Cook v. Colvin
Filing
17
MEMORANDUM OPINION. Signed by Magistrate Judge Pamela Meade Sargent on 9/28/2016. (Bordwine, Robin)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF VIRGINIA
ABINGDON DIVISION
HELEN LUGENE COOK,
Plaintiff
v.
CAROLYN W. COLVIN,
Acting Commissioner of
Social Security,
Defendant
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Civil Action No. 1:15cv00038
MEMORANDUM OPINION
BY: PAMELA MEADE SARGENT
United States Magistrate Judge
I. Background and Standard of Review
Plaintiff, Helen Lugene Cook, (“Cook”), filed this action challenging the
final decision of the Commissioner of Social Security, (“Commissioner”),
determining that she was not eligible for disability insurance benefits, (“DIB”),
under the Social Security Act, as amended, (“Act”), 42 U.S.C.A. § 423 (West
2011). Jurisdiction of this court is pursuant to 42 U.S.C. § 405(g). This case is
before the undersigned magistrate judge by transfer based on consent of the parties
pursuant to 28 U.S.C. § 636(c)(1). Cook has requested oral argument in this matter.
The court’s review in this case is limited to determining if the factual
findings of the Commissioner are supported by substantial evidence and were
reached through application of the correct legal standards. See Coffman v. Bowen,
829 F.2d 514, 517 (4th Cir. 1987). Substantial evidence has been defined as
“evidence which a reasoning mind would accept as sufficient to support a
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particular conclusion. It consists of more than a mere scintilla of evidence but may
be somewhat less than a preponderance.” Laws v. Celebrezze, 368 F.2d 640, 642
(4th Cir. 1966). ‘“If there is evidence to justify a refusal to direct a verdict were the
case before a jury, then there is “‘substantial evidence.’”” Hays v. Sullivan, 907
F.2d 1453, 1456 (4th Cir. 1990) (quoting Laws, 368 F.2d at 642).
The record shows that Cook filed an application for DIB on March 21, 2012,
alleging disability as of September 1, 2006, due to arthritis; chronic back pain;
chronic tendonitis; insomnia; anxiety; depression; and paranoia. (Record, (“R.”), at
183-84, 200, 226.) The claim was denied initially and on reconsideration. (R. at
90-92, 96-98, 101, 103-04, 107-08.) Cook then requested a hearing before an
administrative law judge, (“ALJ”). (R. at 111.) A video hearing was held on
November 20, 2013, at which Cook was represented by counsel. (R. at 34-58.)
By decision dated January 28, 2014, the ALJ denied Cook’s claim. (R. at 2129.) The ALJ found that Cook met the nondisability insured status requirements of
the Act for DIB purposes through December 31, 2011. (R. at 23.) The ALJ also
found that Cook had not engaged in substantial gainful activity since September 1,
2006, her alleged onset date. 1 (R. at 23.) The ALJ found that, through the date last
insured, the medical evidence established that Cook suffered from severe
impairments, namely carpal tunnel syndrome; ulnar nerve disorder; mild
degenerative disc disease of the lumbar spine; myalgias; and hypertension, but he
1
Therefore, Cook must show that she became disabled between September 1, 2006, the
alleged onset date, and December 31, 2011, the date last insured, in order to be entitled to DIB
benefits.
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found that Cook did not have an impairment or combination of impairments listed
at or medically equal to one listed at 20 C.F.R. Part 404, Subpart P, Appendix 1.
(R. at 23-24.) The ALJ found that, through the date last insured, Cook had the
residual functional capacity to perform light work 2 that did not require more than
occasional reaching, handling and fingering. (R. at 24.) The ALJ found that Cook
was unable to perform any of her past relevant work. (R. at 27.) Based on Cook’s
age, education, work history and residual functional capacity and the testimony of
a vocational expert, the ALJ found that jobs existed in significant numbers in the
national economy that Cook could perform, including jobs as a counter rental clerk
and an usher. (R. at 27-28.) Thus, the ALJ found that Cook was not under a
disability as defined by the Act and was not eligible for DIB benefits. (R. at 2829.) See 20 C.F.R. § 404.1520(g) (2015).
