FINGER v. BERRYHILL
Filing
16
MEMORANDUM OPINION AND RECOMMENDATION OF UNITED STATES MAGISTRATE JUDGE signed by MAG/JUDGE JOI ELIZABETH PEAKE on 02/26/2018, that the Commissioner's decision finding no disability be REVERSED, and that the matter be REMANDED to the Commiss ioner under sentence four of 42 U.S.C. § 405(g). The Commissioner should be directed to remand the matter to the ALJ for proceedings consistent with this Recommendation. To this extent, Defendant's Motion for Judgment on the Pleadings [Do c. # 13 should be DENIED, and Plaintiff's Motion for Judgment Reversing the Commissioner [Doc. # 11 should be GRANTED. However, to the extent that Plaintiff' motion seeks an immediate award of benefits, it should be DENIED.(Taylor, Abby)
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF NORTH CAROLINA
JOHNNY RAY FINGER,
Plaintiff,
v.
NANCY A. BERRYHILL,
Acting Commissioner of Social Security,
Defendant.
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1:17CV188
MEMORANDUM OPINION AND RECOMMENDATION
OF UNITED STATES MAGISTRATE JUDGE
Plaintiff Johnny Ray Finger (“Plaintiff”) brought this action pursuant to Sections 205(g)
and 1631(c)(3) of the Social Security Act (the “Act”), as amended (42 U.S.C. §§ 405(g) and
1383(c)(3)), to obtain judicial review of a final decision of the Commissioner of Social Security
denying his claims for Disability Insurance Benefits and Supplemental Security Income under,
respectively, Titles II and XVI of the Act. The parties have filed cross-motions for judgment,
and the administrative record has been certified to the Court for review.
I.
PROCEDURAL HISTORY
Plaintiff protectively filed applications for Disability Insurance Benefits and
Supplemental Security Income Benefits on August 26, 2013, alleging a disability onset date of
September 21, 2012 in both applications. (Tr. at 153, 258-67.) 1 His applications were denied
initially (Tr. at 69-108) and upon reconsideration (Tr. at 109-49).
1
Transcript citations refer to the Sealed Administrative Record [Doc. #8].
Thereafter, Plaintiff
requested an administrative hearing de novo before an Administrative Law Judge (“ALJ”).
(Tr. at 207-09.) Plaintiff, along with his attorney and an impartial vocational expert, attended
the subsequent video hearing on September 17, 2015. (Tr. at 153.) At the hearing, Plaintiff
amended his alleged onset date to December 1, 2013. (Id.) The ALJ ultimately concluded
that Plaintiff was not disabled within the meaning of the Act from his amended alleged onset
date through November 25, 2015, the date of the administrative decision. (Tr. at 165.) On
January 11, 2017, the Appeals Council denied Plaintiff’s request for review of the decision,
thereby making the ALJ’s conclusion the Commissioner’s final decision for purposes of
judicial review. (Tr. at 1-5.)
II.
LEGAL STANDARD
Federal law “authorizes judicial review of the Social Security Commissioner’s denial of
social security benefits.” Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). However, the
scope of review of such a decision is “extremely limited.” Frady v. Harris, 646 F.2d 143, 144
(4th Cir. 1981). “The courts are not to try the case de novo.” Oppenheim v. Finch, 495 F.2d
396, 397 (4th Cir. 1974). Instead, “a reviewing court must uphold the factual findings of the
ALJ if they are supported by substantial evidence and were reached through application of the
correct legal standard.” Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012) (internal
quotation omitted).
“Substantial evidence means ‘such relevant evidence as a reasonable mind might accept
as adequate to support a conclusion.’” Hunter v. Sullivan, 993 F.2d 31, 34 (4th Cir. 1993)
(quoting Richardson v. Perales, 402 U.S. 389, 390 (1971)). “It consists of more than a mere
scintilla of evidence but may be somewhat less than a preponderance.” Mastro v. Apfel, 270
2
F.3d 171, 176 (4th Cir. 2001) (internal citations and quotation marks omitted). “If there is
evidence to justify a refusal to direct a verdict were the case before a jury, then there is
substantial evidence.” Hunter, 993 F.2d at 34 (internal quotation marks omitted).
