United States District Court, E.D. North Carolina, Western Division
MEMORANDUM & ORDER
T. Numbers, II United States Magistrate Judge.
Douglas Pettaway instituted this action on March 29, 2016, to
challenge the denial of his application for social security
income. Pettaway claims that the Administrative Law Judge
(“ALJ”) James Williams erred in evaluating the
medical evidence opinion evidence. Both Pettaway and
Defendant Nancy Berryhill, the Acting Commissioner of Social
Security, have filed motions seeking a judgment on the
pleadings in their favor. D.E. 18, 24.
reviewing the parties' arguments, the court has
determined that ALJ Williams properly evaluated the medical
opinion evidence and accorded it the appropriate weight.
Therefore, the undersigned magistrate judge denies
Pettaway's motion, grants Berryhill's motion, and
affirms the Commissioner's determination.
March 10, 2014, Pettaway filed applications for disability
benefits and supplemental security income. In both
applications, Pettaway alleged a disability that began on
December 4, 2013. After his claims were denied at the initial
level and upon reconsideration, Pettaway appeared at a
hearing before an ALJ Williams on January 5, 2016, to
determine whether he was entitled to benefits. ALJ Williams
determined Pettaway was not entitled to benefits because he
was not disabled. Tr. at 9-21.
Williams found that Pettaway had the following severe
impairments: ischemic heart disease, obesity, degenerative
disc disease (“DDD”), right rotator cuff tear,
affective disorder, hypertension, hyperlipidemia, and
diabetes mellitus (“DM”). Id. at 11. ALJ
Williams found that Pettaway's impairments, alone or in
combination, did not meet or equal a Listing impairment.
Id. at 12. He then determined that Pettaway had the
RFC to perform light work with limitations. Id. at
14. He must have the opportunity to alternate to sitting for
an hour after every hour of standing. Id. Pettaway
is limited to frequent reaching overhead and in all other
directions on the right. Id. He should never climb
ladders or scaffolds, he can frequently stoop, and he can
occasionally crawl. Id. Additionally, Pettaway is
limited to performing simple, routine, repetitive tasks.
Williams concluded that Pettaway is unable to perform his
past relevant work as a machinist or stocker but that
considering his age, education, work experience, and RFC,
there were jobs that existed in significant numbers in the
national economy that Pettaway is capable of performing.
Id. at 20. These jobs included: remnant sorter,
baker worker, and laundry classifier. Id. at 21.
Thus, ALJ Williams found that Pettaway was not disabled.
unsuccessfully seeking review by the Appeals Council,
Pettaway commenced this action on March 29, 2016. 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 history of back and leg pain. He had two coronary
stents placed in September 2010. Tr. at 487. In July 2012, he
was seen for chest pain and substance abuse. Id. at
500. An echocardiogram revealed left ventricle hypertrophy,
with an ejection fraction of 55- 60%. Id. at 497-98.
in March 2013, Pettaway sought treatment for numbness in his
left hand and pain in his neck and shoulder. Id. at
535-36. The assessment was hypertension, coronary artery
disease with two stents, back pain with radiculopathy, and
mild carpal tunnel syndrome on the left side. Id. at
452-53. Pettaway reported chest pain in August 2013, and
reported back pain the following month. Id. at 460,
complained of shoulder and hip pain in March 2014, and a
decrease in range of motion (“ROM”) was noted
upon examination. Id. at 473. That same month, he
sought orthopedic care for his right shoulder pain and back
pain. Id. at 430. Providers assessed right rotator
cuff tear with fatty degeneration and atrophy, for which he
received an injection to the right shoulder. Id. at
429-30. Providers opined that he may need surgery at some
point. Id. at 431. Examination also revealed a
positive straight leg raise on the left side and decreased
sensation in the dorsum of the foot. Id. at 430.
following month, Pettaway sought treatment for hypertension,
shoulder pain, and back pain. Id. at 477. He
reported that Percocet helped with his pain, and he received
a prescription refill. Id. at 477-78.
same month, Pettaway also saw Elwood Moore, a certified
physicians' assistant, with Eastern Neurosurgical &
Spine. Id. at 435. They discussed the results from a
previous MRI which revealed lumbar spondylosis with stenosis
at ¶ 4-5 and L5-S1 as well as lower left extremity
radiculopathy. Id. at 436. Epidural steroid
injections and surgery were discussed, but Pettaway reported
that he lacked funding for either treatment. Id.
2014, Pettaway reported right shoulder pain, and examination
revealed diffuse tenderness along the lumbar spine and
limited ROM in the right shoulder. Id. at 622.
Pettaway also presented to the Emergency Department twice
that month for left leg pain and shoulder pain. Id.
at 638, 643.
underwent a consultative examination with Dr. Jennifer Stahl
in June 2014. Id. at 628-36. Dr. Stahl noted
tenderness to palpitation at the shoulder and lower lumbar
spine. Id. at 631. She opined that Pettaway would
have limitation with reaching on the right side. Id.
2014, Pettaway reported to the Emergency Department for chest
pain. Id. at 648. Records reflect that he appeared
to be depressed and using alcohol and illicit drugs.
Id. at 661. Testing revealed coronary artery
disease. Id. at 664. The following month, Pettaway
again sought treatment for back and right upper extremity
pain. Id. at 715. Savannah Junkins, a certified
physicians' assistant at Opportunities Industrialization
Center (“OIC”), noted fatigue, weakness,
decreased ROM, and joint pain. Id. at 716. Later
that month, she noted he had an antalgic gait. Id.
at 703. Pettaway reported back pain, left leg pain, and
numbness in October 2014. Id. at 700.
authored a letter stating that Pettaway had multiple chronic
conditions including lumbar disc disease with back pain,
hypertension, coronary artery disease, and diabetes.
Id. at 698.
examined Pettaway again in December 2014 for back pain and
hypertension. Id. at 733. She wrote that month that
he was experiencing worsening back pain and leg pain,
especially in the left leg, with paresthesia and numbness.
Id. at 726-28.
McQueen, Pettaway's case manager at the homeless shelter
where he resided, wrote a letter in June 2015 noting that
Pettaway's health had continued to deteriorate.
Id. at 190. The following month, Pettaway returned
to Junkins inquiring about a cane. Id. at 754. ...