United States District Court, E.D. North Carolina, Eastern Division
MEMORANDUM & ORDER
T. NUMBERS, II UNITED STATES MAGISTRATE JUDGE
Ava Gnann Willis instituted this action on December 21, 2015,
to challenge the denial of her application for social
security income. Willis claims that the Administrative Law
Judge (“ALJ”) Christopher Willis erred in
formulating the residual functional capacity
(“RFC”) and in weighing the medical opinion
evidence. Both Willis and Defendant Nancy Berryhill, the
Acting Commissioner of Social Security, have filed motions
seeking a judgment on the pleadings in their favor. D.E. 20,
reviewing the parties' arguments, the court has
determined that ALJ Willis erred in his determination. ALJ
Willis failed to properly evaluate the medical opinion
offered by the psychological consultative examiner.
Additionally, substantial evidence does not support ALJ
Willis's RFC finding as it relates to Willis's
shoulder pathologies and carpal tunnel syndrome
(“CTS”). Therefore, the undersigned magistrate
judge grants Willis's motion, denies Berryhill's
motion, and remands this matter to the Commissioner for
November 19, 2010, Willis filed applications for disability
benefits and supplemental security income. In both
applications, Willis alleged a disability that began on
October 1, 2010. After her claims were denied at the initial
level and upon reconsideration, Willis appeared at a hearing
before an ALJ Willis on July 17, 2014, to determine whether
she was entitled to benefits. ALJ Willis determined Willis
was not entitled to benefits because she was not disabled.
Id. at 19-34.
Willis found that Willis had the following severe
impairments: coronary artery disease (“CAD”),
lumbar degenerative disc disease, CTS, anemia, arthritis,
obesity, rotator cuff syndrome, bilateral plantar fasciitis,
major depressive disorder, bipolar disorder, obsessive
compulsive disorder (“OCD”)/eating disorder,
history of attention deficit hyperactivity disorder
(“ADHD”), generalized anxiety disorder, and panic
attacks. Id. at 22. ALJ Willis found that
Willis's impairments, alone or in combination, did not
meet or equal a Listing impairment. Id. He then
determined that Willis had the RFC to perform light work with
limitations. Id. at 25. She is limited to frequent
use of the bilateral upper extremities for reaching, pushing,
pulling, operating hand controls, handling, fingering, and/or
feeling. Id. Willis must never climb ladders, ropes,
or scaffolds. Id. She must avoid concentrated
exposure to temperature extremes of heat and to pulmonary
irritants, such as fumes, odors, dust, gases, poor
ventilation, and the like. Id. She must also avoid
concentrated exposure to workplace hazards such as dangerous
moving machinery and unprotected heights. Id. Willis
can understand and perform simple, routine, repetitive tasks
and can stay on task for two-hour periods over a typical
eight-hour workday, as required to perform such tasks.
Id. She requires a low-stress setting that is
further defined to mean no production-pace or quota-pace work
but rather a goal-oriented job primarily dealing with things
as opposed to people. Id. She can have no more than
occasional changes in the work setting. Id. Willis
is limited to no more than occasional social interaction with
supervisors and coworkers. Finally, she cannot work with the
public as a component of the job, such as sales or
negotiations, though incidental or casual contact as it may
arise in the workday is not precluded. Id.
Willis concluded that Willis was unable to perform any past
relevant work but that considering her age, education, work
experience, and RFC, there were jobs that existed in
significant numbers in the national economy that Willis is
capable of performing. Id. at 32-33. These jobs
included: cleaner/housekeeper, office helper, and advertising
material distributer. Id. at 34. Thus, ALJ Willis
found that Willis was not disabled. Id.
unsuccessfully seeking review by the Appeals Council, Willis
commenced this action on December 21, 2015. D.E. 6.
Standard for Review of the Acting Commissioner's Final
social security claimant appeals a final decision of the
Commissioner, the district court's review is limited to
the determination of whether, based on the entire
administrative record, there is substantial evidence to
support the Commissioner's findings. 42 U.S.C. §
405(g); Richardson v. Perales, 402 U.S. 389, 401
(1971). Substantial evidence is defined as “evidence
which a reasoning mind would accept as sufficient to support
a particular conclusion.” Shively v. Heckler,
739 F.2d 987, 989 (4th Cir. 1984) (quoting Laws v.
Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966)). If the
Commissioner's decision is supported by such evidence, it
must be affirmed. Smith v. Chater, 99 F.3d 635, 638
(4th Cir. 1996).
Standard for Evaluating Disability
making a disability determination, the ALJ engages in a
five-step evaluation process. 20 C.F.R. § 404.1520;
see Johnson v. Barnhart, 434 F.3d 650 (4th Cir.
