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Bonvillain v. Berryhill

United States District Court, E.D. Virginia, Alexandria Division

March 15, 2019




         Pursuant to the Social Security Act § 205(g), 42 U.S.C. § 405(g), April Bonvillain ("Plaintiff) seeks judicial review of the final decision of Nancy A. Berryhill ("Defendant"), the former Acting Commissioner of Social Security, [1] denying Plaintiffs claim for Supplemental Security Income ("SSI") pursuant to Title XVI of the Social Security Act. On June 4, 2018, the certified Administrative Record ("R.") was filed under seal, pursuant to Local Civil Rules 5(B) and 7(C)(1). By December 4, 2018, both parties filed motions for summary judgment with briefs in support, which are now ripe for resolution.[2] For the reasons set forth below, the undersigned U.S. Magistrate Judge, pursuant to 28 U.S.C. § 636(c)(1), will deny Plaintiffs Motion for Summary Judgment (Dkt. 17), grant Defendant's Motion for Summary Judgment (Dkt. 20), and affirm the final decision of Defendant.


         Plaintiff filed the presently disputed application for SSI on September 26, 2014, [3] alleging disability with an alleged onset date ("AOD") of March 25, 2014. (R. at 182-87.) Plaintiffs claims were first denied on March 31, 2014, then again on reconsideration on September 15, 2014. (R. at 59-92.) On July 13, 2015, Plaintiff requested a hearing in front of an administrative law judge ("ALJ"). (R. at 110-12.) The hearing was held in front of ALJ Francine L. Applewhite on June 7, 2017, with Plaintiff being represented by a non-attorney representative, and during which the testimonies of Plaintiff and a vocational expert ("VE") were taken. (R. at 30-58.) The ALJ issued her decision denying Plaintiffs claims on August 4, 2017. (R. at 10-24.) On August 11, 2017, Plaintiff requested review of the ALJ's decision to the Appeals Council for the Office of Disability and Adjudication and Review ("Appeals Council"). (R. at 176-81.) The Appeals Council denied Plaintiffs request for review on June 6, 2018, making the ALJ's decision the final decision of Defendant. (R. at 1-6.) On August 8, 2018, Plaintiff filed her Complaint for judicial review of Defendant's decision (Dkt. 1). Defendant filed her timely answer on October 9, 2018 (Dkt. 9). By November 2, 2018, Plaintiff filed her Motion for Summary Judgment (Dkt. 17) and Defendant filed her Motion for Summary Judgment (Dkt. 20).


         Under the Social Security Act, the Court's review of Defendant's final decision is limited to determining whether the ALJ's decision was supported by substantial evidence in the record and whether the correct legal standard was applied in evaluating the evidence. 42 U.S.C. § 405(g); Bird v. Comm'r of Soc. Sec. Admin., 699 F.3d 337, 340 (4th Cir. 2012).

         Substantial evidence has long been described as "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). Put another way, substantial evidence is "more than a mere scintilla of evidence but may be less than a preponderance." Pearson v. Colvin, 810 F.3d 204, 207 (4th Cir. 2015). In reviewing for substantial evidence, the Court must examine the record as a whole, but it may not "undertake to re-weigh the conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the Secretary." Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001). The Court must defer to Defendant's decision "[w]here conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled." Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005). The correct law to be applied includes the Social Security Act, its implementing regulations, and controlling case law. See Coffman v. Bowen, 829 F.2d 514, 517-18 (4th Cir. 1987).

         While the aforementioned standard of review is deferential, where the ALJ's determination is not supported by substantial evidence on the record, or where the ALJ has made an error of law, the district court must reverse the decision. See id. at 517. With this standard in mind, the Court evaluates the ALJ's findings and decision.


         An ALJ is required to employ a five-step sequential evaluation in every Social Security disability claim analysis to determine a claimant's eligibility. The Court examines this five-step process on appeal to determine whether the correct legal standards were applied in this case, and whether Defendant's resulting decision is supported by substantial evidence in the record. 20 C.F.R. §§ 404.1520, 416.920. In accordance with the five-step sequential analysis, the ALJ made the following findings of fact and conclusions of law.

