Holder v. Berryhill

Filing 22

ORDER granting 15 Motion for Judgment on the Pleadings and denying 17 Motion for Judgment on the Pleadings. Signed by US District Judge Terrence W. Boyle on 2/27/2018. (Stouch, L.)

IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF NORTH CAROLINA
EASTERN DIVISION
No. 4:17-cv-35-BO
SUSAN S. HOLDER,

)
)
)
)

Plaintiff,

)

~

NANCY A. BERRYHILL,
Acting Commissioner of Social Security,
Defendant.

ORDER

)
)
)
)
)
)

This matter is before the court on the parties' cross-motions for judgment on the pleadings,
[D.E. 15, 17]. On December 21, 2017, the court held a hearing on the matter in Raleigh, North
Carolina. For the reasons discussed below, this matter is REMANDED for further consideration
by the Commissioner.

BACKGROUND
Plaintiff filed applications for disability and disability insurance benefits under Title II of
the Social Security Act ("Act") and alleged a disability onset date of March 17, 2014. See [Tr. 12,
146-150]. Plaintiffs applications were denied initially and upon reconsideration. See [Tr. 12, 67,
83-91]. On July 21, 2016, an Administrative Law Judge ("ALJ") held a hearing to consider
plaintiffs claims de novo. [Tr. 26-55].
On October 12, 2016, the ALJ issued a decision denying plaintiffs claims. [Tr. 12-21].
On January 26, 2017, the Appeals Council denied plaintiffs request for review, and the ALJ's
decision became the Commissioner's final decision. [Tr. 1-7]. On March 27, 2017, plaintiff filed
a complaint seeking judicial review pursuant to 42 U.S.C. § 405(g). [D.E. 5].

LEGAL STANDARD
A district court's review of the Commissioner's final decision is limited to determining
whether the correct legal standard was applied and 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 "such relevant

evidence as a reasonable mind might accept as adequate to support a conclusion." Johnson v.
Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (per curiam) (internal quotation and citation omitted).

"A necessary predicate to engaging in substantial evidence review is a record of the basis
for the ALJ's ruling," including "a discussion of which evidence the ALJ found credible and why,
and specific application of the pertinent

leg~l

requirements to the record evidence." Radford v.

Colvin, 734 F.3d 288, 295 (4th Cir. 2013). An ALJ's decision must "include a narrative discussion

describing how the evidence supports each conclusion," Monroe v. Colvin, 826 F.3d 176, 190 (4th
Cir. 2016) (quoting Mascio v. Colvin, 780 F.3d 632, 636 (4th cfr. 2015)), and an ALJ "must build
an accurate and logical bridge from the evidence to his conclusion." Id. at 189 (quoting Clifford
v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000)).

Under the Act, an individual is considered disabled if she is unable "to engage in any
substantial gainful activity by reason of any medically determinable physical or mental impairment
which can be expected to result in death or which has lasted or can be expected to last for a
continuous period of not less than [twelve] months." 42 U.S.C. § 1382c(a)(3)(A). Further:
an individual shall be determined to be under a disability only if [her] physical or
mental impairment or impairments are of such severity that [she] is not only unable
to do [her] previous work but cannot, considering [her] age, education, and work
experience, engage in any other line of substantial gainful work ....
42 U.S.C. § 1382c(a)(3)(B).

2

The ALJ engages in a sequential five-step evaluation process to make an initial disability
determination. 20 C.F.R. § 404.1520(a); see Johnson, 434 F.3d at 653. 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). If a decision regarding the claimant's disability