2005). The analysis requires the ALJ to consider the
following enumerated factors sequentially. At step one, if
the claimant is currently engaged in substantial gainful
activity, the claim is denied. At step two, the claim is
denied if the claimant does not have a severe impairment or
combination of impairments significantly limiting him or her
from performing basic work activities. At step three, the
claimant's impairment is compared to those in the Listing
of Impairments. See 20 C.F.R. Part 404, Subpart P,
App. 1. If the impairment is listed in the Listing of
Impairments or if it is equivalent to a listed impairment,
disability is conclusively presumed. However, if the
claimant's impairment does not meet or equal a listed
impairment, the ALJ assesses the claimant's RFC to
determine, at step four, whether he can perform his past work
despite his impairments. If the claimant cannot perform past
relevant work, the analysis moves on to step five:
establishing whether the claimant, based on his age, work
experience, and RFC can perform other substantial gainful
work. The burden of proof is on the claimant for the first
four steps of this inquiry, but shifts to the Commissioner at
the fifth step. Pass v. Chater, 65 F.3d 1200, 1203
(4th Cir. 1995).
has a significant medical history. She has suffered from
upper extremity neuropathy since 2009. In May 2009, Willis
had a nerve conduction study (“NCS”) which
revealed severe right median neuropathy at her right wrist
and mild median neuropathy on her left side. Tr. at 516.
Providers diagnosed CTS. Id. at 230, 233.
underwent stenting surgery following a heart attack in
October 2010. Id. at 247, 265. Willis reported
intermittent chest pain and fatigue in follow-up visits.
Id. at 243, 271, 279, 284. Willis presented to the
Emergency Department in February 2011 for chest pain and
dizziness. Id. at 294. Providers continued her
assessments of CAD and angina. Id. at 300. Willis
continued to experience shoulder pain and, upon examination,
the area was tender to palpitation. Id. at 519-21,
527. Her primary care providers noted that her shoulder pain
was affecting her ability perform activities of daily living.
Id. at 528.
2011 MRI of Willis's left shoulder revealed subacromial
narrowing and fairly pronounced tendonitis in the
supraspinatus and insertion, as well as thickening and edema
along with potential adhesive capsulitis. Id. at
417. The following month, Willis reported that she was unable
to write or hold a cup without pain. Id. at 469. She
stated she had severe right hand pain and that her shoulder
pain was 7/10. Id. Examination revealed pain with
range of motion (“ROM”), positive impingement
signs in her left shoulder, and tenderness with decreased
sensation in her right hand. Id. at 470. An x-ray of
her left shoulder disclosed significant acromioclavicular
(“AC”) joint degenerative disc disease with
inferior spur formation at the distal clavicle as well as a
type III acromion suggesting impingement. Id.
Providers diagnosed CTS and shoulder impingement with rotator
cuff tendinopathy. Id.
August 2011, Willis had CTS release surgery on her right
wrist which provided some improvement in the numbness and
tingling she experienced. Id. at 472. She again
reported left should pain in October 2011. Id. at
476-77. Willis attended physical therapy to address her
conditions. Id. at 567-621. After two months of
physical therapy, her providers noted that Willis showed some
improvement in strength but continued to demonstrate weak
grip in her right hand and tenderness and decreased ROM with
marked pain in her right shoulder. Id. at 523, 525.
reported resolution of her shoulder pain in January 2012.
Id. at 480. However, Willis returned to her
orthopedist in March 2012 complaining of worsening left
shoulder pain which radiated through her arm and neck.
Id. at 482-83. Providers diagnosed rotator cuff
tendinopathy and left shoulder impingement, and suggested her
next course of action may be surgery as PT and injections had
failed to provide long-lasting relief. Id. In August
2012, Willis continued to demonstrate positive impingement
signs upon examination. Id. at 484-85.
March 2013, Willis sought care for significant numbness and
tingling in her right wrist. Id. at 486-87. Despite
her previous CTS release surgery, Willis experienced sensory
disturbance which was present with even light activity.
Id. Providers suspected she may have sustained
chronic, long-term damage to her median nerve. Id.
at 487. She also reported continued pain in her left
shoulder, and an x-ray showed moderate AC joint damage.
Id. The following month, an upper extremity nerve
conduction study (“NCS”) showed bilateral median
neuropathy, that was severe on the right side and moderate on
the left side. Id. at 555-59. Providers noted that
her right side “may reflect chronic remnant
changes” and that she had problems with left shoulder
ROM during testing. Id.
2013, Willis sought follow-up care for her bilateral wrist
pain. Id. at 488. On exam, she displayed numbness
and tingling consistent with median neuropathy. Id.
at 488. Providers assessed bilateral CTS and recommended
release surgery for her left wrist. Id. Treatment
notes also reflect that Willis had severe median neuropathy
on the right, which providers ...