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Edwards v. Commissioner of Social Security

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

March 21, 2018

Donna Edwards, Plaintiff,
Commissioner of Social Security, [1] Defendant.


          Robert T. Numbers, II United States Magistrate Judge.

         Plaintiff 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.

         After 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 consideration.[2]

         I. Background

         Edwards 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 134-42.

         ALJ Watson held a second hearing after the Appeals Council remanded the matter for consideration of additional evidence. Tr. at 18.

         After 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.

         According 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.

         ALJ 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 36.

         After unsuccessfully seeking review by the Appeals Council, Edwards began this action in March 2017. D.E. 5.

         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. 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).

         C. Medical Background

         1. Medical Records

         Edwards 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. Id.

         Providers 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. Id.

         In the 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.

         In June 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.

         State 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.

         The 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 hazards. Id.

         Around 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.

         State 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.

         Edwards 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.

         In 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.

         In 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 ...

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