         At step one of the sequential evaluation, the ALJ found that Plaintiff had not engaged in substantial gainful activity since Plaintiffs AOD of March 25, 2014. (R. at 15.) At step two of the sequential evaluation, the ALJ found Plaintiffs lumbar radiculopathy, bursitis of the left hip, carpal tunnel syndrome, and obesity to be severe medically determinable impairments. (R. at 15.) The ALJ determined that Plaintiffs other impairments-hypertension, anxiety, and fibromyalgia-were not severe as they were treatable without significant complication or stable with monitoring, and because the medical evidence did not support a finding of severe limitation. (R. at 15-17.) At step three of the sequential evaluation, the ALJ found Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. at 17.) In between steps three and four of the sequential evaluation, the ALJ found that Plaintiff had the residual functional capacity ("RFC") to perform light work as defined in 20 C.F.R. § 416.967(b), except Plaintiff could never climb ladders, ropes, or scaffolds; occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl; and frequent bilateral handling, grasping or fingering. (R. at 18.) At step four of the sequential evaluation, the ALJ found Plaintiffs RFC did not preclude her from performing any of her past work. (R. at 22.) Nonetheless, the ALJ still made a step five determination and found that Plaintiff was able to perform jobs that existed in significant numbers in the national economy. (R. at 23-24.) Therefore, the ALJ concluded that Plaintiff was not under a disability, as defined by the Social Security Act, since September 26, 2014, the date the application was filed. (R. at 24.)

         IV. ANALYSIS

         Plaintiff essentially raises three issues on appeal in support of her contention that Defendant's final decision is unsupported by substantial evidence and erroneous as a matter of law. First, Plaintiff argues that the ALJ failed to properly evaluate the medical opinion evidence and did not afford appropriate weight to Plaintiffs treating and examining physicians. (Pl's Br. Supp. at 5-11.) Next, Plaintiff contends that the ALJ erred in finding that Plaintiffs impairments did not meet or equal Listing 1.04A. (Id. at 12-14.) Finally, Plaintiff argues that the ALJ failed to consider several of Plaintiff s medical impairments. (Id. at 14-16.) Each argument by Plaintiff is addressed in turn below.

         1. Weight Given to Medical Opinion Evidence

         Plaintiff contends that the ALJ improperly evaluated the findings of Dr. Lagatutta, Dr. Siekerkotte, and the state medical examiners. (Pl's Br. Supp. at 5-11.) Specifically, Plaintiff argues that the ALJ disregarded a great deal of evidence contained in those medical opinions and did not provide a proper explanation for why those opinions were being discredited. (Id.) In response, Defendant argues that substantial evidence supports the ALJ's decision to give the opinions of Dr. Siekerkotte, Dr. Lagutta, and state medical examiners partial or little weight. (Def.'s Mem. Supp. & Opp'n at 7.)

         As Plaintiff recognizes, the question over the weight to be assigned to the medical opinions at issue speaks to the ultimate determination of Plaintiffs RFC. After step three of an ALJ's sequential analysis, but before deciding whether a claimant can perform past relevant work at step four, the ALJ must determine the claimant's RFC. 20 C.F.R. §§ 404.1520(e)-(f), 404.1545(a)(1), 416.902(e)-(f), 416.945(a)(1). Opinions by medical professionals, whether "acceptable medical sources" or "other sources," are one type of evidence that an ALJ is to consider in determining a claimant's RFC. Id. § 404.1527(b); SSR 06-03p, 2006 WL 2329939, at *4 (Aug. 9, 2006).

         When the opinions by medical professionals are inconsistent with each other or with other evidence, the ALJ must evaluate the opinions and assign them respective weight to properly analyze the evidence involved. 20 C.F.R. §§ 404.1527(c)(2)-(6), (d), 416.927(c)(2)-(6), (d); SSR 06-03p, 2006 WL 2329939, at *5. Only opinions from treating physicians may be given controlling weight. See 20 C.F.R. § 404.1527(c)(2). Generally, opinions from treating sources are given more weight than other opinions, and if it is found that a treating source's opinion on the nature and severity of a claimant's impairment is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record," it will be given "controlling weight." 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2). Four requirements essentially exist for an opinion to be given controlling weight: (1) the opinion must come from a "treating source;" (2) the opinion must be a "medical opinion," defined as an opinion about the nature and severity of the claimant's impairments; (3) the opinion must be well-supported by medically acceptable clinical and laboratory diagnostic techniques; and (4) the opinion must not be inconsistent with the other substantial evidence in the record. S.S.R. 96-2p, 1996 WL 324188, at *2.

