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Ward v. Berryhill

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

December 18, 2018

MICHAEL W. WARD, 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 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).

         The 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.

         Mr. 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.[1] 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.[2] (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.

         While 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).

         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 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.

         The 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 instructions.

         In 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).

         The 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).

         In 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. (Tr. 255).

         Mr. 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).

         On 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 ...


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