United States District Court, W.D. Virginia, Lynchburg Division
REPORT AND RECOMMENDATION
S. BALLOU UNITED STATES MAGISTRATE JUDGE.
Mabel H. (“Mabel”) filed this action challenging
the final decision of the Commissioner of Social Security
(“Commissioner”) determining that she was not
disabled and therefore not eligible for disability insurance
benefits (“DIB”) under the Social Security Act
(“Act”). 42 U.S.C. §§ 401-433.
Specifically, Mabel alleges that the ALJ failed to properly
account for the effects of her severe impairments and failed
to provide a narrative discussion explaining why she can
perform light work. Mabel also asserts that additional
evidence submitted to the Appeals Council is new and material
and warrants remand for consideration. I agree that the
additional evidence submitted to the Appeals Council is new,
material and should be considered by the Commissioner.
Accordingly, I RECOMMEND DENYING the
Commissioner's Motion for Summary Judgment (Dkt. No. 14),
GRANTING in part Mabel's Motion for
Summary Judgment (Dkt. No. 12) and remanding this case for
further administrative consideration consistent with this
Report and Recommendation.
Court limits its review to a determination of whether
substantial evidence supports the Commissioner's
conclusion that Mabel 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 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).
filed for DIB on January 4, 2016, claiming that her
disability began on November 5, 2015. R. 192-95. The Commissioner
denied the application at the initial and reconsideration
levels of administrative review. R. 75-76, 86-95. On July 26,
2017, ALJ H. Munday held a hearing to consider Mabel's
disability claim. R. 49-65. Mabel was represented by an
attorney at the hearing, which included testimony from Mabel
and vocational expert Gerald Wells, Ph.D. Id.
January 16, 2018, the ALJ entered his decision analyzing
Mabel's claim under the familiar five-step process,
denying Mabel's claim for benefits. R. 11-19. The ALJ
found that Mabel suffered from the severe impairments of
diabetes mellitus and autoimmune hemolytic anemia. R. 13. The
ALJ found that these impairments did not meet or medically
equal a listed impairment. R. 14. The ALJ further found that
Mabel had the residual functional capacity
(“RFC”) to perform light work, except that she
can occasionally balance, kneel, crouch, and climb ramps and
stairs; never crawl or climb ladders, ropes or scaffolds;
frequently handle and finger; and have occasional exposure to
vibrations and hazardous conditions. Id. The ALJ
determined that Mabel can perform her past relevant work as a
customer service representative, cashier/checker and mail
clerk, and thus was not disabled. R. 18.
requested that the Appeals Council review the ALJ's
decision and submitted additional medical records to the
Appeals Council in support of her claim. R. 30-48. On May 16,
2018, the Appeals Council denied Mabel's request for
review. R. 1-5. This appeal followed.
has diabetes mellitus and was diagnosed with autoimmune
hemolytic anemia (“AHA”) in November 2015. Mabel was
hospitalized upon her initial diagnosis due to complaints of
shortness of breath, weakness and fatigue, and underwent
multiple blood transfusions. R. 376-87. In December 2015,
Mabel reported that her shortness of breath, right leg
swelling, and fatigue were improving since beginning
treatment. R. 404-05. Mabel's complaints from December
2015 through May 2017 include cramping in her hands that was
helped by increased water intake (R. 345), shortness of
breath with exertion (R. 341, 447), fatigue (R. 595), back
pain and occasional pain in her legs (R. 646), and occasional
swelling in her left leg (R. 665). Mabel's physical
examination in March 2017 noted tender points along the
trapezius, lower back and lower arms. R. 665, 670.
December 21, 2011, medical consultant Robert Keeley reviewed
Mabel's records and determined that she was capable of
medium work, including lifting and carrying 50 pounds
occasionally and 25 pounds frequently; standing and/or
walking six hours in an eight-hour workday; sitting six hours
in an eight-hour workday; and had no postural or manipulative
limitations. R. 71-72. In March 2016, Bert Spetzler, M.D.
reviewed Mabel's records and determined that she was
capable of light work; specifically, lifting/carrying 20
pounds occasionally and 10 pounds frequently, standing,
walking or sitting about six hours in an eight-hour workday;
frequently kneeling; occasionally climbing ramps and stairs,
balancing, and crouching; never climbing ladders, ropes or
scaffolds and never crawling. R. 81-83. On September 2, 2016,
Leslie Ellwood, M.D., reviewed Mabel's records and agreed
with Dr. Spetzler's conclusions. R. 91-93.
reviewed Mabel's treatment history and testimony
regarding her limitations and determined that her underlying
impairments could reasonably be expected to produce the pain
or symptoms, but that Mabel's statements about the
intensity, persistence and limiting effects of her symptoms
are inconsistent. R. 15. The ALJ noted that Mabel complained
of hand cramping but reported to her physician that her hand
cramping improved with increased water intake. Id.
The ALJ also noted that Mabel's physical examinations
have been normal with normal muscle strength, and that there
are no records of any falls despite Mabel's testimony
that her legs “go out.” Id. The ALJ also
recognized that Mabel has had no drug infusions since 2015.
gave partial weight to Dr. Keely's opinion that Mabel can
perform medium work, finding that the record supports greater
limitations than those assessed by Dr. Keely in 2011. R. 17.
The ALJ gave great weight to Dr. Keely's conclusion that
Mabel can return to her past relevant work . R. 17. The ALJ
gave great weight to the opinions of Drs. Spetzler and
Ellwood, finding that Mabel can perform a range of light work
and that she can return to her past relevant work as a
customer service/administrative clerk. Id.
Accordingly, the ALJ assessed an RFC that mirrored the
findings of state agency physicians Drs. Spetzler and
Ellwood. R. 14.
February 15, 2018, less than a month after the ALJ's
decision, Mabel submitted an attending physician's
statement completed by hematologist, Hillary Maitland, M.D.,
with Carilion Clinic Rheumatology. R. 41-42. Dr. Maitland had
a treatment visit with Mabel that same day. Dr. Maitland
noted that she had treated Mabel since 2015 and Mabel's
primary condition was hemolytic anemia, with immune
thrombocytopenia (“ITP”) and symptoms of joint
stiffness. R. 41. She found that due to arthritis, Mabel
could sit intermittently with standard breaks for two hours
at a time for a total of eight hours during a workday; stand
intermittently for one hour at a time and four hours total
during an eight-hour workday; and walk intermittently for one
hour at a time for a total of one hour during an eight-hour