“In reviewing for substantial evidence, the court should not undertake to re-weigh
conflicting evidence, make credibility determinations, or substitute its judgment for that of the
[ALJ].” Mastro, 270 F.3d at 176 (internal brackets and quotation marks omitted). “Where
conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the
responsibility for that decision falls on the ALJ.” Hancock, 667 F.3d at 472. “The issue before
[the reviewing court], therefore, is not whether [the claimant] is disabled, but whether the
ALJ’s finding that [the claimant] is not disabled is supported by substantial evidence and was
reached based upon a correct application of the relevant law.” Craig v. Chater, 76 F.3d 585,
589 (4th Cir. 1996).
In undertaking this limited review, the Court notes that “[a] claimant for disability
benefits bears the burden of proving a disability.” Hall v. Harris, 658 F.2d 260, 264 (4th Cir.
1981). In this context, “disability” means the “‘inability 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 12 months.’” Id. (quoting 42 U.S.C. § 423(d)(1)(A)). 2
“The Social Security Act comprises two disability benefits programs. The Social Security Disability Insurance
Program (SSDI), established by Title II of the Act as amended, 42 U.S.C. § 401 et seq., provides benefits to
disabled persons who have contributed to the program while employed. The Supplemental Security Income
Program (SSI), established by Title XVI of the Act as amended, 42 U.S.C. § 1381 et seq., provides benefits to
indigent disabled persons. The statutory definitions and the regulations promulgated by the Secretary for
determining disability, see 20 C.F.R. pt. 404 (SSDI); 20 C.F.R. pt. 416 (SSI), governing these two programs are,
in all aspects relevant here, substantively identical.” Craig, 76 F.3d at 589 n.1.
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“The Commissioner uses a five-step process to evaluate disability claims.” Hancock,
667 F.3d at 472 (citing 20 C.F.R. §§ 404.1520(a)(4); 416.920(a)(4)). “Under this process, the
Commissioner asks, in sequence, whether the claimant: (1) worked during the alleged period
of disability; (2) had a severe impairment; (3) had an impairment that met or equaled the
requirements of a listed impairment; (4) could return to her past relevant work; and (5) if not,
could perform any other work in the national economy.” Id.
A finding adverse to the claimant at any of several points in this five-step sequence
forecloses a disability designation and ends the inquiry. For example, “[t]he first step
determines whether the claimant is engaged in ‘substantial gainful activity.’ If the claimant is
working, benefits are denied. The second step determines if the claimant is ‘severely’ disabled.
If not, benefits are denied.” Bennett v. Sullivan, 917 F.2d 157, 159 (4th Cir. 1990).
On the other hand, if a claimant carries his or her burden at the first two steps, and if
the claimant’s impairment meets or equals a “listed impairment” at step three, “the claimant
is disabled.” Mastro, 270 F.3d at 177. Alternatively, if a claimant clears steps one and two,
but falters at step three, i.e., “[i]f a claimant’s impairment is not sufficiently severe to equal or
exceed a listed impairment,” then “the ALJ must assess the claimant’s residual functional
capacity (‘RFC’).” Id. at 179. 3 Step four then requires the ALJ to assess whether, based on
“RFC is a measurement of the most a claimant can do despite [the claimant’s] limitations.” Hines, 453 F.3d
at 562 (noting that administrative regulations require RFC to reflect claimant’s “ability to do sustained workrelated physical and mental activities in a work setting on a regular and continuing basis . . . [which] means 8
hours a day, for 5 days a week, or an equivalent work schedule” (internal emphasis and quotation marks
omitted)). The RFC includes both a “physical exertional or strength limitation” that assesses the claimant’s
“ability to do sedentary, light, medium, heavy, or very heavy work,” as well as “nonexertional limitations
(mental, sensory, or skin impairments).” Hall, 658 F.2d at 265. “RFC is to be determined by the ALJ only after
[the ALJ] considers all relevant evidence of a claimant’s impairments and any related symptoms (e.g., pain).”
