United States District Court, W.D. Virginia, Roanoke Division
S. Ballou United States Magistrate Judge
Cindy F. (“Cindy”) filed this action challenging
the final decision of the Commissioner of Social Security
(“Commissioner”) finding her not disabled and
therefore ineligible for disability insurance benefits
(“DIB”) under the Social Security Act
(“Act”). 42 U.S.C. §§ 1381-1383f. Cindy
alleges that the Administrative Law Judge (“ALJ”)
erred by failing to: (1) obtain a consultative examination
after having granted her motion for such examination; (2)
find that her spine impairment met listing 1.04; and (3) find
that her urinary incontinence was a severe impairment. I
conclude that the ALJ erred by failing to obtain a
consultative examination. Accordingly, I GRANT in
part Cindy's Motion for Summary Judgment (Dkt.
No. 13) and DENY the Commissioner's
Motion for Summary Judgment (Dkt. No. 15), and
REVERSE AND REMAND this case for further
administrative proceedings consistent with this opinion.
court limits its review to a determination of whether
substantial evidence exists to support the Commissioner's
conclusion that Cindy failed to demonstrate that she was
disabled under the Act. 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.
remand is appropriate if the ALJ's analysis is so
deficient that it “frustrate[s] meaningful
review.” Mascio v. Colvin, 780 F.3d 632, 636
(4th Cir. 2015) (noting that “remand is
necessary” because the court is “left to guess
[at] how the ALJ arrived at his conclusions”); see
also Monroe v. Colvin, 826 F.3d. 176, 189 (4th Cir.
2016) (emphasizing that the ALJ must “build an accurate
and logical bridge from the evidence to his conclusion”
and holding that remand was appropriate when the ALJ failed
to make “specific findings” about whether the
claimant's limitations would cause him to experience his
claimed symptoms during work and if so, how often) (citation
filed for DIB in December 2013, claiming that her disability
began on January 5, 2012, due to obesity, back injury,
depression, anxiety, fibromyalgia, lumbar sciatica with nerve
entrapment, incontinence, knee injury, super morbid obesity,
arthritis, and pitting edema in her lower legs. R. 198, 212, 215.
Cindy's date last insured was June 30, 2015; thus she
must show that her disability began on or before this date
and existed for twelve continuous months to receive DIB. R.
13, 212; 42 U.S.C. §§ 423(a)(1)(A), (c)(1)(B),
(d)(1)(A); 20 C.F.R. §§ 404.101(a), 404.131(a). The
state agency denied Cindy's applications at the initial
and reconsideration levels of administrative review. R.
91-100, 102-114. On November 10, 2016, ALJ Geraldine H. Page
held a hearing to consider Cindy's claims for DIB. R.
32-76. Cindy was represented by counsel at the hearing, which
included testimony from vocational expert Mark A. Hileman.
March 22, 2017, the ALJ entered her decision analyzing
Cindy's claims under the familiar five-step
process and denying her claim for benefits. R.
13-27. The ALJ found that Cindy was insured at the time of
the alleged disability onset and that she suffered from the
severe impairments of degenerative joint disease of the left
knee, degenerative disc disease of the lumbar spine, obesity,
neuropathy, fibromyalgia, and carpal tunnel syndrome of the
right hand.R. 15. The ALJ found that these
impairments, either individually or in combination, did not
meet or medically equal a listed impairment. R. 17-19.
Specifically, the ALJ considered listing 1.02 (major
dysfunction of a joint due to any cause), listing 1.04
(disorders of the spine), listing 11.14 (peripheral
neuropathies), and listing 1.08 (soft tissue injury). The ALJ
also specifically considered Cindy's obesity in relation
to the other body systems listings. R. 18. Further, the ALJ
found that, regarding her mental functioning, Cindy had no
limitation in understanding, remembering, or applying
information, mild limitation in interacting with others, mild
limitation in maintaining concentration, persistence, or
pace, and no limitation in managing oneself. R. 16- 17.
concluded that Cindy retained the residual functional
capacity (“RFC”) to perform a limited range of
sedentary work. R. 19. Specifically, the ALJ found that Cindy
can lift and carry 20 pounds occasionally and 10 pounds
frequently, stand and walk for no more than four hours, and
sit for no more than six hours, in an eight-hour workday.
Further, Cindy can occasionally push/pull with her lower
extremities and her right upper extremity, climb ramps and
stairs, and kneel, stoop, crouch, and balance. Cindy can
frequently, but not constantly handle, feel, and finger with
her right hand. Cindy should never crawl, and should avoid
all exposure to hazardous machinery, working at unprotected
heights, climbing ladders, ropes, or scaffolds, working on
vibrating surfaces, and concentrated exposures to extreme
temperatures. Id. The ALJ determined that Cindy was
not capable of performing her past relevant work as a nursing
assistant. R. 25. However, Cindy could perform other jobs
that exist in significant numbers in the national economy,
such as addressing clerk, call out operator, and stuffer. R.
26. Thus, the ALJ determined that Cindy was not disabled.
Id. Cindy appealed the ALJ's decision and the
Appeals Council denied her request for review on April 10,
2018. R. 1-4.
alleges that the ALJ erred by failing to: (1) obtain a
consultative examination after granting her motion for such
examination; (2) find that her spine impairment met listing
1.04; and (3) find that her urinary incontinence was a severe
had complaints of back pain following an injury in September
2011, while she was lifting a patient at work. R. 397. An MRI
in March 2012 showed L5/S1 right sided disc herniation, and
Ishaq Y. Syed, M.D., recommended surgery. R. 587. In April
2012, Cindy underwent a right sided L5-S1 microdiskectomy. R.
576-78. At a follow-up appointment in July 2012, Cindy
reported improvement in her buttock and leg pain, but some
continued low back pain, and was encouraged to continue with
physical therapy. R. 549. Dr. Syed referred Cindy to the
Carolinas Pain Institute, where on examination in June and
December 2012, she had 5/5 strength in her upper and lower
extremities, and non-antalgic gait. R. 312, 334. She was
assessed with hand pain, hand neuralgia, lumbosacral
radiculopathy, and piriformis syndrome. Id. Steroid
injections administered at her June 2012 visit provided
improved pain relief, while a piriformis injection in
December 2012 helped her pain “immensely.” R.
November 16, 2012, Cindy underwent a Functional Capacity
Evaluation performed by Mark M. Durlak, PT, Cert. MDT. R.
531-41. Mr. Durlak found that Cindy could work at the
light-medium physical demand level for a four hour day. R.
531. Mr. Durlak noted that testing showed, “an unusual
combination of symptom/disability exaggeration and non
organic signs which are significantly out of proportion to
the medical impairment.” R. 531. However, he concluded
that Cindy was “giving her best effort” and the
results of the test were valid and could “be used for
medical and vocational planning.” Id. Still,
the ALJ gave Mr. Durlaks's opinion “no