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Cindy F. v. Berryhill

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

May 15, 2019

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

          MEMORANDUM OPINION

          Robert S. Ballou United States Magistrate Judge

         Plaintiff 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”).[2] 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.

         STANDARD OF REVIEW

         This 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.[3] 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).

         However, 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 omitted).

         CLAIM HISTORY

         Cindy 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.[4] 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.

         On March 22, 2017, the ALJ entered her decision analyzing Cindy's claims under the familiar five-step process[5] 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.[6]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.

         The ALJ 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.

         ANALYSIS

         Cindy 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 impairment.

         A. Medical History

         Cindy 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. 305, 329.

         On 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 ...


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