Hines, 453 F.3d at 562-63.
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that RFC, the claimant can “perform past relevant work”; if so, the claimant does not qualify
as disabled. Id. at 179-80. However, if the claimant establishes an inability to return to prior
work, the analysis proceeds to the fifth step, which “requires the [Government] to prove that
a significant number of jobs exist which the claimant could perform, despite the claimant’s
impairments.” Hines, 453 F.3d at 563. In making this determination, the ALJ must decide
“whether the claimant is able to perform other work considering both [the claimant’s RFC]
and [the claimant’s] vocational capabilities (age, education, and past work experience) to adjust
to a new job.” Hall, 658 F.2d at 264-65. If, at this step, the Government cannot carry its
“evidentiary burden of proving that [the claimant] remains able to work other jobs available
in the community,” the claimant qualifies as disabled. Hines, 453 F.3d at 567.
III.
DISCUSSION
In the present case, the ALJ found that Plaintiff had not engaged in “substantial gainful
activity” since his amended alleged onset date. Plaintiff therefore met his burden at step one
of the sequential evaluation process. At step two, the ALJ further determined that Plaintiff
suffered from the following severe impairments:
status post cervical fusion, cervical radiculopathy, and major depressive
disorder.
(Tr. at 155.) The ALJ found at step three that none of these impairments, individually or in
combination, met or equaled a disability listing. (Tr. at 156.) Therefore, the ALJ assessed
Plaintiff’s RFC and determined that he had the following limitations:
[T]he claimant can lift or carry up to ten pounds occasionally and frequently.
[He] can stand or walk for four hours and can sit for up to six hours. The
claimant can engage in occasional stooping, crouching, kneeling, crawling or
climbing of ramps and stairs. [He] can engage in frequent handling/fingering,
and occasional overhead reaching with both extremities, but should never climb
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ladders, ropes[,] or scaffolds. The claimant is limited to simple, routine[,] and
repetitive work tasks and can occasionally interact with supervisors and have
incidental interaction with the general public[,] but should not engage in direct
customer service. [He] can work in proximity to co-workers but should not
work with them. Additionally, the claimant can work in an environment with
few, in any, workplace changes. Furthermore, the claimant would need a
sit/stand option every hour for three to five minutes.
(Tr. at 158.) Based on the RFC determination, the ALJ found under step four of the analysis
that Plaintiff could not perform any of his past relevant work. (Tr. at 163.) However, the ALJ
determined at step five that, given Plaintiff’s age, education, work experience, RFC, and the
testimony of the vocational expert as to these factors, he could perform other jobs available
in the national economy. (Tr. at 164-65.) Therefore, the ALJ concluded that Plaintiff was not
disabled under the Act. (Tr. at 165.)
Plaintiff now contends that the ALJ erred in failing to analyze and assign weight to the
medical opinion statement completed by Dr. Landis S. Williams, one of Plaintiff’s treating
pain management physicians. After a thorough review of the record, the Court agrees that,
under the specific fact of this case, the ALJ’s omission merits remand.
For claims, like Plaintiff’s, that are filed before March 24, 2017, the ALJ evaluates
medical opinion evidence in accordance with 20 C.F.R. §§ 404.1527(c) and 416.927(c) and the
“treating physician rule” embodied within the regulations. Brown v. Comm’r Soc. Sec., 873
F.3d 251, 255 (4th Cir. 2017). Under the regulations, “medical opinions” are “statements from
acceptable medical sources that reflect judgments about the nature and severity of your
impairment(s), including your symptoms, diagnosis and prognosis, what you can still do
despite impairment(s), and your physical or mental restrictions.” Id. (citing 20 C.F.R.
§ 404.1527(a)(1)); see also 20 C.F.R. § 416.927(a)(1). While the regulations mandate that the
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ALJ evaluate each medical opinion presented to him, generally “more weight is given to the
medical opinion of a source who has examined you than to the medical opinion of a medical
source who has not examined you.”
Brown, 873 F.3d at 255 (quoting 20 C.F.R.
