United States District Court, W.D. Virginia
C. Hoppe, United States Magistrate Judge
Lisa F. asks the Court to review the Commissioner of Social
Security's final decision denying her claim for
supplemental security income ("SSI") under Title
XVI of the Social Security Act (the "Act"), 42
U.S.C. §§ 1381-1383f. The case is before me by the
parties' consent under 28 U.S.C. § 636(c). ECF No.
13. Having considered the administrative record, the
parties' briefs, and the applicable law, I cannot find
that substantial evidence supports the Commissioner's
final decision. Accordingly, the decision will be reversed,
and the case remanded under the fourth sentence of 42 U.S.C.
Standard of Review
Social Security Act authorizes this Court to review the
Commissioner's final decision that a person is not
entitled to disability benefits. 42 U.S.C. §§
405(g), 1383(c)(3); see Hines v. Barnhart, 453 F.3d
559, 561 (4th Cir. 2006). The Court's role, however, is
limited-it may not "reweigh conflicting evidence, make
credibility determinations, or substitute [its]
judgment" for that of agency officials. Hancock v.
Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Instead, a
court reviewing the merits of the Commissioner's final
decision asks only whether the Administrative Law Judge
("ALJ") applied the correct legal standards and
whether substantial evidence supports the ALJ's factual
findings. Meyer v. Astrue, 662 F.3d 700, 704 (4th
Cir. 2011); see Riley v. Apfel, 88 F.Supp.2d 572,
576 (W.D. Va. 2000) (citing Melkonyan v. Sullivan,
501 U.S. 89 (1991)).
evidence" means "such relevant evidence as a
reasonable mind might accept as adequate to support a
conclusion." Richardson v. Perales, 402 U.S.
389, 401 (1971). It is "more than a mere scintilla"
of evidence, id, but not necessarily "a large or
considerable amount of evidence," Pierce v.
Underwood, 487 U.S. 552, 565 (1988). Substantial
evidence review considers the entire record, and not just the
evidence cited by the ALJ. See Universal Camera Corp. v.
NLRB, 340 U.S. 474, 487-89 (1951); Gordon v.
Schweiker, 725 F.2d 231, 236 (4th Cir. 1984).
Ultimately, this Court must affirm the ALJ's factual
findings if "conflicting evidence allows reasonable
minds to differ as to whether a claimant is disabled."
Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir.
2005) (per curiam). However, "[a] factual finding by the
ALJ is not binding if it was reached by means of an improper
standard or misapplication of the law." Coffman v.
Bowen, 829 F.2d 514, 517 (4th Cir. 1987).
person is "disabled" within the meaning of the Act
if he or she is unable to engage in "any substantial
gainful activity by reason of any medically determinable
physical or mental impairment which can be expected to result
in death or which has lasted or can be expected to last for a
continuous period of not less than 12 months." 42 U.S.C.
§ 1382c(a)(3)(A). Social Security ALJs follow a
five-step process to determine whether a claimant is
disabled. The ALJ asks, in sequence, whether the claimant (1)
is working; (2) has a severe impairment that satisfies the
Act's duration requirement; (3) has an impairment that
meets or equals an impairment listed in the Act's
regulations; (4) can return to his or her past relevant work
based on his or her residual functional capacity; and, if not
(5) whether he or she can perform other work. See Heckler
v. Campbell, 461 U.S. 458, 460-62 (1983); Lewis v.
Berryhill, 858 F.3d 858, 861 (4th Cir. 2017); 20 C.F.R.
§ 416.920(a)(4). The claimant bears the burden of
proof through step four. Lewis, 858 F.3d at 861. At step
five, the burden shifts to the agency to prove that the
claimant is not disabled. See id.
December 2014, Lisa filed for SSI alleging that she was
disabled by degenerative disc and joint disease, chronic back
pain, and arthritis, among other medical conditions. See
Administrative Record ("R.") 15, 67-68, 173-76, ECF
No. 11. Lisa was forty-six years old, or a "younger
person" under the regulations, when she allegedly became
disabled in June 2014. See R. 24, 67; 20 C.F.R. §
416.963(c). Disability Determination Services
("DDS"), the state agency, denied her claim
initially in June 2015, R. 66-79, and upon reconsideration
that September, R. 80-94. In December 2016, Lisa appeared
with a non-attorney representative and testified at an
administrative hearing before ALJ Susan Smith. R. 31-57. A
vocational expert ("VE") also testified at this
hearing. R. 53-56.
Smith issued an unfavorable decision on March 13, 2017. R.
15-26. Lisa had the following "severe impairments: hip
joint dysfunction status post replacement; carpal tunnel
syndrome and tendinitis; degenerative disc disease of the
cervical and lumbar spine; chronic obstructive pulmonary
disease (COPD); and arthritis." R. 17. These impairments
did not meet or medically equal any listed impairment. R. 19.
ALJ Smith then evaluated Lisa's residual functional
capacity ("RFC") and found that she could perform
"sedentary work" with additional restrictions:
[Occasionally climb ramps and stairs, stoop, kneel, and
balance; never crouch and crawl; never climb ladders, ropes,
and scaffolds; should avoid concentrated exposure to hazards
including dangerous moving machinery, uneven terrain, and
unprotected heights; should avoid concentrated exposure to
fumes, odors, dusts, gases, and poor ventilation; and
frequently use hands bilaterally for fingering and handling.