After the ALJ issued his decision, Cook pursued her administrative appeals,
(R. at 16), but the Appeals Council denied her request for review. (R. at 1-5.) Cook
then filed this action seeking review of the ALJ’s unfavorable decision, which now
stands as the Commissioner’s final decision. See 20 C.F.R. § 404.981 (2015). The
case is before this court on the Commissioner’s motion for summary judgment
filed February 25, 2016.3
2
Light work involves lifting items weighing up to 20 pounds at a time with frequent
lifting or carrying of items weighing up to 10 pounds. If someone can perform light work, she
also can perform sedentary work. See 20 C.F.R. § 404.1567(b) (2015).
3
Cook did not file a motion for summary judgment, but did file a brief pursuant to court
order. (Docket Item No. 11.)
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II. Facts
Cook was born in 1960, (R. at 37, 183), which, at the time of the ALJ’s
decision, classified her as a “person closely approaching advanced age” under 20
C.F.R. § 404.1563(d). Cook has a high school education and past work experience
as a cook, a cook helper and a pizza delivery person. (R. at 39-40, 201.) Cook
testified that her medications helped to relieve her symptoms “quite a bit,” but that
they caused drowsiness. (R. at 51.)
Vocational expert, John Newman, also testified at Cook’s hearing. (R. at 40,
54-57.) Newman was asked to consider a hypothetical individual of Cook’s age,
education and work experience, who would be limited to light work that did not
require more than occasional handling or fingering. (R. at 54-55.) Newman stated
that such an individual could not perform Cook’s past job of pizza delivery
because of the limitation to occasional handling and fingering. (R. at 55.) Newman
stated that the individual could perform other jobs existing in significant numbers
in the national economy, including those of counter and rental clerks and ushers or
lobby attendants/ticket takers. (R. at 55.) Newman was asked to consider the same
individual, but who would be limited to sedentary4 work that did not require more
than occasional handling and fingering. (R. at 55-56.) He stated that there would be
no jobs available that such an individual could perform. (R. at 56.) Newman stated
4
Sedentary work involves lifting items weighing up to 10 pounds with occasional lifting
or carrying of articles like docket files, ledgers and small tools. Although a sedentary job is
defined as one which involves sitting, a certain amount of walking and standing is often
necessary in carrying out job duties. Jobs are sedentary if walking and standing are required
occasionally and other sedentary criteria are met. See 20 C.F.R. § 404.1567(a) (2015).
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that, if the individual was limited as indicated by Dr. Craven’s assessment, there
would be no jobs available that such an individual could perform. (R. at 57.)
In rendering his decision, the ALJ reviewed medical records from Dr.
Michael Hartman, M.D., a state agency physician; Dr. Jagjit Sandhu, M.D., a state
agency physician; April L. Strobel-Nuss, Psy.D., a state agency psychologist; Blue
Ridge Family Chiropractic; Dr. Melvin L. Heiman, M.D.; Dr. John M. Chandler,
M.D.; Johnston Memorial Hospital; Holston Family Health; Pioneer Medical
Center of King; Stone Mountain Health Services; University of Virginia Health
System; and Mountainview Medical Center. Cook’s attorney also submitted a
Medical Source Statement from Dr. Bickley Craven, M.D., to the Appeals
Council. 5
The record shows that Cook was treated at Stone Mountain Health Services,
(“Stone Mountain”), from April 2003 through August 2012 for complaints of back
pain; urinary tract infections; abdominal pain/strain; tendonitis of the right arm,
elbow and thumb; mild chronic obstructive pulmonary disease, (“COPD”); restless
leg syndrome; insomnia; headaches; left shoulder pain; and hypertension. (R. at
492-736.)6 In June and August 2003, Cook complained of back pain after chasing
5
Since the Appeals Council considered and incorporated this additional evidence into the
record in reaching its decision, (R. at 1-5), this court also must take these new findings into
account when determining whether substantial evidence supports the ALJ's findings. See Wilkins
v. Sec'y of Dep't of Health & Human Servs., 953 F.2d 93, 96 (4th Cir. 1991).
6
Although there are numerous medical reports contained in the administrative record
from Stone Mountain, the court cannot determine who the treating health provider was on many
of these. It does appear, however, that the provider’s signature on some of these reports
resembles Dr. Craven’s signature on her November 2013 assessments.
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her dog and painting her kitchen. (R. at 617-18.) Dr. Bickley Craven, M.D.,
diagnosed lateral epicondylitis, recurrent back pain and hypertension. (R. at 617.)
