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Hall v. Berryhill

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

December 18, 2017

George D. Hall, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security, [1] Defendant.



         Plaintiff George D. Hall instituted this action on October 11, 2016, to challenge the denial of his application for social security income. Hall claims that the Administrative Law Judge (“ALJ”) Carl B. Watson erred in (1) finding that he had the residual functional capacity (“RFC”) to perform a reduced range of light work, (2) considering the opinion of his treating orthopedist, and (3) evaluating his credibility. Based these errors, Hall also contends ALJ Watson incorrectly determined that he could perform substantial gainful work. Both Hall and Defendant Nancy A. Berryhill, the Acting Commissioner of Social Security, have filed motions seeking a judgment on the pleadings in their favor. D.E. 10, 12.

         After reviewing the parties' arguments, the court has determined that ALJ Watson erred in his decision because his RFC determination is not supported by substantial evidence. Also, ALJ Watson's evaluations of the medical opinion evidence and Hall's credibility were flawed. Because of these errors, the undersigned cannot conclude that ALJ Watson correctly determined that there is other work which Hall can perform. Thus, the undersigned magistrate judge recommends that the court grant Hall's motion, deny Berryhill's motion, and remand the matter for further consideration.[2]

         I. Background

         On February 1, 2011, Hall protectively filed an application for disability benefits alleging a disability that began on October 29, 2009. After his claim was denied at the initial level and upon reconsideration, Hall appeared before ALJ Watson for a hearing to determine whether he was entitled to benefits. ALJ Watson determined Hall was not entitled to benefits because he was not disabled. Tr. at 16-26.

         After he unsuccessfully sought review from the Appeals Council, Hall filed a complaint in this court in July 2014. See Hall v. Colvin, Case No. 7:14-cv-00153-BO (E.D. N.C. July 23, 2014). In June 2015, the court remanded the case to the Commissioner for further consideration of Hall's RFC and, specifically, additional evaluation of Hall's treating physician's opinion finding restrictions in the use of his upper right extremity. Id. at D.E. 25.

         On remand, ALJ Watson found that Hall had several severe impairments: status-post right shoulder injury with superior labral anterior-to-posterior (“SLAP”) tear grade II lesion, partial bicep tendon rupture, partial anterior ligament rupture, impingement syndrome, partial thickness rotator cuff tendon tear, hypothyroidism, and depression. Tr. at 343.

         ALJ Watson found that Hall's impairments, either alone or in combination, did not meet or equal a Listing impairment. Id. at 344.

         ALJ Watson then determined that Hall had the RFC to perform a range of light work with additional limitations. Id. at 346. He cannot climb ladders, ropes, or scaffolds. Id. He can only occasionally reach overhead with his right upper extremity and he could frequently, but not constantly, reach in all other directions with his right arm. Id. Finally, Hall is limited to performing simple, routine, repetitive tasks in an environment where there is only casual interactions with the general public and where changes are infrequent and gradually introduced. Id.

         ALJ Watson concluded that Hall was incapable of performing his past relevant work as a tractor-trailer truck driver/trainer. Id. at 353. But ALJ Watson determined that, considering Hall's age, education, work experience, and RFC, there were other jobs that existed in significant numbers in the national economy that Hall was capable of performing. Id. at 353-54. These include: garment tag stringer, stock checker, and drying room attendant. Id. Thus, ALJ Watson found that Hall was not disabled. Id. at 354.

         After unsuccessfully seeking review by the Appeals Council, Hall commenced this action in October 2016. D.E. 1.

         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 determining 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)). The court must affirm the Commissioner's decision if it is supported by substantial evidence. 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 ALJ must consider the factors in order. At step one, if the claimant is 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

         Hall sustained a shoulder injury after a motor vehicle accident in December 2008. Although he was originally diagnosed with tendonitis, he underwent surgery with Dr. Andrew Bush in October 2009 after subsequent testing showed more extensive injuries to his right shoulder. Tr. at 347. In March 2010, Hall reported persistent pain despite medications and injections. Id. Dr. Bush determined Hall was suffering from bicipital tenosynovitis and administered another injection. Id. at 209. The next month, Hall saw Dr. Bush for right shoulder pain despite having received medications and injections. Id. at 210-15. Dr. Bush believed Hall was suffering from bicipital tenosynovitis and rotator cuff syndrome. Id. at 215.

         Hall still experienced persistent pain and occasional swelling in August 2010. Id. at 222. After noting that Hall had only a fair response to medication, Dr. Bush concluded he had reached maximum medical improvement and referred him to pain management. Id. at 222-24.

         Dr. Bush also completed a Work Status Note at that time. Id. at 206. He assessed several permanent limitations: Hall could lift up to 20 pounds, with frequent lifting and carrying limited to 10 pounds; he could not walk or stand to a significant degree; and he could not sit with pushing or pulling of arm/leg controls. Id. Hall could not lift more than five pounds with his right hand; he could not perform forceful pushing or pulling of more than pounds with his right hand; and he could not grip or twist with his right hand. Id. Dr. Bush also found that Hall could not reach overhead with his right arm; he could not use vibratory tools or power tools; and he was unable to drive a commercial vehicle. Id.

         In September 2010, Hall saw Dr. Aaron H. Gootman in hopes of managing his chronic pain. Id. at 255-57. Although Dr. Gootman prescribed medications for him, Hall returned two months later complaining of worsening pain. Id. at 225. Dr. Gootman gave Hall an injection after an examination found tenderness and painful range of motion. Id. at 226, 227, 256. In December, Dr. Gootman found that Hall's pain was moderately uncontrolled with medication. Id. at 259-60. Later that month and in February 2011, he found Hall's pain to be slightly uncontrolled. Id.

         Hall's wife completed a Function Report in March 2011. Id. at 175-82. She claimed that Hall spent most of his day watching television and that he got very little sleep at night. Id. at 175- 76. She assisted him with dressing and grooming and she said that he had a very limited ability to perform household chores. Id. at 177. She also stated that she did most of the driving and that he had problems focusing. Id. at 178-79. She estimated he could walk about half a mile. Id. at 180.

         Hall returned to Dr. Bush the next month complaining of worsening pain. Id. at 287-89. Dr. Bush noted decreased range of motion and administered an injection. Id. at 289. In May 2011, Dr. Bush remarked that Hall showed decreased strength in his shoulder and elbow, and he referred Hall to pain management once again. Id. at 292.

         Dr. Ayman Gebrail performed a consultative examination later that month. Id. at 264-68. His examination found a significantly limited range of motion in Hall's right shoulder, as well as tenderness. Id. Hall was unable to perform several testing maneuvers because of his pain. Id. Dr. Gebrail opined that Hall would have “significant difficulty with the function of his right shoulder and right upper extremity due to pain.” Id.

         In June, Hall saw Dr. Toni Harris, a pain management specialist. Id. at 284-85. Hall claimed that he experienced pain in both shoulders, with the right being more severe. Id. He also reported numbness in his right arm and an inability to raise his right arm above shoulder-height. Id. Dr. Harris found that Hall had diminished right biceps reflex, atrophy of his right trapezius, and limited ...

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