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Venable v. Berryhill

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

June 6, 2019

JAMIE LYNN VENABLE, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION

          DAVID J. NOVAK, UNITED STATES MAGISTRATE JUDGE

         On September 14, 2014, Jamie Lynn Venable ("Plaintiff) protectively applied for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under the Social Security Act ("Act"), alleging disability from depression, a hand/wrist problem, an ankle problem and sarcoidosis, with an alleged onset date of June 28, 2014. The Social Security Administration ("SSA") denied Plaintiffs claims both initially and upon reconsideration. Thereafter, an Administrative Law Judge ("ALJ") denied Plaintiffs claims in a written decision and the Appeals Council denied Plaintiffs request for review, rendering the ALJ's decision as the final decision of the Commissioner.

         Plaintiff now seeks judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g), arguing that the ALJ erred by: (1) failing to consider whether the combination of Plaintiff s systemic lupus erythematosus ("SLE") and sarcoidosis met or medically equaled Listing 14.02; (2) finding that Plaintiffs statements concerning the intensity persistence and limiting effects of her symptoms proved inconsistent with the evidence of record; (3) affording improper weight to the opinions of Sumeja Zahirovic, M.D., and the state agency medical and psychological consultants; and, (4) relying on an incomplete hypothetical at step five. (PL's Mem. of L. in Supp. of Soc. Sec. Appeal ("PL's Mem.") (ECF No. 15) at 12-22.) This matter now comes before the Court by consent of the parties pursuant to 28 U.S.C. § 636(c)(1) on the parties' cross-motions for summary judgment, rendering the matter ripe for review.[1]For the reasons set forth below, the Court hereby GRANTS Plaintiffs Motion for Summary Judgment (ECF No. 13), DENIES Defendant's Motion for Summary Judgment (ECF No. 20) and VACATES and REMANDS the final decision of the Commissioner pursuant to the fourth sentence of 42 U.S.C. § 405(g) for further administrative proceedings.

         I. PROCEDURAL HISTORY

         On September 14, 2014, Plaintiff filed an application for DIB and SSI with an alleged onset date of June 28, 2014. (R. at 225-32.) The SSA denied these claims initially on April 28, 2015, and again upon reconsideration on October 5, 2015. (R. at 99-100, 135-36.) At Plaintiffs written request, the ALJ held a hearing on May 12, 2017. (R. at 34-67.) On October 30, 2017, the ALJ issued a written opinion, denying Plaintiffs claims and concluding that Plaintiff did not qualify as disabled under the Act. (R. at 19-28.) On May 2, 2018, the Appeals Council denied Plaintiffs request for review, rendering the ALJ's decision as the final decision of the Commissioner subject to review by this Court. (R. at 1-3.)

         II. STANDARD OF REVIEW

         In reviewing the Commissioner's decision to deny benefits, a court "will affirm the Social Security Administration's disability determination 'when an ALJ has applied correct legal standards and the ALJ's factual findings are supported by substantial evidence.'" Mascio v. Colvin, 780 F.3d 632, 634 (4th Cir. 2015) (quoting Bird v. Comm V of Soc. Sec. Admin., 699 F.3d 337, 340 (4th Cir. 2012)). Substantial evidence requires more than a scintilla but less than a preponderance, and includes the kind of relevant evidence that a reasonable mind could accept as adequate to support a conclusion. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012); Craig v. Chafer, 76 F.3d 585, 589 (4th Cir. 1996). Indeed, "the substantial evidence standard 'presupposes ... a zone of choice within which the decision makers can go either way, without interference by the courts. An administrative decision is not subject to reversal merely because substantial evidence would have supported an opposite decision.'" Dunn v. Colvin, 607 Fed.Appx. 264, 274 (4th Cir. 2015) (quoting Clarke v. Bowen, 843 F.2d 271, 272-73 (8th Cir. 1988)). To determine whether substantial evidence exists, the court must examine the record as a whole, but may not "undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [ALJ]." Hancock, 667 F.3d at 472 (quoting Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005)); see also Biestek v. Berryhill, 139 S.Ct. 1148, 1157 (2019) (holding that the substantial-evidence inquiry requires case-by-case consideration, with deference to the presiding ALJ's credibility determinations). In considering the decision of the Commissioner based on the record as a whole, the court must "tak[e] into account... 'whatever in the record fairly detracts from its weight.'" Breeden v. Weinberger, 493 F.2d 1002, 1007 (4th Cir. 1974) (quoting Universal Camera Corp. v. N.L.R.B., 340 U.S. 474, 488 (1951)). The Commissioner's findings as to any fact, if substantial evidence in the record supports the findings, bind the reviewing court to affirm regardless of whether the court disagrees with such findings. Hancock, 667 F.3d at 477. If substantial evidence in the record does not support the ALJ's determination or if the ALJ has made an error of law, the court must reverse the decision. Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).