In January 2004, Cook complained of right arm tendonitis. (R. at 615.) She
reported that Percocet was not helping and requested Roxicet. (R. at 615.) It was
noted that Cook exhibited drug seeking behavior. (R. at 614.) A review of the chart
showed that Cook had complained of arm pain one time in August 2003. (R. at
615.) Physical examination was normal. (R. at 614-15.) In August 2006, Cook
suffered a back sprain following a motor vehicle accident. (R. at 588.) She reported
that her migraine headaches had improved. (R. at 588.) Dr. Craven diagnosed
piriformis muscle spasms. (R. at 588.) In February 2007, Cook saw Dr. Craven for
follow up of a fractured finger. (R. at 581.) She reported that her back and hand
pain was relieved with medication. (R. at 581.) On April 3, 2007, Cook reported
that she had experienced back pain “on and off” since 2003, after attempting to roll
a log into a fire. (R. at 576.) Dr. Craven diagnosed improved piriformis muscle
spasm; chronic low back pain; upper body muscle spasm; fracture to fourth finger;
and mild COPD. (R. at 578.) On April 14, 2007, a spirometry test was performed,
which showed only mild obstruction. (R. at 729-31.) In November 2007, Dr.
Craven noted that Cook’s hypertension was stable while off of medication. (R. at
570.)
On January 16, 2008, Cook complained of lower mid-abdominal pain and
back pain after pulling on a hot tub cover. (R. at 569.) On June 26, 2008, Cook
complained of left-sided rib pain after her step-daughter was pulling her arms in an
attempt to carry her on her back. (R. at 563.) In July 2008, Cook continued to
complain of left rib cage tenderness. (R. at 560.) Dr. Craven diagnosed strained
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intercostal muscle, recurrent back pain and hypertension. (R. at 558.) On
September 30, 2008, Cook complained of anxiety and depression resulting from
raising her boyfriend’s teenagers. (R. at 557.) On December 2, 2008, Cook
reported that she was taking care of and boarding dogs. (R. at 554.) On April 15,
2009, Cook stated that she had been driving a lot and, as a result, she had arm and
hand pain. (R. at 551.) She also complained of feet and right hip pain after walking
her dogs and working outside. (R. at 551.) Dr. Craven noted that Cook’s anxiety
was stable, and her hypertension was controlled. (R. at 549.) On July 29, 2009,
Cook reported anxiety related to raising step-children. (R. at 548.) On October 28,
2009, Cook complained of abdominal pain after cleaning for more than one hour.
(R. at 545.) She also continued to complain of anxiety related to her step-children.
(R. at 545.) On March 10, 2010, Cook complained of chronic back pain after doing
“outside jobs at home” and housework. (R. at 542.) On July 20, 2010, Cook
reported increased stress related to her boyfriend’s children. (R. at 539.) On
October 19, 2010, Cook reported that the muscle spasms in her arms and legs were
better with medication and that her chronic back pain was stable with medication.
(R. at 534.)
On January 26, 2011, Cook complained of increased pain in her right elbow
after “cracking a lot [of] black walnuts.” (R. at 528.) On April 19, 2011, Cook
complained of increased stress following the breakup with her boyfriend. (R. at
522.) She stated that her back pain was better since her Lortab prescription had
been increased. (R. at 522.) Cook also reported pain in her arms and elbows with
physical exertion. (R. at 522.) Dr. Craven noted that Cook’s depression and anxiety
symptoms were stable. (R. at 520.) On April 27, 2011, a transvaginal ultrasound
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showed a small subserosal fibroid and a small myometrial cyst. (R. at 529.) On
May 31, 2011, Cook complained of chronic back pain after a lawn chair fell with
her in it. (R. at 519.) On September 28, 2011, Cook reported that she was in the
process of moving. (R. at 513.) She complained of increased tendonitis since
running out of Klonopin. (R. at 513.) On November 29, 2011, Cook complained of
increased pain in her hands and arms, as well as muscle spasms in her right
forearm and neck. (R. at 510.) She stated that Lortab and Klonopin helped relieve
her symptoms. (R. at 510.) On February 29, 2012, Cook complained of increased
back pain after pushing a hot tub lid up against a window. (R. at 507.) She reported
that her symptoms of depression and anxiety had improved. (R. at 507.) On May
30, 2012, Cook complained of low back and shoulder pain after moving household
items to her new residence. (R. at 504.) On August 21, 2012, Cook complained of
right elbow pain and back pain after pulling a golf cart off of a cliff. (R. at 493-95.)
