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Willis v. Berryhill

United States District Court, E.D. North Carolina, Eastern Division

March 14, 2017

Ava Gnann Willis, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security, [1] Defendant.



         Plaintiff 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, 22.

         After 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 further consideration.[2]

         I. Background

         On 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.

         ALJ 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.

         ALJ 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.

         After unsuccessfully seeking review by the Appeals Council, Willis commenced this action on December 21, 2015. D.E. 6.

         II. Analysis

         A. Standard for Review of the Acting Commissioner's Final Decision

         When a 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).

         B. Standard for Evaluating Disability

         In 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).

         C. Medical Background

         Willis 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.

         Willis 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.

         A July 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.

         In 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.

         Willis 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.

         In 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.

         In May 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 ...

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