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Sandra L. v. Berryhill

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

February 20, 2019

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

          REPORT AND RECOMMENDATION

          Robert S. Ballou, United States Magistrate Judge.

         Plaintiff Sandra L. (“Sandra”) filed this action challenging the final decision of the Commissioner of Social Security (“Commissioner”) finding her not disabled and therefore ineligible for supplemental security income (“SSI”) and disability insurance benefits (“DIB”) under the Social Security Act (“Act”). 42 U.S.C. §§ 401-433, 1381-1383f. Sandra alleges that the Administrative Law Judge (“ALJ”) erred because he failed to properly evaluate the opinions of Sandra's treating primary care physician.

         I conclude that substantial evidence supports the Commissioner's decision. Accordingly, I RECOMMEND DENYING Sandra's Motion for Summary Judgment (Dkt. 12) and RECOMMEND 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 Sandra failed to demonstrate that she was disabled under the Act.[2] 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).

         CLAIM HISTORY

         Sandra filed for DIB and SSI on January 25, 2013, claiming disability due to back and neck problems/right knee problems/tennis elbow, tendonitis in her right hand, and osteoporosis, with an alleged onset date of March 2, 2012. R. 79, 90. Sandra was 55 years old when she applied for DIB and SSI, making her 53 years old on her alleged onset date. Id. Based on her earnings record, the ALJ determined that Sandra had acquired sufficient quarters of coverage to remain insured through September 30, 2017. R. 18, 222. Thus, she must show that her disability began on or before September 30, 2017, and existed for twelve continuous months to receive DIB. R. 18, 20; 42 U.S.C. §§ 423(a)(1)(A), (c)(1)(B), (d)(1)(A); 20 C.F.R. §§ 404.101(a), 404.131(a). Additionally, to receive SSI, Sandra must show that she has been disabled for at least twelve months prior to the date of filing her disability application. R. 79. The state agency denied Sandra's applications at the initial and reconsideration levels of administrative review. R. 79- 123. On June 22, 2016, ALJ Thomas W. Erwin held a hearing to consider Sandra's claims for DIB and SSI. R. 43-68. Counsel represented Sandra at the hearing, which included testimony from vocational expert Mark Howlin. R. 43. On August 24, 2016, the ALJ entered his decision analyzing Sandra's claims under the familiar five-step process[3] and denying her claim for benefits. R. 18-37.

         The ALJ found that Sandra had not engaged in substantial gainful activity since March 2, 2012, the alleged onset date. R. 20. The ALJ determined that Sandra suffered from the severe impairments of lumbar degenerative disc disease and degenerative joint disease of the right knee. R. 21-22, 24. The ALJ determined that these impairments, either individually or in combination, did not meet or medically equal a listed impairment, specifically listings 1.02 (major joint dysfunction) or 1.04 (disorders of the spine). R. 22. The ALJ found that Sandra's medically determinable impairments of osteoporosis and right wrist pain were non-severe. R. 24, 248. The ALJ also determined that Sandra's neck and shoulder pain was not medically determinable, as there were no diagnoses of any neck or shoulder impairments. Id. The ALJ found that the record did not establish any medically determinable mental impairment. Id. He determined that Sandra has no more than mild limitations in activities of daily living, social functioning, and concentration, persistence, or pace, and no episodes of decompensation. R. 21, 24.

         The ALJ concluded that Sandra retained the residual functional capacity (“RFC”) to perform sedentary work. R. 22. Regarding limitations, the ALJ determined that Sandra can: never operate foot controls, crawl, or climb ladders, ropes, or scaffolds; occasionally climb ramps or stairs, balance, stoop, kneel, or crouch; and have no more than occasional exposure to vibrations or other hazardous machinery, and to operational control of moving machinery. Id. The ALJ ultimately concluded that Sandra was capable of performing her past relevant work as a receptionist and accounting clerk, as actually performed by Sandra and as generally performed in the national economy. R. 35. Thus, the ALJ concluded that Sandra was not disabled. R. 36-37. The Appeals Council denied Sandra's request for review on July 26, 2017. R. 1-5.

         ANALYSIS

         Sandra alleges that the ALJ erred because he failed to properly evaluate the opinions of her treating primary care physician, Michael A. Malpass, M.D., and so substantial evidence does not support the ALJ's decision.

         A. Medical History

         1. Physical Impairments

         In her initial disability report, Sandra claimed disability based on back and neck problems/right knee problems/tennis elbow, tendonitis in her right hand, and osteoporosis. R. 79, 90. Sandra testified that her pain is primarily in her lower back and right leg, particularly in her right knee. R. 58, 248. Sandra reported the pain started after a car accident in 2001. R. 248-49. She testified to using a cane for around five years, although her doctors never prescribed one. R. 49-50. Sandra testified that she stopped working in 2012 because her back kept her from doing her job. R. 52. There was no precipitating event at that time; instead, Sandra just decided she could no longer work. R. 53. Sandra lies down for four to five hours each ...


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