United States District Court, W.D. Virginia, Roanoke Division
REPORT AND RECOMMENDATION
S. BALLOU UNITED STATES MAGISTRATE JUDGE.
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.
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. 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).
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.
filed for SSI and DIB on May 19, 2014, claiming that his
disability began on October 1, 2012. 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.
April 7, 2017, the ALJ entered his decision analyzing
Wayne's claim under the familiar five-step process,
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.
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
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.
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.
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.
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 ...