She also complained of increased depression and anxiety due to a relationship
breakup and her dog being diagnosed with cancer. (R. at 495.) Dr. Craven assessed
increased depression and anxiety; right ulnar pain; back pain; hypertension; and
recurrent forearm tendonitis. (R. at 493.)
On November 15, 2013, Dr. Craven completed a Clinical Assessment of
Pain, indicating that Cook’s pain was present and found to be incapacitating; that
physical activity greatly increased her pain, causing abandonment of tasks related
to daily activities or work; and that Cook was restricted from the workplace as she
was unable to function at a productive level. (R. at 798.)
On November 18, 2013, Dr. Craven completed a physical assessment,
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indicating that Cook could rarely lift and carry items weighing up to 10 pounds and
never lift or carry items weighing more than 10 pounds. (R. at 799-803.) She
opined that Cook could only rarely operate foot controls and never climb, balance,
stoop, kneel, crouch or crawl. (R. at 801.) Dr. Craven opined that Cook could
occasionally operate a motor vehicle and work around quiet to moderate noise;
rarely work around dusts, odors, fumes and pulmonary irritants and vibrations; and
never work around unprotected heights, moving mechanical parts, humidity and
wetness, extreme cold or heat and loud to very loud noises. (R. at 802.) Dr. Craven
opined that these limitations had lasted or would last for 12 consecutive months.
(R. at 803.) She stated that Cook would be expected to be absent from work 15 out
of 20 workdays monthly. (R. at 803.) On May 22, 2014, Dr. Craven stated that she
had been Cook’s primary care physician since approximately 2002. (R. at 805.)
She stated that Cook had been seen regularly for pain due to “tendonitis, arthritis,
etc.” (R. at 805.)
The record shows that Cook was treated at University of Virginia Health
System in July and August 2004 for numbness in her right hand with pain and
paresthesias in the right thumb and wrist, which extended into the forearm. (R. at
754-70.) On July 28, 2004, x-rays of Cook’s cervical spine showed a slight anterior
listhesis at the C3-C4 and C4-C5 disc spaces. (R. at 770.) On August 18, 2004, a
nerve conduction study showed right median neuropathy in the forearm with the
most common cause being noted as pronator teres syndrome; no significant
electrodiagnostic evidence of carpal tunnel syndrome, radial neuropathy or cervical
neuropathy; and borderline bilateral ulnar nerve slowing across the elbow with no
significant side-to-side difference. (R. at 760.) An electromyography, (“EMG”),
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showed that all muscles tested were normal. (R. at 760.) X-rays of Cook’s right
elbow and forearm were normal, and her right wrist showed mild osteopenia and
mild ulnar minus variance. (R. at 754.) X-rays of Cook’s cervical spine showed
minimal uncovertebral joint degeneration bilaterally at the C3-C4 and C4-C5 disc
spaces and no foraminal encroachment. (R. at 757.)
The record shows that Dr. Melvin L. Heiman, M.D., treated Cook from
December 2005 through April 2006. (R. at 290-94.) On December 20, 2005,
examination revealed mild residual carpal tunnel symptoms and arthritic
complaints. (R. at 293-94.) On January 20, 2006, Cook continued to have
significant right arm symptoms, but she stated that a counterforce brace provided
improvement. (R. at 292.) Nerve conduction studies showed possible pronator
syndrome, normal ulnar nerve and normal radial nerve. (R. at 292.) X-rays of
Cook’s cervical spine were normal. (R. at 292.) Examination revealed tenderness
in the dorsal extensor mass; negative extensor stress test; good range of motion of
the elbow; and no pain on stress of the trapeziometacarpal joint. (R. at 292.) On
March 13, 2006, Cook reported that she was doing extremely well and that her
right hand symptoms had resolved, 7 but she reported developing very similar
symptoms in her left hand and wrist. (R. at 291.) She had full range of motion of
her right hand and wrist. (R. at 291.) On April 25, 2006, Cook complained of
significant problems with her left arm and recurring symptoms in her right hand.
(R. at 290.) Dr. Heiman referred her to Dr. John Chandler, M.D., a hand surgeon.
(R. at 290.)
7
Cook participated in therapy at Johnston Memorial Hospital Occupational Therapy
department from January 2006 through August 2007, (R. at 330-410), where she continued to
report improvement of her symptoms. (R. at 335, 356, 358, 374, 382, 410, 479.)
