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Hilton v. Berryhill

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

July 11, 2018

SUSAN P. HILTON, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION

          Robert S. Ballou, United States Magistrate Judge.

         Plaintiff Susan P. Hilton (“Hilton”) filed this action challenging the final decision of the Commissioner of Social Security (“Commissioner”) finding her not disabled and therefore ineligible for disability insurance benefits (“DIB”) under the Social Security Act (“Act”). 42 U.S.C. §§ 401-433. Hilton alleges that the Administrative Law Judge (“ALJ”) erred by: (1) finding that Hilton engaged in substantial gainful activity through her date last insured; (2) failing to give proper weight to Hilton's treating physician; and (3) failing to perform a proper function-by-function analysis. I find that the ALJ's conclusion that Hilton engaged in substantial gainful activity through her date last insured is not supported by substantial evidence. I further find that the ALJ failed to provide a sufficient explanation for the weight given to the treating physician's opinion. As such, I GRANT Hilton's Motion for Summary Judgment (Dkt. No. 12), DENY the Commissioner's Motion for Summary Judgment (Dkt. No. 14) and REMAND for further consideration by the Commissioner.

         STANDARD OF REVIEW

         This court limits its review to a determination of whether substantial evidence exists to support the Commissioner's conclusion that Hilton failed to demonstrate that she was disabled under the Act.[1] Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001). “Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996) (internal citations and alterations omitted). The final decision of the Commissioner will be affirmed where substantial evidence supports the decision. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990).

         However, remand is appropriate if the ALJ's analysis is so deficient that it “frustrate[s] meaningful review.” Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (noting that “remand is necessary” because the court is “left to guess [at] how the ALJ arrived at his conclusions”); see also Monroe v. Colvin, 826 F.3d 176, 189 (4th Cir. 2016) (emphasizing that the ALJ must “build an accurate and logical bridge from the evidence to his conclusion” and holding that remand was appropriate when the ALJ failed to make “specific findings” about whether the claimant's limitations would cause him to experience his claimed symptoms during work and if so, how often) (citation omitted).

         CLAIM HISTORY

         Hilton filed for DIB on January 5, 2013, claiming that her disability began on July 20, 2010, due to degenerative joint disease of the right knee, left hip, and lumbar spine, arthritis, and muscle tearing in the right knee. R. 16, 167-68, 186. Hilton's date last insured was December 31, 2010; thus she must show that her disability began on or before this date and existed for twelve continuous months to receive DIB.[2] R. 183; 42 U.S.C. §§ 423(a)(1)(A), (c)(1)(B), (d)(1)(A); 20 C.F.R. §§ 404.101(a), 404.131(a). The state agency denied Hilton's applications at the initial and reconsideration levels of administrative review. R. 72-76, 78-83. On November 13, 2015, ALJ Thomas W. Erwin held a hearing to consider Hilton's claims for DIB. R. 36-70. Counsel represented Hilton at the hearing, which included testimony from vocational expert Ricky D. Bradley. On December 22, 2015, the ALJ entered his decision analyzing Hilton's claims under the familiar five-step process[3] and denying her claim for benefits. R. 16-30. The ALJ found that Hilton was insured at the time of the alleged disability onset. The ALJ found that during the period of her alleged disability Hilton engaged in substantial gainful activity by working at an arts and crafts store she owned through the date last insured. R. 18. Accordingly, the ALJ determined at step one that Hilton was not disabled because she was engaging in substantial gainful activity. Id.

         In addition, the ALJ continued with the five step process and made an alternative finding at step four, concluding that Hilton was not disabled. R. 19-30. The ALJ determined that Hilton suffered from the severe impairments of degenerative joint disease of the right knee, degenerative disc disease of the lumbar spine, history of right ankle fracture, and hip dysfunction. R. 20. The ALJ determined that these impairments, either individually or in combination did not meet or medically equal a listed impairment. Id. The ALJ specifically considered listings 1.02 (major joint dysfunction), 1.03 (reconstructive surgery of major weight-bearing joint), and 1.04 (disorders of the spine). The ALJ determined that Hilton retained the residual functional capacity (“RFC”) to perform a limited range of light work. R. 21. Specifically, the ALJ found that Hilton can only occasionally operate foot controls with the right lower extremity, climb, stoop, kneel, crouch, or crawl, and can never be exposed to hazardous machinery, unprotected heights, or climb ladders, ropes or scaffold. Id.

         The ALJ determined that Hilton was capable of performing her past relevant work as a phlebotomist and sales clerk. R. 29. Thus, the ALJ concluded that Hilton was not disabled. R. 30. Hilton appealed the ALJ's decision and the Appeals Council denied her request for review on January 30, 2017. R. 1-3.

         ANALYSIS

         Hilton alleges that the ALJ erred by: (1) finding that Hilton engaged in substantial gainful activity through her date last insured; (2) failing to give proper weight to Hilton's treating physician; and (3) failing to perform a proper a function-by-function analysis.

         A. Relevant Medical History

         Hilton has a long history of right knee and back pain. Records indicate Hilton's right knee issues date back to 1977, when her knee locked up during a run in basic training. R. 332. On June 28, 2010, James Lovelace, M.D. performed a right knee arthroscopy with partial medial meniscectomy and removed painful hardware from Hilton's right ankle.[4] Following the surgery, Hilton continued to consistently complain of pain in her knee and ankle, as well as back pain, during follow up visits with Dr. Lovelace. R. 270, 276-279. In August 2010, Dr. Lovelace administered steroid injections, which provided temporary relief. R. 277, 278.

         In February 2011, and again in April 2011, Hilton presented to the Salem VA Medical Center for a Compensation and Pension examination concerning her left hip, low back, and right knee. R. 338-49, 331-38. On examination, Hilton had antalgic gait and limited range of motion in her left hip and right knee. R. 334, 335, 339, 341. She complained of back pain, unsteadiness, and weakness, and used a cane and knee brace. R. 343-44. Hilton was given a 10% disability rating for her knee by the Veterans Administration (“VA”) in 2010, and continued to have a 10% disability rating for her knee until approximately 2013. R. 22, 23. Hilton testified at the hearing before the ALJ that the ALJ had given her a 30% disability rating on her right knee, 20% on her back, and 10% on her left hip. R. 22.

         Dr. Lovelace completed a form on November 12, 2015, where he indicated that Hilton could sit, stand, and walk less than two hours, and would be absent from work about three times a month as a result of her impairments. R. 631-32. Dr. Lovelace found that the limitations related back to July 20, 2010. R. 632. State agency doctors Luc Vinh, M.D., and Joseph Duckwall, M.D., both found that there was insufficient evidence to find Hilton disabled during the required time frame, i.e. between her alleged onset date of July 20, 2010 and her date last insured of December 31, 2010. R. 74, 81.

         B. Substantial ...


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