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William M v. Berryhill

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

August 16, 2018

WILLIAM M., Plaintiff,
v.
NANCY A. BERRYHILL,[1] Acting Commissioner of Social Security, Defendant.

          REPORT AND RECOMMENDATION

          Robert S. Ballou United States Magistrate Judge.

         Plaintiff William M. (“William”)[2] filed this action challenging the final decision of the Commissioner of Social Security (“Commissioner”) determining that he was not disabled and therefore not eligible for disability insurance benefits (“DIB”) under the Social Security Act (“Act”). 42 U.S.C. §§ 401-433. Specifically, William alleges that (1) the Administrative Law Judge (“ALJ”): (1) erred in giving little weight to the opinion of his treating psychologist; (2) improperly discounted his credibility; (3) improperly relied on his daily activities in rendering a credibility determination; and (4) erred in giving little weight to the hypothetical questions posed by his attorney at the administrative hearing. I find that substantial evidence supports the ALJ's opinion in its entirety. Accordingly, I RECOMMEND DENYING William's Motion for Summary Judgment (Dkt. 12) and GRANTING the Commissioner's Motion for Summary Judgment (Dkt. 14).

         STANDARD OF REVIEW

         This Court limits its review to a determination of whether substantial evidence exists to support the Commissioner's conclusion that William failed to demonstrate that he was disabled under the Act.[3] 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 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).

         CLAIM HISTORY

         William protectively filed for DIB on January 11, 2013, claiming that his disability began on March 21, 2012. R. 181-82. The Commissioner denied the application at the initial and reconsideration levels of administrative review. R. 79, 99. On May 19, 2015, ALJ Geraldine H. Page held an administrative hearing to consider William's disability claim. R. 31-58. William was represented by an attorney at the hearing, which included testimony from William and vocational expert John Newman. Id.

         On February 10, 2016, the ALJ entered her decision analyzing William's claim under the familiar five-step process, [4] and denying William's claim for disability. R. 8-22. The ALJ found that William suffered from the severe impairments of obesity, vertigo/dizziness, cervical pain, hernia with inguinal neuralgia, depressive and dependent personality, and anxiety disorders. R. 10. The ALJ found that these impairments did not meet or medically equal a listed impairment. R. 11-13. The ALJ further found that William retained the residual functional capacity (“RFC”) to perform light work, except William can: (1) lift and carry 10 pounds frequently and 20 pounds occasionally; (2) stand, walk, and sit for six hours in an eight-hour workday; (3) occasionally balance, kneel, stoop, crouch, crawl, and climb ramps and stairs; (4) frequently reach overhead; (5) never be exposed to hazardous machinery; (6) only be moderately exposed to vibrating surfaces, unprotected heights, or climbing ladders, ropes, and scaffolds; (7) understand, remember, and execute simple instructions in repetitive, unskilled work; (8) work jobs that involve occasional interaction with the general public, coworkers, and supervisors; and (9) respond appropriately to supervision, coworkers, and usual work situations. R. 13. The ALJ determined that William cannot perform his past relevant work as a flagger, road roller operator, warehouse material handler, and welder helper. R. 20. However, the ALJ determined that William can work jobs that exist in substantial numbers in the national economy, such as assembler, packer, and inspector/tester/sorter. R. 20-21. Thus, the ALJ concluded that William was not disabled. R. 21.

         William appealed the ALJ's decision to the Appeals Council, but his request for review was denied. R. 1-3. This appeal followed.

         ANALYSIS

         William argues that (1) the ALJ erred in giving little weight to the opinion of his treating psychologist; (2) improperly discounted his credibility; (3) improperly relied on his daily activities in rendering a credibility determination; and (4) erred in giving little weight to the hypothetical questions posed by his attorney at the administrative hearing.

         Medical Evidence

         William underwent a laparoscopic left inguinal hernia repair in July 2011. R. 303. Michael D. Goodrich, M.D., performed a “left ilioinguinal and left iliohypogastric nerve block” for continued pain on March 6, 2012. R. 323.

         William returned to Dr. Goodrich on September, 182012. R. 315. William reported decreased pain after the March 2012 injection which lasted for two to three weeks before slowly returning to normal. Id. William “denie[d] any qualitative changes to his symptomatology with the exception of back pain.” Id. William received a second nerve block injection. R. 317.

         On January 21, 2013, William saw Tajal Raju, M.D., for management of his groin pain secondary to inguinal neuralgia that has been persistent since his surgery. R. 431. William reported sharp pain in his left groin that is most severe when sitting. Id. Dr. Raju explained that William was alert and oriented with normal mood and affect. R. 433. Physical examination in January, February, April, and June 2013 revealed “[n]o signs of depression, ” appropriate mood and affect, normal gait, no acute distress, normal range of motion in the spine, normal sensation, and normal strength. R. 434, 440, 444, 448.

         William saw Stacy C. Moore, FNP, on June 10, 2013 for dizziness and shaking in his hands. R. 635. Ms. Moore diagnosed depression, anxiety, panic attacks, and possible positional vertigo. R. 635-37.

         On July 2, 2013, Dr. Raju diagnosed “a severe exacerbation of inguinal neuralgia.” R. 565. Dr. Raju noted that William was diagnosed with anxiety and depression in December 2012. Id. Physical examination showed no signs of depression, no acute distress, and appropriate mood and affect. R. 567.

         Dr. Raju explained on August 2, 2013 that “swimming in the pool really helped [William's] pain.” R. 571. Physical examination showed no signs of depression, no acute distress, and appropriate mood and affect. R. 572.

         William saw neurologist Jill B. Cramer, M.D., on August 19, 2013 for dizziness, gait problems, and tremors. R. 602. Physical examination showed diminished sensation in the right arm and left leg, slight tremor bilaterally, and some sway while walking, but otherwise showed normal findings such as full strength and intact coordination. R. 603-04. A mental status examination showed alertness, orientation, cooperative attitude, normal remote and recent memory, normal attention and concentration, normal language, and normal fund of knowledge. R. 604. Dr. Cramer diagnosed mild tremors bilaterally, vertigo, memory loss, gait disturbance, and scalp lesion. Id. A brain MRI on August 30, 2013 was normal. R. 620.

         On August 20, 2013, William returned to Dr. Goodrich, who explained that William had seen a “60-70% pain reduction with [nerve block] injections and medical management” and that “[h]e had been able to perform his regular activities of daily living with greater ease following the injections.” R. 985. Dr. Goodrich implemented a “[l]eft spinal cord stimulator trial for chronic and unremittent left groin pain.” Id. On August 27, 2013, William reported that his activity level improved significantly without pain. R. 984. William “was able to ride in a vehicle for several hours, which he had not been able to do previously. He has been able to perform his regular activities of daily living with much greater improvement.” Id. Because of William's “remarkably good experience with the trial, ” he elected to proceed with a permanent spinal cord stimulator placement. Id.

         On September 11, 2013, William saw Yongyue Chen, M.D. for a psychiatric evaluation. R. 640. Dr. Chen noted a history of depression not alleviated by anti-depressants, and that William is more irritable, has a low tolerance for noise, and experiences stress due to financial and familial problems. Id. Dr. Chen conducted a mental status examination, finding:

No psychomotor agitation or retardation. The speech is of normal rate, tone and volume. The gait is WNL. Mood is “ok”. Affect is congruent. The perception is without auditory or visual hallucination. The thinking process is linear, logic [sic] and goal directed. The thinking associations are tight. There is no obsessive, paranoic or delusional thinking content. There is no suicidal or homicidal thought. The patient is alert and oriented to time, place and person. The ...

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