McCraw v. Colvin
MEMORANDUM OF DECISION AND ORDER: Plaintiff's 11 Motion for Summary Judgment is GRANTED and Defendant's 16 Motion for Summary Judgment is DENIED. The decision of the Commissioner is REVERSED and the case is hereby REMANDED for further administrative proceedings consistent with this opinion. Signed by District Judge Martin Reidinger on 3/12/2018. (maf)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF NORTH CAROLINA
CIVIL CASE NO. 1:16-cv-00402-MR
ANGELA HILL McCRAW,
NANCY A. BERRYHILL, Acting
Commissioner of Social Security,
DECISION AND ORDER
THIS MATTER is before the Court on the Plaintiff’s Motion for
Summary Judgment [Doc. 11] and the Defendant’s Motion for Summary
Judgment [Doc. 16].
On March 26, 2013, the Plaintiff Angela Hill McCraw protectively filed
an application for a period of disability and disability insurance benefits under
Title II of the Social Security Act, alleging an onset date of October 10, 2012.
[Transcript (“T.”) at 214]. The Plaintiff’s application was denied initially and
upon reconsideration. [T. at 156, 161]. Upon the Plaintiff’s request, a
hearing was held on September 16, 2015, before an Administrative Law
[T. at 57-102].
The Plaintiff, who was represented by
counsel, testified at the hearing, as did a vocational expert (“VE”). [Id.]. On
October 15, 2015, the ALJ issued a decision, wherein the ALJ concluded
that the Plaintiff was not disabled. [T. at 39-50]. On December 15, 2016,
the Appeals Council denied the Plaintiff’s request for review [T. at 1-3],
thereby making the ALJ’s decision the final decision of the Commissioner.
The Plaintiff has exhausted all available administrative remedies, and this
case is now ripe for review pursuant to 42 U.S.C. § 405(g).
STANDARD OF REVIEW
The Court’s review of a final decision of the Commissioner is limited to
(1) whether substantial evidence supports the Commissioner’s decision,
Richardson v. Perales, 402 U.S. 389, 401 (1971); and (2) whether the
Commissioner applied the correct legal standards, Hays v. Sullivan, 907
F.2d 1453, 1456 (4th Cir. 1990).
“When examining [a Social Security
Administration] disability determination, a reviewing court is required to
uphold the determination when an ALJ has applied correct legal standards
and the ALJ’s factual findings are supported by substantial evidence.” Bird
v. Comm’r, 699 F.3d 337, 340 (4th Cir. 2012). “Substantial evidence is 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)
(internal quotation marks omitted). “It consists of more than a mere scintilla
of evidence but may be less than a preponderance.” Hancock v. Astrue, 667
F.3d 470, 472 (4th Cir. 2012) (internal quotation marks omitted).
“In reviewing for substantial evidence, [the Court should] not undertake
to reweigh conflicting evidence, make credibility determinations, or substitute
[its] judgment for that of the ALJ.”
Johnson, 434 F.3d at 653 (internal
quotation marks and alteration omitted).
Rather, “[w]here conflicting
evidence allows reasonable minds to differ,” the Court defers to the ALJ’s
decision. Id. (internal quotation marks omitted). To enable judicial review
for substantial evidence, “[t]he record should include a discussion of which
evidence the ALJ found credible and why, and specific application of the
pertinent legal requirements to the record evidence.” Radford v. Colvin, 734
F.3d 288, 295 (4th Cir. 2013).
THE SEQUENTIAL EVALUATION PROCESS
A “disability” entitling a claimant to benefits under the Social Security
Act, as relevant here, is “[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.”
42 U.S.C. § 423(d)(1)(A). The Social Security Administration regulations set
out a detailed five-step process for reviewing applications for disability. 20
C.F.R. §§ 404.1520, 416.920; Mascio v. Colvin, 780 F.3d 632, 634 (4th Cir.
2015). “If an applicant’s claim fails at any step of the process, the ALJ need
not advance to the subsequent steps.” Pass v. Chater, 65 F.3d 1200, 1203
(4th Cir. 1995) (citation omitted). The burden is on the claimant to make the
requisite showing at the first four steps. Id.
At step one, the ALJ determines whether the claimant is engaged in
substantial gainful activity.
If so, the claimant’s application is denied
regardless of the medical condition, age, education, or work experience of
the claimant. Id. (citing 20 C.F.R. § 416.920). If not, the case progresses to
step two, where the claimant must show a severe impairment. If the claimant
does not show any physical or mental deficiencies, or a combination thereof,
which significantly limit the claimant’s ability to perform work activities, then
no severe impairment is established and the claimant is not disabled. Id.