§ 404.1527(c)(1)); see also 20 C.F.R. § 416.927(c)(1). And, under what is commonly referred
to as the “treating physician rule,” the ALJ generally accords the greatest weight—controlling
weight—to the well-supported opinion of a treating source as to the nature and severity of a
claimant’s impairment, based on the ability of treating sources to
provide a detailed, longitudinal picture of [the claimant’s] medical impairment(s)
[which] may bring a unique perspective to the medical evidence that cannot be
obtained from the objective medical findings alone or from reports of individual
examinations, such as consultative examinations or brief hospitalizations.
20 C.F.R. § 404.1527(c)(2). However, if a treating source’s opinion is not “well-supported by
medically acceptable clinical and laboratory diagnostic techniques or is inconsistent with other
substantial evidence in the case record,” it is not entitled to controlling weight. Social Security
Ruling (“SSR”) 96-2p, 1996 WL 374188, at *5; 20 C.F.R. § 404.1527(c)(2); see also Brown,
873 F.3d at 255; Craig, 76 F.3d at 590; Mastro, 270 F.3d at 178. 4 Instead, the opinion must
be evaluated and weighed using all of the factors provided in 20 C.F.R. § 404.1527(c)(2)-(c)(6),
including (1) the length of the treatment relationship, (2) the frequency of examination, (3) the
nature and extent of the treatment relationship, (4) the supportability of the opinion, (5) the
consistency of the opinion with the record, (6) whether the source is a specialist, and (7) any
For claims filed after March 27, 2017, the regulations have been amended and several of the prior Social
Security Rulings, including SSR 96-2p, have been rescinded. The new regulations provide that the Social
Security Administration “will not defer or give any specific evidentiary weight, including controlling weight, to
any medical opinion(s) or prior administrative medical finding(s), including those from your medical sources.”
20 C.F.R. § 404.1520c. However, the claim in the present case was filed before March 27, 2017, and the Court
has therefore analyzed Plaintiff’s claims pursuant to the treating physician rule set out above.
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other factors that may support or contradict the opinion. In addition, even if an opinion by a
treating physician is given controlling weight with respect to the nature and severity of a
claimant’s impairment, opinions by physicians regarding the ultimate issue of whether a
plaintiff is disabled within the meaning of the Act are never accorded controlling weight
because the decision on that issue is reserved for the Commissioner alone. 20 C.F.R.
§ 404.1527(d). “Thus, for example, when a medical source renders an opinion that a claimant
is ‘disabled’ or ‘unable to work,’ the ALJ will consider ‘all of the medical findings and other
evidence that support’ the medical source’s opinion, but will not necessarily make a favorable
disability determination.” Brown, 873 F.3d at 256 (citing 20 C.F.R. § 404.1527(d)(1)); see also
20 C.F.R. § 416.927(d)(1).
Where an ALJ declines to give controlling weight to a treating source opinion, he must
“give good reasons in [his] ... decision for the weight” assigned, taking the above factors into
account. 20 C.F.R. § 416.927(c)(2). “This requires the ALJ to provide sufficient explanation
for ‘meaningful review’ by the courts.” Thompson v. Colvin, No. 1:09CV278, 2014 WL
185218, at *5 (M.D.N.C. Jan. 15, 2014) (quotations omitted); see also SSR 96–2p (noting that
the decision “must contain specific reasons for the weight given to the 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”).
Notably, even “implicit
assignments of weight can support meaningful review” so long as the ALJ’s decision “make[s]
clear that he ‘recognized and evaluated the treating relationships’ of medical sources.’”
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Thomas v. Comm’r of Soc. Sec., No. Civ. WDQ-10-3070, 2012 WL 670522, at *7 (D. Md.
Feb. 27, 2012).
