United States District Court, W.D. Virginia, Roanoke Division
Michael F. Urbanski, Chief United States District Judge.
Roberta M. ("Roberta") has filed this action
challenging the final decision of the Commissioner of Social
Security in denying her claim for a period of Disability
Insurance Benefits ("DIB") under the Social
Security Act, 42 U.S.C. §§ 401-433. In her motion
for summary judgment, ECF No. 14, Roberta argues mat the
administrative law judge ("ALJ") erred by failing
to properly analyze evidence from her treating physician and
that the Appeals Council erred when it declined to consider
additional evidence she submitted after the hearing. The
Commissioner responded in his own motion for summary
judgment, ECF No. 19, that substantial evidence supports the
denial of disability benefits and that the Appeals Council
properly declined to consider the additional evidence.
discussed more fully the below, the court finds that
substantial evidence does not support the ALJ's
determination to accord little weight to the opinion of
Roberta's treating physician on the effects of her
impairments. The court further finds that the additional
evidence was properly excluded by the Appeals Council.
Accordingly, Roberta's motion for summary judgment is
GRANTED; the Commissioner's motion for
summary judgment is DENIED; the ALJ's
determination is VACATED, and this case is
REMANDED for further consideration
consistent with this opinion.
Judicial Review of Social Security Determinations
not the province of a federal court to make administrative
disability decisions. Rather, judicial review of disability
cases is limited to determining whether substantial evidence
supports the Commissioner's conclusion that the plaintiff
failed to meet his burden of proving disability. See Hays
v. Sullivan. 907 F.2d 1453, 1456 (4th Cir. 1990); see
also Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir.
1966). In so doing, the court may neither undertake a de
novo review of the Commissioner's decision nor
re-Weigh the evidence of record. Hunter v. Sullivan,
993 F.2d 31, 34 (4th Cir. 1992). Evidence is substantial
when, considering the record as a whole, it might be deemed
adequate to support a conclusion by a reasonable mind,
Richardson v. Perales, 402 U.S. 389, 401 (1971), or
when it would be sufficient to refuse a directed verdict in a
jury trial. Smith v. Chater. 99 F.3d 635, 638 (4th
evidence is not a "large or considerable amount of
evidence, " Pierce v. Underwood. 487 U.S. 552,
565 (1988), but is more than a mere scintilla and somewhat
less than a preponderance. Perales, 402 U.S. at 401;
Laws, 368 F.2d at 642. "It means-and means
only-'such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion."'
Biestek v. Berryhill. 139 S.Ct. 1148, 1154 (2019)
(quoting Consolidated Edison Co. v. NLRB. 305 U.S.
197, 229 (1938)). If the Commissioner's decision is
supported by substantial evidence, it must be affirmed. 42
U.S.C. § 405(g); Perales. 402 U.S. at 401.
remand is appropriate when the ALJ's analysis is so
deficient that it "frustrate[s] meaningful review."
Mascio v. Colvin. 780 F.3d 632, 636-637 (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).
was born on December 2, 1963 and graduated from high school.
R. 53. Her past relevant work includes being a childcare or
daycare worker and working as a general motor vehicle
assembler. R. 76. Roberta filed an application for DIB on
August 21, 2014, alleging an onset date of October 9, 2013.
R. 17. She was last insured for purposes of DIB on December
31, 2014, giving her a narrow window in which to establish
her disability-from October 9, 2013 through December 31,
alleged disability based on systemic lupus erythematosus and
scleroderma, Sjogren's syndrome, Reynaud's
phenomenon, fibromyalgia, impingement of the right
shoulder-failed surgical repair, depression, anxiety, panic
attacks, migraine headaches, chronic fatigue, and arthritis
in her arms, hands, hips, knees, wrists, and elbows. R. 271.
The application was denied at the initial and reconsideration
levels of review. R. 113-117, 122-128. On April 11, 2017, ALJ
Geraldine H. Page held a hearing to consider Roberta's
claim for DIB. Roberta was represented by counsel and a
vocational expert also testified. R. 51-82.
