United States District Court, W.D. Virginia, Roanoke Division
MICHAEL W. WARD, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
Glen E. Conrad Senior United States District Judge
has filed this action challenging the final decision of the
Commissioner of Social Security denying plaintiffs claim for
a period of disability and disability insurance benefits
under the Social Security Act, as amended, 42 U.S.C.
§§ 416(i) and 423. Jurisdiction of this court is
established pursuant to 42 U.S.C. § 405(g). 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).
plaintiff, Michael W. Ward, was born on December 7, 1975, and
eventually completed his high school education. Mr. Ward has
been employed as a certified nursing assistant (CNA), truck
driver, security guard, and newspaper delivery person. He
last worked at the beginning of January 2013. On March 11,
2013, Mr. Ward filed an application for a period of
disability and disability insurance benefits. In filing his
current claim, Mr. Ward alleged that he became disabled for
all forms of substantial gainful employment on January 9,
2013, due to diabetes, nerve damage in his legs and feet, and
depression. (Tr. 189). Mr. Ward now maintains that he has
remained disabled to the present time. The record reveals
that Mr. Ward met the insured status requirements of the Act
through the fourth quarter of 2014, 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 he has
established that he became disabled for all forms of
substantial gainful employment on or before his date last
insured, December 31, 2014.
Ward's application was denied upon initial consideration
and reconsideration. He then requested and received a de
novo hearing and review before an Administrative Law
Judge. In an opinion dated December 28, 2015, the Law Judge
also determined, after applying the five-step sequential
evaluation process, that Mr. Ward was not disabled on or
before his date last insured. See 20 C.F.R. § 404.1520.
The Law Judge found that Mr. Ward suffered from several
severe impairments through that date, including obesity,
diabetes, diabetic peripheral neuropathy, left heel spur, and
bilateral lower extremity varicose veins, but that these
impairments did not, either individually or in combination,
meet or medically equal the requirements of a listed
impairment. (Tr. 10-12). The Law Judge then assessed
Mr. Ward's residual functional capacity as follows:
After careful consideration of the entire record, the
undersigned finds that, through the date last insured, the
claimant had the residual functional capacity to perform
sedentary work as defined in 20 C.F.R. 404.1567(a) with
exceptions. The claimant could lift and carry twenty pounds
occasionally and ten pounds frequently. In an eight-hour
workday, he could stand and/or walk for two hours and sit for
six or more hours with normal breaks. The claimant could
never use his left lower extremity and occasionally use his
right lower extremity to operate foot controls. He could
never crawl or climb ladders, ropes, and scaffolds, but could
frequently balance and occasionally climb ramps and stairs,
kneel, crouch, and stoop/bend. The claimant could tolerate no
more than occasional exposure to vibration and could tolerate
no exposure to hazards such as machinery and heights.
(Tr. 13). Given such a residual functional capacity, and
after considering testimony from a vocational expert, the Law
Judge determined that Mr. Ward was unable to perform any past
relevant work through the date last insured. (Tr. 21).
However, the Law Judge found that plaintiff retained the
capacity to perform other work roles existing in significant
number in the national economy. (Tr. 22-23). Accordingly, the
Law Judge concluded that Mr. Ward was not disabled at any
time from the alleged onset date through the date last
insured, and that he is not entitled to a period of
disability or disability insurance benefits. See 20
C.F.R. § 404.1520(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, Mr. Ward has
now appealed to this court.
plaintiff may be disabled for certain forms of employment,
the crucial factual determination is whether plaintiff was
disabled for all forms of substantial gainful employment.
See 42 U.S.C. § 423(d)(2). 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).
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 Mr. Ward's
medical problems and the extent to which they affected his
ability to work. Although Mr. Ward suffered from a
combination of impairments, substantial evidence supports the
Law Judge's determination that he retained the residual
functional capacity to perform certain sedentary work roles
through his date last insured.
record reflects that Mr. Ward was diagnosed with Type II
diabetes in January of 2010. prior to his alleged onset date.