In the present case, the ALJ omitted any reference to a one-page medical opinion
statement completed by Dr. Williams on September 11, 2015. (Tr. at 518.) In the statement,
Dr. Williams checked boxes finding that the following were “present on examination or
testing”:
Chronic neck pain with loss of range of motion
Associated numbness and tingling that radiate into bilateral upper extremities
Chronic low back pain
Carpal tunnel syndrome
Significant depressive disorder due to physical condition
(Tr. at 518.) Dr. Williams then opined that, due to his impairments, Plaintiff could only
occasionally “perform fine and gross manipulative tasks with his upper extremities,” would be
unable to perform sedentary work on a full-time basis, and would be off task for more than
20% of the workday or absent from work more than two days per month due to his symptoms.
(Tr. at 518.)
Defendant concedes that the ALJ failed to address Dr. Williams’ opinion. Defendant
nevertheless contends that the ALJ’s failure to address this opinion constitutes harmless error,
as another physician, Dr. Joseph Davis, completed a one-page medical opinion statement
similar to Dr. Williams’ statement just one day earlier, on September 10, 2015, and checked or
circled the same eight answers as Dr. Williams. (See Tr. at 163, 516, 518.) Dr. Davis also
added notes indicating the degree to which Plaintiff’s sitting, standing, and manipulative
limitations would impact his work and included two diagnoses, namely depression and low
back pain, not listed by Dr. Williams. (Tr. at 516, 518.) The ALJ considered Dr. Davis’
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opinions at length in her decision and ultimately accorded them “some weight.” Defendant
asserts that, because Dr. Williams’ medical statement contains the same opinions as Dr. Davis’,
the ALJ’s reasons for discounting Dr. Davis’ opinions are “equally applicable” to Dr. Williams,
and therefore support meaningful review. See Yuengal v. Astrue, No. 4:10-CV-42-FL, 2010
WL 5589102, at *9 (E.D.N.C. Dec. 17, 2010) (finding harmless error where the ALJ failed to
consider the opinion of the plaintiff’s treating psychiatrist but evaluated an identical opinion
from the psychiatrist who handled the plaintiff’s subsequent psychiatric care).
However, Dr. Williams and Dr. Davis are not part of the same medical practice, and
there is no basis to believe that they completed the forms in a coordinated way. Dr. Williams
is an anesthesiologist at the Northeast Pain Management Center. Plaintiff received treatment
from Dr. Williams and other physicians and nurse practitioners at the Northeast Pain
Management Center over a two-year period from September 2013 to August 2015. (Tr. at
159-160, 519, 402, 470, 511, 518-19.) In contrast, Dr. Davis was Plaintiff’s primary care
physician at Concord Internal Medicine. (Tr. at 31, 163, 447, 508, 516.) Thus, this is not a
situation where two providers at the same practice completed a duplicate form, or where a
later provider who took over care in the same specialty completed a form that incorporated
the findings in the record of an earlier provider. Instead, Dr. Williams’ medical statement
appears to be a separate opinion that reaches the same conclusions as Dr. Davis.
Moreover, the sole reason the ALJ gave for discounting Dr. Davis’ opinion was that it
was “not consistent with the greater weight of the clinical evidence which demonstrates that
the claimant is capable of a wide range of function despite his pain levels.” (Tr. at 163.) As
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Plaintiff correctly notes, Dr. Davis’ opinion was consistent with Dr. Williams’ unaddressed
opinion. Thus, as Plaintiff notes in his Reply Brief, Defendant’s argument:
ignores the fact that the ALJ cited inconsistency with other evidence on file as
a reason for his assigning Dr. Davis’ opinion less than controlling weight. (See
Tr. at 163.) Thus, the fact that Dr. Williams’ medical opinion is consistent with
Dr. Davis’ opinion does not render it less persuasive, but rather undermines
substantial support for the ALJ’s treatment of Dr. Davis’ medical opinion.
(Pl.’s Resp. Br. [Doc. #15] at 2.)
