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Pettaway v. Berryhill

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

June 6, 2017

Douglas Pettaway, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security, [1]Defendant.


          Robert T. Numbers, II United States Magistrate Judge.

         Plaintiff 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.

         After 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.[2]

         I. Background

         On 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.

         ALJ 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. Id.

         ALJ 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. Id.

         After unsuccessfully seeking review by the Appeals Council, Pettaway commenced this action on March 29, 2016. 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

         Pettaway 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.

         Thereafter, 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, 468.

         Pettaway 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.

         The 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.

         That 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.

         In May 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.

         Pettaway 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. at 634.

         In July 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.

         Junkins 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.

         Junkins 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.

         DeFonda 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. ...

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