         The Social Security Administration regulations set forth a five-step process that the agency employs to determine whether disability exists. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); see Mascio, 780 F.3d at 634-35 (describing the ALJ's five-step sequential evaluation). To summarize, at step one, the ALJ looks at the claimant's current work activity. §§ 404.1520(a)(4)(i), 416.920(a)(4)(i). At step two, the ALJ asks whether the claimant's medical impairments meet the regulations' severity and duration requirements. §§ 404.1520(a)(4)(H), 416.920(a)(4)(h). Step three requires the ALJ to determine whether the medical impairments meet or equal an impairment listed in the regulations. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii). Between steps three and four, the ALJ must assess the claimant's residual functional capacity ("RFC"), accounting for the most that the claimant can do despite her physical and mental limitations. §§ 404.1545(a), 416.945(a). At step four, the ALJ assesses whether the claimant can perform her past work given her RFC. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). Finally, at step five, the ALJ determines whether the claimant can perform any work existing in the national economy. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). At any step, if the ALJ finds the claimant disabled or not disabled, the ALJ makes his determination or decision and thus does not go on to the next step. §§ 404.1520(a)(4), 416.920(a)(4).

         III. THE ALJ'S DECISION

         On May 12, 2017, the ALJ held a hearing during which Plaintiff (represented by counsel) and a vocational expert ("VE") testified. (R. at 36-67.) On October 30, 2017, the ALJ issued a written opinion, finding that Plaintiff did not qualify as disabled under the Act. (R. at 19-28.)

         The ALJ followed the five-step evaluation process established by the Social Security Act in analyzing Plaintiffs disability claim. (R. at 20-21.) At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since June 28, 2014, her alleged onset date. (R. at 21.) At step two, the ALJ concluded that Plaintiff had the following severe impairments: SLE, [2]sarcoidosis, [3] depressive disorder, attention deficit disorder ("ADD") and anxiety disorder. (R. at 21.) At step three, the ALJ found that Plaintiffs combination of impairments did not meet or medically equal the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1. (R. at 21-22.)

         In assessing Plaintiffs RFC, the ALJ found that Plaintiff could perform sedentary work with additional limitations. (R. at 23-24.) Specifically, the ALJ limited Plaintiff to standing or walking for up to four hours during an eight-hour workday. (R. at 23.) The ALJ found that Plaintiff could frequently operate hand controls and handle objects with her right upper extremity, and she could push, pull, lift and carry with the left upper extremity and bilateral lower extremities. (R. at 23-24.) The ALJ further concluded that Plaintiff could occasionally climb ramps, stairs and ladders and could occasionally stoop, kneel, crouch and crawl. (R. at 24.) As to Plaintiffs mental abilities, the ALJ estimated that Plaintiff could concentrate and focus for two hours before requiring a fifteen-minute break and could maintain attendance and punctuality, though Plaintiff would experience one attendance problem per month and could not perform work at a production-rate pace. (R. at 24.) Plaintiff also required the option to sit or stand while working. (R. at 24.)

         At step four, the ALJ determined that Plaintiff could not perform her past relevant work as a store manager. (R. at 26.) However, at step five, the ALJ concluded that Plaintiffs age, education, work experience and RFC allowed her to perform sedentary occupations, such as surveillance monitor and telephone information clerk. (R. at 26-27.) Therefore, the ALJ concluded that Plaintiff did not qualify as disabled under the Act. (R. at 28.)

         IV. ANALYSIS

         Plaintiff, thirty-nine years old at the time of this Memorandum Opinion, previously worked as a store manager and cashier. (R. at 26, 83, 244.) She applied for Social Security benefits, alleging disability from depression, a hand/wrist problem, an ankle problem and sarcoidosis, with an alleged onset date of June 28, 2014. (R. at 24, 71, 101, 125.) Plaintiffs appeal to this Court alleges that the ALJ erred by: (1) failing to consider whether the combination of Plaintiff s SLE and sarcoidosis met or medically equaled Listing 14.02; (2) finding that Plaintiffs statements concerning the intensity persistence and limiting effects of her symptoms proved inconsistent with the evidence of record; (3) affording improper weight to the opinions of Dr. Zahirovic and the state agency medical and psychological consultants; and, (4) relying on an incomplete hypothetical at step five. (PL's Mem. at 12-22.) For the reasons set forth below, the ALJ erred in her decision.