         If an opinion does not meet the aforementioned four requirements, it cannot be given controlling weight. Id. If an opinion is not given controlling weight as a treating source's opinion, the Social Security regulations require that certain factors be considered to determine the weight given to the medical opinion. Those factors include: (1) examining relationship, (2) treatment relationship, (3) supportability, (4) consistency, (5) specialization, and (6) any other factors that tend to support or contradict the medical opinion. 20 C.F.R. §§ 404.1527(c)(1)-(6), 416.927(c)(1)-(6); S.S.R. 96-2p, 1996 WL 324188, at *4. An ALJ is not required to explicitly analyze each of the aforementioned factors so long as the ALJ is clear as to which factor justified his or her conclusion. Bishop v. Comm'r of Soc. Sec. 583 Fed.Appx. 65, 67 (4th Cir. 2014) (per curiam) ("While the ALJ did not explicitly analyze each of the ... factors on the record, the ALJ was clear that he concluded that the doctor's opinion was not consistent with the record or supported by the medical evidence, which are appropriate reasons."). Under the substantial evidence standard, "[a]n ALJ's determination as to the weight to be assigned to a medical opinion generally will not be disturbed absent some indication that the ALJ has dredged up specious inconsistencies, or has failed to give a sufficient reason for the weight afforded a particular opinion." Dunn v. Colvin, 607 Fed.Appx. 264, 267 (4th Cir. 2015) (citations and quotations omitted).

         Here, the ALJ gave Dr. Lagattuta's and Dr. Siekerkotte's opinions little weight. (R. at 21-22.) Additionally, the ALJ gave the state medical examiners' opinions only some weight. (R. at 22.) The Court addresses each evaluation in turn.

         A. Dr. Lagutta

         Dr. Lagutta, Plaintiffs treating physician, completed an RFC questionnaire on August 4, 2015. (R. at 431-34.) He noted that he had been treating Plaintiff on a monthly basis since May 4, 2015. (R. at 431.) Dr. Lagutta reported Plaintiff suffered from headaches, feeling light headed, night sweats, sleep disturbances and fatigue, and that she had constant pain, including pins and needles, which radiated to her legs and arms. (R. at 431.) He stated his objective findings were supported by conducting an EMG, x-ray, and MRI on Plaintiff. (R. at 431.)

         Based on his observations, Dr. Lagutta opined that the severity of Plaintiff s pain and other symptoms would frequently interfere with the attention and concentration necessary to sustain simple, repetitive work tasks. (R. at 432.) Dr. Lagutta also determined that Plaintiff could not tolerate "low stress" work, though he did not explain the basis for such an extreme restriction. (R. at 432.) Dr. Lagutta then opined that Plaintiff could sit as well as stand for only one (1) hour at a time and thus was limited to less than two (2) hours of sitting, standing, walking in an eight (8) hour workday and would need one unscheduled break every two hours. (R. at 432-33.) He also opined that Plaintiff could lift no more than ten (10) pounds and had limitations in doing repetitive reaching, handling or fingering. (R. at 433.) However, he did not explain whether the reaching, handling, or fingering limitations were mild, moderate, or severe but instead explained the limitations were due to Plaintiffs carpal tunnel syndrome. (R. at 433.) Finally, Dr. Lagutta explained that Plaintiffs limitations would result in good and bad days and would also cause Plaintiff to miss more than four (4) days of work per month. (R. at 434.)

