Vaughn, Jr. v. Commissioner Of Social Security

Filing 21

MEMORANDUM OPINION. Signed by Magistrate Judge Pamela Meade Sargent on 08/14/2017. (Bordwine, Robin)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF VIRGINIA
BIG STONE GAP DIVISION
BILLY JOE VAUGHN, JR.,
Plaintiff
v.
NANCY A. BERRYHILL,1
Acting Commissioner of
Social Security,
Defendant

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Civil Action No. 2:16cv00012
MEMORANDUM OPINION

By: PAMELA MEADE SARGENT
United States Magistrate Judge

I. Background and Standard of Review
Plaintiff, Billy Joe Vaughn, Jr., (“Vaughn”), 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,
1

Nancy A. Berryhill became the Acting Commissioner of Social Security on January 23,
2017. Berryhill is substituted for Carolyn W. Colvin, the previous Acting Commissioner of
Social Security.
-1-

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
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 Vaughn filed applications for DIB and SSI on

December 15, 2010, alleging disability as of June 15, 2008. (Record, (“R.”), at 22122, 229-37.) The claims were denied initially and on reconsideration. (R. at 72-84,
86-98, 100-14, 116-30, 132-34, 140-44, 146-51, 153-55.) Vaughn requested a hearing
before an administrative law judge, (“ALJ”), which was held on January 15, 2013. (R.
at 34-71, 156-57.) By decision dated February 1, 2013, an ALJ denied Vaughn’s
claims. (R. at 20-28.) The Appeals Council thereafter denied Vaughn’s request for
review. (R. at 1-3.) Vaughn appealed the denial of benefits to this court. On the
Commissioner’s motion, this court remanded Vaughn’s claims to the Commissioner
for further development on October 23, 2014. See Vaughn v. Colvin, Civil Action No.
2:14cv00010 (W.D. Va. Oct. 23, 2014). On remand, the ALJ held another hearing

on August 6, 2015, at which Vaughn was represented by counsel. (R. at 513-49.)
By decision dated August 14, 2015, the ALJ again denied Vaughn’s claims.
(R. at 491-505.) The ALJ found that Vaughn met the nondisability insured status
requirements of the Act for DIB purposes through December 31, 2013. (R. at 494.)
The ALJ found that Vaughn had not engaged in substantial gainful activity since
June 15, 2008, the alleged onset date. (R. at 494.) The ALJ found that the medical
evidence established that Vaughn had severe impairments, namely degenerative
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disc disease and spondylosis of the cervical spine with radiculopathy into the right
upper extremity, right shoulder bursitis and chronic low back pain, but he found
that Vaughn 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 494-97.) The ALJ found that Vaughn had the residual
functional capacity to perform sedentary work, except that he could lift and carry
items weighing up to 20 pounds occasionally and 10 pounds frequently, 2 that he
must be allowed position changes between sitting and standing every 20 minutes,
that he cannot perform more than occasional climbing of ramps and stairs,
kneeling, crawling, crouching, balancing and stooping and that he cannot climb
ladders, ropes or scaffolds or work in concentrated exposure to cold, wetness,
unprotected heights and hazards. (R. at 497-503.) The ALJ found that Vaughn was
unable to perform his past relevant work. (R. at 503.) Based on Vaughn’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 Vaughn could perform, including jobs as an addresser, a
packing machine operator and a sorter. (R. at 503-04.) Thus, the ALJ concluded
that Vaughn was not under a disability as defined by the Act, and was not eligible
for DIB or SSI benefits. (R. at 504-05.) See 20 C.F.R. §§ 404.1520(g) 416.920(g)
(2016).
After the ALJ issued his decision, Vaughn pursued his administrative
appeals, (R. at 478-79, 487), but the Appeals Council denied his request for
2

