Blanton v. Colvin

Filing 14

MEMORANDUM OPINION. Signed by Magistrate Judge Pamela Meade Sargent on 02/01/2017. (Bordwine, Robin)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF VIRGINIA
BIG STONE GAP DIVISION
GLENN A. BLANTON,
Plaintiff
v.
CAROLYN W. COLVIN,
Acting Commissioner of
Social Security,
Defendant

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Civil Action No. 2:15cv00023
MEMORANDUM OPINION

By: PAMELA MEADE SARGENT
United States Magistrate Judge

I. Background and Standard of Review
Plaintiff, Glenn A. Blanton, (“Blanton”), filed this action challenging the
final decision of the Commissioner of Social Security, (“Commissioner”), denying
his claims for disability insurance benefits, (“DIB”), and supplemental security
income, (“SSI”), under the Social Security Act, as amended, (“Act”), 42 U.S.C.A.
§§ 423 and 1381 et seq. (West 2011 & West 2012). Jurisdiction of this court is
pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). This case is before the
undersigned magistrate judge upon transfer by consent of the parties pursuant to 28
U.S.C. § 636(c)(1). Neither party has requested oral argument; therefore, this case
is ripe for decision.
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 Blanton protectively filed his applications for DIB
and SSI1 on October 11, 2011, alleging disability as of September 15, 2011, due to
a herniated disc in his thoracic spine, carpal tunnel syndrome, depression and
inability to handle stress. (Record, (“R.”), at 324-40, 355, 359, 397, 407.) The
claims were denied initially and upon reconsideration. (R. at 181-204.) Blanton
then requested a hearing before an administrative law judge, (“ALJ”). (R. at 205.)
Blanton’s original hearing was scheduled on June 13, 2013; however, Blanton
requested a continuance so that he could submit additional evidence related to an
upcoming neurological examination. (R. at 102-20.) The ALJ held a second
hearing on January 15, 2014, at which Blanton was represented by counsel. (R. at
37-78.)
By decision dated March 28, 2014, the ALJ denied Blanton’s claims. (R. at
12-31.) The ALJ found that Blanton met the nondisability insured status
requirements of the Act for DIB purposes through December 31, 2016. (R. at 15.)
The ALJ found that Blanton had not engaged in substantial gainful activity since

1

On October 24, 2011, Blanton’s application for SSI was denied based on him having
too much income to be eligible for SSI. (R. at 181-85.)
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September 15, 2011, the alleged onset date. 2 (R. at 15.) The ALJ found that the
medical evidence established that Blanton had severe impairments, namely
thoracic and lumbar spine arthrosis; headache disorder; gastroesophageal reflux
disease, (“GERD”); history of hyperlipidemia; vertigo; carpal tunnel syndrome,
status-post bilateral carpal tunnel release; borderline intellectual functioning;
anxiety; and depression, but he found that Blanton did not have an impairment or
combination of impairments that met or medically equaled one of the listed
impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. at 15, 21.) The ALJ
found that Blanton had the residual functional capacity to perform simple,
unskilled, light work 3 that did not require him to sit more than four hours in an
eight-hour workday; that did not require him to stand and/or walk more than four
hours in an eight-hour workday; that did not require more than occasional
crouching, stooping and overhead reaching; and that did not require continuous
reaching, handling or fingering with the bilateral upper extremities. (R. at 27.) The
ALJ found that Blanton was unable to perform his past relevant work. (R. at 29.)
Based on Blanton’s age, education, work history and residual functional capacity
and the testimony of a vocational expert, the ALJ found that a significant number
of other jobs existed in the national economy that Blanton could perform, including
jobs as a gate guard/night guard and a cafeteria attendant. (R. at 29-30.) Thus, the
ALJ concluded that Blanton was not under a disability as defined by the Act and
was not eligible for DIB or SSI benefits. (R. at 31.) See 20 C.F.R. §§ 404.1520(g)
416.920(g) (2016).
Therefore, Blanton must show that he was disabled between September 15, 2011, the
alleged onset date, and March 28, 2014, the date of the ALJ’s decision, in order to be eligible for
DIB benefits.
2