In addition, the ALJ’s failure to address Dr. Williams’ opinion statement is further
aggravated by the ALJ’s failure to even mention or address the treatment records reflecting
Dr. Williams’ examination of Plaintiff prior to the completion of his September 2015 medical
opinion statement. In generally reviewing the treatment records, the ALJ noted that Plaintiff
began experiencing increased neck pain, along with numbness and tingling in his arms, in May
2013. Plaintiff had previously undergone an anterior cervical spine discectomy and fusion of
the C3 through C6 levels in 2009, following injury in a car accident. (Tr. at 159.) Although
Plaintiff’s 2013 MRIs warranted a referral to a neurosurgeon, Plaintiff was uninsured and
unable to afford further surgery at that time. (Tr. at 159-60, 470-71.) Instead, he was referred
to a pain management program, where, among other providers, he was treated by Dr. Williams.
(Id.) The ALJ noted that, in December 2013, Plaintiff “was not a candidate for epidural steroid
injections.” (Tr. at 160.) However, in so noting, the ALJ failed to mention that the reason
Plaintiff was not a candidate for the injections was that his stenosis was considered too severe.
(Tr. at 438, 471, 511.) Instead, his providers recommended that “he get in to see his
neurosurgeon as soon as possible.” (Tr. at 430.) Because Plaintiff was still unable to afford
specialist treatment a year later, Dr. Williams agreed to try a “right C3-C4 and C5 medial
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branch block” to help Plaintiff achieve better pain control. (Tr. at 471.) Plaintiff saw Dr.
Williams in April 2015, and Dr. Williams noted that Plaintiff
was found to have a combination of cervical radiculopathy with severe left and
moderate to severe foraminal stenosis and change at the C5-C6 level, also mild
to moderate canal stenosis from combined disk bulge and endplate spurring
ligamentum flavum thickening at C5-C6 with restriction of the cerebrospinal
fluid, both anterior and posterior, with slight flattening of the left ventral cord,
no edema or gliosis of the cervical spine noted.
(Tr. at 511.) Dr. Williams noted that Plaintiff’s MRI reflected “fairly severe stenosis” at C5C6 and “left side neural foraminal narrowing which was graded severe at the C6-C7 level where
more severe bilateral narrowing was noted at C5-C6.” (Tr. at 511.) Dr. Williams noted that
Plaintiff experienced “marked difficulty with pain in the hand, particularly the thumb and
index finger and pain with radiation from neck into the arms bilaterally, right side greater than
left,” and “marked difficulty with extension and flexion of the wrist causing pain in the medial
aspect of the wrist and tingling into the index finger and thumb.” (Tr. at 511.) Dr. Williams
explained that “comorbidities may be at play to include carpal tunnel syndrome in conjunction
with upper extremity radiculopathy in a C5, C6 and C7 distribution, also potentially affecting
C4 as well.” (Tr. at 511.) Dr. Williams then chronicled the following objective findings upon
examination:
Motor examination showed bilateral weakness in arm abduction at 15 degrees,
graded 4/5. Shoulder shrug graded 4/5, weaker on the right than left. Elbow
flexion and extension both 4/5, somewhat weaker potentially on the right side
again, particularly with elbow extension. Wrist flexion and extension both
weakened, greater on the right side, again, still within the 3-4 range in strength.
Finger flexion graded 4/5 as well, greater strength was noted on the left than
right. Also, opponens of thumb to index finger weaker on the right graded 4/5
and inability to easily place thumb to fifth finger at all, particularly on the right.
The patient did demonstrate positive Chvostek’s sign with increased pain with
extension of the wrists and tapping on carpal tunnel on the right, not so on the
left. This pain was worsened in the wrists with both attempts at extreme ranges
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to match left wrist of flexion and extension. Deep tendon reflexes for bilateral
triceps tendons, biceps tendons and brachioradialis were ¼.
(Tr. at 512.) In light of these findings, Dr. Williams planned to perform “a median nerve block
at the wrists . . . to assess what degree of symptomatology is related to carpal tunnel syndrome
in the right upper extremity versus radiculopathy from cervical pathology.” (Id.) He also
scheduled “a cervical selective nerve root block and/or transforaminal epidural injection of
the right C5-C6 and C6-C7 neural foramen in approximately 2-4 weeks.” (Id.) In July and
August of 2015, Dr. Williams performed right transforaminal epidural steroid injections at C5C6 and C6-C7. (Tr. at 161, 532-35.) Dr. Williams specifically noted that these injections
differed from the interlaminar epidural steroid injections precluded by the severity of Plaintiff’s
stenosis. (Tr. at 511.) Dr. Williams also noted that Plaintiff “does have cervical facet
arthropathy, without insurance coverage to perform a medial branch denervation in the area.”