can be made at any step of the process, the ALJ's inquiry ceases. 20 C.F.R. § 404.1520(a)(4).
The ALJ denies the claim at step one if the claimant is currently engaged in substantial
gainful activity. 20 C.F.R. § 416.920(a)(4). At step two, the ALJ denies the claim ifthe claimant
does not have a severe impairment or combination of impairments significantly limiting her from
performing basic work activities. Id. At step three, the ALJ compares the claimant's impairment
to those in the Listing of Impairments. See 20 C.F.R. Part 404, Subpart P, App. 1. If the
impairment is listed, or equivalent to a listed impairment, disability is conclusively presumed
without considering the claimant's age, education, and work experience. 20 C.F.R. § 416.920(d).
However, if the impairment does not meet or equal a listed impairment, the ALJ then makes a
residual functional capacity ("RFC") finding. 20 C.F .R. § 404.1545(e).
The ALJ' s RFC finding considers both severe and non-severe impairments, and takes into
account both objective medical evidence as well as subjective complaints of pain and limitations.
20 C.F.R. § 404.1545(e). The ALJ considers the claimant's ability to meet the physical, mental,
sensory, and other requirements of accomplishing work. 20 C.F.R. § 404.1545(a)(4). An RFC
finding is meant to reflect the most that a claimant can do, despite her limitations. 20 C.F .R.
§ 404.1545(a)(l). An RFC finding should also reflect the claimant's ability to perform sustained
work-related activities in a work setting on regular and continuing basis, meaning eight-hours per
day and five days per week. See SSR 96-8p; Hines v. Barnhart, 453 F.3d 559, 562 (4th Cir. 2006).

3

At step four, the ALJ considers a claimant's RFC to determine whether she can perform
past relevant work ("PRW"). 20 C.F.R. § 416.920(a)(4). If not, the ALJ proceeds to step five:
establishing whether the claimant-based on her RFC, age, education, and work experience-can
perform substantial gainful other work. Id. To determine the available occupations that a claimant
could perform, the ALJ relies on the Dictionary of Occupational Titles ("DOT"). If the claimant
cannot perform other work, the ALJ finds her disabled. 20 C.F.R. § 416.920(a)(4).

THE ALJ'S DECISION
Applying the sequential five-step evaluation process, the ALJ found that steps one through
three favored plaintiff. [Tr. 14-20]. At step one, the ALJ found that, although plaintiff had worked
subsequent to her alleged disability onset date of March 17, 2014, plaintiff nevertheless had not
engaged in substantial gainful activity because her earnings were too modest. [Tr. 14].
At step two, the ALJ listed plaintiffs severe impairments, including: degenerative disc
disease (DDD), sciatica, Chronic Obstructive Pulmonary Disease (COPD), history of methicillin
resistant staphylococcus aureus (MRSA) infections, and obesity. Id. The ALJ determined that
plaintiffs complaints of hypertension, hyperlipidemia, gastro-esophageal reflux disease (GERD),
colon polyps, mild ileitis, diverticulosis, cholelithiasis, tinnitus, osteoporosis, and left knee pain
were not severe impairments because these conditions no more than minimally impact her ability
to work. [Tr. 15]. Specifically as to plaintiffs mental impairments-including depression, anxiety,
alcohol dependence, and personality disorder-the ALJ found that these conditions were non-severe
because they caused only mild limitations in her ability to perform basic mental work activities
and did not result in any extended episodes of decompensation. [Tr. 15-16].
At step three, the ALJ found that none of plaintiffs severe or non-severe impairments, nor
any combination, met or equaled one of the conditions in the Listing oflmpairments. [Tr. 16-17].

4

The ALJ then determined that plaintiff had the RFC to perform light work, as defined in 20 C.F.R.
§404.1567(b), with the following restrictions:
the claimant can frequently climb ramps and stairs, but occasionally climb ladders,
ropes, or scaffolds; she can frequently balance, but occasionally stoop, and
frequently kneel, crouch and/or crawl; she must avoid concentrated exposure to
temperature extremes of cold and heat, as well as humidity, and also concentrated
exposure to pulmonary irritants, such as fumes, odors, dusts, gases, poor
ventilation, and the like.
[Tr. 17]. The ALJ found that, although plaintiff had impairments which could reasonably be
expected to produce the symptoms alleged, plaintiffs statements about the severity of her
symptoms nevertheless were not fully credible. [Tr. 18]. The ALJ also noted that a June 2016
Magnetic Resonance Imaging (MRI) of plaintiffs lumbar spine indicated "mild spondylosis, facet
arthropathy and grade 1 anterolisthesis of L4 on LS with uncovering of the disc resulting in mild
to moderate spinal canal stenosis and moderate narrowing of the left lateral recess; mild right and
mild to moderate left exit foraminal stenosis." [Tr. 18] (quoting [Tr. 549]).
At step four, the ALJ found that plaintiff had the RFC to perform her PRW as a fast food
worker, fast food manager, check/cahier, and computer systems sales representative [Tr. 20]. The
ALJ accepted the testimony of the vocational expert ("VE") stating that "an individual of the
claimant's age, education, work experience, and residual functional capacity, could perform all of
these jobs consistent with the DOT. [Tr. 21]. The ALJ did not proceed to step five because he
had determined that that plaintiff could perform her PRW at step four. Thus, the ALJ concluded
that plaintiff was not disabled under the terms of the Act.
DISCUSSION