Sedentary work involves lifting items weighing up to 10 pounds at a time and
occasionally lifting or carrying articles like docket files, ledgers and small tools. Although a
sedentary job is defined as one which involves sitting, a certain amount of walking or standing is
often necessary in carrying out job duties. Jobs are sedentary if walking or 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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review. (R. at 471-74.) Vaughn 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 Vaughn’s
motion for summary judgment filed October 27, 2016, and the Commissioner’s
motion for summary judgment filed December 30, 2016.
II. Facts
Vaughn was born in 1972, (R. at 519), which classifies him as a “younger
person” under 20 C.F.R. §§ 404.1563(c), 416.963(c). Vaughn has a seventh-grade
education and past relevant work as roof bolter in an underground coal mine. (R. at
519.) Vaughn testified that he has not worked since 2008. (R. at 519.) At his
January 15, 2013, hearing, Vaughn testified that he suffered from constant pain
that improved some when he took his pain medication. (R. at 631.) He complained
that his pain medication made him drowsy. (R. at 636.) Vaughn said that he
experienced neck pain that ran down his right arm. (R. at 636-37.) Vaughn also
claimed that he had no strength to grip anything with his right hand. (R. at 637-38.)
Medical expert Dr. Anthony E. Francis, M.D., an orthopedic surgeon,
testified at Vaughn’s August 2015 hearing. (R. at 521-38.) Based on his review of
the medical evidence, Dr. Francis testified:
The pathology that we have here would be some degenerative
disk disease of the lumbar and cervical spine, with an intermittent
radiculopathy. Now, the problem … with radiculopathy, especially
looking at them over an extended period of time, is that the
radiculopathy may be, or usually is, acute at some point, meaning
severely impairing due to pain, weakness, all the other things that go
along with the radiculopathy.
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Most radiculopathies are going to clear up. You know, if you
don’t do anything, they’ll clear up….
But most of them, especially in a younger patient, are going to
clear up and either go completely away, or just become sort of a
nuisance instead of a significantly impairing problem, and that may be
what we have here.
(R. at 528-29.)
In rendering his decision, the ALJ reviewed records from Wellmont
Lonesome Pine Hospital; Lee Regional Medical Center; Blue Ridge Neuroscience
Center, P.C.; Wellmont Rehabilitation Services; Jonesville Rural Health Clinic; Dr.
Kevin Blackwell, D.O.; Medical Associates of Jonesville; Stone Mountain Health
Clinic, St. Charles; Simpson Clinic; Eugenie Hamilton, Ph.D.; and Dr. Richard
Surrusco, M.D..
On October 14, 2010, Vaughn was seen at the emergency department at
Lonesome Pine Hospital for neck pain radiating into his right shoulder and arm.
(R. at 337.) Vaughn denied any recent injury or repetitive motion. (R. at 337.) A
physical examination revealed normal range of motion in Vaughn’s neck. (R. at
338.) No sensory or motor loss was noted. (R. at 338.) A CT scan of Vaughn’s
cervical spine revealed mild to moderate degenerative disc changes at the C4-5 and
C5-6 levels. (R. at 339, 364.) X-rays of his cervical spine showed degenerative disc
changes at the C5-6 and C6-7 levels with loss of cervical curvature due to muscle
spasm of the neck. (R. at 361.) Vaughn’s was diagnosed with cervical
radiculopathy. (R. at 338.)

