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Green v. Berryhill

United States District Court, W.D. North Carolina, Statesville Division

March 7, 2017

ALICIA GAYE GREEN, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OF DECISION AND ORDER

          Martin Reidinger, Judge

         THIS MATTER is before the Court on the Plaintiff's Motion for Summary Judgment [Doc. 12] and the Defendant's Motion for Summary Judgment. [Doc. 15]. As more fully explained below, the Court will grant the Plaintiff's motion and remand this matter.

         I. BACKGROUND

         Plaintiff asserts that arthritis in her hands, knees, ankles, back, neck, and joints, along with associated pain, constitute severe physical impairments under the Social Security Act rendering her disabled. [Doc. 10-4 at 2; 4 (Transcript (“T.”) at 62; 64)]. On August 6, 2012, the Plaintiff filed an application for a period of disability and disability insurance benefits, alleging an onset date of October 1, 2011. [Doc. 10-3 at 14 (T. at 13)]. The Plaintiff's claim was denied initially on August 20, 2012 [Doc. 10-4 at 2 to 8 (T. at 62 to 68)], and upon reconsideration on November 26, 2012. [Id. 10-4 at 10 to 17 (T. at 70 to 77)]. At the Plaintiff's request, a video/telephonic hearing was held before an Administrative Law Judge (“ALJ”) on April 18, 2014. [Doc. 10-3 at 26 to 62 (T. at 25 to 61)]. The Plaintiff appeared with counsel in Charlotte, North Carolina. Present with the ALJ in Florence, Alabama, was Jewel E.B. Euto, the Vocational Expert (“VE”). [Id.]. On July 14, 2014, the ALJ issued a written decision denying the Plaintiff benefits. [Id. at 14 to 22 (T. at 13 to 21)]. The Appeals Council denied the Plaintiff's request for review on October 20, 2015, thereby making the ALJ's decision the final decision of the Commissioner. [Id. at 2 to 4 (T. at 1 to 3)]. The Plaintiff, having exhausted all available administrative remedies, filed her action in this Court. This case is now ripe for review pursuant to 42 U.S.C. § 405(g).

         II. STANDARD OF REVIEW

         The Court's review of a final decision of the Commissioner is limited to (1) whether substantial evidence supports the Commissioner's decision, Richardson v. Perales, 402 U.S. 389, 401 (1971), and (2) whether the Commissioner applied the correct legal standards, Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990). “When examining [a Social Security Administration] disability determination, a reviewing court is required to uphold the determination when an ALJ has applied correct legal standards and the ALJ's factual findings are supported by substantial evidence.” Bird v. Comm'r, 699 F.3d 337, 340 (4th Cir. 2012).

         III. THE SEQUENTIAL EVALUATION PROCESS

         A “disability” entitling a claimant to benefits under the Social Security Act, as relevant here, is “[the] inability 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. § 423(d)(1)(A) (2012). The claimant “bears the burden of proving that he is disabled within the meaning of the Social Security Act.” English v. Shalala, 10 F.3d 1080, 1082 (4th Cir. 1993). In determining whether or not a claimant is disabled, the ALJ follows a five-step sequential process. 20 C.F.R. §§ 404.1520, 416.920. If the claimant's case fails at any step, the ALJ does not go any further and benefits are denied. Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995).

         At the first step, the ALJ determines whether the claimant is engaged in substantial gainful activity. If so, the claimant's application is denied regardless of the medical condition, age, education, or work experience of the claimant. 20 C.F.R. §§ 404.1520, 416.920. If not, the case progresses to the second step where the claimant must show a severe impairment. If the claimant does not show any physical or mental deficiencies or a combination thereof which significantly limit the claimant's ability to perform work activities, then no severe impairment is established and the claimant is not disabled. Id. Third, if a severe impairment is shown and meets or equals one of the listed impairments (“Listings”) found at 20 C.F.R. § 404, Appendix 1 to Subpart P, the claimant is automatically deemed disabled regardless of age, education or work experience. Id. Fourth, if the severe impairment does not meet any of the Listings, then the ALJ determines the claimant's residual functional capacity (“RFC”) and reviews the physical and mental demands of work done in the past. If the claimant can still perform his/her prior work despite the severe impairment, then a finding of not disabled is mandated. Id. If the claimant has a severe impairment but cannot perform past relevant work, then the case progresses to the fifth step where the burden shifts to the Commissioner.

         At step five, the Commissioner must establish that, given the claimant's age, education, work experience, and RFC, the claimant can perform alternative work that exists in substantial numbers in the national economy. Id.; Hines v. Barnhart, 453 F.3d 559, 567 (4th Cir. 2006) (noting Commissioner bears evidentiary burden at step five). The Commissioner may meet this burden by relying on the Medical-Vocational Guidelines (“Grids”) found at 20 C.F.R. § 404, Appendix 2 to Subpart P, if applicable, or by calling a VE to testify. 20 C.F.R. § 404.1566. If the Commissioner succeeds in shouldering her burden at step five, the claimant is not disabled. Otherwise, the claimant is entitled to benefits. In this case, the ALJ rendered a determination adverse to the Plaintiff at the fourth step.

