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Kristyn H. v. Berryhill

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

June 21, 2019

KRISTYN H., [1] Plaintiff,
v.
NANCY A. Berryhill, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION [2]

          Robert S. Ballou United States Magistrate Judge

         Plaintiff Kristyn H. (“Kristyn”) 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. §§ 401-433. Kristyn alleges that the Administrative Law Judge (“ALJ”) erred because substantial evidence does not support: (1) the ALJ's determination that Kristyn engaged in substantial gainful activity in 2015; (2) the ALJ's physical RFC findings; (3) the ALJ's assessment of Kristyn's mental impairments under SSR 96-8p; and (4) the ALJ's assessment of Kristyn's credibility.

         I agree that the ALJ's assessment of Kristyn's mental impairments is deficient, and thus substantial evidence does not support the ALJ's decision. Accordingly, I GRANT in part Kristyn's Motion for Summary Judgment (Dkt. No. 15), DENY the Commissioner's Motion for Summary Judgment (Dkt. No. 17), 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 Kristyn 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, 188 (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). In Mascio and Monroe, the Court of Appeals remanded because the ALJ failed to adequately explain how he arrived at conclusions regarding the claimant's RFC. Mascio, 780 F.3d at 636; Monroe, 826 F.3d at 189. Similarly, I find that remand is appropriate here because the ALJ's opinion leaves the court to guess at how he reached his conclusions regarding Kristyn's mental RFC.

         CLAIM HISTORY

         Kristyn filed for DIB on September 29, 2014, claiming disability due to degenerative disc disease (DDD), spinal stenosis, arthritis of the thoracic spine, bipolar disorder II with impulsive behavior, depression, and PTSD, with an alleged onset date of September 13, 2011. R. 85. Kristyn was 36 years old when she applied for DIB, making her 32 years old on her alleged onset date. Id. Kristyn's date last insured was June 30, 2018;[4] thus, she must show that her disability began on or before this date and existed for twelve continuous months to receive DIB. R.18, 207; 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 Kristyn's application at the initial and reconsideration levels of administrative review. R. 85-115. On March 8, 2017, ALJ Michael Dennard held a hearing to consider Kristyn's claim for DIB. R. 33-84. Counsel represented Kristyn at the hearing, which included testimony from vocational expert Robert Jackson. R. 33. On August 22, 2017, the ALJ entered his decision analyzing Kristyn's claims under the familiar five-step process[5] and denying her claim for DIB. R. 16-27.

         The ALJ found that Kristyn had engaged in substantial gainful activity in 2015, and that she met the insured status requirements of the Act through June 30, 2018. R. 18. The ALJ determined that Kristyn suffered from the severe impairments of DDD, obesity, somatoform disorders, affective disorders, and anxiety disorders. Id. The ALJ noted that the record reflected a history of substance abuse with alcohol and cocaine, and treatment for asthma and hypertension, but the ALJ found that these impairments were not severe because they did not impose any significant restrictions on Kristyn's ability to perform basic work activities. R. 19. The ALJ determined that Kristyn's impairments, either individually or in combination, did not meet or medically equal a listed impairment, specifically considering listings 1.04 (disorders of the spine), 12.04 (depressive, bipolar, and related disorders), and 12.07 (somatic symptoms and related disorders). R. 19-21. The ALJ considered the “paragraph B” criteria and determined that they were not satisfied, finding that Kristyn had mild limitation in understanding, remembering, or applying information; moderate limitation in interacting with others; mild limitation in concentrating, persisting, or maintaining pace; and no limitation in adapting or managing herself. R. 19-20. The ALJ determined that the “paragraph C” criteria were also not satisfied. R. 20.

