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Williams v. Berryhill

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

June 17, 2019

CAROL S. WILLIAMS, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          REPORT AND RECOMMENDATION

          DAVID J. NOVAK UNITED STATES MAGISTRATE JUDGE.

         On September 1, 2015, Carol S. Williams ("Plaintiff") applied for Social Security Disability Benefits ("DIB"), alleging disability from arthritis, high blood pressure, high cholesterol, left hip pain, carpel tunnel syndrome and right knee pain, with an alleged onset date of June 1, 2015. 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 in: (1) affording little weight to the opinion of Plaintiff s treating physician, Malalai Azmi, M.D.; (2) assessing the opinions of the state agency physicians; and, (3) failing to account for Plaintiffs need for an assistive walking device in the ALJ's residual functional capacity ("RFC") assessment. (Mem. in Support of Pl.'s Mot. For Summ. J. ("Pl.'s Mem.") (ECF No. 17) at 9-16.) This matter now comes before the Court for a Report and Recommendation pursuant to 28 U.S.C. § 636(b)(1)(B) on the parties' cross-motions for summary judgment, rendering the matter ripe for review.[1] For the reasons that follow, the Court recommends that Plaintiffs Motion for Summary Judgment (ECF No. 16) be GRANTED, that Defendant's Motion for Summary Judgment (ECF No. 18) be DENIED and that the final decision of the Commissioner be REVERSED and REMANDED.

         I. PROCEDURAL HISTORY

         On September 1, 2015, Plaintiff filed an application for DIB. (R. at 193-96.) The SSA denied these claims initially on October 15, 2015, and again upon reconsideration on January 7, 2016. (R. at 98-109.) At Plaintiffs written request, the ALJ held a hearing on April 6, 2017. (R. at 35-84, 133-34.) On October 16, 2017, the ALJ issued a written opinion, denying Plaintiffs claims and concluding that Plaintiff did not qualify as disabled under the Act, because she could perform work existing in significant numbers in the national economy. (R. at 20-30.) On July 31, 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'r 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. Chater, 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 "take 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); 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). At step two, the ALJ asks whether the claimant's medical impairments meet the regulations' severity and duration requirements. § 404.1520(a)(4)(ii). 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). Between steps three and four, the ALJ must assess the claimant's RFC, accounting for the most that the claimant can do despite her physical and mental limitations. § 404.1545(a). At step four, the ALJ assesses whether the claimant can perform her past work given her RFC. § 404.1520(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).

         III. THE ALJ'S DECISION

         On April 6, 2017, the ALJ held a hearing during which Plaintiff (represented by counsel) and a vocational expert ("VE") testified. (R. at 35-84.) On October 16, 2017, the ALJ issued a written opinion, finding that Plaintiff did not qualify as disabled under the Act. (R. at 20-30.)

         The ALJ followed the five-step evaluation process established by the Social Security Act in analyzing Plaintiffs disability claim. (R. at 22-30.) At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since July 1, 2015 - the amended alleged onset date. (R. at 22.) At step two, the ALJ found that Plaintiff had the following severe impairments: osteoarthritis and obesity. (R. at 22.) At step three, the ALJ found that 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. Subpart P, Appendix 1. (R. at 22-23.)

         In assessing Plaintiffs RFC, the AIJ found that Plaintiff could perform light work with additional limitations. Specifically, Plaintiff could lift and carry twenty pounds occasionally and ten pounds frequently. (R. at 23.) Plaintiff could stand and walk for six hours and sit for six hours during an eight-hour workday, and she could periodically alternate between sitting and standing at will while remaining on task. (R. at 23.) Plaintiff could push and pull as much as she could lift and carry, but she could never operate foot controls with either foot. (R. at 23.) Plaintiff could occasionally climb ramps and stairs, but she could never climb ladders, ropes or scaffolds. (R. at 23.) Plaintiff could occasionally stoop, but she could never kneel crouch or crawl, and she could never work at unprotected heights. (R. at 23.) Plaintiff could occasionally work with moving mechanical parts and in vibration. (R. at 23.) Lastly, the ALJ limited Plaintiff to unskilled work due to pain. (R. at 23.) At step four, the ALJ found that Plaintiff could not perform any past relevant work. (R. at 29.) At step five, the ALJ determined that Plaintiff could perform jobs existing in significant numbers in the national economy. (R. at 29-30.) Therefore, Plaintiff did not qualify as disabled under the Act. (R. at 30.)

         IV. ANALYSIS

         Plaintiff, age fifty-four at the time of this Report and Recommendation, previously worked as a correctional officer. (R. at 193, 209.) She applied for Social Security Benefits, alleging disability from arthritis, high blood pressure, high cholesterol, left hip pain, carpel tunnel syndrome and right knee pain with an alleged onset date of June 1, 2015. (R. at 207-08.) Plaintiffs appeal to this Court alleges that the ALJ erred in: (1) affording little weight to the opinion of Plaintiff s treating physician, Dr. Azmi; (2) assessing the opinions of the state agency physicians; and, (3) failing to account for Plaintiffs need for an assistive walking device in the ALJ's RFC assessment. (Pl.'s Mem. at 9-15.) For the reasons set forth below, the ALJ erred in her decision.