         IV. THE ALJ'S DECISION

         At steps one and two, the ALJ found that Plaintiff had not engaged in substantial gainful activity since her alleged onset date and that she suffers from the following severe impairments: degenerative disk disease of the lumbar spine at ¶ 5; mild osteoarthritis of the bilateral wrists, hands and feet; right hip osteopenia; and mild right carpal tunnel syndrome. [Doc. 10-3 at 16 (T. at 15)]. At step three, the ALJ determined that Plaintiff's impairments did not meet or equal one of the Listings. [Id.].

         At step four, the ALJ made her determination with regard to the Plaintiff's RFC and concluded that:

the claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b). She can occasionally lift and/or carry twenty pounds and frequently lift and/or carry ten pounds. She can stand and/or walk in combination, with normal breaks, for at least six hours during an eight-hour workday and sit, with normal breaks, for up to eight hours during an eight-hour workday. She can occasionally climb ramps and stairs and should never climb ladders, ropes or scaffolds. She can frequently balance, stoop, kneel, crouch, and crawl. She can frequently perform fine and gross manipulations bilaterally. She should avoid concentrated exposure to extreme heat, extreme cold, and working in areas of vibration. She should avoid exposure to industrial hazards including working at unprotected heights and working in close proximity to moving dangerous machinery.

[Id. at 16-7 (T. at 15-6)].

         Based upon her RFC determination, the ALJ determined that Plaintiff was able to perform her past relevant work, including: “billing clerk, DOT #214.382-014, sedentary, semiskilled work with SVP 4; sales clerk, DOT #211.462-014, light semiskilled work with SVP 3; and manager of a convenience store, DOT #185.167-910, light, highly skilled work with SVP 7.” [Doc. 10-3 at 22 (T. at 21)]. The ALJ indicated that “[t]his work does not require the performance of work-related activities precluded by the claimant's residual functional capacity.” [Id.]. Accordingly, the ALJ concluded Plaintiff could perform past relevant work, was not disabled, and therefore denied benefits. [Id.].

         V. DISCUSSION

         The Plaintiff presents two arguments as to why the decision of the ALJ should be reversed. First, Plaintiff asserts that the ALJ erred by failing to follow the correct legal standard when arriving at the Plaintiff's RFC determination. [Doc. 13 at 8]. Second, Plaintiff contends the ALJ erred in failing to fully develop the medical record by declining to order a consultative examination and bilateral diagnostic studies of Plaintiff's knees. [Id. at 8]. The Plaintiff argues that these errors render the ALJ's decision infirm and it must, therefore, be reversed and the matter remanded to the ALJ for rehearing. [Id. at 20].

         A. Failure to Follow the Correct Legal Standard.

         Residual Functional Capacity is an administrative assessment of “the most” a claimant can still do despite his or her physical or mental limitations. SSR 96-8p; 20 C.F.R. §§ 404.1545(c); 416.945. In assessing a claimant's RFC and thus her ability to work, the ALJ must evaluate all of the claimant's medically determinable physical or mental impairments, together with symptoms such as pain, “based on all the relevant evidence in [the] case record.[1] 20 C.F.R. § 404.1545(a)(1). However, a symptom, like pain, is not a “medically determinable physical or mental impairment” and no symptom by itself can establish the existence of such an impairment. SSR 96-4p. In this matter, both parties concede the ALJ found at step 2 that Plaintiff suffered from several severe physical impairments that could be expected to cause pain, notably degenerative disk disease; osteoarthritis of the wrists, hands and feet; right hip osteopenia; and right carpal tunnel syndrome. The Plaintiff's claim of debilitating pain, therefore, was not foreclosed at step two.

         In order for pain, however, to be considered in the formulation an ALJ's RFC determination, the claimant's severe physical or mental impairment(s) must reasonably be expected to produce the pain alleged by the claimant. SSR 96-7p. “The regulation thus requires at the threshold a showing by objective evidence of the existence of a medical impairment which could reasonably be expected to produce the actual pain, in the amount and degree, alleged by the claimant. Craig v. Chater, 76 F.3d 585, 595 (4th Cir. 1996) (citation and quotation marks omitted). Once this threshold showing is made,

the adjudicator must evaluate the intensity, persistence, and limiting effects of the individual's symptoms to determine the extent to which the symptoms limit the individual's ability to do basic work activities. For this purpose, whenever the individual's statements about the intensity, persistence, or functionally limiting effects of pain or other symptoms are not substantiated by objective medical evidence, the adjudicator must make a finding on the credibility of the individual's statements based on a consideration of the entire case record.

SSR 96-7p.[2] This symptom evaluation process requires a two-step analysis. First, an ALJ can conclude that the objective medical evidence that establishes the existence of an impairment which could reasonably be expected to produce actual pain, also substantiates the claimant's statements about the intensity, persistence, or functionally limiting effects of such pain. Second, if she cannot so conclude, the ALJ must make a finding on whether the individual's statements about the intensity, persistence, or functionally limiting effects of pain are corroborated or refuted based on a consideration of the entire case record.

         The ALJ, however, failed to follow this standard, instead framing the standard in this way:

The two-step process first requires evidence of an underlying medical condition; and the second part is two-pronged, requiring (1) objective medical evidence that confirms the severity of the alleged pain arising from that condition and (2) that the objectively determined medical condition is of such ...

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