         The ALJ concluded that Kristyn retained the residual functional capacity (“RFC”) to perform light work. R. 21. For postural limitations, the ALJ determined that Kristyn could frequently balance and climb ramps and stairs, and occasionally stoop, kneel, crouch, crawl, and climb ladders, ropes, or scaffolds. Id. For environmental limitations, Kristyn could do occasional work at unprotected heights and around moving mechanical parts, occasionally operate a motor vehicle, and have only occasional exposure to extreme cold or vibration. Id. For non-exertional limitations, Kristyn would be limited to performing simple, routine tasks. Id. She could use judgment to make simple work-related decisions, could occasionally respond appropriately to the public and coworkers, and, in dealing with changes in a work setting, would be limited to simple work-related decisions. Id.

         The ALJ found that Kristyn was not able to perform her past relevant work as a certified nurse assistant, fast food cashier, or hair stylist. R. 25. Based on Kristyn's age, education, work experience, and RFC, the ALJ determined that Kristyn could perform jobs that exist in significant numbers in the regional and national economies, such as marker and inspector/grader. R. 25-26. Thus, the ALJ concluded that Kristyn was not disabled. R. 26-27. Kristyn appealed the ALJ's decision and the Appeals Council denied her request for review on May 31, 2018. R. 1-7.

         ANALYSIS

         Kristyn alleges that the ALJ erred because substantial evidence does not support: (1) the ALJ's determination that Kristyn engaged in substantial gainful activity in 2015; (2) the ALJ's physical RFC findings; (3) the ALJ's assessment of Kristyn's mental impairments under SSR 96-8p; and (4) the ALJ's assessment of Kristyn's credibility.

         A. Medical History

         1. Physical Impairments[6]

         Prior to her DLI, Kristyn had an anterior cervical diskectomy and fusion in January 2010. R. 59, 1050. A March 2011 MRI showed DDD at ¶ 4-L5 and L5-S1, but surgery was not recommended. R. 1048. In August 2012, another MRI showed no changes. R. 996. A September 2014 MRI showed “essentially negative” findings in the thoracic spine, and degenerative facet arthrosis changes at ¶ 4-L5 and L5-S1. R. 385. At an August 2016 neurosurgery evaluation, a July 2016 MRI again showed that Kristyn's disks were “essentially normal, ” but that she did have “some facet arthrosis” and multilevel degenerative lumbar spondylosis. R. 1321, 1896. The neurosurgeon recommended physical therapy and weight loss, but not surgery. R. 1321, 1842.

         Kristyn regularly received pain medication for conditions she complained of either in the ER or at normal appointments, including for back pain, headaches, stomach pain, shoulder pain, and neck pain. R. 325, 335, 349, 957, 1021, 1023, 1026, 1028, 1044, 1450, 1593, 1616, 1653. Doctors frequently noted that Kristyn exhibited drug-seeking behavior and eventually refused to prescribe narcotic pain medication. R. 920, 922, 931, 933, 996, 1321, 1539, 1576-77, 1601, 1660, 1842, 1895, 1900. After going to the ER in September 2014 for back pain, one doctor even noted, “Patient seems better able to get around when she thinks we are not looking.” R. 387. Kristyn also has a history of substance abuse of alcohol, marijuana, and cocaine.

         Kristyn saw several primary care doctors from August 2011 to February 2017. Over time, doctors regularly assessed Kristyn with obesity (R. 945, 992, 1019, 1027, 1029, 1032, 1041, 1418, 1589, 1593, 1598) and chronic lower back pain (R. 381, 920, 930, 932, 945, 952, 990, 992, 1019, 1027, 1031-32, 1407, 1449, 1451, 1588, 1593, 1601, 1604, 1616, 1653, 1655, 1669, 1900). They also consistently recommended diet modification, exercise, and weight loss. R. 1027, 1029, 1032, 1042, 1598, 1842. At times, she was referred to physical therapy, but there is no indication she attended therapy sessions and sometimes refused to go. R. 1407. Kristyn also stated that steroid injections and over-the-counter medications did not help with her pain. R. 1449, 1493, 1496, 1842. Kristyn was in a handful of car accidents during the relevant period, after which she complained of back, neck, and head pain, but there were never any acute injuries noted. R. 335, 337, 968-73, ...


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