3

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, he
also can perform sedentary work. See 20 C.F.R. §§ 404.1567(b), 416.967(b) (2016).
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After the ALJ issued his decision, Blanton pursued his administrative
appeals, (R. at 6-8, 423-25), but the Appeals Council denied his request for review.
(R. at 1-5.) Blanton 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, 416.1481 (2016). This case is before this court on Blanton’s motion for
summary judgment filed May 13, 2016, and the Commissioner’s motion for
summary judgment filed June 14, 2016.
II. Facts
Blanton was born in 1975, (R. at 324, 328), which classifies him as a
“younger person” under 20 C.F.R. §§ 404.1563(c), 416.963(c). Blanton has a high
school education and past work experience as a material handler, an installer of
mobile homes, an order clerk and a machine operator. (R. at 29, 66-68, 116-18,
360.) Blanton stated that medication helped his headaches “a little bit.” (R. at 46.)
He stated that he could stand and walk for up to five minutes without interruption.
(R. at 50.) Blanton stated that, when he stands for a long time, his legs feel “real
heavy.” (R. at 50.) He stated that it was difficult for him to keep his balance due to
dizziness. (R. at 52.) Blanton stated that he experienced periods of blurred vision.
(R. at 53.) He stated that he quit his job because he “started messing up” and he did
not want to be fired. (R. at 54-55.) Blanton stated that his medication helped his
symptoms of anxiety. (R. at 55.) Other than being evaluated by psychologist
Steward, Blanton stated that he had not been treated by a psychologist, counselor
or mental health therapist. (R. at 55-56.) Blanton stated that he had never used
cocaine or illegal drugs, and that, while he had consumed alcoholic beverages in
the past, he was not an alcoholic. (R. at 64-65.)

