United States District Court, E.D. North Carolina, Eastern Division
Angela M. Tatum, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security, Defendant.
MEMORANDUM & RECOMMENDATION
T. Numbers, II United States Magistrate Judge.
Angela Tatum instituted this action in September 2017, to
challenge the denial of her application for social security
income. Tatum claims that Administrative Law Judge
(“ALJ”) Helen O. Evans erred in (1) determining
the limitations on her social interactions, and (2)
concluding that Tatum has the residual functional capacity
(“RFC”) to perform a reduced range of light work,
and (3) failing to afford appropriate weight to the opinion
of her treating providers. Both Tatum and Defendant Nancy A.
Berryhill, Acting Commissioner of Social Security, have filed
motions seeking a judgment on the pleadings in their favor.
D.E. 20, 24.
reviewing the parties' arguments, the court has
determined that ALJ Evans erred in her determination. ALJ
Evans's RFC determination is not supported by substantial
evidence because it fails to reflect all of Tatum's
well-supported limitations. And ALJ Evans's evaluation of
the medical opinion evidence is flawed because the reasons
given for discounting some of the findings made by
Tatum's medical providers lack support in the record. The
undersigned magistrate judge thus recommends that the court
grant Tatum's motion, deny the Commissioner's motion,
and remand this matter to the Commissioner for further
January 2014, Tatum protectively filed an application for
supplemental security income, alleging a disability that
began in September 2003. After her claim was denied at the
initial level and upon reconsideration, Tatum appeared before
ALJ Evans for a hearing to determine whether she was entitled
to benefits. ALJ Evans determined Tatum was not entitled to
benefits because she was not disabled. Tr. at 15-26.
Evans found that Tatum's lumbago, plantar fibroma,
obesity, HIV-positive status, bipolar disorder,
schizoaffective disorder, personality disorder, cocaine
abuse, and alcohol abuse were severe impairments. Tr. at 18.
ALJ Evans also found that Tatum's impairments, either
alone or in combination, did not meet or equal a Listing
Evans then determined that Tatum had the RFC to perform a
reduced range of light work. Tr. at 20. Tatum can never climb
ladders, ropes, or scaffolds but she can occasionally climb
ramps and stairs. Id. She can occasionally stoop and
crouch. Id. Tatum can occasionally operate foot
controls with her bilateral lower extremities. Id.
And she can occasionally operate moving machinery and work at
unprotected heights. Id.
can perform simple, routine, repetitive tasks that require
only occasional decision-making and she can handle occasional
changes in the workplace. Id. She cannot do fast
production rate or pace work. Id. Tatum can have
occasional interactions with the public and she can be around
coworkers throughout the day, but she can only interact with
them occasionally. Id. Finally, Tatum can respond
appropriately and follow directions and criticism from
Evans concluded that Tatum had no past relevant work. Tr. at
25. But considering her age, education, work experience, and
RFC, ALJ Evans found that there were jobs that existed in
significant numbers in the national economy that Tatum could
perform. Tr. at 25-26. These jobs include: car wash
attendant, marker, and garment folder. Id. Thus, ALJ
Evans found that Tatum was not disabled. Tr. at 26.
unsuccessfully seeking review by the Appeals Council, Tatum
filed this action in September 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 has no 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).
has a history of mental illness stemming back to childhood.
Tr. at 65. She has a diagnosis of schizoaffective disorder.
Since 2010, Assertive Community Treatment
(“ACT”), a multi-disciplinary team, has provided
Tatum with psychiatric care and support services. Tr. at 65,
628, 789, 1255. The ACT team visits Tatum's residence
several times per week and escorts her to appointments, the
food pantry, the laundromat, and the housing office. Tr. at
946, 1062, 1117, 1120.
June 2013, providers, including Dr. Stephen Sanders, a
psychiatrist, have prescribed medications, such as Risperdal
and Trazodone, to Tatum. When she reported an increase in her
depressive symptoms in March 2015, providers increased her
Trazodone dosage. Tr. at 1119.
contends that she has a pattern of engaging with healthcare
providers and other services for a period of time before
withdrawing and self-isolating. Tr. at 80-83. During periods
of engagement, Tatum will attend church regularly as well as
a support meeting for people who are HIV-positive and a
substance abuse recovery group. Tr. at 986, 1014, 1016, 1103,
1252-56. When she isolates herself, Tatum will not answer the
door for ACT team members. Tr. at 80-83. Providers attribute
this pattern of behavior to her mental health conditions. Tr.
at 81-82, 1296.
Cassity, director of Higher Ground, a supportive retreat and
community resource center for people living with HIV, runs a
recovery group that Tatum sporadically attends. Tr. at 1255.
Cassity stated that Tatum can make other attendees
uncomfortable and “on edge” with her presence as
she is “quick to take offense and react in a loud,
intimidating way that can be frightening to others.”
Tr. at 1255-56. He also remarked that Tatum verbally attacked
other attendees on multiple occasions. Id.
Mages, MSW, runs a weekly support group for women with HIV.
Tr. at 1253- 54. Mages observed that Tatum had problems
interacting with others and became physically agitated during
meetings, resulting in discomfort for other group members.
Tr. at 1253.
addition to her mental health conditions, Tatum has also
experienced physical impairments. Her diagnoses include HIV,
obesity, and substance abuse disorder. Tr. at 18. Providers
have characterized Tatum's substance abuse as
intermittent and remarked that she is honest about her
substance use. Tr. at 640, 1256, 1295.
has also experienced problems with her feet. Since 2011,
Tatum has consistently reported bilateral foot pain to
several providers. Tr. at 706, 763-66, 1005, 1013, 1022,
1039, 1066-68, 1272, 1293. In 2013, Dr. Kristen Bray, a
consultative examiner, noted that Tatum had a “tumor
like effect on the plantar surfaces of both feet” but
it was unclear if these were recurring abscesses or large
neuromas. Tr. at 763-66. Dr. Bray opined that Tatum would be
limited in standing or walking. Id. In 2015, Dr.
Norman Regal diagnosed Tatum with probable bilateral plantar
fibroma with keratotic lesions and a hammertoe deformity. Tr.
agency physician Dr. Nathan Strahl reviewed Tatum's
records in August 2015. Tr. at 795. Dr. Strahl concluded that
Tatum's functioning was significantly impaired only
during periods of substance use. Id. He also
observed that when Tatum was sober and complied with
treatment, she could perform simple, routine, repetitive
tasks and interact appropriately with coworkers and
supervisors. Id. Dr. Strahl found, however, that
Tatum should have no more than occasional ...