Dickens v. Colvin
Filing
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ORDER granting 17 Plaintiff's Motion for Judgment on the Pleadings and denying 19 Defendant's Motion for Judgment on the Pleadings. Signed by District Judge Terrence W. Boyle on 9/22/2015. (Romine, L.)
IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF NORTH CAROLINA
EASTERN DIVISION
No. 4:14-CV-134-BO
JEFFREY DICKENS,
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Plaintiff,
v.
ORDER
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CAROLYN COLVIN,
Acting Commissioner of Social Security,
Defendant.
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This matter is before the Court on the parties' cross-motions for judgment on the
pleadings. [DE 17, 19]. A hearing on this matter was held in Edenton, North Carolina on
September 9, 2015. For the reasons discussed below, plaintiffs motion is GRANTED,
defendant's motion is DENIED, and the judgment of the commissioner is REVERSED.
BACKGROUND
Plaintiff applied for a period of disability and disability insurance benefits on June 24,
2010, alleging disability beginning May 11, 2010. [Tr. 296, 300]. This application was denied
initially and upon reconsideration. [Tr. 14]. An Administrative Law Judge held a hearing on
November 29,2011 and rendered an unfavorable decision to plaintiff on December 21,2011.
The Appeals Council granted plaintiffs request for review and remanded to a new
Administrative Law Judge (ALJ) to give further consideration to plaintiffs residual functional
capacity. [Tr. 14]. The second ALJ rendered an unfavorable decision to plaintiff on October 3,
2013. [Tr. 11]. This decision became the final decision ofthe Commissioner on May 30, 2014,
when the Appeals Council denied review. [Tr. 1]. Mr. Dickens then sought timely review in this
Court.
On his alleged onset of disability date, plaintiff was 46 years old, though he is now 51
years old. [Tr. 22]. He has a high school education and a prior career as an assistant computer
technician. [!d.]. Mr. Dickens has left knee traumatic arthritis, hypertension, and degenerative
disc disease of the lumbar spine with pain syndrome. [Tr. 17].
DISCUSSION
When a social security claimant appeals a final decision of the Commissioner, the Court's
review is limited to the determination of 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)). If the Commissioner's decision is supported by such evidence, it must be affirmed. Smith
v. Chafer, 99 F.3d 635, 638 (4th Cir. 1996).
To find a claimant disabled, an ALJ must conclude that the claimant satisfies each of five
steps. 20 C.F.R. § 404.1520(a)(4). First, a claimant must not be able to work in a substantial
gainful activity. !d. Second, a claimant must have a severe physical or mental impairment or
combination of impairments. !d. Third, a claimant's impairment( s) must be of sufficient duration
and must either meet or equal an impairment listed by the regulations. !d. Fourth, a claimant
must not have the residual functional capacity (RFC) to meet the demands of claimant's past
relevant work. !d. Finally, the claimant must not be able to do any other work, given the
claimant's residual functional capacity, age, education, and work experience. !d. The claimant
bears the burden of proof at steps one through four, but the burden shifts to the Commissioner at
step five. Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987).
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Here, the ALJ found that plaintiff has not engaged in substantial gainful activity since
May 11, 2010. [Tr. 16]. Second, the ALJ determined that plaintiffs left knee traumatic arthritis,
hypertension, and degenerative disc disease of the lumbar spine with pain syndrome were severe
impairments. [Tr. 17]. However, none of plaintiffs impairments or combination of impairments
met or medically equaled a listing. [!d.]. Next, the ALJ determined that plaintiff was capable of
performing only sedentary work with additional limitations for balancing and climbing, walking
with a cane, avoiding kneeling and crawling, and working around dangerous machinery and
unprotected heights. [!d.]. Finally, though plaintiff was unable to perform his past relevant work,
the ALJ determined that there are jobs that exist in significant numbers in the national economy
that plaintiff can perform. [Tr. 23]. A vocational expert testified that these would include data
entry clerk, order clerk, and receptionist. [!d.]. Accordingly, the ALJ, on remand, found that
plaintiff was not disabled since May 11, 201 0. [!d.]. Plaintiff now seeks review of the
determination that he is not disabled.
Substantial evidence does not support the ALJ's RFC finding in this case. First, the ALJ
did not afford appropriate weight to several doctors who reported on plaintiffs condition.
According to the regulations, the ALJ is to give controlling weight to the opinion of a treating
physician whose conclusions "on the issue(s) of the nature and severity of [the] impairment(s) is
well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not
inconsistent with the other substantial evidence." 20 CFR 404.1527.
Here, the ALJ elected to give treating physician Dr. Josiah Duke's opinion "little weight
as the doctor's opinion is without substantial support from the evidence of record." [Tr. 19].
However, examination ofthe record does not support this statement. Dr. Duke observed that
plaintiff was suffering from degenerative changes in his back at L4-5 and disc protrusion at L5-
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S 1, as well as "difficulties with extension, weightbearing and pain" in his left knee, including
being unable to put his full weight on his left knee. [Tr. 425, 419].