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Medical expert, Dr. William S. Erwin, Jr., M.D., also testified at Blanton’s
hearing. (R. at 57-64.) Dr. Erwin stated that the record showed that Blanton had an
abnormal MRI; GERD; thoracic and lumbar osteoarthrosis; bulging discs; a history
of hyperlipidemia; a history of chronic tenderness and vertigo; and a history of
depression and anxiety. (R. at 60-61.) Dr. Erwin stated that Blanton’s impairments
did not meet or equal a listed impairment. (R. at 62.) He stated that, Steward’s
assessment, indicating that Blanton’s emotional and psychiatric problems were so
severe that he could not work, was the first time that the record indicated that
Blanton suffered from such a severe level of depression and anxiety. (R. at 62.) Dr.
Erwin stated that, if Steward’s assessment was accepted, Blanton would meet a
psychiatric listed impairment. (R. at 62.) He stated that Blanton’s documented
functional impairments, aside from his documented physical impairments, were not
severe enough to render him unable to work. (R. at 63.) Dr. Erwin stated that there
would be some impact on Blanton’s activities as a result of osteoarthrosis of the
thoracic lumbar spine. (R. at 63.) Dr. Erwin stated that Blanton’s physical
impairments would not preclude him from sitting six hours in an eight-hour
workday or limit him to less than six hours of standing and/or walking in an eighthour workday. (R. at 64.)
Gerald Wells, a vocational expert, also was present and testified at Blanton’s
hearing. (R. at 66-76.) Wells was asked to consider a hypothetical individual of
Blanton’s age, education and work history, who would be limited to simple, light
work that did not require more than occasional overhead reaching, stooping and
crouching; that did not require more than frequent reaching, handling or fingering;
and who would be able to understand, remember and carry out short, simple
instructions, to follow a supervisor’s directions, to interact with others and to adapt
to or respond to routine work changes. (R. at 68-69.) Wells stated that the
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individual could perform jobs existing in significant numbers in the national
economy, including those of a mail room clerk and an order filler. (R. at 69.) Wells
was asked to consider the same individual, but who would be limited to sedentary4
work. (R. at 70.) He stated that there would be jobs available that such an
individual could perform, including jobs as a dispatcher of maintenance workers,
an inspector, a tester/sorter and a surveillance monitor. (R. at 69-71.) He stated that
all jobs identified would allow for some alternation of sitting and standing while
remaining at the work station. (R. at 71-72.) He stated that all jobs identified would
be eliminated if the individual was limited to only occasional bilateral handling,
fingering and feeling. (R. at 72.) When asked if the individual would be limited to
only occasional handling, fingering and feeling with one upper extremity, Wells
stated that there would be a very narrow range of jobs available, such as a ticket
taker and a host. (R. at 72-73.) Wells stated that it would be difficult for a person to
sustain work in these jobs if they were absent from work more than one day a
month. (R. at 73.)
When asked to consider an individual who could occasionally lift 20 pounds
and sit, stand and/or walk up to four hours in an eight-hour workday, Wells stated
that the individual could perform jobs as a gate guard, a night guard and a cafeteria
cashier. (R. at 74-75.) Wells stated that these jobs did not require overhead
reaching, more than occasional stooping and crouching and constant other
reaching, handling and fingering. (R. at 75.) He stated that, as long as the
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), 416.967(a)
(2016).
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individual could follow short, simple instructions, follow a supervisor’s directions
and interact with others appropriately, the individual could perform the jobs as a
gate guard, a night guard and a cafeteria cashier. (R. at 75.)
In rendering his decision, the ALJ reviewed records from Wise County
Public Schools; Dr. Robert Keeley, M.C., a state agency physician; Howard S.
Leizer, Ph.D., a state agency psychologist; Dr. Joseph Duckwall, M.D., a state
agency physician; Appalachian Orthopaedic Associates, P.C.; Dr. Matthew W.
Wood, Jr., M.D.; Stacey Gipe, P.A., a physician’s assistant; L. Andrew Steward,
Ph.D., a licensed clinical psychologist; Dr. Gale E. Jackson, M.D.; Dr. Emily S.
Shields, M.D., a neurologist; Dr. Larry Hartman, M.D.; Dr. Wes Campbell, D.O.;
Norton Community Hospital; Dr. David Jones, M.D., a neurologist; University of
Virginia Hospital; and Dr. Pema O. Bhutia, M.D.
On August 12, 2010, Blanton underwent an electromyogram and nerve
conduction study, which showed moderately severe bilateral carpal tunnel
syndrome. (R. at 672.) The record shows that Blanton underwent bilateral carpal
tunnel release in October and November 2010. (R. at 427, 475-78.) In January
2011, Blanton reported that his numbness, paresthesias and pain had resolved. (R.
at 428.) He reported that he had returned to work without any problems. (R. at
428.)
On October 25, 2010, Blanton saw Stacey Gipe, P.A., a physician’s assistant
with Appalachian Healthcare Associates, P.C., for complaints of thoracic back pain
and headaches; however, he stated that he was doing better. (R. at 497.) Blanton
reported that his back pain was doing much better and that he was doing well
following bilateral carpal tunnel surgery. (R. at 496.) On September 15, 2011,
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Blanton’s examination was normal with the exception of tenderness over his
thoracic spine. (R. at 494.) Gipe ordered a thoracic MRI and referred Blanton for a
neurosurgery consultation. (R. at 494.) On September 23, 2011, an MRI of
Blanton’s thoracic spine showed some Schmorl’s nodes at the mid thoracic spine
with some mild, chronic appearing compression deformities; left paracentral disc
protrusion osteophytes complex at the T6-T7 level; and some minor degenerative
changes at the T5-T6 level. (R. at 674.) On October 27, 2011, Blanton reported that
he was doing much better overall. (R. at 490.) He stated that his pain was under
control with medication. (R. at 490.) Gipe noted that Blanton had good grip
strength in both hands; he had mild tenderness and some paraspinous thoracic
muscle spasm of the back; straight leg raising tests were negative; he had good
dorsal plantar flexion of the feet; and a normal gait. (R. at 490-91.) Gipe noted that
a form was completed to keep Blanton out of work, but she stated that she could
not do this indefinitely. (R. at 491.)
On November 3, 2011, Gipe and Dr. Wes Campbell, D.O., completed a
physical assessment, indicating that Blanton could occasionally lift and carry items
weighing up to five pounds; that he could stand and/or walk up to 10 minutes
without interruption; and that he could sit up to 15 minutes without interruption.5
(R. at 512-14.) They reported that Blanton could not climb; stoop; kneel; balance;
crouch; and crawl. (R. at 513.) They found that Blanton’s abilities to reach, to
handle, to feel, to push and to pull were affected by his impairment. (R. at 513.) No
environmental restrictions were noted. (R. at 514.) They noted that Blanton was
“not able to work at all.” (R. at 514.) On January 5, 2012, Blanton stated that,
despite the neurosurgeon’s belief that he would have no problem with returning to
5

