Woodyard v. SSA

Filing 11

MEMORANDUM OPINION & ORDER: 1. Plaintiff Woodyard's Motion for Summary Judgment [Record No. 7 ] is GRANTED, in part, to the extent that she seeks a remand for further administrative proceedings. 2. Defendant Berryhill's Motion for S ummary Judgment [Record No. 9 ] is DENIED. 3. Plaintiff Woodyard's Motion for Leave to File Reply Memorandum [Record No. 10 ] is DENIED. 4. The decision of Administrative Law Judge Dennis Hansen is REMANDED for further administrative proceedings consistent with this opinion and pursuant to sentence four of 42 U.S.C. § 42 U.S.C. 405 (g). Signed by Judge Danny C. Reeves on 03/16/2018.(KJA)cc: COR

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF KENTUCKY
SOUTHERN DIVISION
(at London)
TAMMY ROSE WOODYARD,
Plaintiff,
V.
NANCY A. BERRYHILL, Acting
Commissioner of Social Security,
Defendant.

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Civil Action No. 6: 17-277-DCR

MEMORANDUM OPINION
AND ORDER

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This matter is pending for consideration of cross-motions for summary judgment filed
by Plaintiff Tammy Woodyard (“Woodyard” or “the Claimant”) and Defendant Nancy A.
Berryhill, Acting Commissioner of the Social Security Administration (“the Commissioner”).
[Record Nos. 7, 9] Woodyard argues that the Administrative Law Judge (“ALJ”) assigned to
her case erred in concluding that she was not disabled within the meaning of the Social Security
Act (“Act’). Specifically, she asserts that the ALJ failed to properly consider the opinion of
her treating physician. Woodyard requests that this matter be remanded with instructions that
she be awarded benefits.

Woodyard has also filed a motion for leave to file a reply

memorandum in support of her motion. [Record No. 10]
The Commissioner contends that the ALJ properly evaluated the evidence and that the
ALJ’s decision should be affirmed because it is supported by substantial evidence. For the
reasons that follow, the Claimant’s motion for summary judgment will be granted, in part, and
the matter will be remanded for further consideration. The Claimant’s motion for leave to file
a reply memorandum will be denied, as additional briefing is not needed to resolve this matter.
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I.
Woodyard filed a Title II application for a period of disability and disability insurance
benefits (“DIB”) on July 15, 2014. [See Administrative Transcript, hereinafter “Tr.,” 152-53.]
She alleged an onset of disability date of November 6, 2013. [Tr. 152, 42] After the
application was denied initially and on reconsideration, Woodyard requested a hearing before
an administrative law judge. [Tr. 113-14, 119, 130] She appeared before ALJ Dennis Hansen
at a hearing in Middlesboro, Kentucky in April 2016. [Tr. 68-87] ALJ Hansen denied benefits
in a written decision on June 17, 2016, which the Appeals Council affirmed. [Tr. 49-58, 1-4]
Accordingly, the Claimant has exhausted her administrative remedies and this matter is ripe
for review under 42 U.S.C. § 405(g).
II.
Woodyard was 42-years-old at the time of the ALJ’s decision. [See Tr. 71, 58] She
worked at Wal-Mart for more than 15 years, where she processed items that had been returned.
[Tr. 72-73] Her position required her to unload items from shopping carts, place them on
pallets, shrink-wrap the pallets, and load the pallets on a truck weekly. [Tr. 73] Woodyard
estimated that she lifted or carried up to 50 pounds. Id. She testified that she stopped working
in 2013 because she was no longer able lift, stand, squat and bending in performing her duties.
[Tr. 73-74]
Woodyard reported that her inability to work was caused by rheumatoid arthritis,
osteoarthritis, systemic lupus erythematosus, osteoporosis, Raynaud’s phenomenon, mixed
connective tissue disease, sleeping problems, moodiness and anxiety. [Tr. 208] When
questioned about her inflammatory arthritis, Woodyard testified that her hands were most
affected and that she was unable to grip. [Tr. 74-75] She also reported that her fingertips turn
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blue and she has no feeling in them. [Tr. 78] Woodyard reported that the severity of her
symptoms fluctuated, but her hands had not been “normal” for a long time. [Tr. 75] She also
reported swelling in her knees and feet, which limited her ability to bend or squat. [Tr. 76, 81]
Woodyard testified that lupus had also “affected [her] lungs.” She testified that she had
suffered from pleurisy about three times and that the condition had been treated with
prednisone. [Tr. 76-77] She reported that her use of prednisone had caused swelling in her
face and that she had gained approximately 45 pounds since she began taking the medication.
[Tr. 81]
At the time of the hearing, Woodyard believed that she could stand or sit for thirty
minutes before changing positions. [Tr. 79] She believed she could lift “five pounds, maybe.”
Woodyard reported driving, but did not help with the cooking and cleaning, other than
occasionally loading the washer or dishwasher. [Tr. 72, 80, 205] She accompanied her
husband to the grocery store and sometimes out to lunch. [Tr. 80] Woodyard reported that,
on a normal day, she watched television to pass the time. Id. The only social activity she
reported was visiting her mother. [Tr. 205]
Gina Bingham, M.D., was Woodyard’s primary care physician and provided treatment
beginning in December 2009. Bingham treated Woodyard for hypertension and occasional
problems such as a cold or urinary tract infection. [Tr. 414, 422, 434] Bingham performed
testing in May 2013 which revealed that Woodyard had osteoporosis. [Tr. 428, 487] Bingham
also ordered an “arthritis workup,” which was positive for ANA, “Smith AB,” and rheumatoid