Vaughn returned to the emergency department at

Lonesome Pine Hospital on October 19, 2010, with complaints of chronic neck and
back pain. (R. at 345.) Physical examination revealed painful range of motion in
Vaughn’s neck with normal range of motion in his back. (R. at 346.)
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G. Elaine Hamilton, F.N.P., saw Vaughn at Jonesville Rural Health Clinic
on October 21, 2010, for complaints of neck and arm pain. (R. at 393.) Physical
exam revealed that Vaughn’s neck was tender and painful to palpation, more on
the right side. (R. at 393.) Vaughn was given prescriptions for Lortab, Soma,
ibuprofen and Xanax, and an MRI was ordered of his cervical spine. (R. at 393.)
Vaughn returned on November 2, 2010, complaining of neck pain radiating into
his right arm and numbness in his fourth finger through thumb. (R. at 392.)
Physical exam revealed decreased range of motion in Vaughn’s neck. (R. at 392.)
Vaughn returned on November 17, 2010, with similar findings. (R. at 391.)
An MRI of Vaughn’s cervical spine was performed at Lee Regional Hospital
on November 19, 2010. (R. at 351-53.) The MRI showed a deformity of the
vertebrae at the C6-7 level, most likely related to an old fracture, and mild
multilevel spondylosis with central disc protrusions at the C4-5 and C5-6 levels.
(R. at 352, 362-63.) As a result of the MRI findings, Hamilton referred Vaughn to
a neurosurgeon. (R. at 390.)
On January 4, 2011, Dr. David M. Pryputniewicz, M.D., with Blue Ridge
Neuroscience Center, P.C., saw Vaughn. (R. at 357-60.) Dr. Pryputniewicz noted
that Vaughn complained of cervical pain and right upper extremity pain for the
previous four to five months. (R. at 357.) Vaughn complained of numbness in his
right arm, hand and fingers and generalized weakness in his arm. (R. at 357.) Dr.
Pryputniewicz noted that Vaughn was alert, cooperative and in no apparent acute
distress. (R. at 358.) He stated that examination of Vaughn’s neck revealed mild
muscle spasms and tenderness and limited range of motion. (R. at 358.) Strength
and muscle tone of Vaughn’s upper extremities was normal. (R. at 358.) Dr.
Pryputniewicz diagnosed Vaughn has having cervical spondylosis, without
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myelopathy; cervical degenerative disc disease; cervical herniated disc, without
myelopathy; neck pain; cervical radiculopathy; and arm pain. (R. at 359.) He
recommended conservative treatment and prescribed Medrol and four to six weeks
of physical therapy. (R. at 360.) He scheduled Vaughn to return to see him on
February 22, 2011, and cautioned that surgical intervention might be necessary if
Vaughn’s symptoms persisted. (R. at 360.)
A Physical Therapy Evaluation was performed on Vaughn on January 18,
2011, at Wellmont Outpatient Rehabilitation Services at Lonesome Pine Hospital.
(R. at 369-70.) Vaughn called and canceled his return appointment on January 20,
2011. (R. at 379.) Vaughn returned for physical therapy on January 25, 2011, and
then never returned. (R. at 380-82.)
Vaughn returned to see Hamilton on February 9, 2011, stating that he had an
abcessed tooth, which had caused him to miss two physical therapy appointments
that week. (R. at 416.) He also complained of intolerable neck pain without pain
medication. (R. at 416.) Hamilton increased Vaughn’s Percocet dosage. (R. at
416.) On March 8, 2011, Vaughn reported that the pain in his neck and arm was
“much improved” with the increased dosage of Percocet. (R. at 415.) Vaughn
stated that since the pain medication had decreased his pain, he did not want to
have surgery on his neck and had applied for Social Security disability benefits. (R.
at 415.) Hamilton noted a limited range of motion in Vaughn’s neck and right arm.
(R. at 415.) On April 6, 2011, Hamilton noted that Vaughn stated that he had quit
physical therapy after only three sessions because it had increased his pain. (R. at
414.) Hamilton recommended that Vaughn return to see the neurosurgeon. (R. at
414.) She also stated that she had tried to decrease Vaughn’s Percocet dosage and

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would require him to bring in his prescription each month to do a pill count. (R. at
414.)
On May 31, 2011, Vaughn did not bring in his pill bottle, and Hamilton
noted that, if he forgot it again, she would not prescribe any further pain
medication. (R. at 413.) On June 23, 2011, Hamilton noted that Vaughn brought in
his pill bottle for a pill count and that he was complaining of increased pain in his
low back. (R. at 412.)