         The ALJ gave little weight to Dr. Lagutta's opinions. (R. at 22.) Although recognizing that Dr. Lagutta was Plaintiffs treating physician, the ALJ nonetheless chose to disregard Dr. Lagutta's medical opinions as his restrictive RFC was not supported by the longitudinal medical record. (R. at 22.) In the weight determination paragraph, the ALJ specifically found that (1) Dr. Lagutta's medical notes revealed no problems or complaints regarding Plaintiffs gait, (2) Plaintiff exhibited consistent strength in her back and hips, and (3) Plaintiffs pain could be managed through injections and prescriptions. (R. at 22.) In that same paragraph, the ALJ also noted that Plaintiff testified during the hearing that she managed her pain with Aleve (R. at 22, 41), and could perform daily activities such as driving and laundry (R. at 22, 37, 41-42). Finally, the ALJ found that Plaintiffs grip strength of "4" was inconsistent with Dr. Lagutta's opinion that Plaintiff could rarely carry ten (10) pounds and occasionally less than ten pounds. (R. at 22, 412.)

         In addition to those specific findings in the weight determination paragraph, the ALJ devoted several pages to discussing the objective medical evidence in the record. (R. at 19-21.) In this section of the decision, the ALJ found that Plaintiffs alleged difficulties arising from her lumbar radiculopathy were inconsistent with the objective medical evidence. The ALJ acknowledged that Plaintiff possessed nerve root inflammation and an injured disc in her lumbar region, but determined that Plaintiff nonetheless demonstrated relative stability. (R. at 20, 458, 466.) In support of her findings, the ALJ directly cited to several portions of Plaintiff s medical records. (R. at 20.) For example, the ALJ pointed to Plaintiff's examination with Dr. Siekerkotte in which Dr. Siekerkotte reported that while Plaintiff could not stand on her toes, she could still stand on her heels. (R. at 411.) The ALJ also noted that in that same examination, Plaintiffs (1) range of motion for her lumbar region was 0-90 degrees for her flexion, 0-25 degrees for her extension, and 0-25 degrees for her lateral flexion bilaterally and (2) straight-leg test was negative bilaterally in a seated position. (R. at 411-12.) Further, the ALJ found that Plaintiffs multiple epidural injections, received in February 2016, provided Plaintiff with some manner of relief. (R. at 454.) While Plaintiff continued to feel pain, she nonetheless could continue to move. (R. at 441, 446, 451.) Moreover, Plaintiffs gait was described as "smooth" with an upright posture in March 2017, (R. at 498), and Plaintiff previously denied any problems walking (R. at 441). Furthermore, an independent review by the Court of Plaintiff s medical records establishes Plaintiff consistently denied any musculoskeletal weakness or instances of falling. (R. at 442, 446-47, 451-52, 457-58, 461-62, 465-66.)

         The ALJ also found that Plaintiffs alleged difficulties caused by her left hip bursitis were inconsistent with the objective medical evidence. (R. at 20-21.) Plaintiff was definitely diagnosed with "trochanteric bursitis of the left hip" in May 2017. (R. at 506.) This matches the consultative examiner's notation that Plaintiff could not tolerate any range of motion testing on her left side during the examination. (R. at 411.) However, Plaintiffs past examinations "revealed consistent right and left hip flexion strength at 5/5, hip extension at 5/5, and hip abduction at 5/5 with a slightly reduced left hip abduction at 4/5." (R. at 20, 442, 446, 451.) Again, as previously noted, Plaintiff previously denied any difficulties with her gait and exhibited an upright posture. (R. at 441, 498.)

         In addition to inconsistencies with the objective medical evidence, the ALJ noted inconsistencies with Plaintiffs subjective evidence. (R. at 19-20.) Plaintiff stated in January 2015 that she went grocery shopping, performed household chores, drove her kids to school, and went to physical therapy. (R. at 239, 240-42.) But in that same statement, Plaintiff claimed to no longer be able to sit, stand, or walk for extend periods of time. (R. at 238.) At the hearing before the ALJ, Plaintiff testified that she possessed a driver's license, drove around town, and continued to go to physical therapy. (R. at 37, 40.) Plaintiffs testimony also established that her pain medication relieved some of the pain. (R. at 41.) Finally, Plaintiff stated she could not, or at least struggled to, perform household chores such as laundry. (R. at 41-42, 46, 240.) However, when describing why she struggled to do the laundry, Plaintiff specifically ...

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