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factor.1 [Tr. 476, 479] She referred Woodyard to a rheumatologist, Mansoor Ahmed, M.D.,
based on these results. [Tr. 476]
Ahmed saw Woodyard for the first time on September 13, 2013, noting that she
presented with “bilaterally asymmetric polyarthritis,” which caused pain and tenderness in the
joints of both hands, wrists, knees, and toes of both feet. [Tr. 282-83] Ahmed prescribed
Plaquenil at Woodyard’s next visit in October 2013. [Tr. 288] The following month, Amhed
increased the dosage, noting that Woodyward had “+1 synovitis” at the metacarpophalyngeal
joints and wrist. [Tr. 291]
Woodyard requested a second opinion. It appears that this request was triggered, at
least in part, by Ahmed’s refusal to provide Woodyard with a work excuse. [Tr. 463, 582]
Bingham referred Woodyard to Shannon Florea, M.D., in November 2013, but it is unclear if
Woodyard ever saw Dr. Florea. [Tr. 463, 582, 587] Woodyard began treating with another
rheumatologist at the University of Kentucky, Thomas Howard, M.D., in December 2013. [Tr.
685] Howard noted that Woodyard suffered from fatigue but, other than valgus knees, her
joints appeared normal. [Tr. 583-84] By July 2014, Howard described Woodyard as having
systemic lupus erythematosus, with manifestations of arthritis including pleurisy and “+ANA,
SM, [and] RnP.” [Tr. 630] She presented with a maculopapular rash involving her feet and
hands and reported that methotrexate was not helping her joint pain. Id. Howard described
Woodyard’s digits, nails, joints, bones, and muscles as abnormal, with tenderness upon