At step three, the ALJ must determine whether one or more of the
claimant’s impairments meets or equals one of the listed impairments
(“Listings”) found at 20 C.F.R. 404, Appendix 1 to Subpart P. If so, the
claimant is automatically deemed disabled regardless of age, education or
work experience. Id. If not, before proceeding to step four, the ALJ must
assess the claimant’s residual functional capacity (“RFC”). The RFC is an
administrative assessment of “the most” a claimant can still do on a “regular
and continuing basis” notwithstanding the claimant’s medically determinable
impairments and the extent to which those impairments affect the claimant’s
ability to perform work-related functions.
SSR 96-8p; 20 C.F.R. §§
404.1546(c); 404.943(c); 416.945.
At step four, the claimant must show that his or her limitations prevent
the claimant from performing his or her past work. 20 C.F.R. §§ 404.1520,
416.920; Mascio, 780 F.3d at 634. If the claimant can still perform his or her
past work, then the claimant is not disabled.
Otherwise, the case
progresses to the fifth step where the burden shifts to the Commissioner. At
step five, the Commissioner must establish that, given the claimant’s age,
education, work experience, and RFC, the claimant can perform alternative
work which exists in substantial numbers in the national economy. Id.; Hines
v. Barnhart, 453 F.3d 559, 567 (4th Cir. 2006). “The Commissioner typically
offers this evidence through the testimony of a vocational expert responding
to a hypothetical that incorporates the claimant’s limitations.” 20 C.F.R. §§
404.1520, 416.920; Mascio, 780 F.3d at 635. If the Commissioner succeeds
in shouldering her burden at step five, the claimant is not disabled and the
application for benefits must be denied. Id. Otherwise, the claimant is
entitled to benefits. In this case, the ALJ rendered a determination adverse
to the Plaintiff at the fifth step.
THE ALJ’S DECISION
At step one, the ALJ found that Plaintiff has not engaged in substantial
gainful activity since October 10, 2012, her alleged onset date. [T. at 41]. At
step two, the ALJ found that the Plaintiff has the following severe
impairments: obesity, migraine headaches, mild to moderate degenerative
disc disease of the lumbar and cervical spine, left-sided hearing loss status
post removal of mastoid air cell carcinoma, mild obstructive sleep apnea,
anxiety, depression, and bipolar disorder. [Id.]. At step three, the ALJ
determined that the Plaintiff does not have an impairment or combination of
impairments that meets or medically equals the Listings. [Id. at 43-44]. The
ALJ then determined that the Plaintiff, notwithstanding her impairments, has
[T]o perform light work as defined in 20 CFR
404.1567(b) except: she can never climb ladders,
ropes, and/or scaffolds; she can occasionally climb
ramps and stairs; she can have occasional exposure
to noise and workplace hazards, such as unprotected
heights and dangerous machinery; she can have
occasional exposure to pulmonary irritants such as
dust, fumes, odors, and gases; she is limited to
simple, routine, repetitive tasks; she can have
occasional interaction with the general public and
coworkers; she cannot perform fast paced
production rate work; and she can have few, if any,
[Id. at 45-48].
At step four, the ALJ noted that the Plaintiff has past relevant work as
a CNA and a home attendant, both of which are classified as medium in
exertion and semi-skilled. [Id. at 48-49]. The ALJ found that the Plaintiff is
unable to perform this past relevant work. [Id.]. At step five, the ALJ found
that, considering the Plaintiff’s age, education, work experience, and RFC,
there are unskilled jobs at the light level of exertion that exist in significant
numbers in the national economy that the Plaintiff can perform, such as
storage facility rental clerk (DOT 295.367-026), a checker I (DOT 222.687010), and a mail clerk, non-postal (DOT 209.867-026). [T. at 49-50]. The
ALJ concluded, therefore, that the Plaintiff was not “disabled” as defined by
the Social Security Act from October 10, 2012, the alleged onset date,
through October 15, 2015, the date of the ALJ’s decision. [T. at 50].
In this appeal, the Plaintiff argues, inter alia, that the ALJ failed to
properly consider the medical and opinion evidence of record. Specifically,
she argues that the ALJ failed to provide an adequate explanation for
assigning “little weight” to the opinions of the Plaintiff’s primary treating
physician, Tracy Phelps, M.D. [Doc. 11-1 at 5-9].
Rather than set forth a separate summary of the facts in this case, the Court has
incorporated the relevant facts into its legal analysis.
In making disability determinations, the Regulations require an ALJ to
consider all medical opinions of record, regardless of their source. 20 C.F.R.
§§ 404.1527(c), 416.927(c); 20 C.F.R. § 404.1527(b) (“In determining
whether you are disabled, we will always consider the medical opinions in
your case record together with the rest of the relevant evidence we receive.”);
SSR 06-03p (The ALJ must “consider all of the available evidence in the
individual’s case record in every case.”). “The RFC assessment must always
consider and address medical source opinions. If the RFC assessment
conflicts with an opinion from a medical source, the adjudicator must explain
why the opinion was not adopted.” SSR 96-8p.