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On August 8, 2006, Cook presented to the emergency room at Johnston
Memorial Hospital, (“Johnston Memorial”), for complaints of lower back pain
following a motor vehicle accident the previous week. (R. at 420-26.) X-rays of
Cook’s lumbar spine were normal. (R. at 423.) She was diagnosed with acute
lumbar myofascial strain. (R. at 422.) On November 24, 2006, Cook presented to
the emergency room at Johnston Memorial for complaints of an injury to her left
ring finger after she tried to separate two dogs while fighting. (R. at 413-19.) Xrays of Cook’s left ring finger showed displaced comminuted fractures through the
mid and distal aspect of the fourth proximal phalanx. (R. at 416.)
On November 1, 2006, Cook underwent an independent medical evaluation
at Blue Ridge Family Chiropractic. (R. at 262-72.) Cook reported severe, constant
and chronic neck, mid-back and low back pain; bilateral hip pain; arm pain and
weakness; bilateral hand and arm numbness and tingling; weakness of her grip in
both hands; migraine headaches; chronic fatigue; insomnia; and fibromyalgia. (R.
at 262.) Cook reported a history of several motor vehicle accidents resulting in
injuries that most likely contributed to her then-current condition. (R. at 263.) Dr.
Dan Levesque, D.C., a chiropractor, diagnosed Cook with vertebral subluxations of
L5, T12, T5 and C7 with resulting cervicalgia, thoracalgia and lumbalgia;
herniated discs at these spinal levels resulting in cervical and lumbar
neuritis/radiculitis; osteoarthritis of the spine; degenerative disc disease; carpal
tunnel syndrome; headaches; chronic fatigue; insomnia; and fibromyalgia. (R. at
270.) Cook’s prognosis was deemed poor. (R. at 270.) Dr. Levesque noted that
Cook had permanent and progressively accelerating disc damage in her spine;
neuritis/radiculitis complicated by degenerative disc damage at these levels,
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leading to problems of weakness and more neuritis; and advanced disc
degeneration which had permanently changed the mechanics of Cook’s spine. (R.
at 270-71.) Dr. Levesque noted that Cook could not stand or walk for more than 15
minutes at a time; she could not sit for more than 30 minutes at a time; she was
limited from performing any fine motor skills; and her grip strength limited her
from activities such as grasping, pinching, holding or carrying anything that
weighed more than five to 10 pounds. (R. at 271.) It was noted that Cook had not
responded to treatment; that there was very little that could be done for her; and
she was disabled. (R. at 271.)
On June 5, 2007, Dr. John M. Chandler, M.D., an orthopaedist, saw Cook
for evaluation of her left hand following an injury on November 24, 2006. (R. at
297-98.) X-rays of Cook’s left ring and long fingers showed well-healed fractures;
some narrowing of the proximal interphalangeal, (“PIP”), joint, particularly in the
ring finger, but the joint space was well maintained; and good alignment of the
condyles. (R. at 297.) He recommended serial casting. (R. at 298.) On August 21,
2007, Dr. Chandler noted that Cook’s range of motion in the left ring PIP joint was
improving with therapy. (R. at 296.)
On August 14, 2012, Dr. Michael Hartman, M.D., a state agency physician,
reported that the evidence provided to the agency was not sufficient to determine
whether Cook was disabled prior to December 31, 2011, the date last insured. (R.
at 65-66.)
On October 17, 2012, Cook presented to the emergency room at Pioneer
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Medical Center of King for complaints of an injury to her right knee and right
shoulder after falling while walking her dogs. (R. at 747-53.) She was diagnosed
with abrasions to the hands and right knee and contusions to the left knee and right
chest wall. (R. at 749.) On January 1, 2013, Cook presented to the same emergency
room for complaints of pain in her right side after falling down five to six steps.
(R. at 737-46.) X-rays of Cook’s chest and right ribs were normal. (R. at 745.) She
was diagnosed with a contusion and a urinary tract infection. (R. at 739.)
On October 22, 2012, Cook was seen at Mountainview Medical Center for
new patient establishment. (R. at 790-92.) She reported that she recently moved to
the area after her brother came with eight other people and extricated her from a
relationship that had gone on for a year and a half where the man basically held her
as “a prisoner.” (R. at 790.) Cook reported that prior to that, she had an abusive
husband and sustained a patellar fracture during that time. (R. at 790.) Cook
complained of persistent right knee pain since her dogs ran after a squirrel and
pulled her along with them on the asphalt. (R. at 790.) Examination of Cook’s right
knee showed the anterior and posterior drawers were intact; McMurray’s was
negative; she had pain on palpation; no ligamentous laxity; some crepitus with
extension; and no effusion, edema or erythema. (R. at 790.) X-rays of Cook’s right
knee were normal. (R. at 790, 797.) She was diagnosed with right knee pain;
contusion; chronic back pain; and insomnia. (R. at 791.)