Vaughn said that he was awaiting a call from the

neurosurgeon to schedule a return appointment after he had canceled his last
appointment due to emergency surgery. (R. at 412.)
On August 2, 2011, Vaughn told Hamilton that his pain had decreased with
his pain medication. (R. at 470.) On September 13, 2011, Vaughn told Hamilton
that he had experienced a strange sensation approximately one week earlier and
that his left arm and leg had felt weak since. (R. at 469.) Hamilton recommended
that he return to see his neurosurgeon, and Vaughn reported that he had called the
neurosurgeon’s office to request a follow-up appointment and was told the office
would call him when they had an opening. (R. at 469.) Vaughn complained of
increased pain on December 20, 2011, and Hamilton ordered physical therapy. (R.
at 467.)
Dr. Kevin Blackwell, D.O., performed a consultative examination of
Vaughn on October 16, 2011, at the request of the state agency. (R. at 432-435.)
Vaughn complained of neck and back pain for the previous 10-12 years, worsening
in the previous year. (R. at 432.) Vaughn claimed that he was supposed to start
physical therapy soon. (R. at 432.) Vaughn complained of severe pain and said that
he was taking no pain medication. (R. at 432.) Later in the report, Dr. Blackwell
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noted that Vaughn said he was taking Xanax, Atenolol, Percocet, Soma and
ibuprofen. (R. at 432.) Dr. Blackwell noted that Vaughn was alert, cooperative,
oriented times three with good mental status and in no apparent acute distress. (R.
at 433.)
Dr. Blackwell noted that Vaughn’s neck was supple and nontender, his gait
was symmetrical and balanced, his shoulder and iliac crest height was good and
equal bilaterally, his upper and lower extremities were normal for size, symmetry
and strength, his grip strength was good, his fine motor movement skills of the
hands were normal, and his reflexes were within normal limits. (R. at 434.) Dr.
Blackwell stated that, based on his physical examination, Vaughn should be able to
sit for four to six hours in an eight-hour workday and stand for one to two hours in
an eight-hour workday with changes in postural positions every 15 to 20 minutes.
(R. at 434.) He stated that Vaughn could operate a vehicle, bend at the waist, kneel,
reach above his head and operate foot pedals one-third of the day or less, and he
should avoid squatting, stooping, crouching and crawling. (R. at 435.) He stated
that Vaughn could occasionally lift up to 35 pounds and frequently lift up to 15
pounds. (R. at 435.)
Vaughn returned to physical therapy at Wellmont Outpatient Rehabilitation
Services on January 12, 2012, and continued through February 23, 2012. (R. at
437-52.) He again quit therapy and did not return. (R. at 452.)
On March 1, 2012, Vaughn reported increased pain to Hamilton since
starting physical therapy. (R. at 465.) On May 30, 2012, Hamilton’s notes reflect
that she confronted him about quitting physical therapy. (R. at 463.) Vaughn stated

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that he quit because his pain got worse every time he participated in physical
therapy. (R. at 463.)
On August 29, 2012, Vaughn reported acute increased pain to Hamilton, but
he reported no new problems. (R. at 461.) Hamilton also completed a Medical
Evaluation form for Vaughn on this date. (R. at 458-59.) On this form, Hamilton
checked a box indicating that Vaughn was not able to participate in employment
and training activities in any capacity and would be unlikely to do so for 12
months. (R. at 458.) Hamilton stated that Vaughn was disabled based on physical
limitations, but she did not list any specific restriction on his work-related
activities. (R. at 459.) Hamilton noted that Vaughn needed additional evaluation
by his neurosurgeon to determine current and future functioning, but she stated that
he had no follow-up appointment scheduled with his neurosurgeon. (R. at 459.)
On February 21, 2013, Hamilton noted for the first time that Vaughn’s neck
problems started when he fractured his C4, C5, C6 and C7 vertebrae in a mining
accident. (R. at 761.) Hamilton also complained of severe pain in his low back on
this occasion. (R. at 761.) On March 29, 2013, Vaughn complained to Hamilton
that his pharmacy had changed the generic Percocet he was receiving and that the
new kind did not work to control his pain. (R. at 759.) Vaughn stated that he was
out of pain medication, even though he could not refill his prescription until April
5, because he had to increase the amount he took to control his pain. (R. at 759.)
Hamilton also noted that Vaughn had a full range of motion without tenderness in
his neck. (R. at 760.) On May 30, 2013, Vaughn again complained of worsening
pain, which forced him to take more of his pain medication than prescribed. (R. at
755.)