Gipe and Dr. Campbell did not indicate how many hours that Blanton could sit, stand
and walk in an eight-hour workday. (R. at 512-13.)
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regular work, he was afraid to return to work because he continued to have pain
when he did not take his pain medication. (R. at 534.) Gipe noted that Blanton had
good range of motion of the thoracic spine; he had negative straight leg raising
tests; and he had tenderness over the thoracic paraspinous muscles. (R. at 534.) She
reported that Blanton was obviously stressed and mildly depressed. (R. at 534.)
On October 21, 2011, Dr. Matthew W. Wood, Jr., M.D., a neurosurgeon,
saw Blanton for complaints of thoracic pain with lower extremity paresthesias and
weakness. (R. at 486-87.) Upon examination, Blanton’s upper and lower extremity
strengths were normal and symmetric; dorsiflexion and plantar flexion were intact;
he had no focal tenderness to palpation in the posterior cervical, thoracic or lumbar
region; he had good range of motion of the shoulders with no signs of
impingement; straight leg raising tests were negative; his hip examination was
unremarkable; and he was neurologically intact. (R. at 486.) Dr. Wood noted that
an MRI study performed on September 23, 2011, revealed a small paracentral and
left T6-T7 disc protrusion without central canal compromise, spinal cord
compression or significant neural foraminal stenosis and a mild encroachment of
the T7 nerve root. (R. at 486.) Dr. Wood diagnosed small paracentral and left T7T7 disc protrusion; thoracic discomfort with some radicular complaints in a T7
distribution; lower extremity paresthesias with fatigue and heaviness of unclear
etiology with no findings on his recent MRI study or physical examination;
bilateral carpal tunnel decompression performed in 2010; anxiety; GERD; and
tobacco use. (R. at 486-87.) Dr. Wood noted that Blanton’s small disc protrusion
would not cause his lower extremity paresthesias or complaints of heaviness, but
could result in some periodic exacerbation of thoracic pain and radicular
discomfort. (R. at 487.) Dr. Wood also noted that Blanton and his wife were not
receptive to his findings and discussions regarding Blanton’s recent MRI study and
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the fact that Blanton was not at increased risk for impending paralyzation. (R. at
487.)
On November 28, 2011, Dr. Larry Hartman, M.D., saw Blanton for
complaints of chronic back pain and numbness. (R. at 527-30.) Blanton denied
depression, anxiety, nervousness and hallucinations. (R. at 528.) Dr. Hartman
noted that Blanton’s neck was tender with a severely diminished range of motion
of the cervical spine; he had marked tenderness over a single spinous process in the
lower thoracic region; diminished range of motion of the lumbar spine; no atrophy,
cyanosis or ecchymosis of the extremities; he was fully oriented; and his deep
tendon reflexes were intact and symmetric. (R. at 528-29.) Dr. Hartman found no
evidence of a particularly focal radiculopathy, and he noted that the source of the
numbness in Blanton’s lower extremities did not appear to be consistent with a
thoracic lesion, as most of his pain was myofascial. (R. at 529.) Dr. Hartman
recommended conservative treatment, including physical therapy. 6 (R. at 530.) On
December 5, 2011, an MRI of Blanton’s lumbar spine showed mild lumbar
discogenic disease. (R. at 516-17, 525-26.) On January 4, 2012, Blanton’s deep
tendon reflexes were intact and symmetric; his motor examination was intact; and
he had good range of motion of the lumbar spine, but demonstrated diminished
sensitivity to pain involving both lower extremities extending to the hips. (R. at
520-21.) Dr. Hartman noted that Blanton’s disc bulges at the L6 level were not of
clinical significance. (R. at 521.) He noted that Blanton did not have a clinical
syndrome consistent with a surgically remediable lesion in either the thoracic or
lumbar regions. (R. at 521.)