R. 19. The limitation to sedentary work ruled out Lisa's
return to her past jobs as a waitress and certified nursing
assistant. R. 24; see R. 53-54. Finally, based on this RFC
finding and the VE's testimony, ALJ Smith concluded at
step five that Lisa was not disabled because she could
perform three sedentary occupations (order clerk; inspector,
sorter, and tester; materials packer and sealer) that offered
a significant number of jobs in the national economy. R. 25;
see R. 54. The Appeals Council denied Lisa's request for
review, R. 1-3, and this appeal followed.
argues that ALJ Smith did not give "good reasons"
for discounting a treating physician's medical opinion
that, because of her severe lumbar and hip pain, Lisa
"cannot lift, bend, stoop," or walk more than one
hundred feet and frequently needs to change positions.
Pl's Br. 5-6 (citing R. 436), ECF No. 15. This opinion
conflicted with ALJ Smith's RFC findings that Lisa could
frequently lift ten pounds, occasionally stoop (i.e., bend at
the waist), and sit for about six hours and stand/walk for
about two hours during a normal eight-hour workday. See R.
19, 23-24, 75-76; 20 C.F.R. § 416.967(a); SSR 96-9p,
1996 WL 374185, at *3, *8. It also bolstered Lisa's
testimony that she must "shift positions to help
alleviate her overall pain," R. 20 (citing R. 48-49,
52), which ALJ Smith did not include in her RFC finding.
claimant's RFC is her "maximum remaining ability to
do sustained work activities in an ordinary work
setting" for eight hours a day, five days a week despite
her medical impairments and symptoms. SSR 96-8p, 1996 WL 374184,
at *2 (July 2, 1996) (emphasis omitted). It is a factual
finding "made by the [ALJ] based on all the relevant
evidence in the case record," Felton-Miller v.
Astrue, 459 Fed.Appx. 226, 230-31 (4th Cir. 2011), and
it should reflect specific, credibly established
"restrictions caused by medical impairments and their
related symptoms," including pain, that affect the
claimant's "capacity to do work-related physical and
mental activities," SSR 96-8p, 1996 WL 374184, at *1,
*2. See Mascio, 780 F.3d at 637-40; Reece v. Colvin,
7:14cv428, 2016 WL 658999, at *6-7 (W.D. Va. Jan. 25,
2016), adopted by 2016 WL 649889 (W.D. Va. Feb. 17, 2016).
The ALJ has broad (but not unbounded) discretion to determine
whether an alleged limitation is supported by or consistent
with other relevant evidence in the claimant's record.
See Perry v. Colvin, No. 2:15cvl 145, 2016 WL
1183155, at *5 (S.D. W.Va. Mar. 28, 2016) (citing
Oppenheim v. Finch, 495 F.2d 396, 397 (4th Cir.
1974)). Generally, a reviewing court will affirm the
ALJ's RFC findings when it is clear that she considered
all the relevant evidence under the correct legal standards,
see Brown v. Comm 'r of Soc. Sec. Admin., 873
F.3d 251, 268-72 (4th Cir. 2017), and she built an
"accurate and logical bridge from that evidence to h[er]
conclusion[s]," Woods v. Berryhill, 888 F.3d
686, 694 (4th Cir. 2018) (quotation marks and brackets
omitted). See Thomas v. Berryhill, 916F.3d307,
311-12 (4th Cir. 2019); Patterson v. Comm 'r of Soc.
Sec, 846 F.3d 656, 662 (4th Cir. 2017).
provided the following information in her testimony at the
administrative hearing and her submissions to the state
agency. Lisa stopped working as a certified nursing assistant
around June 2014 because she "couldn't lift the
patients" and "walking was becoming ridiculously
painful." R. 37. She had a total hip replacement on the
right in January 2015, followed by a total hip replacement on
the left in April 2016. R. 39-40. Her chronic pain was
"even worse" after the second surgery, but her
doctors said the prosthetic joints "look[ed] good."
R. 41. Lisa usually used a walker or a crutch, R. 42-43, on
the "very rare" occasions when she went out into
the community, R. 72 (June 2015). See also R. 216. She could
"get dressed, shower, and take care of morning"
activities, but she did "everything slower" than
she used to. R. 71 (June 2015); see also R. 211 (Jan. 2015).
She needed "help bending over to get [her] shoes and
socks on." R. 71; see also R. 215. Lisa could prepare
microwave meals, but her mother did "mostly all" of
the cooking, cleaning, and shopping. R. 214-16. When Lisa did
go grocery shopping "once a month" she used a
motorized cart to get around the store and someone went with
her to get things off the shelves. R. 216.
December 2016, Lisa's chronic back and hip pain was
"pretty much" uncontrolled. R. 43. Sometimes she
used "marijuana or methadone," R. 52-53, to
supplement the four prescription pain medications she took
every day, R. 258. Trigger point injections
"sometimes" dulled her back pain "a little
bit," but only for "a few days" after each
treatment. R. 44. Lisa spent most days lying in bed with her
legs elevated, R. 43, or switching between sitting, standing,
and lying down, R. 213-15 (June 2015). See also R. 48-49, 52
(Dec. 2016); R. 71 ("[M]ust alternate between sitting
and standing because of pain."). She could sit for about
30 minutes before needing to reposition herself or get up and
take "a few steps around." R. 48; see also R. 52,
71, 86, 211, 213. She could stand for about 10 minutes and
walk at most 70 feet, but only if she had a crutch or walker
for support. R. 48-49; see also R. 71-72 ("Cannot walk
very far because of pain. . . . [U]ses a walker [that] was
prescribed."); R. 219 (uses prescription walker when
"pain gets very severe"). She was not sure if she
could lift or carry something weighing between five and ten
pounds. R. 50; see R. 72. ...