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On July 8, 2013, Hamilton noted that she could not see Vaughn or prescribe
him narcotic pain medication because Vaughn had let his insurance lapse. (R. at
754.) On August 5, 2013, Vaughn complained of being without pain medication
for almost a month. (R. at 751.) Vaughn stated that he had recently fallen in the
bathtub and had sought treatment at local emergency departments. (R. at 751.) He
requested referral to a pain management specialist. (R. at 751.)
Records from Lonesome Pine Hospital Emergency Department show that
Vaughn sought treatment there on August 3, 2013, and again on August 4, 2013,
for back and neck pain due to a fall at home. (R. at 765-94.) The August 4 records
reflect that Vaughn also sought treatment on August 3 at Lee Regional Hospital
Emergency Department. (R. at 778.) X-rays of Vaughn’s cervical spine taken on
August 3, 2013, showed no acute bony lesions, but a congenital defect at the C6
level and significant degenerative disc changes at the C5-6 and C6-7 levels with
bulging disc noted, impinging on the thecal sac at the C5-6 level. (R. at 773.) On
August 3, Vaughn was given Toradol and Demerol injections and discharged. (R.
at 767.) On August 4, the examining physician noted neck and back tenderness and
spasm with normal neurologic distal examination. (R. at 777.) The physician noted
no evidence of lower extremity weakness and no specific sensory findings. (R. at
777.) Vaughn was given two doses of Percocet and was encouraged to follow up
with his primary physician. (R. at 778.)
On September 4, 2013, Hamilton noted that recent x-rays showed a bulging
disc impinging on the thecal sac. (R. at 846.) She stated that Vaughn needed
surgery, but was “scared to death” to have it done. (R. at 846.) She recommended
an orthopedic referral for epidural injection. (R. at 846.) On October 2, 2013,

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Vaughn said that he had not received an orthopedic appointment. (R. at 843.) He
stated that his pain was “terrible all the time.” (R. at 843.)
Vaughn presented to the Emergency Department at Lonesome Pine Hospital
on October 11, 2013, where he was seen by Dr. Glenn Quarles, M.D. (R. at 92333.) Dr. Quarles noted that Vaughn appeared to be “moderately intoxicated.” (R. at
926.) A blood test showed no alcohol in Vaughn’s system, however. (R. at 929.)
Radiographic images were normal, except for evidence of degenerative disc
disease in Vaughn’s cervical spine. (R. at 930-33.)
Kellie Brooks, F.N.P., at Stone Mountain Health Clinic St. Charles, saw
Vaughn as a new patient on September 24, 2014. (R. at 864-66.) Brooks noted that
Vaughn came in requesting prescriptions for Percocet, Soma and Xanax after being
terminated from treatment by Hamilton for missing a urine drug screen and pill
count. (R. at 864.) Vaughn stated that he had been getting his medication “off of
the street.” (R. at 864.) Vaughn complained of neck, low back and knee pain. (R. at
864.) Brooks noted that Vaughn refused any nonnarcotic alternative medications.
(R. at 864.)
Vaughn saw Dr. Leigh A. Young, M.D., at the Simpson Clinic on October
17, 2014. (R. at 868-78.) On this occasion, Vaughn again claimed that he was
involved in a mining accident in 2006 that resulted in six fractured vertebrae. (R. at
868.) Vaughn complained of right-sided neck pain with radiating pain to his elbow,
a weakening in his arm and hand and loss of feeling in four fingers. (R. at 868.)
Vaughn also complained of low back pain and bilateral knee pain. (R. at 868.) Dr.
Young’s examination showed mild crepitus in both knees with free range of
motion, as well as palpable muscle spasm in Vaughn’s lumbar and thoracic spine
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with no neurological focal deficits. (R. at 869.) Dr. Young prescribed Voltaren gel,
oxycodone, Baclofen, Doxepin and alprazolam. (R. at 869.)
On November 13, 2014, Dr. Richard Surrusco, M.D., a state agency
physician, completed a Physical Residual Functional Capacity Assessment. (R. at
895-902.) He opined that Vaughn could lift items weighing up to 20 pounds
occasionally and 10 pounds frequently, could stand and/or walk about six hours in
an eight-hour workday and sit about six hours in an eight-hour workday. (R. at
896.)