On November 21, 2012, examination revealed that Cook was diffusely
tender to palpation at all 18 trigger points for fibromyalgia. (R. at 785.) She had
good range of motion of all joints and residual pain after the muscles were
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palpated. (R. at 785.) Her speech was reported as pressured. (R. at 785.) X-rays of
Cook’s thoracic and lumbar spines showed only mild degenerative change and
kyphosis. (R. at 785.) Cook was diagnosed with back pain and myalgias, possibly
fibromyalgia and mood disorder. (R. at 785.)
On December 14, 2012, it was noted that Cook’s previous urine drug screen
was positive for marijuana and her prescribed hydrocodone. (R. at 780-81.) She
complained of right knee pain after she fell out of a camper earlier in the week
after missing a step. (R. at 781.) Cook stated that she might have to return to work
because she was not making any progress with her disability claim. (R. at 781.)
Cook’s speech was pressured along with tangential thoughts. (R. at 781.) It was
noted that, throughout the conversation, it was extremely difficult to redirect her.
(R. at 781.) It was noted that the words “pain” and “swelling” were written in ink
on her knee to indicate where she had pain and swelling. (R. at 781.) Examination
of Cook’s right knee showed the anterior and posterior drawers were intact;
McMurray’s was negative; and she had a “little bit” of swelling along the medial
joint line. (R. at 781.)
On January 11, 2013, Cook’s mood was stable. (R. at 777.) She was able to
cross her legs and walk without difficulty. (R. at 777.) She reported using
Biofreeze on her right knee, which provided relief. (R. at 777.) Cook reported that
she was doing much better and was very pleased with her progress. (R. at 777.) On
March 11, 2013, Cook complained of persistent right knee pain resulting from a
fall. (R. at 771.) She reported that she used an Ace bandage, which gave her some
relief. (R. at 771.) Examination of the right knee showed circles drawn on it with
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the word “pain.” (R. at 772.) She was described as a pleasant lady who was
extremely talkative and difficult to follow, but no overt agitation was noted. (R. at
772.) It was noted that Cook was extremely anxious. (R. at 772.) An injection to
the knee was offered, but Cook declined. (R. at 771.) She was diagnosed with right
knee pain; high-risk medication use; mood disorder; lipoma of the abdominal wall;
and hot flashes. (R. at 772.)
On January 8, 2013, April L. Strobel-Nuss, Psy.D., a state agency
psychologist, reported that there was not enough evidence to fully evaluate Cook’s
level of functioning prior to December 31, 2011, the date last insured. (R. at 84.)
On January 9, 2013, Dr. Jagjit Sandhu, M.D., a state agency physician,
reported that there was not enough evidence to fully evaluate Cook’s level of
functioning prior to December 31, 2011, the date last insured. (R. at 83.)
III. Analysis
The Commissioner uses a five-step process in evaluating DIB claims. See 20
C.F.R. § 404.1520 (2015); see also Heckler v. Campbell, 461 U.S. 458, 460-62
(1983); Hall v. Harris, 658 F.2d 260, 264-65 (4th Cir. 1981). This process requires
the Commissioner to consider, in order, whether a claimant 1) is working; 2) has a
severe impairment; 3) has an impairment that meets or equals the requirements of a
listed impairment; 4) can return to her past relevant work; and 5) if not, whether
she can perform other work. See 20 C.F.R. § 404.1520. If the Commissioner finds
conclusively that a claimant is or is not disabled at any point in this process, review
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does not proceed to the next step. See 20 C.F.R. § 404.1520(a) (2015).
As stated above, the court’s function in this case is limited to determining
whether substantial evidence exists in the record to support the ALJ’s findings.
The court must not weigh the evidence, as this court lacks authority to substitute its
judgment for that of the Commissioner, provided her decision is supported by
substantial evidence. See Hays, 907 F.2d at 1456. In determining whether
substantial evidence supports the Commissioner’s decision, the court also must
consider whether the ALJ analyzed all of the relevant evidence and whether the
ALJ sufficiently explained his findings and his rationale in crediting evidence. See
Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).