Blanton participated in physical therapy at Mountain States Rehabilitation from
December 19, 2011, through February 8, 2012. (R. at 519, 523-24, 542-63.)
6

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On December 20, 2011, Dr. Robert Keeley, M.C., a state agency physician,
opined that Blanton had the residual functional capacity to perform medium 7 work.
(R. at 139.) No postural, manipulative, visual, communicative or environmental
limitations were noted. (R. at 110.)
On April 6, 2012, Howard S. Leizer, Ph.D., a state agency psychologist,
completed a Psychiatric Review Technique form, (“PRTF”), indicating that
Blanton had no restrictions in his activities of daily living or in maintaining social
functioning; had mild difficulties in maintaining concentration, persistence or pace;
and that he had experienced no repeated episodes of decompensation of extended
duration. (R. at 151-52.) Leizer noted that Blanton’s impairment was controlled
with medication. (R. at 152.)
On April 10, 2012, Dr. Joseph Duckwall, M.D., a state agency physician,
opined that Blanton had the residual functional capacity to perform medium work.
(R. at 153-55.) He opined that Blanton could frequently climb ramps and stairs,
balance, kneel and crouch and occasionally climb ladders, ropes and scaffolds,
stoop and crawl. (R. at 154.) No postural, manipulative, visual or communicative
limitations were noted. (R. at 155.)
On August 7, 2012, Blanton saw Dr. Gale Jackson, M.D., for complaints of
dizziness and numbness and tingling in his hands. (R. at 569-71.) Blanton’s
physical examination was normal with the exception of tenderness in the thoracic
and lumbosacral spines. (R. at 571.) On August 30, 2012, Blanton complained of
7

Medium work involves lifting items weighing up to 50 pounds at a time with frequent
lifting or carrying of items weighing up to 25 pounds. If an individual can do medium work, he
also can do sedentary and light work. See 20 C.F.R. §§ 404.1567(c), 416.967(c) (2016).
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left facial pain; left anterior cervical pain; left-sided headache; and left ear pain
associated with worsening vertigo, tinnitus and hearing loss on the left. (R. at 56668.) Dr. Jackson admitted Blanton to Norton Community Hospital to rule out a
transient ischemic attack. (R. at 568, 597-610.) On admission, Blanton underwent a
CT scan of the head, which was normal. (R. at 597.) An MRI of Blanton’s head
was concerning for multiple sclerosis, (“MS”). (R. at 597-98.) An ultrasound of
Blanton’s carotid arteries was normal. (R. at 598.) An ultrasound of the soft tissue
of Blanton’s neck showed some small nonspecific lymph nodes. (R. at 598.)
Blanton was then transferred to Johnson City Medical Center for a neurological
evaluation with Dr. Stephen M. Kimbrough, M.D. (R. at 578-79, 598.) Dr.
Kimbrough determined that Blanton’s symptoms and findings were very
suggestive of demyelinating disease (MS), and he recommended further
evaluation. (R. at 579.)
Blanton then returned to Dr. Jackson for management of his general medical
issues. (R. at 566-68, 676-79, 680-87.) Blanton reported improved vision
disturbance and paresthesias, but complained of some left-sided weakness. (R. at
676, 680, 684.) Physical examinations were normal, with the exception of some
paraspinal tenderness in the thoracic and lumbar spines. (R. at 678, 682, 686.)
On June 7, 2013, Dr. Jackson completed a mental assessment, indicating that
Blanton had a seriously limited ability to make all occupational, performance and
personal/social adjustments. (R. at 717-19.) Dr. Jackson found that Blanton would
be absent from work more than two days a month. (R. at 719.)
That same day, Dr. Jackson completed a physical assessment, indicating that
Blanton could occasionally lift and carry objects weighing up to 20 pounds; that he
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could stand, walk and/or sit a total of four hours in an eight-hour workday and that
he could do so for 30 minutes to one hour without interruption. (R. at 721-22.) He
opined that Blanton could occasionally balance and never climb, stoop, kneel,
crouch or crawl. (R. at 722.) Dr. Jackson indicated that Blanton’s ability to push
and pull was affected by his impairment. (R. at 722.) He opined that Blanton would
be restricted from working around heights and moving machinery. (R. at 723.) He
found that Blanton would be absent from work about two days a month. (R. at
723.)
On December 6, 2012, Blanton saw Dr. David Jones, M.D., a neurologist at
the University of Virginia Hospital, for a possible diagnosis of MS. (R. at 612-17.)
The examination was significant for some mild sensory deficit in the left side of
the face and leg with a positive Hoffman’s sign. (R. at 614.) Blanton had a normal
gait and appropriate affect, mood and behavior. (R. at 613-14.) Dr. Jones opined
that Blanton did not meet the criteria for MS, but that it could not be entirely ruled
out. (R. at 614.)
On May 10, 2013, Blanton saw Dr. Pema O. Bhutia, M.D., to establish care.
(R. at 730-33.) Upon physical examination, Blanton was in no acute distress and
had a normal gait; full range of motion throughout; no tenderness on palpation;
negative straight leg raising tests; no joint instability; normal muscle tone, bulk and
strength; and no neurological deficits. (R. at 732.) His mood was euthymic, and he
had an appropriate affect. (R. at 732.) Follow-up physical examinations through
November 2013 were unchanged. (R. at 727, 747, 761.) In August and November
2013, Blanton reported that medication helped with his headaches. (R. at 745,
759.) He reported that his GERD was stable on medication and that his depression
symptoms had improved with medication. (R. at 745, 759.) Blanton also reported
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that his medications were helping with his chronic pain. (R. at 748.) Blanton had
appropriate judgment; good insight; euthymic mood; and appropriate affect. (R. at
747, 761.)
On May 24, 2013, L. Andrew Steward, Ph.D., a licensed clinical
psychologist, evaluated Blanton at the request of Blanton’s attorney. (R. at 70215.) Blanton reported memory and concentration problems. (R. at 704.) Blanton
had a constricted affect and anxious and dysphoric mood. (R. at 704.) His thought
content and organization were not impoverished or confused; he had average
mental functions of general fund of knowledge, abstract reasoning, judgment and
attention and concentration; and he had average memory functions. (R. at 704.)
The Wechsler Adult Intelligence Scale - Fourth Edition, (“WAIS-IV”), was
administered, and Blanton obtained a full-scale IQ score of 80. (R. at 711.) The
Beck Anxiety Inventory, (“BAI”), and the Beck Depression Inventory - II (“BDIII”), were administered, indicating that Blanton suffered from severe anxiety and
severe depression. (R. at 711.) Steward diagnosed major depressive disorder,
recurrent, severe without psychotic features; generalized anxiety disorder;
borderline intellectual functioning; and MS with body pain, memory and
concentration problems, vision problems and severe ringing in the ears. (R. at 714.)
Steward assessed Blanton’s then-current Global Assessment of Functioning,
(“GAF”), 8 score at 49. 9 (R. at 714.) Steward reported that Blanton appeared to be
permanently and totally disabled. (R. at 715.)
8