(Tr. 463). He was established as a new patient at New
Horizons Healthcare in August of 2011, where he was examined
by Dr. Ayesha Nazli. (Tr. 463-66). Based on plaintiffs
critically high glucose level, Dr. Nazli counseled him on the
importance of medication compliance, diet, and exercise. When
Mr. Ward returned three months later, Dr. Nazli recommended
that he go to the emergency room for uncontrolled diabetes.
(Tr. 462). Although Mr. Ward was instructed to return for a
follow-up appointment two weeks later, the record contains no
indication that he complied with the physician's
2012, plaintiff presented to the emergency room at Carilion
Roanoke Memorial Hospital on several occasions. In March,
plaintiff complained of dental and facial pain. He denied
experiencing any back or joint pain, and exhibited no
tenderness or edema on physical examination. (Tr. 285-86).
The attending physician prescribed Mobic, Ultram, and
Amoxycillin, and referred plaintiff to a dental clinic. (Tr.
290). Mr. Ward returned in July with complaints of a rash and
right lower extremity pain. (Tr. 300). At that time, he was
noted to be "morbidly obese." (Tr. 301). On
physical examination, plaintiff exhibited normal range of
motion, sensation, strength, and reflexes, and no edema or
weakness. (Tr. 301). Vascular testing was negative for deep
vein thrombosis (DVT) or superficial vein thrombosis (SVT).
The examination notes reveal a differential diagnosis of
diabetic neuropathy. (Tr. 303).
following month, Mr. Ward returned to the emergency room with
complaints of generalized body aches, lightheadedness, and
blurred vision. (Tr. 320). His physical examination was
normal, but his glucose level was 373. (Tr. 312-13). Diabetic
medications were administered and plaintiff was discharged
with a diagnosis of uncontrolled diabetes. (Tr. 316). On
October 31, 2012, plaintiff presented to the emergency room
with shortness of breath. However, his physical examination
revealed no signs of respiratory distress and was otherwise
normal. (Tr. 332). Diabetic medications were administered and
plaintiff was discharged with an inhaler for bronchitis. (Tr.
335). Less than two weeks later, plaintiff returned with
complaints of back pain associated with lifting patients at
work. He exhibited some tenderness on physical examination,
but his range of motion was normal. The examining physician
diagnosed him with a low back strain for which he prescribed
Naprosyn and Flexeril, and recommended that plaintiff perform
stretching exercises. (Tr. 355).
February of 2013, after the alleged onset date of disability,
Mr. Ward was established as a new patient at Carilion Blue
Ridge Family Practice, where he was seen by Dr. Sarat Burri.
Dr. Burri noted that plaintiff had not been taking his
diabetic medications for several months, but that he had been
trying to "watch his diet and walk 2-3 times per
week." (Tr. 253). Plaintiff complained of worsening pain
in his feet and legs, which he primarily experienced at
night. An examination of plaintiffs lower extremities was
"grossly normal." (Tr. 254). Dr. Burri diagnosed
Mr. Ward with several conditions, including uncontrolled Type
II diabetes, diabetic neuropathy, and morbid obesity. (Tr.
255). He adjusted plaintiffs medications and recommended that
plaintiff exercise thirty minutes a day, five days per week.
Ward returned for a follow-up appointment on March 12, 2013.
At that time, plaintiff reported that his neuropathic pain
had improved while taking Neurontin, but that he had recently
experienced pain in his right shoulder. (Tr. 260). Dr. Burri
noted that the pain was mostly likely from a strain or
sprain, and recommended that plaintiff take Tylenol and apply
warm compresses. (Tr. 262). The following month, plaintiff
reported that his neuropathic pain had continued to improve,
but that his feet still bothered him. (Tr. 266). He denied
having any other complaints and his musculoskeletal
evaluation was "grossly normal." (Tr. 267).
April 22, 2013, plaintiff presented to the emergency room
with left ankle pain. He reported that he had injured his
ankle while playing basketball. (Tr. 402). On physical
examination, plaintiff exhibited normal range of motion and
no edema. (Tr. 403). Plaintiff was diagnosed with a left