced range of motion, sensory or motor deficits, or positive straight leg raise. (Tr. 28). Accordingly, the Law Judge concluded that while plaintiff has work-related limitations resulting from her musculoskeletal impairments, the clinical findings and other evidence in the record do not fully support the plaintiffs statements concerning the intensity and persistence of the symptoms she claims to experience.

         The Law Judge also declined to accept Dr. Culkin's opinion regarding plaintiffs ability to work. In July of 2015, Dr. Culkin completed a medical source statement of the plaintiffs physical ability to perform work-related activities that is inconsistent with the Law Judge's assessment of plaintiff s physical residual functional capacity. In particular, Dr. Culkin opined that Ms. Young can occasionally lift no more than ten pounds, stand and/or walk for less than two hours in an eight-hour workday, and engage in only limited reaching, pushing, and pulling. (Tr. 590-91).

         Upon review of the record, the court believes that the Law Judge reasonably afforded little weight to Dr. Culkin's assessment. While the Law Judge recognized Dr. Culkin as a "long time treating source, " he noted that Dr. Culkin is not a specialist in the areas of the plaintiffs impairments, and that she did not identify any objective studies or findings that would support her opinions regarding the plaintiffs functional limitations. (Tr. 29). The Law Judge also emphasized that Dr. Culkin's opinions were inconsistent with those offered by two state agency physicians, as well as the opinion of Dr. William Humphries, who performed a consultative physical evaluation on July 19, 2013. Based on his own clinical findings, which were essentially normal, Dr. Humphries opined that plaintiff can stand and walk up to six hours in an eight-hour day, and lift up to fifty pounds occasionally and twenty pounds frequently.[2] (Tr. 534). Both of the state agency physicians concurred with Dr. Humphries' assessment, emphasizing that Ms. Young's medical records simply do not include objective documentation of serious musculoskeletal problems. (Tr. 115, 116, 143, 144).

         Having reviewed the record in its entirety, which is notably devoid of significant physical findings and clinical signs, the court concludes that substantial evidence supports the Law Judge's decision to not give controlling weight to Dr. Culkin's opinion. Although the opinions of a treating source are generally. entitled to greater weight under the administrative regulations applicable to plaintiffs claims, see 20 C.F.R. §§ 404.1527(c)(2) and 416.927(c)(2), the court believes that, in the instant case, the Law Judge properly determined to give greater weight to other medical evidence, including the reports from Dr. Humphries and the state agency physicians. All three physicians observed that the medical record simply does not include objective documentation of serious musculoskeletal problems, and that there is no indication that the plaintiffs fibromyalgia could be expected to render her disabled for all work-related activity. In short, ...


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