Contrary to the ALJ's conclusion, these observations are consistent with the evidence of
record. For example, Dr. Kumar observed that plaintiff limped, "cannot stand on his toes because
of the pain in his left knee" and observed reduced ability to bend the left knee compared to right
before diagnosing plaintiff with pain in the left knee. [Tr. 431]. Additionally, Dr. Maximous
observed limping, swelling, tenderness, limitation with pain in attempting to bend and extend the
knee, and decreased sensation of the left leg consistent with an impression of traumatic arthritis.
[Tr. 434]. Dr. Masere, to be discussed further infra, also observed limited ability to bend and
extend the left knee, inability to walk on heels and toes and tandem walk, swelling, and severe
degenerative joint disease that may require another surgery. [Tr. 442]. Dr. Kim also noted back
problems at L5-S 1 as well as continued suffering in the knee, assessing chronic pain syndrome as
a result. [Tr. 620, 624]. Each of these observations was made after plaintiffs knee surgery of
December 2009. [Tr. 19]. Moreover, a subsequent back MRI showed disc protrusion and
spondylosis, among other things. [Tr. 19]. Each of these observations is consistent with Dr.
Duke's observations about plaintiff, therefore rendering his conclusions "not inconsistent with
the other substantial evidence" and, thus, worthy of more than the "little weight" afforded by the
ALJ. [Tr. 19].
The ALJ also stated that he afforded Dr. Duke "little weight" in part because Dr. Duke
"acknowledged he was unable to diagnose the cause of claimant's symptoms." [Tr. 19].
However, the record does not fully support this conclusion. In fact, Dr. Duke observed that
plaintiff was "certainly having some type of a pain syndrome;" however, he recommended
getting a second opinion as to which exact pain syndrome it was. [Tr. 419]. Dr. Maximous-the
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type of pain specialist to whom Dr. Duke referred-was able to conclude that plaintiff was
suffering from reflex sympathetic dystrophy. [Tr. 434].
The ALI's consideration of Dr. Masere is also inconsistent. The ALJ stated that he
afforded Dr. Masere's opinion "significant weight" despite not being a treating physician. [Tr.
20]. The ALJ justified this by stating that Dr. Masere's opinion was "supported substantially by
other evidence of record and not only findings stemming from this single evaluation." [Tr. 20].
However, the ALJ then made a conclusion contrary to Dr. Masere's finding. Dr. Masere found
plaintiff incapable of "bending, stooping, crouching, and so on." [Tr. 42]. Nevertheless, despite
supposedly giving Dr. Masere "significant weight," the ALJ placed no limitations on any of
these activities when determining plaintiffs RFC, thus rendering his report internally
inconsistent. [Tr. 17].
Finally, the ALI's explanation for affording "only some weight" to plaintiffs favorable
Medicaid decision is unsatisfying. [Tr. 21]. The ALJ rightly notes that the finding of a disability
is reserved to the Commissioner. [SSR 06-03p]. However, though the Medicaid decision is not
binding on the ALJ, he is instructed to "explain the consideration given to these decisions." [SSR
06-03p]. Here, the ALI's only explanation-or discussion ofthe decision at all-was that "the
decision does not offer a comprehensive discussion of evidence." [Tr. 21-22]. However, review
of the Medicaid decision rebuts this. The Medicaid decision provides a thorough summary of
plaintiffs impairments, treatment history, and prognosis before concluding that he is capable of
only "less than sedentary work." [Tr. 373-76]. Therefore, the ALI's consideration of the
Medicaid decision is inadequate.
The decision of whether to reverse and remand for benefits or reverse and remand for a
new hearing is one which "lies within the sound discretion of the district court." Edwards v.
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Bowen, 672 F.Supp. 230, 236 (E.D.N.C. 1987). The Fourth Circuit has held that it is appropriate
for a federal court to "reverse without remanding where the record does not contain substantial
evidence to support a decision denying coverage under the correct legal standard and when
reopening the record for more evidence would serve no purpose." Breeden v. Weinberger, 493
F.2d 1002, 1012 (4th Cir. 1974). Remand, rather than reversal, is required when the ALJ fails to
explain his reasoning and there is ambivalence in the medical record, precluding a court from
"meaningful review." Radford v. Colvin, 734 F.3d 288, 296 (4th Cir. 2013) (citing Kastner v.
Astrue, 697 F.3d 642, 648 (7th Cir. 2012)). Here, it is clear that the record does not contain
substantial evidence to support a decision denying coverage. The Court therefore REVERSES
the decision of the Commissioner and remands to the agency for an award of benefits for the
closed period beginning with plaintiffs alleged onset date of May 11, 201 0.
CONCLUSION
For the foregoing reasons, defendant's motion for judgment on the pleadings [DE 19] is
DENIED, plaintiffs motion for judgment on the pleadings [DE 17] is GRANTED, and the
decision of the Commissioner is REVERSED. Accordingly, this case is REMANDED for an
award of benefits consistent with this Order.
SO ORDERED, this Uday of September, 2015.
TERRENCE W. BOYLE
UNITED STATES DISTRICT JU
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