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Roberta M. v. Saul

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

September 30, 2019

ROBERTA M., [1] Plaintiff
ANDREW SAUL, Commissioner of Social Security, Defendant


          Hon. Michael F. Urbanski, Chief United States District Judge.

         Plaintiff 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.

         As 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.

         I. Judicial Review of Social Security Determinations

         It is 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 Cir. 1996).

         Substantial 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.

         Nevertheless, 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).

         II. Claim History

         Roberta 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, 2014.

         Roberta 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.

         On July 19, 2017 the ALJ rendered an opinion finding Roberta not disabled, applying the five-step evaluation process described in the regulations.[2] 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.

         The ALJ 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. 17-27.

         III. Evidence

         A. Medical Records

         In 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. R. 545.

         ANA 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.

         Roberta 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.

         Roberta 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 syndrome ...

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