The GAF scale ranges from zero to 100 and “[c]onsider[s] psychological, social, and
occupational functioning on a hypothetical continuum of mental health-illness.” DIAGNOSTIC
AND STATISTICAL MANUAL OF MENTAL DISORDERS FOURTH EDITION, (“DSM-IV”), 32
(American Psychiatric Association 1994).
9

A GAF score of 41-50 indicates that the individual has “[s]erious symptoms ... OR any
serious impairment in social, occupational, or school functioning….” DSM-IV at 32.
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That same day, Steward completed a mental assessment, indicating that
Blanton had a seriously limited ability to follow work rules; to use judgment; to
function independently; to understand, remember and carry out detailed and simple
job instructions; and to maintain personal appearance. (R. at 698-700.) He opined
that Blanton had no useful ability to relate to co-workers; to deal with the public; to
interact with supervisors; to deal with work stresses; to maintain attention and
concentration; to understand, remember and carry out complex job instructions; to
behave in an emotionally stable manner; to relate predictably in social situations;
and to demonstrate reliability. (R. at 698-99.) Steward found that Blanton would be
absent from work more than two days a month. (R. at 700.)
On June 26, 2013, Dr. Emily S. Shields, M.D., a neurologist, saw Blanton
for a neurological examination. (R. at 741-44.) Dr. Shields reported that Blanton
had intact recent and remote memory, attention span, concentration and language.
(R. at 741.) He had normal fund of vocabulary, visual acuity and visual fields. (R.
at 741.) Blanton had normal range of motion of the neck and spine. (R. at 741.) He
had a normal gait and reflexes, and his extremities exhibited normal bulk and tone.
(R. at 742.) On July 24, 2013, Blanton saw Dr. Shields for follow-up regarding
abnormal MRIs of Blanton’s brain. (R. at 756-57.) Dr. Shields noted that Blanton’s
MRI findings were consistent with migraines. (R. at 757.) Dr. Shields prescribed
medication and a repeat MRI. (R. at 757.) Again, on September 5, 2013, Dr.
Shields noted that an MRI of Blanton’s brain, taken August 2, 2013, was
representative of migraines. (R. at 755.) Blanton reported that his migraines
improved with medication. (R. at 754-55.) Dr. Shields noted that Blanton had some
difficulty with balance on his toes, but he had normal casual station and gait. (R. at
755.)