Here, the ALJ acknowledged that plaintiffs back impairment-DDD/sciatica-was severe
[Tr. 14], and noted that plaintiff had testified that she was unable to lift 20 pounds, had difficult
standing for an eight-hour workday, and that her employer sends her home early two days a week
5

because of back pain [Tr. 17-18]. Nevertheless, the ALJ found that the weight of the evidence
was not persuasive of a back disability [Tr. 18] and did not require any further RFC restrictions to
address her back impairment beyond those discussed above, see [Tr. 17].
The court finds that the ALJ did not create a "logical bridge" to link the record evidence to
the present RFC determination or otherwise indicate why, in spite of her severe back impairment,
plaintiff was nevertheless capable of performing her PRW. See Monroe, 826 F.3d 189. For
example, the ALJ noted the results of the June 2016 MRI [Tr. 18], but did not discuss whether
these results indicated a worsening of plaintiffs back impairment or whether the current RFC
actually accounts for this diagnostic result. Moreover, although the ALJ cited several record
medical opinions indicating that plaintiffs ability to lift or carry would be "moderately impaired,"
"moderately severely impaired," or "moderately limited" due to her back condition, the ALJ
merely found these medical opinions were vague or imprecise and gave them only partial weight,

see [Tr. 19-20], but did not adequately explain this seemingly contradictory evidence in the record.
See Cichocki v. Astrue, 729 F.3d 172, 177 (2d Cir. 2013) ("Remand may be appropriate, however,
where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite
contradictory evidence in the record, or where other inadequacies in the ALJ's analysis frustrate
meaningful review."); accord Mascio, 780 F.3d at 636.
Because the ALJ did not adequately address plaintiffs ability to perform the relevant
functions ·of her PRW, frustrating meaningful review, the court finds that it is precluded from
determining whether the ALJ's decision is supported by substantial evidence. See Perales, 402
U.S. at 401. Accordingly, the court will exercise its discretion and remand to the Commissioner
for additional fact-fmding, as necessary, to resolve the matter. See Radford, 734 F.3d at 296

6

(noting that remand, not 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.").
Plaintiff also alleges that the ALJ erred by (1) failing to give a full function-by-function
analysis of the non-exertional mental impairments, and (2) failing to give legally sufficient reasons
for rejecting plaintiffs testimony and making a negative credibility determination. See [D.E. 16]
at 2. However, because this case must be remanded on other grounds, the court need not address
these additional contentions of error. See Boone v. Barnhart, 353 F.3d 203, 211 n.19 (3d Cir.
2003), as amended (Dec. 18, 2003).
Upon remand, the Commissioner shall properly assess the severity of the symptoms of, and
the practical effects resulting from, plaintiffs back condition to determine whether plaintiff is able
to lift, carry, and stand for extended periods as required for "light work." See 20 C.F.R. §
404.1567(b) (defining "light work" as work that requires a claimant to lift "no more than 20 pounds
at a time with frequent carrying of objects weighing up to 10 pounds" and may also require "a
good deal of walking or standing."); SSR 96-8p; Hines, 453 F.3d at 562.
CONCLUSION
For the foregoing reasons, plaintiffs motion for judgment on the pleadings [D.E. 15] is
GRANTED and defendant's motion [D.E. 17] is DENIED. The decision of the Commissioner is
REMANDED to the Commissioner for further proceedings consistent with this decision.

SO ORDERED.

-

ThisV day of February, 2018.

~
TERRENCE W. BOYLE
UNITED STATES DISTRI

7