(Tr. at 534.)
The ALJ failed to mention or cite Dr. Williams’ April 2015 treatment note or any of
the findings therein. Its absence from the administrative decision compounds the ALJ’s
previous error, as she omitted not only Dr. Williams’ opinion, but much of the basis for it. As
noted above, Dr. Williams indicated in his September 11, 2015 statement that Plaintiff suffered
from “chronic neck pain with loss of range of motion,” “associated numbness and tingling
that radiate[s] into [the] bilateral upper extremities,” “chronic low back pain,” “carpal tunnel
syndrome,” and “significant depressive disorder due to physical symptoms.” (Tr. at 518.) Dr.
Williams then opined that, due to his impairments, Plaintiff could only occasionally “perform
fine and gross manipulative tasks with his upper extremities,” would be unable to perform
sedentary work on a full-time basis, and would be off task for more than 20% of the workday
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or absent from work more than two days per month. (Tr. at 518) Ultimately, the ALJ’s failure
to address Dr. Williams’ opinion evidence and related treatment records render the Court
unable to meaningfully review the ALJ’s decision to determine if it is supported by substantial
evidence, and attempts to infer how the ALJ would have weighed or addressed this evidence
“would require excessive intrusion into the ALJ’s domain.” Anderson v. Colvin, No.
1:10CV671, 2014 WL 1224726 at *3 (M.D.N.C. March 25, 2014). 5 As noted in Anderson,
while the Court may make simple conclusions of law in finding that an ALJ’s error is harmless,
the Court may not “parse the administrative transcripts and make . . . dispositive findings of
fact that the ALJ did not make.” Id. at *4. Here, accepting the Commissioner’s arguments
would require the Court to do just that. 6 The relevant evidence should be considered and
addressed by the ALJ in the first instance. Accordingly, this matter merits remand.
IT IS THEREFORE RECOMMENDED that the Commissioner’s decision finding
no disability be REVERSED, and that the matter be REMANDED to the Commissioner
under sentence four of 42 U.S.C. § 405(g). The Commissioner should be directed to remand
the matter to the ALJ for proceedings consistent with this Recommendation. To this extent,
Defendant’s Motion for Judgment on the Pleadings [Doc. #13] should be DENIED, and
In Anderson, the Court noted that “[r]eview of the ALJ’s ruling is limited further by the so-called ‘Chenery
Doctrine,’ which prohibits courts from considering post hoc rationalizations in defense of administrative
agency decisions. . . . Under the doctrine, a reviewing court ‘must judge the propriety of [agency] action solely
by the grounds invoked by the agency. . . . If those grounds are inadequate or improper, the court is powerless
to affirm the administrative action by substituting what it considers to be a more adequate or proper basis.’ ”
Id. at *1 (quoting Sec. & Exch. Comm’n v. Chenery Corp., 332 U.S. 194 (1947)). In applying this doctrine in
Anderson, the Court noted that “jurisprudence on this issue is far from clear,” and “this court will err on the
side of caution” and avoid “excessive intrusion into the ALJ’s domain.” Id. at *3.
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In addition, as discussed above, because both Dr. Williams’ contemporaneous opinion and his earlier
treatment notes corroborate Dr. Davis’ findings, yet were omitted from the ALJ’s decision, there remain
unaddressed issues regarding how the ALJ would address Dr. Davis’ opinion in light of Dr. Williams’ treatment
notes and similar opinion evidence.
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Plaintiff’s Motion for Judgment Reversing the Commissioner [Doc. #11] should be
GRANTED. However, to the extent that Plaintiff’s motion seeks an immediate award of
benefits, it should be DENIED.
This, the 26th day of February, 2018.
/s/ Joi Elizabeth Peake
United States Magistrate Judge
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