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III. Analysis
The Commissioner uses a five-step process in evaluating DIB and SSI
claims. See 20 C.F.R. §§ 404.1520, 416.920 (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 his past relevant
work; and 5) if not, whether he can perform other work. See 20 C.F.R. §§
404.1520, 416.920. If the Commissioner finds conclusively that a claimant is or is
not disabled at any point in this process, review does not proceed to the next step.
See 20 C.F.R. §§ 404.1520(a), 416.920(a) (2016).
Under this analysis, a claimant has the initial burden of showing that he is
unable to return to his past relevant work because of his impairments. Once the
claimant establishes a prima facie case of disability, the burden shifts to the
Commissioner. To satisfy this burden, the Commissioner must then establish that
the claimant has the residual functional capacity, considering the claimant’s age,
education, work experience and impairments, to perform alternative jobs that exist
in the national economy. See 42 U.S.C.A. §§ 423(d)(2)(A), 1382c(a)(3)(A)-(B)
(West 2011 & West 2012); McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir.
1983); Hall, 658 F.2d at 264-65; Wilson v. Califano, 617 F.2d 1050, 1053 (4th Cir.
1980).
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.
This court must not weigh the evidence, as this court lacks authority to substitute
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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).
Thus, 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). 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), 416.927(c), if he sufficiently explains his rationale and if the record
supports his findings.
Blanton argues that the ALJ erred by improperly determining his residual
functional capacity. (Plaintiff’s Memorandum In Support Of His Motion For
Summary Judgment, (“Plaintiff’s Brief”), at 6-8.) Blanton also argues that the ALJ
erred by giving little weight to the mental assessments of Dr. Jackson, Steward,
Gipe and Dr. Campbell. (Plaintiff’s Brief at 6-8.) He further argues that the ALJ
gave significant weight to Dr. Jackson’s physical assessment, but rejected some
limitations without valid reasons. (Plaintiff’s Brief at 7.)
The ALJ found that Blanton had the residual functional capacity to perform
simple, unskilled, light work that did not require him to sit more than four hours in
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an eight-hour workday; that did not require him to stand and/or walk more than
four hours in an eight-hour workday; that did not require more than occasional
crouching, stooping and overhead reaching; and that did not require continuous
reaching, handling or fingering with the bilateral upper extremities. (R. at 27.)
Based on my review of the record, I find that substantial evidence exists to support
this finding.
Blanton argues that the ALJ, in arriving at his residual functional capacity
finding, should have given more weight to the opinions of Dr. Jackson, Steward,
Gipe and Dr. Campbell. I find this argument unpersuasive. The ALJ noted that he
was giving little weight to the opinions of Gipe and Dr. Campbell because they
were not supported by the longitudinal evidence of Blanton’s impairments and
were not consistent with the level of activities that Blanton was performing during
the period under adjudication. (R. at 28.) The ALJ also noted that their assessments
did not appear to be assessments of impairment severity over time, but limited to
one discrete period. (R. at 28.) Treatment records do not show a significant degree
of muscle atrophy, paravertebral muscle spasm, sensory or motor loss, reflex
abnormality, gait disturbance or reduced range of motion. (R. at 29, 529, 727, 732,
747, 761.) Gipe only saw Blanton three times between September 2011 and
January 2012, and when she completed the medical source statement in November
2011, she noted that she could not keep Blanton out of work indefinitely. (R. at
490-91, 494, 507, 534.)
The ALJ also stated that he was giving little weight to Steward’s opinion
because other evidence of record did not document the level of debilitating mental
deficits put forth by Steward. (R. at 27.) The ALJ noted that the GAF rating and
functional limitations also were not supported by the other medical treatment
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evidence of record. (R. at 27.) The ALJ further noted that the medical evidence
Steward reviewed did not document mental functioning prior to Steward’s
evaluation that supported the GAF rating assessed by Steward; thus, the ALJ found
that Steward’s opinion was wholly inconsistent with Blanton’s lack of mental
health treatment. (R. at 27.) In fact, treatment notes dated prior to Steward’s
evaluation show nothing more than one notation of “mild depression” and a
prescription for Celexa. (R. at 534, 573.) Dr. Jackson’s treatment notes do not
document subjective complaints of depression or anxiety; objective psychiatric
findings; or a psychiatric diagnosis. (R. at 566-75, 676-87, 689-95, 707.) Treatment
notes dated after Steward’s evaluation are likewise unremarkable, documenting
that Blanton was in no acute distress with euthymic mood, appropriate affect and
judgment and good insight. (R. at 613, 732, 747, 761.) In June 2013, Blanton had
intact recent and remote memory, attention span and concentration. (R. at 741.)
The ALJ noted that he was giving little weight to Dr. Jackson’s mental
residual functional capacity assessment because it conflicted with the other
evidence of record and was outside the scope of Dr. Jackson’s expertise. (R. at 26,
717-19.) Dr. Jackson’s treatment notes do not document subjective complaints of
depression or anxiety; objective psychiatric findings; or a psychiatric diagnosis. (R.
at 566-75, 676-87, 689-95.) In fact, the record shows that in May 2013, one month
prior to Dr. Jackson’s mental residual functional capacity assessment, and in
August 2013, two months following Dr. Jackson’s assessment, Blanton reported
that his depression symptoms had improved with medication. (R. at 745, 759.) “If a
symptom can be reasonably controlled by medication or treatment, it is not
disabling.” Gross v. Heckler, 785 F.2d 1163, 1166 (4th Cir. 1986).

