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Mabel H. v. Saul

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

June 24, 2019

MABEL H., Plaintiff,
v.
ANDREW SAUL, Commissioner of Social Security, Defendant.

          REPORT AND RECOMMENDATION

          ROBERT S. BALLOU UNITED STATES MAGISTRATE JUDGE.

         Plaintiff 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.

         STANDARD OF REVIEW

         This 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.[1] 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).

         CLAIM HISTORY

         Mabel filed for DIB on January 4, 2016, claiming that her disability began on November 5, 2015.[2] 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.

         On January 16, 2018, the ALJ entered his decision analyzing Mabel's claim under the familiar five-step process, [3] and 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.

         Mabel 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.

         ANALYSIS

         Mabel has diabetes mellitus and was diagnosed with autoimmune hemolytic anemia (“AHA”)[4] 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.

         On 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.

         The ALJ 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. Id.

         The ALJ 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.

         On 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 ...


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