Cook argues that the ALJ erred by relying on material mistakes of fact.
(Brief In Support Of Plaintiff’s Motion For Summary Judgment, (“Plaintiff’s
Brief”), at 3-7.) In particular, Cook argues that the ALJ erroneously found that she
did not begin treating with Dr. Craven until after her date last insured. (Plaintiff’s
Brief at 3-7.) Cook further argues that the ALJ erred in his weighing of the medical
evidence. (Plaintiff’s Brief at 7-9.) Specifically, Cook argues that the ALJ erred by
assigning significant weight to the opinions of the nonexamining state agency
physicians while giving little weight to the opinions of her treating physician.
(Plaintiff’s Brief at 7-9.)
It is the ALJ’s responsibility to weigh the evidence, including the medical
evidence, in order to resolve any conflicts which might appear therein. See Hays,
907 F.2d at 1456; Taylor v. Weinberger, 528 F.2d 1153, 1156 (4th Cir. 1975).
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Furthermore, while an ALJ may not reject medical evidence for no reason or for
the wrong reason, see King v. Califano, 615 F.2d 1018, 1020 (4th Cir. 1980), an
ALJ may, under the regulations, assign no or little weight to a medical opinion,
even one from a treating source, based on the factors set forth at 20 C.F.R.
§ 404.1527(c), if he sufficiently explains his rationale and if the record supports his
findings.
In reaching his conclusions regarding Cook’s impairments and their effect
on her work-related abilities, the ALJ stated:
… Little weight is given to the opinion of the claimant’s treating PCP
[primary care physician], Dr. Craven. Dr. Craven completed a medical
source statement of the claimant’s ability to perform work-related
physical activities in November 2013, well after the DLI [date last
insured],…. Dr. Craven did not begin treating the claimant until after
the DLI. While the claimant’s condition may indeed be worse now
than at the DLI, there is nothing to suggest her impairments were
work preclusive during the period at issue.
(R. at 27.) Cook, through her counsel, concedes that Dr. Craven completed the
assessment at issue in November 2013, well after her date last insured, December
31, 2011. Nonetheless, she asserts that the ALJ should have given Dr. Craven’s
opinion as to her residual functional capacity more weight because it was based on
his treatment prior to her date last insured. To prove that the ALJ incorrectly
found that Dr. Craven had not treated Cook prior to her date last insured, Cook
references only one laboratory report dated April 21, 2003, which noted that the
tests performed were ordered by Dr. Craven, (R. at 635), and a May 22, 2014,
letter from Dr. Craven, stating that she had treated Cook since approximately 2002
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for issues with pain due to tendonitis and arthritis. (R. at 805.) To the court, it
appears that the administrative record contains other records documenting
treatment by Dr. Craven. Nonetheless, a review of Dr. Craven’s November 15,
2013, assessments shows that they do not state that they are based on Cook’s
condition prior to her date last insured. (R. at 798-803.) Therefore, I hold that the
ALJ was justified in giving Dr. Craven’s assessments little weight.
Having found that the ALJ properly discounted Dr. Craven’s opinion, does
not mean that the court finds that substantial evidence supports the ALJ’s finding
with regard to Cook’s residual functional capacity. The ALJ found that, through
the date last insured, Cook was capable of performing light work with only
occasional reaching, handling or fingering with the upper extremities. In reaching
this finding, the ALJ stated that he was giving significant weight to the opinions of
the state agency physicians, Dr. Hartman and Dr. Sandhu. The assessments
completed by Dr. Hartman and Dr. Sandhu, however, do not support the ALJ’s
finding on this issue. Instead, both of these physicians opined that the evidence of
record was insufficient to fully evaluate Cook’s level of functioning prior to her
date last insured.
I further note that the ALJ also erred in providing a hypothetical to the
vocational expert that did not include his finding as to Cook’s limited reaching
ability.
Based on the above reasoning, I find that substantial evidence does not exist
in the record to support the ALJ’s finding that Cook was not disabled, and I will
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remand her claim to the Commissioner for further development consistent with this
Memorandum Opinion. Based on this, I will deny Cook’s request for oral
argument. An appropriate Order and Judgment will be entered.
ENTERED: September 28, 2016.
s/
Pamela Meade Sargent
UNITED STATES MAGISTRATE JUDGE
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