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Horton v. Berryhill

United States District Court, E.D. Virginia, Alexandria Division

June 19, 2018

TRACY HORTON, Plaintiff,
v.
NANCY A. BERRYHILL, Defendant.

          REPORT AND RECOMMENDATION

          THERESA CARROLL BUCHANAN UNITED STATES MAGISTRATE JUDGE

         Pursuant to the Social Security Act § 205(g), 42 U.S.C. § 405(g), Tracy Horton ("Plaintiff') seeks judicial review of the final decision of Nancy A. Berryhill ("Defendant"), the Acting Commissioner of Social Security, denying Plaintiffs claim for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") pursuant to Titles II and XVI of the Social Security Act. On January 16, 2018, the certified Administrative Record ("R.") was filed under seal, pursuant to Local Civil Rules 5(B) and 7(C)(1). By March 9, 2018, both parties filed motions for summary judgment with briefs in support, which are now ripe for resolution.[1]Pursuant to 28 U.S.C. § 636(b)(1)(B), the undersigned U.S. Magistrate Judge recommends, for the following reasons, that Plaintiffs Motion for Summary Judgment (Dkt. 10) be GRANTED IN PART and Defendant's Motion for Summary Judgment (Dkt. 13) be DENIED.

         I. PROCEDURAL BACKGROUND

         Plaintiff filed the presently disputed applications for SSI and DIB on July 1, 2013, alleging disability resulting from a herniated disc, degenerative disc disease, a back injury, arthritis, endometriosis, cervicalgia, depression, post-traumatic stress disorder, seasonal effective disorder, a knee injury to the left knee, an injury to the left pinky finger, and blurred vision, with an alleged onset date ("AOD") of June 30, 2012. (R. at 359-62, 370-73, 417-30.) Plaintiffs claims were first denied on February 6, 2014, then again on reconsideration on July 17, 2014. (Id at 204-33, 236-71, 291-95.) On August 8, 2014, Plaintiff filed a request for a hearing in front of an administrative law judge ("ALJ"). (Id at 297-98.) The hearing was held in front of ALJ Francine L. Applewhite on July 20, 2016, for which Plaintiff was not present, but Plaintiffs counsel still presented argument and vocational expert ("VE") Dr. James Michael Ryan provided testimony. (Id. at 195-203.) The ALJ issued her decision denying Plaintiffs claims on August 25, 2016. (Id. at 164-78.) On October 21, 2016, Plaintiff requested review of the ALJ's decision to the Appeals Council for the Office of Disability and Adjudication and Review ("Appeals Council"). (Id at 354.) The Appeals Council denied Plaintiffs request for review on August 17, 2017, making the ALJ's decision the final decision of Defendant. (Id. at 1-6.) Plaintiff filed her Complaint (Dkt. 1) for judicial review of Defendant's decision on October 18, 2017. Defendant filed her timely Answer (Dkt. 7) on January 16, 2018. By March 9, 2018, Plaintiff filed her Motion for Summary Judgment (Dkt. 10) and Defendant filed her Motion for Summary Judgment (Dkt. 13). The matter is now ripe for review.

         II. STANDARD OF REVIEW

         Under the Social Security Act, the Court's review of Defendant's final decision is limited to determining whether the ALJ's decision was supported by substantial evidence in the record and whether the correct legal standard was applied in evaluating the evidence. 42 U.S.C. § 405(g); Havs v. Sullivan. 907 F.2d 1453, 1456 (4th Cir. 1990). Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales. 402 U.S. 389, 401 (1971). It is more than a scintilla but less than a preponderance. Havs, 907 F.2d at 1456. While the standard is deferential, where the ALJ's determination is not supported by substantial evidence on the record, or where the ALJ has made an error of law, the district court must reverse the decision. Coffman v. Bowen. 829 F.2d 514, 517 (4th Cir. 1987).