         A. The ALJ Provided an Insufficient Explanation for Affording Little Weight to Dr. Azmi's Opinion.

         Plaintiff argues that the ALJ erred in assigning little weight to Dr. Azmi's opinion and provided insufficient reasoning for doing so. (Pl.'s Mem. at 9.) Defendant asserts that the ALJ provided legally sufficient reasoning for assigning Dr. Azmi's opinion little weight and that substantial evidence supports the ALJ's opinion. (Def.'s Mot. for Summ. J. and Br. in Supp. (ECF No. 18) ("Def.'s Mem.") at 15-22.)

         During the sequential analysis, when the ALJ determines whether the claimant has a medically-determinable severe impairment, or combination of impairments, that would significantly limit the claimant's physical or mental ability to do basic work activities, the ALJ must analyze the claimant's medical records that are provided and any medical evidence resulting from consultative examinations or medical expert evaluations that have been ordered. 20 C.F.R. §§ 404.1512, 404.1527. When the record contains a number of different medical opinions, including those from Plaintiffs treating sources, consultative examiners or other sources that are consistent with each other, then the ALJ makes a determination based on that evidence. § 404.1527(c). If, however, the medical opinions are inconsistent internally with each other or other evidence, the ALJ must evaluate the opinions and assign them respective weight to properly analyze the evidence involved. §§ 404.1527(c)(2)-(6), (d).

         Under the regulations, only an "acceptable medical source" may be considered a treating source that offers an opinion entitled to controlling weight. SSR 06-03p.[2] Acceptable medical sources include licensed physicians, licensed or certified psychologists and certain other specialists, depending on the claimed disability. SSR 06-03p. The regulations also provide for the consideration of opinions from "other sources," including nurse-practitioners, physician's assistants or therapists. SSR 06-03p; § 404.1527(f).[3]

         A treating source's opinion must be given controlling weight if it is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence in the record. Lewis v. Berryhill, 858 F.3d 858, 867 (4th Cir. 2017); Craig, 76 F.3d at 590; § 404.1527(c)(2); SSR 96-2p. Further, the regulations do not require that the ALJ accept opinions from a treating source in every situation, e.g., when the source opines on the issue of whether the claimant is disabled for purposes of employment (an issue reserved for the Commissioner), or when the treating source's opinion is inconsistent with other evidence or when it is not otherwise well-supported. § 404.1527(c)(3)-(4).

         Courts generally should not disturb an ALJ's decision as to the weight afforded a medical opinion absent some indication that the ALJ "dredged up 'specious inconsistences.'" Dunn v. Colvin, 607 Fed.Appx. 264, 267 (4th Cir. 2015) (citing Scivally v. Sullivan, 966 F.2d 1070, 1077 (7th Cir. 1992)). Indeed, an ALJ's decision regarding weight afforded a medical opinion should be left untouched unless the ALJ failed to give a sufficient reason for the weight afforded. Id.

         The ALJ must consider the following when evaluating a treating source's opinion: (1) the length of the treating source relationship and frequency of examination; (2) the nature and extent of the treatment relationship; (3) supportability based upon the medical record; (4) consistency between the opinion and the medical record; (5) any specialization on the part of the treating source; and, (6) any other relevant factors. § 404.1527(c). However, those same regulations specifically vest the ALJ - not the treating source - with the authority to determine whether a claimant is disabled as that term is defined under the Act. § 404.1527(d)(1). Although the regulations explicitly apply these enumerated factors only to treating sources, those same factors may be applied in evaluating opinion evidence from "other sources." SSR 06-03p.

         Dr. Azmi treated Plaintiff multiple times between 2015 and 2017. (R. at 293, 296, 299, 447, 661-78). On February 14, 2017, Dr. Azmi completed a medical source statement for Plaintiff. (R. at 549-50.) Dr. Azmi listed chronic lower back pain with radiculopathy as Plaintiffs primary ailments. (R. at 549.) Utilizing a check-the-box format, Dr. Azmi further indicated that Plaintiff could occasionally sit, stand and walk, never stoop, and infrequently climb with assistance. (R. at 549.) Dr. Azmi opined that Plaintiff could infrequently carry one to five pounds, occasionally carry six to ten pounds and never carry more than ten pounds. (R. at 549.) However, Dr. Azmi believed that Plaintiff could frequently use her hands for fine and gross manipulation and frequently raise both arms over her shoulders. (R. at 549.) Dr. Azmi checked a box describing Plaintiffs pain as severe and he opined that Plaintiff would be off task 70 percent of the time during an eight-hour workday due to pain. (R. at 550.) Further, Dr. Azmi believed that Plaintiff would need to elevate her legs over her waist for approximately three to four hours per day. (R. at 550.) Lastly, Dr. Azmi opined that Plaintiff would need to take unscheduled break periods during an eight-hour workday and required an assistive device to ambulate. (R. at 550.)

         The ALJ assigned little weight to Dr. Azmi's opinion because it lacked consistency with the record evidence as a whole, and because Dr. Azmi used a check-the-box form to complete his opinion. (R. at 27.) Plaintiff argues that the ALJ provided legally insufficient reasoning for ...


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