The ALJ must always give “good reasons” in the decision “for the
weight given to a treating source’s medical opinion(s), i.e., an opinion(s) on
the nature and severity of an individual’s impairment(s).”
Furthermore, for treating source opinions:
[T]he notice of the determination or 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
Id. (emphasis added).
In the present case, Dr. Phelps completed an “Attending Physician's
Statement” on June 27, 2014, setting forth a number of diagnoses, reports
of symptoms, and medical opinions. [T. at 890-91]. Specifically, Dr. Phelps
diagnosed the Plaintiff with mastoid liposarcoma, chronic jaw pain,
depression and/or anxiety, and frequent migraines. Dr. Phelps reported that
more than half of the Plaintiff’s migraines lasted more than one hour; that
they were accompanied by symptoms of nausea, photophobia, blurred
vision, and drowsiness due to prescribed medications; that they prevented
all activity and required her to lie still in a darkened room; and that they
prevented her from performing postural activities including stooping,
climbing, crawling, bending, squatting, and kneeling. Dr. Phelps opined that
the Plaintiff would need to take 4-5 unscheduled breaks, “or more,” in an
eight-hour workday; and that she would likely be absent from work more than
four days a month. [Id.].
Dr. Phelps also opined as to a number of activities that the Plaintiff
“would be unable to do for 8 hours a day, 5 days a week, on an independent
basis,” including the abilities to remember work-like procedures; to maintain
attention for extended periods of two-hour segments; to complete a normal
workday and workweek without interruptions from psychologically based
symptoms and perform at a consistent pace without an unreasonable
number and length of rest periods; to accept instructions and respond
appropriately to criticism from supervisors; to get along with co-workers or
peers without distracting them or exhibiting behavioral extremes; and to
respond appropriately to changes in a work setting. [T. 891]. These are all
“abilities needed for any job,” a substantial loss of which, “severely limits the
potential occupational base and thus, would justify a finding of inability to
perform other work even for persons with favorable age, education and work
experience.” POMS DI 25020.010.2 These opinions, if adopted, would
support at a minimum a significantly more restrictive RFC finding than the
ALJ actually made. See 20 C.F.R. § 404 1520a.
The ALJ gave “little weight” to Dr. Phelps’s opinions, stating simply,
without any further explanation, that: “Dr. Phelps’s opinion is not fully
supported by the objective medical evidence of record.” [T. at 48 (emphasis
added)]. In making this short, conclusory statement, the ALJ failed to provide
good, specific reasons in her decision for the weight she ascribed to Dr.
Phelps’s opinions. Fox v. Colvin, 632 F. App'x 750, 756 (4th Cir. 2015)
(“Such a cursory and conclusory analysis does not provide any reason, let
“We require adjudicators at all levels of administrative review to follow agency policy, as set
out in the Commissioner’s regulations, SSRs, Social Security Acquiescence Rules (ARs), and other
instructions, such as the Program Operations Manual System (POMS), Emergency Messages, and
the Hearings, Appeals and Litigation Law manual (HALLEX).” SSR 13-2p.
alone a ‘good reason[ ],’ why the ALJ concluded that [the treating physician’s]
opinion was inconsistent with other medical findings.”).
While the ALJ generally discussed the objective evidence of record
[see T. at 41-48], the ALJ made no attempt to specifically explain how Dr.
Phelps’s opinions are not “fully supported” by any other findings in the record.
As such, the Court is unable to effectively review the ALJ’s conclusion
regarding the weight of Dr. Phelps’s medical opinions. Because the Court
cannot determine whether the ALJ properly evaluated the opinions of the
Plaintiff’s primary treating physician, the Court cannot say that the Plaintiff’s
RFC was properly addressed or that the ALJ’s ultimate decision was
supported by substantial evidence. See Patterson v. Comm'r of Soc. Sec.
Admin., 846 F.3d 656, 662 (4th Cir. 2017). For the reasons stated, the Court
concludes that a remand is required.3
IT IS, THEREFORE, ORDERED that the Plaintiff’s Motion for
Summary Judgment [Doc. 11] is GRANTED and the Defendant’s Motion for
Summary Judgment [Doc. 16] is DENIED. Pursuant to the power of this
Because the Court is remanding this matter based upon the Plaintiff’s first assignment
of error, the Court need not address the other issues raised by the Plaintiff.
Court to enter judgment affirming, modifying or reversing the decision of the
Commissioner under Sentence Four of 42 U.S.C. § 405(g), the decision of
the Commissioner is REVERSED and the case is hereby REMANDED for
further administrative proceedings consistent with this opinion. A judgment
shall be entered simultaneously herewith.
IT IS ORDERED.
Signed: March 12, 2018
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