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Lisa C. v. Saul

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

August 6, 2019

LISA C., Plaintiff,
v.
ANDREW SAUL, Commissioner of Social Security, Defendant.

          REPORT AND RECOMMENDATION

          Robert S. Ballou United States Magistrate Judge

         Plaintiff Lisa C. (“Lisa”) 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. Lisa alleges that the Administrative Law Judge (“ALJ”) erred because substantial evidence does not support: (1) her evaluation of the opinion of Lisa's treating physician; (2) her physical RFC findings; and (3) her assessment of Lisa's subjective allegations of impairment. I conclude that the ALJ failed to adequately explain the basis for her evaluation of Lisa's treating physician's opinion. Accordingly, I RECOMMEND GRANTING in part Lisa's Motion for Summary Judgment (Dkt. No. 19) and RECOMMEND DENYING the Commissioner's Motion for Summary Judgment (Dkt. No. 13).

         STANDARD OF REVIEW

         This Court limits its review to a determination of whether substantial evidence exists to support the Commissioner's conclusion that Lisa 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 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 she reached her conclusions regarding the opinion of Lisa's treating physician.

         CLAIM HISTORY

         Lisa filed for DIB on November 18, 2013, claiming disability due to pain in her back and legs, anxiety, depression, fibroid tumors, pain from her neck to buttocks, left knee pain, status post left ankle fracture with pain and swelling, weakness in her left ankle, pain in her arms and hands, pre-diabetes, and difficulty leaving the safety of her home, with an alleged onset date of January 2, 2013. R. 518-19. Lisa was 45 years old when she applied for DIB, making her 44 years old on her alleged onset date. R. 518. Lisa's date last insured was December 31, 2017; thus, she must show that her disability began on or before December 31, 2017, and existed for twelve continuous months, to receive DIB. R. 13; 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 Lisa's application at the initial and reconsideration levels of administrative review. R. 518-41. On March 28, 2017, ALJ Geraldine H. Page held a hearing to consider Lisa's claim for DIB. R. 486-517. Counsel represented Lisa at the hearing, which included testimony from vocational expert Barry Hensley. R. 486. On May 31, 2017, the ALJ entered her decision analyzing Lisa's claims under the familiar five-step process[2] and denying her claim for benefits. R. 11-23.

         The ALJ found that Lisa had not engaged in substantial gainful activity since January 2, 2013, the alleged onset date. R. 13. The ALJ determined that Lisa suffered from the severe impairments of diabetes mellitus, fibromyalgia, degenerative joint disease of the right elbow and left shoulder, osteoarthritis of the left knee, and status post left ankle fracture. Id. The ALJ found that Lisa's myopia, astigmatism, presbyopia, fibroid tumors, dermatitis and allergic rhinitis, hypertension, GERD, vitamin D deficiency, Raynaud's, and heart blockage were either not severe or not medically determinable because they have been responsive to treatment, cause no more than minimal vocationally relevant limitations, have not lasted or are not expected to last at a severe level for a continuous period of twelve months, are not expected to result in death, or have not been properly diagnosed by an acceptable medical source. R. 13-14. The ALJ determined that Lisa's impairments, either individually or in combination, did not meet or medically equal a listed impairment, specifically considering listing 1.02 (major dysfunction of a joint), the relevant listings for diabetes mellitus, and the regulations governing consideration of fibromyalgia and obesity. R. 14-15. The ALJ did not find that Lisa had a mental impairment.

         The ALJ concluded that Lisa retained the residual functional capacity (“RFC”) to perform light work with certain limitations. R. 15. Lisa can lift and carry no more than twenty pounds occasionally and ten pounds frequently, stand and walk for no more than two to four hours in an eight-hour workday, and sit for no more than six hours in an eight-hour workday. Id. Lisa's postural limitations include frequent overhead reaching; occasionally climbing ramps and stairs, balancing, kneeling, stooping, and crouching; and never crawling. Id. For environmental limitations, the ALJ found that Lisa should avoid concentrated exposure to extreme temperatures, excess humidity, and pulmonary irritants. Id. She should also avoid all exposure to hazardous machinery, working at unprotected heights, working on vibrating surfaces, and climbing ladders, ropes, or scaffolds. Id. The ALJ found that Lisa is unable to perform her past work as a cashier, assistant manager/manager, stocker, self-employed cosmetic salesperson, or optic technician/polisher. R. 21. The ALJ determined that Lisa could still perform jobs that exist in significant numbers in the national economy, such as office helper, nonpostal mail clerk, and order clerk. R. 22. The ALJ ultimately concluded that Lisa was not disabled. R. 23. The Appeals Council denied Lisa's request for review on April 21, 2018. R. 1-7.

         ANALYSIS

         Lisa alleges that the Administrative Law Judge (“ALJ”) erred because substantial evidence does not support (1) her evaluation of Lisa's treating physician's opinion, (2) her physical RFC findings, and (3) her assessment of Lisa's subjective allegations of impairment.

         A. Medical History

         1. Physical Impairments[3]

         In August 2013, Lisa suffered a left ankle lateral malleolar fracture. R. 777, 789. By October, Lisa had no restrictions. R. 775-76. In January 2014, Dr. Randolph Clements evaluated the same ankle after Lisa complained that it had not gotten any better. R. 907, 913. Her x-rays were completely normal, but an MRI showed an absent anterior talofibular ligament and a diminutive calcaneofibular ligament with irregularity ...


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