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Wayne B. v. Saul

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

June 24, 2019

WAYNE B., Plaintiff,
ANDREW SAUL, Commissioner of Social Security, Defendant.



         Plaintiff Wayne B. (“Wayne”) filed this action challenging the final decision of the Commissioner of Social Security (“Commissioner”) determining that he was not disabled and therefore not eligible for supplemental security income (“SSI”), and disability insurance benefits (“DIB”) under the Social Security Act (“Act”). 42 U.S.C. §§ 401-433, 1381-1383f. Specifically, Wayne alleges that the ALJ erred by disregarding the medical opinions in the record, improperly evaluating his symptoms, failing to perform a function by function analysis, and by concluding that he could perform medium work. I conclude that the ALJ failed to adequately explain the weight he gave to the medical opinions in the record and how he determined that Wayne is capable of medium work, so as to allow for meaningful review. Accordingly, I RECOMMEND GRANTING in part Wayne's Motion for Summary Judgment (Dkt. No. 11), and DENYING the Commissioner's Motion for Summary Judgment. Dkt. No. 14.


         This court limits its review to a determination of whether substantial evidence supports the Commissioner's conclusion that Wayne failed to demonstrate that he 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).

         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, 189 (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 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 Wayne's RFC.


         Wayne filed for SSI and DIB on May 19, 2014, claiming that his disability began on October 1, 2012.[2] R. 12. The Commissioner denied the application at the initial and reconsideration levels of administrative review. R. 120-45. On March 17, 2017, ALJ Dan Balutis held a video hearing to consider Wayne's disability claim. R. 31-84. Wayne was represented by an attorney at the hearing, which included testimony from Wayne and vocational expert Nadine Henzes. Id.

         On April 7, 2017, the ALJ entered his decision analyzing Wayne's claim under the familiar five-step process, [3] and denying Wayne's claim for disability. R. 12-23. The ALJ found that Wayne suffered from the severe impairments of diabetes mellitus, small fiber neuropathy, and obesity. R. 14. The ALJ further found that Wayne retained the RFC to perform a broad range of medium work, and can lift/carry and push/pull up to 25 pounds frequently and 50 pounds occasionally; can occasionally crawl and climb ramps and stairs; can never climb ladders, ropes or scaffolds; can frequently stoop, kneel and crouch; can be exposed to unlimited vibrations and loud noise; can frequently work in occupations at unprotected heights, with moving mechanical parts and operate a motor vehicle; and can frequently work in weather, humidity, wetness, dust, odors, pulmonary irritants, extreme cold, but never in extreme heat. R. 18. The ALJ determined that Wayne could return to his past relevant work as an extruder and cleaner, and that other jobs exist in significant numbers in the national economy that he can perform, such as packer, bagger, and vehicle cleaner. R. 22-23. Thus, the ALJ concluded that Wayne was not disabled. Id.

         Wayne requested that the Appeals Council review the ALJ's decision. On January 10, 2018, the Appeals Council denied Wayne's request for review (R. 1-4), and this appeal followed.


         Wayne argues that the ALJ erred by disregarding all of the medical opinions in the record which concluded that Wayne was capable of no more than light exterional work, and instead concluding that Wayne is capable of medium work. Wayne was 56 years old on his date last insured, has a high school education and last worked in maintenance/housekeeping at a medium level of exertion. R. 45, 55, 74. Wayne has diabetes and complained of episodes involving dizziness, shortness of breath, sweating, nausea and chest pains for several years. Wayne's primary care physician referred him for cardiac and pulmonary testing, which was negative. Wayne sought treatment from several neurologists and, after multiple visits and tests, was eventually diagnosed with autonomic dysfunction and small fiber neuropathy. R. 593-94, 629- 32, 707-08.

         The ALJ reviewed and weighed three opinions from medical providers when assessing Wayne's RFC. The ALJ gave “limited” and “little” weight to all three of the medical opinions in the record, including the opinions of Wayne's treating physician and treating neurologist. R. 20- 21. The ALJ rejected the findings of the Wayne's physicians that he was limited to light work and instead determined that he can perform medium work.

         Specifically, on August 26, 2014, state agency medical specialist James Wickham reviewed Wayne's records and determined that he was limited to lifting and carrying 20 pounds occasionally and 10 pounds frequently; and standing/walking and sitting six hours in an eight hour workday. R. 127-128. The ALJ did not discuss this opinion in his decision.

         On September 20, 2016, Wayne's treating physician, Scott C. Hippeard, M.D., completed a physical capacities evaluation and found that Wayne was capable of sitting for 30 minutes at a time for a total of four hours in an eight hour workday, and standing for 20 minutes at a time, for a total of one hour in an eight hour workday, due to his weakness, shortness of breath, fatigue and sweating. R. 633. Dr. Hippeard found that Wayne would need the flexibility to change positions frequently, and can occasionally lift or carry up to 20 pounds, but never lift or carry over 20 pounds. R. 633-34. Dr. Hippeard noted that Wayne has limitations with his right upper extremity, and cannot squat, crawl, climb, or kneel. R. 634-35. Dr. Hippeard found that Wayne could not tolerate exposure to unprotected heights, moving machinery, marked changes in temperature, dust, fumes, gases, smoke and perfumes, or noise. R. 635. Dr. Hippeard also noted that Wayne's objective sings of pain were redness, nerve/muscle findings and cardiac/angina; that Wayne's pain was chronic and slight to moderate; and that he would need to lie down ...

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