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The ALJ did give Dr. Jackson’s June 2013 physical residual functional
assessment significant weight. (R. at 28.) The ALJ noted that the evidence of
record supported Dr. Jackson’s opinion that Blanton could lift and/or carry items
weighing up to 20 pounds occasionally; sit four hours in an eight-hour workday;
and stand and/or walk up to four hours in an eight-hour workday. (R. at 28, 72122.) However, the ALJ determined that Dr. Jackson’s finding that Blanton could
never climb, stoop, kneel, crouch or crawl and that he would miss two days of
work per month were not supported by the objective evidence of record. (R. at 28,
722-23.) Specifically, the ALJ noted that Dr. Jackson’s opinion was inconsistent
with his own clinical notes, which failed to document anything more than some
paraspinal tenderness. (R. at 28, 678, 682, 686.) In addition, Dr. Jackson failed to
document why such benign findings would result in such extreme limitations. (R.
at 28.) Treatment notes do not show a significant degree of muscle atrophy,
paravertebral muscle spasm, sensory or motor loss, reflex abnormality, gait
disturbance or reduced range of motion. (R. at 29, 727, 732, 747, 761.) Physicians
ruled out MS as a diagnosis, and two separate examining neurologists determined
that Blanton did not have a surgically remediable back impairment. (R. at 487,
521.) Furthermore, Blanton reported that medication helped control his chronic
pain and migraines. (R. at 490, 745, 748, 754, 759.) See Gross, 785 F.2d at 1166.
The ALJ stated that he was giving significant weight to Dr. Erwin’s
testimony. (R. at 28.) Dr. Erwin stated that Steward’s assessment, indicating that
Blanton’s emotional and psychiatric problems were so severe that he could not
work, was the first time that the record indicated that Blanton suffered from such a
severe level of depression and anxiety. (R. at 62.) He stated that Blanton’s
documented functional impairments, aside from his documented physical
impairments, were not severe enough to render him unable to work. (R. at 63.) Dr.
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Erwin stated that Blanton’s physical impairments would not preclude him from
sitting six hours in an eight-hour workday or limit him to less than six hours of
standing and/or walking in an eight-hour workday. (R. at 64.)
Based on the above, I find that substantial evidence exists to support the
ALJ’s weighing of the medical evidence and his finding as to Blanton’s residual
functional capacity.
Based on the above reasoning, I find that substantial evidence exists to
support the ALJ’s conclusion that Blanton was not disabled and not entitled to
benefits. An appropriate Order and Judgment will be entered.
DATED:

February 1, 2017.
/s/

Pamela Meade Sargent

UNITED STATES MAGISTRATE JUDGE

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