United States District Court, E.D. North Carolina, Southern Division
MEMORANDUM & ORDER
T. Numbers, II United States Magistrate Judge.
Donna Edwards instituted this action in March 2017, to
challenge the denial of her application for social security
income. Edwards claims that Administrative Law Judge
(“ALJ”) Carl B. Watson improperly evaluated the
medical opinion evidence and applied the incorrect
Medical-Vocational Guidelines (“Grid Rule”) on
the way to his determination that she was not disabled. Both
Edwards and Defendant, the Commissioner of Social Security,
have filed motions seeking a judgment on the pleadings in
their favor. D.E. 21, 25.
reviewing the parties' arguments, the court has
determined that ALJ Watson erred in his determination. It is
appropriate to remand this matter because of ALJ
Watsons's failure to obtain disability paperwork from one
of Edwards's providers as directed by the Appeals
Council. The information in disability paperwork could
influence the ALJ's consideration of, and assignment of
weight to, the medical opinions. And it is also appropriate
to remand this matter because the ALJ did not adequately
discuss the effect of the fact that Edwards was close to
reaching an older age category under the Grid Rules on her
potential disability. The court therefore grants
Edwards's motion, denies the Commissioner's motion,
and remands the matter to the Commissioner for further
protectively filed applications for disability insurance
benefits and supplemental security income. In both
applications, she alleged that she suffered from a disability
that began in May 2010. After her claims were denied at the
initial level and upon reconsideration, Edwards appeared
before ALJ Watson for a hearing to determine whether she was
entitled to benefits. ALJ Watson determined Edwards was not
entitled to benefits because she was not disabled. Tr. at
Watson held a second hearing after the Appeals Council
remanded the matter for consideration of additional evidence.
Tr. at 18.
the second hearing, ALJ Watson found that Edwards had several
severe impairments: post infection intercostal neuralgia,
neuropathic pain syndrome, pulmonary hypertension, right
renal cyst and abdominal pain, diabetes, hernia, and obesity.
Tr. at 21. He also found that Edwards's impairments,
either alone or in combination, did not meet or equal a
Listing impairment. Tr. at 23.
to the ALJ, Edwards had the RFC to perform a range of light
work with additional limitations. Tr. at 25. She cannot climb
ladders, ropes, or scaffolds but she can occasionally climb
ramps and stairs. Id. Edwards must also avoid
working at unprotected heights. Id.
Watson concluded that Edwards cannot perform her past work as
a chemical mixer, electrical motor assembler, machine
operator, or cutting machine operator. Tr. at 34. But he
determined that, considering her age, education, work
experience, and RFC, there were other jobs that existed in
significant numbers in the national economy that Edwards was
capable of performing. Tr. at 35. These include ticket
seller, check room attendant, and hand presser. Id.
Thus, ALJ Watson found that Edwards was not disabled. Tr. at
unsuccessfully seeking review by the Appeals Council, Edwards
began this action in March 2017. D.E. 5.
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
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).
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 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. But 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).
began experiencing stabbing chest pain in 2011. Tr. at 26. In
February 2011, Edwards spent a week in the hospital because
of her symptoms. Tr. at 27. Upon discharge, providers
assessed her with atypical chest pain after a recent viral
illness. Id. Her presentation was most consistent
with costochondritis. Id. Two months later, David
Richardson, FNP-C, under the supervision of Dr. Aymen
Gebrail, released Edwards to part-time work for four hours
per day and imposed a ten-pound lifting restriction.
at Duke Hospital saw Edwards in May 2011 for management of
her chronic sternal pain, after she had a respiratory
infection accompanied by a persistent cough. Id.
Edwards received a diagnosis of intercostal neuralgia,
costochondritis, and neuropathic pain syndrome. Id.
Nerve blocks provided temporary relief of her symptoms.
following months, treatment records from Edwards's
primary care providers at Costal Internal Medicine reflect
that she continued to complain of chest wall pain, shortness
of breath, weakness, and back pain. Id. She reported
difficulty lifting, carrying, standing, walking, bending, and
climbing stairs. Id. She also had to shift positions
while seated. Id. Records reflect that Edwards was
unable to pursue regular treatment because she lacked health
insurance. Id. Providers advised Edwards to pursue
employment to obtain insurance coverage which would enable
her to return to pain management. Id.
2011, Teresa Baughman, a caseworker with the Department of
Social Services, stated that Edwards had trouble breathing
and sitting still, and also noted that she appeared to be in
significant pain. Tr. at 28.
agency medical consultant Dr. Edward Woods evaluated
Edwards's records in December 2011. Tr. at 33. He opined
that she was capable of light work with restrictions to
frequent balancing and frequent climbing of ramps, stairs,
ladders, ropes, and scaffolds. Id. He also concluded
that Edwards should avoid moderate exposure to pulmonary
irritants and concentrated exposure to hazards. Id.
next month, state agency consultant Dr. Bertron Haywood
reviewed Edwards's records. Id. He determined
that she could perform light work with frequent climbing of
ramps and stairs but only occasional climbing of ladders,
ropes, or scaffolds. Id. Like Dr. Woods, Dr. Haywood
found that Edwards should avoid concentrated exposure to
this same time, Edwards underwent a consultative
psychological examination with C. Craig Farmer, Ph.D. Tr. at
22. He noted that she had low mood but full orientation and
clear thought processes. Id. He opined that Edwards
could understand, retain, and follow instructions and that
she had an adequate ability to relate to others. Id.
Dr. Farmer concluded that her abilities to sustain attention
for simple, repetitive tasks and to tolerate stress may be
limited because of her chronic pain. Id.
agency consultant Jennifer Fulmer, Ph.D., also assessed
Edwards's mental abilities. Id. Dr. Fulmer
opined that she had the ability to perform simple, routine,
repetitive tasks in a low-production setting. Id.
spent two days in the hospital in February 2012 because of
her chronic chest pain. Tr. at 33. Providers ruled out a
cardiac event and considered her symptoms to be neuropathic.
Tr. at 28. Her follow-up treatment records reflect
unremarkable physical examinations, aside from ongoing chest
pain. Id. Richardson remarked that cortisone
injections helped address Edwards's pain, but she could
not continue to afford the injections. Id.
March 2012, after Edwards sought emergency treatment for
chest pain which she rated as ten out of ten, providers
prescribed her various medications. Id. Edwards also
had an MRI of her abdomen, which did not identify a cause for
her abdominal pain. Id.
August 2012, Edwards underwent a cardiac evaluation and rated
her chest pain as a six out of ten. Tr. at 28. Three
months later, Edwards told providers that her chronic chest
pain had curtailed any leisure activities. Tr. at 29. She
reported some relief from using a heating pad and lying on
her side. Id. Providers believed Edwards ...