         A. The ALJ Properly Explained Why Plaintiffs Impairments, Both Singly and in Combination, Failed to Meet or Medically Equal Listing 14.02, and Substantial Evidence Supports the ALJ's Findings.

         Plaintiff first challenges the ALJ's step-three determination that Plaintiffs physical impairments did not meet or medically equal the severity of the listed impairments in Listing 14.02. (PL's Mem. at 13.) Specifically, Plaintiff contends that the ALJ failed to consider whether the impairments caused by the combination of Plaintiff s SLE and sarcoidosis medically equaled the criteria of Listing 14.02. (PL's Mem. at 13-14.) Plaintiff further contends that the ALJ focused only on Plaintiffs complaints of fatigue and tenderness and neglected to mention potential sarcoidosis-related issues with Plaintiffs pulmonary, nervous and integumentary systems.[4] (PL's Mem. at 13-14.) And Plaintiff argues that the ALJ "summarily dismissed" evidence that Plaintiff experienced malaise. (PL's Mem. at 14.) Defendant responds that substantial evidence supports the ALJ's step-three conclusions. (Def.'s Mot. Summ. J. & Br. in Supp. Thereof ("Def.'s Mem.") (ECF No. 20) at 14-17.)

         At step three, Plaintiff bears the burden of proving that she meets or medically equals a listing. Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987). The listings "were designed to operate as a presumption of disability that makes further inquiry unnecessary" and, consequently, require an exacting standard of proof. Sullivan v. Zebley, 493 U.S. 521, 532-33 (1990.) "For a claimant to show that his impairment matches a listing, it must meet all of the specified medical criteria. An impairment that manifests only some of those criteria, no matter how severely, does not qualify." Id. at 530.

         Plaintiffs condition must satisfy all of the enumerated criteria in Listing 14.02 to qualify her as disabled at step three. Id. Specifically, to meet the requirements of Listing 14.02, Plaintiff must provide medical documentation of SLE with either:

A. Involvement of two or more organs/body systems, with: 1. One of the organs/body systems involved to at least a moderate level of severity;[5] and 2. At least two of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss). [OR]
B. Repeated manifestations of SLE, [6] with at least two of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss) and one of the following at the marked level: 1. Limitation of activities of daily living; 2. Limitation in maintaining social functioning; [or] 3. Limitation in completing tasks in a timely manner due to deficiencies in concentration, persistence, or pace.[7]

20 C.F.R. Part 404, Subpart P, App. 1, 14.02(A)-(B).

         Here, the ALJ found that Plaintiffs physical impairments failed to meet or medically equal the criteria of Listing 14.02. (R. at 22.) The ALJ noted that although Plaintiff had complained of symptoms involving multiple body systems, the objective medical findings appeared minimal, showing only mild tenderness to palpitation in Plaintiffs hands and feet. (R. at 22.) Additionally, the ALJ found that the Plaintiff exhibited only one of the constitutional symptoms or signs, with significant complaints of fatigue but no reports of fever or malaise and only intentional - not involuntary - weight loss. (R. at 22.)

         In reaching her step-three conclusions, the ALJ considered the opinion of medical expert Maria Rivero, M.D., who opined that Plaintiffs impairments did not meet or medically equal the criteria of Listing 14.02. (R. at 23.) The ALJ noted that Dr. Rivero had cited to objective findings throughout the medical record to support her conclusions and consequently afforded Dr. Rivero's opinion concerning Listing 14.02 great weight. (R. at 23.)

         Ultimately, with neither Paragraph A nor Paragraph B of Listing 14.02 satisfied, the ALJ concluded that Plaintiffs impairments - both singly and in combination - did not meet or medically equal the criteria of the Listing. (R. at 22.) Substantial evidence supports the ALJ's conclusion.

         1. Plaintiffs Objective Medical Records Support the ALJ's Listing 14.02 Findings.

         A review of the entire medical record provides substantial evidence to support the ALJ's findings regarding Listing 14.02. First, Plaintiffs records support the ALJ's finding that the objective medical record provided minimal evidence of multisystemic effects. (R. at 22.) Indeed, although Plaintiff cites to records from May and August 2016 indicating possible sarcoidosis/SLE involvement with her nervous system, (PL's Mem. at 13 (citing R. at 747, 776)), the May 2016 record noted that her neurological exam appeared "ok" and questioned Plaintiffs complaints of seizures, (R. at 747), and the August 2016 record reflected that Plaintiffs palsies and neuropathy could be a manifestation of her rheumatological disease, (R. at 776). Moreover, medical studies performed after August 2016 showed no abnormalities in Plaintiffs nervous system. (R. at 739 (noting results from October 2016 electroencephalogram ("EEG") showing no seizure activity and ...


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