1

Blood tests for lupus include the anti-nuclear antibody (ANA) and anti-Smith antibody tests.
https://www.hopkinslupus.org/lupus-tests/lupus-blood-tests/ (last visited March 15, 2018).
Rheumatoid factor and ANA tests assist in the diagnosis of rheumatoid arthritis.
https://www.mayoclinic.org/tests-procedures/rheumatoid-factor/about/pac-20384800
(last
visited March 15, 2018).
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palpation of her fingers. [Tr. 632] Other symptoms included shortness of breath with
prolonged standing or walking up stairs. [Tr. 625]
Woodyard also began taking prednisone to manage her symptoms. She experienced a
significant increase in pain and swelling when she tried to taper off of that medication. [Tr.
652] She tried another medication (Imuran) without much success. Id. In March 2015,
Woodyard had been using prednisone again due to increase hand and wrist pain, with an
erythematous rash overlying the dorsal aspects of her hands. [Tr. 643, 646] Despite her fear
of injections, Woodyard began treatment with Humira. [Tr. 649] By May 2015, Woodyard
still suffered malaise and fatigue, but the rash on her hands was improving. [Tr. 641] Although
Howard did not detect synovitis during that visit, he noted that the arthritis was not controlled
without prednisone. Id. Woodyard was advised to keep her entire body warm. Id.
Woodyard had tapered off prednisone and was “doing well overall” in July 2015, but
still had some hand joint pain and new bilateral foot swelling. [Tr. 662] She also developed
a new rash on her chest. This was thought to be caused by the Humira, so she discontinued it.
[Tr. 692] A few months later, her rash had worsened and spread to her upper arms. [Tr. 692]
Although her hand pain was “tolerable,” she advised Howard that she felt best while taking
prednisone and she resumed taking a tapered dose of that medication. [Tr. 695] Woodyard
followed up with Howard in February 2016 and reported pain in her hands, wrists, and knees
that was “much better” while taking prednisone. [Tr. 686] Howard counseled Woodyard
regarding the risks associated with chronic use of prednisone including avascular necrosis of
bone and osteoporosis. [Tr. 689]
Howard provided a medical source statement on February 9, 2016. [Tr. 683] He
indicated that Woodyard’s symptoms were severe enough to frequently interfere with attention
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and concentration and that her maximum tolerance for sustained, reliable work activity was
less than eight hours. Id. He also opined that Woodyard would be able to sit, stand, or walk
for less than one hour in an eight-hour work day, and that she would rarely or never be able to
carry under 10 pounds. [Tr. 683-84] Howard also believed that Woodyard needed to lie down
on a daily basis and that she had limitations when it came to reaching, handling, and fingering.
[Tr. 684] Specifically, he reported that she could occasionally grasp, turn, and twist objects
with her hands, as well as reach overhead with her arms. Id. However, he stated that she could
never perform fine manipulations with her fingers. Id. Finally, Howard believed that
Woodyard’s symptoms would be likely to interfere with her work attendance more than six
days per month. Id.
State agency consultant Donna Sadler, M.D., reviewed Woodyard’s file and on
February 11, 2015, provided an opinion regarding her functional abilities. [Record No. 10712] Based on her review of the medical records up to that point, Sadler reported that Woodyard
could occasionally lift or carry 20 pounds and could frequently lift or carry 10 pounds. [Tr.
108] She opined that Woodyard could stand, walk, or sit for about six hours in an eight-hour
workday. Id. She believed that Woodyard’s ability to push and pull was unlimited and that
she could climb stair and ramps frequently. Id. She also reported that Woodyard could stoop
and kneel frequently and climb ladders, ropes, and scaffolds occasionally. Id. Although Sadler
felt that Woodyard’s ability to reach overhead was unlimited, she believed that her gross and
fine manipulation were limited. [Tr. 108-09] Further, she believed Woodyard should avoid
concentrated exposure to extreme cold, extreme heat, and vibration. [Tr. 109]

ALJ Hansen determined that Woodyard did not have an impairment or combination of

impairments that met a listing under 20 C.F.R. Part 404, Subpart P, Appendix 1. He concluded,
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however, that Woodyard had the following severe impairments: mixed connective tissue
disease, inflammatory arthritis, lupus, osteoarthritis and Reynaud’s syndrome.