19, 2017 the ALJ rendered an opinion finding Roberta not
disabled, applying the five-step evaluation process described
in the regulations. R. 17-27. The ALJ first found that Roberta
last met the insured status requirements on December 31, 2014
and that she had not engaged in substantial gainful activity
during the period from her alleged onset date of October 9,
2013 through December 31, 2014. The ALJ further found that
Roberta had the following severe impairments-right shoulder
degenerative joint disease; lumbosacral degenerative disc
disease; history of injury to the bilateral knees, mixed
connective tissue disease ("MCTD") (including
features of scleroderma, lupus, Sjogren's syndrome,
Reynaud's syndrome, arthralgias, and sicca), and
inflammatory arthritis-but that none of the impairments or
combination of impairments met or medically equaled the
severity of a listed impairment.
then found that Roberta had the residual functional capacity
("RFC") to do light work with additional
limitations of pushing and pulling occasionally with the
right upper extremity and the bilateral lower extremities;
could never crawl; would need to avoid all exposure to
hazardous machinery; and could not work at unprotected
heights, climb ladders, ropes, or scaffolds, or work on
vibrating surfaces. She could occasionally climb ramps and
stairs, balance, kneel, stoop, and crouch. She could
frequently handle, feel, and finger with the bilateral hands
and could occasionally reach overhead with her right
shoulder. The ALJ found that Roberta could not return to her
past relevant work, but could do other work that exists in
the national economy. Based on testimony by the vocational
expert, the ALJ found that Roberta could do work such as that
of a cafeteria attendant, ticket taker, or cashier II. R.
February 2014 Roberta reported to her health care provider
that for the previous six months she had been having soft
tissue pain and swelling along with difficulty using her
hands for fine motor skills. She also had pain in her knee,
hip, and elbow joints. She reported a history of nodularity
in both hands, which usually was worse in the morning and
caused decreased mobility and pain. R. 658. X-rays of her
feet showed that she had bilateral osteotomies involving the
distal front metatarsals and had orthopedic hardware in the
form of two small cortical screws with no evidence of
hardware failure or loosening. She also had minimal
osteoarthritis involving both first MTP joints. R. 544.
X-rays of her hands showed minimal periarticular osteopenia.
testing was positive and she was referred to Edward Tackey,
M.D., a rheumatologist, who diagnosed her with inflammatory
arthritis, positive ANA, and Raynaud phenomenon. R. 557. In
March 2014 Roberta reported aches and pains she described as
7/10, worse with activity and better with rest. Her wrists
and hand joints were tender. She also reported shortness of
breath. Dr. Tackey diagnosed Roberta with Lupus, Raynaud
phenomenon, and Sicca syndrome. R. 554.
began to see rheumatologist Joseph Lemmer, M.D., in June
2014, reporting generalized moderate worsening pain,
particularly in her lower legs, feet, forearms, hands, chest,
and back. She had generalized puffiness in the hand, Reynaud
phenomenon, dryness of the eyes and mouth, poor sleep,
fatigue, and anxiety. Dr. Lemmer assessed Roberta with
overlapping connective tissue disease with features of lupus,
scleroderma, and Sjogren syndrome, manifested by arthralgias,
puffy hands, Reynaud phenomenon, dry eyes and mouth, and
positive anticardiolipin antibodies; pleuritic type chest
pain, possibly related to the connective tissue disease,
dysesthesia of the feet with possible peripheral neuropathy,
possibly related to the connective tissue disease;
generalized myalgias and arthralgias with tender points
consistent with fibromyalgia syndrome;. sleep disturbance and
fatigue, probably associated with chronic pain syndrome;
shortness of breath, possibly psychophysiological; and
hyperlipidemia. R. 552. A pulmonary function study was
normal. R. 548.
saw Dr. Lemmer again in September 2014, and he noted that she
was mildly symptomatic, but unstable. In addition to his
previous assessment, he noted that her pleurisy had improved
but her fibromyalgia syndrome, sleep disturbance, and fatigue