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Tatum v. Berryhill

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

June 25, 2018

Angela M. Tatum, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security, Defendant.


          Robert T. Numbers, II United States Magistrate Judge.

         Plaintiff 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.

         After 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 consideration.[1]

         I. Background

         On 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.

         ALJ 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 impairment. Id.

         ALJ 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.

         Tatum 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 supervisors. Id.

         ALJ 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.

         After unsuccessfully seeking review by the Appeals Council, Tatum filed this action in September 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 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).

         C. Medical Background

         Tatum 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.

         Since 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.

         Tatum 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.

         Mark 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.

         Adrienne 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.

         In 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.

         Tatum 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. at 1293.

         State agency physician Dr. Nathan Strahl reviewed Tatum's records in August 2015. Tr. at 795.[2] 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 ...

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