After

considering the entire record, the ALJ found that Woodyard had the residual functional
capacity (“RFC”) to perform light work as defined in 20 C.F.R. § 404.1567(b) except
she could lift and carry 20 pounds occasionally and 10 pounds frequently. She
can sit for six hours in an eight-hour workday and could stand and/or walk for
six hours in an eight/hour workday. She can frequently climb ramps and stairs,
stoop, kneel, crouch, crawl, handle, finger, and feel bilaterally. She can
occasionally climb ladders, ropes or scaffolds, and should avoid concentrated
exposure to extreme heat, extreme cold and vibration.
The ALJ determined that Woodyard was capable of performing past relevant work as
a claims supervisor, but Woodyard asserted that she actually performed the work at the heavy
exertion level. [Tr. 56] The ALJ went on to determine that there were other jobs existing in
the national economy that Woodyard was able to perform. Accordingly, he concluded that she
had not been under a disability during the relevant period. [Tr. 57]
III.
Under the Act, a “disability” is defined as “the inability to engage in ‘substantial gainful
activity’ because of a medically determinable physical or mental impairment of at least one
year’s expected duration.” Cruse v. Comm’r of Soc. Sec., 502 F.3d 532, 539 (6th Cir. 2007)
(citing 42 U.S.C. § 423(d)(1)(A)). A claimant’s Social Security disability determination is
made by an ALJ in accordance with “a five-step ‘sequential evaluation process.’” Combs v.
Comm’r of Soc. Sec., 459 F.3d 640, 642 (6th Cir. 2006) (en banc) (quoting 20 C.F.R. §
404.1520(a)(4)). If the claimant satisfies the first four steps of the process, the burden shifts
to the Commissioner with respect to the fifth step. See Jones v. Comm’r of Soc. Sec., 336 F.3d
469, 474 (6th Cir. 2003).
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A claimant must first demonstrate that she is not engaged in substantial gainful
employment at the time of the disability application. 20 C.F.R. § 404.1520(b). Second, the
claimant must show that she suffers from a severe impairment or a combination of
impairments. 20 C.F.R. § 404.1520(c). Third, if the claimant is not engaged in substantial
gainful employment and has a severe impairment which is expected to last for at least twelve
months and which meets or equals a listed impairment, she will be considered disabled without
regard to age, education, and work experience. 20 C.F.R. § 404.1520(d). Fourth, if the
claimant has a severe impairment but the Commissioner cannot make a determination of the
disability based on medical evaluations and current work activity, the Commissioner will
review the claimant’s RFC and relevant past work to determine whether she can perform her
past work. 20 C.F.R. § 404.1520(e). If she can, she is not disabled. 20 C.F.R. § 404.1520(f).
Under the fifth step of the analysis, if the claimant’s impairments prevent her from
doing past work, the Commissioner will consider her RFC, age, education, and past work
experience to determine whether she can perform other work. If she cannot perform other
work, the Commissioner will find the claimant disabled. 20 C.F.R. § 404.1520(g). “The
Commissioner has the burden of proof only on ‘the fifth step, proving that there is work
available in the economy that the claimant can perform.’” White v. Comm’r of Soc. Sec., 312
F. App’x 779, 785 (6th Cir. 2009) (quoting Her v. Comm’r of Soc. Sec., 203 F.3d 388, 391 (6th
Cir. 1999)).
This Court’s review is limited to determining whether the ALJ’s findings are supported
by substantial evidence and whether the ALJ employed the proper legal standards in reaching
her decision. Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007). Substantial
evidence is such relevant evidence as reasonable minds might accept as sufficient to support
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the conclusion. Richardson v. Perales, 402 U.S. 389, 401 (1971); Bass v. McMahon, 499 F.3d
506, 509 (6th Cir. 2007). The Commissioner’s findings are conclusive if they are supported
by substantial evidence. 42 U.S.C. § 405(g).
IV.
ALJs must follow certain standards in assessing the evidence supplied in support of a
claim for social security benefits. For instance, greater deference generally is given to the
opinions of treating physicians than the opinions of non-treating physicians.2 Rogers v.
Comm’r of Soc. Sec., 486 F.3d at 242. If a treating physician’s opinion is “well-supported by
medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with
other substantial evidence in [the] case record, ‘then it will be afforded controlling weight.’”
Id. (quoting Wilson v. Comm’r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004)). When a
treating physician’s opinion is not given controlling weight, the ALJ must consider a number
of factors in determining how much weight is appropriate. Id. These factors include: “the
length, frequency, nature, and extent of the treatment relationship; the supportability and
consistency of the physician’s conclusions; the specialization of the physician; and any other
relevant factors.” Id.
In the event a treating physician’s opinion is not given controlling weight, the ALJ is
required to provide good reasons for the amount of weight given to the treating source’s
opinion. 20 C.F.R. § 1527(c)(2). This permits meaningful review of the ALJ’s decision and
allows a claimant to understand the reasons for the ALJ’s decision. Wilson, 378 F.3d at 54445. A decision denying benefits “must contain specific reasons for the weight given to the