         In reviewing for substantial evidence, the Court must examine the record as a whole, but it may not "undertake to re- weigh the conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the Secretary." Mastro v. Apfel 270 F.3d 171, 176 (4th Cir. 2001) (citing Craig v. Chater. 76 F.3d at 589 (4th Cir. 1996)). The correct law to be applied includes the Social Security Act, its implementing regulations, and controlling case law. See Coffman. 829 F.2d at 517-18. Moreover, relevant law charges Defendant with evaluating the medical evidence and assessing symptoms, signs, and medical findings to determine the functional capacity of a claimant, not the reviewing district court. See Havs, 907 F.2d at 1456-57. With this standard in mind, the Court evaluates the ALJ's findings and decision.

         III. THE ALJ'S DECISION

         An ALJ is required to employ a five-step sequential evaluation in every Social Security disability claim analysis to determine a claimant's eligibility. The Court examines this five-step process on appeal to determine whether the correct legal standards were applied in this case, and whether Defendant's resulting decision is supported by substantial evidence in the record. 20 C.F.R. §§ 404.1520, 416.920. In accordance with the five-step sequential analysis, the ALJ made the following findings of fact and conclusions of law.

         At step one of the sequential evaluation, the ALJ found that Plaintiff has not engaged in substantial gainful activity since June 30, 2012. (R. at 169.) At step two of the sequential evaluation, the ALJ found that Plaintiff had various severe and non-severe medically determinable impairments. (Id at 169-70.) The ALJ found Plaintiffs degenerative disc disease of the cervical and lumbar spine, arthritis, and cervicalgia to be severe medically determinable physical impairments. (Id.) The ALJ found Plaintiffs alleged endometriosis, blurry vision, and repeated headaches to be non-severe medically determinable physical impairments. (Id at 170.) The ALJ found Plaintiffs alleged carpal tunnel syndrome to not be a medically determinable impairment at all. (Id.) The ALJ found Plaintiffs depression, seasonal affective disorder, and posttraumatic stress disorder to be non-severe medically determinable mental impairments. (Id at 170-71.) At step three of the sequential evaluation, the ALJ found Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Id at 172.) In between steps three and four of the sequential evaluation, the ALJ found that Plaintiff had the residual functional capacity ("RFC") to perform light work as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b), except that Plaintiff could occasionally climb ladders, ropes, or scaffolds, frequently climb of stairs or ramps, frequently stoop, crouch, or kneel, occasionally crawl, and occasionally be exposed to hazards such as unprotected heights. (Id at 172.) At step four of the sequential evaluation, the ALJ found that Plaintiff had no past relevant work. (Id at 176.) At step five of the sequential evaluation, the ALJ found that Plaintiff was able to perform jobs that existed in significant numbers in the national economy. (Id at 176-77.) Therefore, the ALJ concluded that Plaintiff was not under a disability, as defined by the Social Security Act, from June 30, 2012, to the date of the ALJ's decision. (Id. at 177.)

         IV. ANALYSIS

         Plaintiff raises four issues on appeal in supporting its contention that Defendant's final decision fails to be supported by substantial evidence and is erroneous as a matter of law. First, Plaintiff argues that the ALJ erroneously assessed Plaintiffs RFC by not evaluating all pertinent evidence related to Plaintiffs ability to do work-related activities. (PL's Mem. Supp. at 6-7; PL's Mem. Opp. & Reply at 4-5.) Second, Plaintiff argues that the ALJ also erroneously assessed the Plaintiffs RFC by failing to properly evaluate the opinions of Plaintiff s treating physician Dr. William Carter. (PL's Mem. Supp. at 7-13; PL's Mem. Opp. & Reply at 2-4.) Third, Plaintiff argues that the Appeals Council erroneously failed to consider new evidence presented by Plaintiff during the pendency of her appeal of the ALJ's decision. (PL's Mem. Supp. at 13-15; PL's Mem. Opp. & Reply at 5-6.) Fourth, Plaintiff argues that the ALJ deprived Plaintiff of due process of law. (PL's Mem. Supp. at 15-17; PL's Mem. Opp. & Reply at 6-7.) Each issue is considered by the undersigned in turn.