2

This rule applies to claims filed before March 27, 2017. See 20 C.F.R. § 404.1527.
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treating source’s medical opinion, supported by the evidence in the case record, and must be
sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave
to the treating source’s medical opinion and the reasons for that weight.” SSR 96-2p, 1996
WL 374188, *5 (1996).
Here, the ALJ assigned “marginal weight” to Howard’s opinion because the “extreme
limitations” he assessed were not consistent with the “conservative treatment” he provided to
Woodyard. Woodyard contests this point because she contends that conservative treatment
(i.e., non-surgical treatment) is the only treatment available for her inflammatory conditions.
See Thomas v. Colvin, No. 0:14-CV-129-JMH, 2015 WL 1281701, *6 (E.D. Ky. March 20,
2015) (“‘Conservative treatment’ is used to refer to non-surgical treatment options, like
injections, not to indicate less or fewer incidents of treatment.”). The ALJ did not indicate
what type of surgery or more invasive treatment might be indicated, given the Claimant’s
diagnoses.
The ALJ also stated that the limitations assessed by Howard were inconsistent with his
treatment notes, which revealed “generalized control of symptoms.” [Tr. 56] The ALJ’s
explanation for failing to afford Howard’s opinion controlling weight leaves something to be
desired. While the ALJ did discuss some of Howard’s later treatment notes indicating that
Woodyard’s symptoms had improved during that time period, there is no indication that he
considered the length, frequency, nature, and extent of the treatment relationship or Howard’s
specialization. See 20 C.F.R. § 404.1527(c)(2)-(6). Further, the ALJ did not provide specific
reasons for assigning marginal weight to Howard’s opinion. The ALJ’s general assertion that
Howard’s opinion was not consistent with his treatment notes, which cover a two-year period,
is largely incapable of meaningful review. See Fisk v. Astrue, 253 F. App’x 580, 586 (6th Cir.
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2007) (meaningful review impossible where ALJ’s reasoning did not indicate that ALJ realized
the nature and extent of treating relationship).
In assigning “predominant weight” to the opinion of state agency consultant Sadler, the
ALJ concluded that her opinion was “supported by the objective evidence of record that
establishes the [C]laimant suffers from mixed connective tissue disease, lupus, inflammatory
arthritis, osteoarthritis and Reynaud’s syndrome, but evidences a generalized control of
symptoms resulting from said conditions.” [Tr. 55] Sadler reviewed Woodyard’s file on
February 11, 2015, approximately one year before Howard provided his medical statement.
[Tr. 110, 685] Accordingly, Sadler reviewed an incomplete file which did not include
Howard’s opinion or the last year of his medical notes.
It is well-established that, in appropriate circumstances, opinions from state agency
medical consultants may be entitled to greater weight than the opinions of treating sources.
SSR 96-6p, 1996 WL 374180, *3. One such circumstance is where the consultant’s opinion
is “based on a review of a complete case record that . . . provides more detailed and
comprehensive information than what was available to the individual’s treating source.” Id.
But where a consultant’s opinion is based on an incomplete record, the ALJ must at least
concede that fact before giving greater weight to the state consultant’s opinion. See Blakley v.
Comm’r, 581 F.3d 399, 409 (6th Cir. 2009) (citing Fisk, 253 F. App’x at 585). Here, the ALJ
did not acknowledge that the consulting source’s opinion was based on an incomplete record
that did not include the treating physician’s medical source statement.
The shortcomings in the ALJ’s analysis do not amount to harmless de minimis
procedural violations. See Blakley, 581 F.3d at 409 (citing Wilson v. Comm’r, 378 F.3d 541,
547 (6th Cir. 2004)). First, there is no evidence that Howard’s opinion is “so patently deficient
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that the Commissioner could not possibly credit it.” Id. Howard saw Woodyard on several
occasions over a substantial period of time and relied on both subjective and objective data in
his treatment plan. He cited her various diagnoses, confirmed by positive diagnostic tests in
support of his opinion. [Tr. 683] Additionally, the Commissioner has not complied with the
spirit of § 1527(c)(2) by satisfying “the procedural safeguard of reasons.” See Wilson, 378
F.3d at 544-45.

As previously stated, the ALJ has not provided specific reasons for

disregarding Howard’s opinion and, essentially, adopting Sadler’s. Accordingly, the Court is
unable to engage in a meaningful review and cannot conclude that the Commissioner’s
decision is supported by substantial evidence.
V.
Based on the foregoing analysis, it is hereby
ORDERED as follows:
1.

Plaintiff Woodyard’s Motion for Summary Judgment [Record No. 7] is

GRANTED, in part, to the extent that she seeks a remand for further administrative
proceedings.
2.

Defendant Berryhill’s Motion for Summary Judgment [Record No. 9] is

DENIED.
3.

Plaintiff Woodyard’s Motion for Leave to File Reply Memorandum [Record

No. 10] is DENIED.
4.

The decision of Administrative Law Judge Dennis Hansen is REMANDED for

further administrative proceedings consistent with this opinion and pursuant to sentence four
of 42 U.S.C. § 42 U.S.C. 405(g).

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This 16th day of March, 2018. 

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