         A. The Evaluation of Evidence Related to Plaintiffs Ability to Do Work-Related Activities

         Plaintiff argues that the ALJ erroneously assessed Plaintiffs RFC by not evaluating all pertinent evidence related to Plaintiffs ability to do work-related activities. (PL's Mem. Supp. at 6-7; PL's Mem. Opp. & Reply at 4-5.) Specifically, Plaintiff states that the ALJ failed to evaluate evidence of Plaintiff s upper extremity impairments, including carpal tunnel syndrome and cervical radiculopathy, which spoke to Plaintiffs abilities to reach, handle, finger, or feel objects. (PL's Mem. Supp. at 6-7.) In response, Defendant argues that the ALJ addressed all functional limitations and the RFC was supported by substantial evidence. (Def.'s Mem. Supp. & Opp'n at 22-23.)

         After step three of the ALJ's sequential analysis, but before deciding whether a claimant can perform past relevant work at step four, the ALJ must determine the claimant's RFC. 20 C.F.R. §§ 404.1520(e)-(f), 404.1545(a)(1), 4l6.9O2(e)-(f), 416.945(a)(1). RFC is generally defined as the most that an individual is able to do despite limitations caused by his or her impairments. Id. §§ 404.1545(a)(1), 416.945(a)(1). In analyzing a claimant's abilities, the ALJ must assess the nature and extent of the claimant's physical abilities, mental abilities, and other abilities affected by impairments and then determine the claimant's RFC for work activity on a regular and continuing basis. Id. §§ 404.1545(b)-(d), 4l6.945(b)-(d); S.S.R. 96-8p, 1996 WL 374184, at *1 (July 2, 1996). This includes limitations from both severe and non-severe impairments, so long as they are medically determinable impairments. 20 C.F.R. §§ 404.1545(e), 416.945(e); S.S.R. 96-8p, 1996 WL 374184, at *5. In the RFC assessment, the ALJ "must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations)." S.S.R. 96-8p, 1996 WL 374184, at *7. In making the RFC assessment, an ALJ is required to consider all relevant medical evidence and other evidence in the case record. 20 C.F.R. §§ 404.1545(a)(3), 416.945(a)(3).

         At issue in this case is the ALJ's alleged lack of consideration of evidence of Plaintiff s carpal tunnel syndrome and cervical radiculopathy that addressed Plaintiffs upper extremities and her abilities to reach, handle, finger, or feel objects. The undersigned considers evidence of Plaintiffs carpal tunnel syndrome and Plaintiffs cervical radiculopathy in turn.

         1. Evidence of Carpal Tunnel Syndrome

         Plaintiff only briefly mentions that the ALJ failed to properly evaluate evidence of Plaintiffs carpal tunnel syndrome, and Plaintiff points to no specific evidence that the ALJ failed to consider or inappropriately considered. (PL's Mem. Supp. at 7.) Plaintiff seems to take issue with the fact that the ALJ did not consider Plaintiffs carpal tunnel syndrome when evaluating Plaintiffs RFC. Plaintiff is correct that the ALJ did not consider evidence of Plaintiff s carpal tunnel syndrome when assessing Plaintiffs RFC. Instead, the ALJ examined evidence of Plaintiffs carpal tunnel syndrome at step two of the sequential analysis when determining whether Plaintiff had a medically determinable impairment that was severe or a combination of impairments that was severe. (R. at 170.) The ALJ acknowledged that Plaintiff was diagnosed with carpal tunnel syndrome. (Id.) However, the ALJ also noted that no objective testing was performed that confirmed carpal tunnel syndrome, and therefore, Plaintiffs carpal tunnel syndrome was not a medically determinable impairment. (Id.)

         The ALJ did not err by not addressing Plaintiffs carpal tunnel syndrome in the RFC assessment. As previously stated, an RFC assessment must include limitations from both severe and non-severe impairments, but only if they are from medically determinable impairments. 20 C.F.R. §§ 404.1545(e), 416.945(e); S.S.R. 96-8p, 1996 WL 374184, at *5. Medically determinable impairments must be established by objective medical abnormalities such as medical signs and laboratory findings. S.S.R. 96-4p, 1996 WL 374187, at *1 (July 2, 1996). The ALJ's determination that Plaintiffs carpal ...


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