He

stated

that

Vaughn

could

occasionally

climb

ramps/stairs/-

ladders/ropes/scaffolds, stoop, kneel, crouch and crawl. (R. at 897.) Dr. Surrusco
also stated that Vaughn’s ability to reach was limited. (R. at 898.)
Vaughn returned to the Simpson Clinic on December 3, 2014, and was seen
by Dr. Harland Simpson, M.D. (R. at 903.) Dr. Simpson noted that Vaughn had
missed his last appointment. (R. at 903.) At one point, Dr. Simpson noted that
Vaughn missed his appointment due to pain; at another point, Dr. Simpson said
that he missed the appointment for financial reasons. (R. at 903.) Dr. Simpson
noted that Vaughn’s missed appointment would be considered a failed pill count
and that he would not write Vaughn any more prescriptions for narcotic medication
if he missed another appointment. (R. at 903.) Vaughn claimed that he had been
out of pain medication for the previous two weeks except that he had saved two
pills for the ride to the doctor. (R. at 903.) At another point in the records, it was
noted that Vaughn claimed that he had not taken any medication in more than
week, even though he tested positive for the use of oxycodone and
benzodiazepines. (R. at 909.)

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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 (2016). 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.
Vaughn argues that the ALJ erred by failing to find that his condition met or
equaled § 1.04(A) of the Listing of Impairments. (Plaintiff’s Brief In Support Of
Motion For Summary Judgment, (“Plaintiff’s Brief”), at 9-13.) Vaughn also argues
that the ALJ erred by failing to properly evaluate the findings of Dr. Blackwell, a
consultative physician. (Plaintiff’s Brief at 13-16.)
To qualify for benefits based on the listed impairment for disorders of the
spine, found at 20 C.F.R. Pt. 404, Subpt. B, App. 1, § 1.04(A), a claimant must
show that he suffers from a disorder of the spine resulting in compromise of a
nerve root (including the cauda equina) or the spinal cord, with evidence of nerve
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root compression characterized by neuro-anatomic distribution of pain, limitation
of motion of the spine and motor loss accompanied by sensory or reflex loss. The
regulations’ basic definition of disability requires that a physical or mental
impairment be expected to result in death or has lasted or is expected to last for a
continuous period of not less than 12 months. See 20 C.F.R. §§ 404.1505, 416.905
(2016). A claimant’s condition must meet a listed impairment and the durational
requirement to be considered disabling. See 20 C.F.R. §§ 404.1520(a)(4)(iii),
416.920(a)(4)(iii) (2016).
In reaching his decision that Vaughn’s condition did not meet or equal §
1.04(A), the ALJ wrote:
…The current evidence … fails to establish an impairment that is
accompanied by all of the required signs that are reflective of listinglevel severity. Also, the claimant’s treating and examining physicians
of record have not reported each required necessary clinical,
laboratory, or radiographic finding specified in the listings.
(R. at 495-96.) The ALJ stated that he gave “great weight” to the opinion of Dr.
Francis that Vaughn’s condition did not meet this listed impairment because
Vaughn had not consistently exhibited a neuro-anatomic distribution of pain for 12
consistent months. (R. at 496-97.) Dr. Francis agreed that the medical evidence of
record showed that Vaughn had been diagnosed with cervical radiculopathy and
possible nerve root compression as early as 2010. (R. at 496.) Dr. Francis also
agreed that Vaughn had exhibited limited range of motion, muscle weakness or
sensory loss at times through 2013, but he also noted that Vaughn’s physical
examination sometimes also showed none of these findings. (R. at 496.)

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In particular, the medical record shows Dr. Blackwell noted no limitation of
motion on October 16, 2011. There also was no evidence of any motor, reflex or
sensory deficits. Vaughn was treated at the emergency room in August and
October of 2013 for neck pain, and, on each occasion, he denied any radiating
symptoms or weakness in his arms. Physical examination revealed full strength
and sensation. On January 4, 2011, Dr. Pryputniewicz noted normal strength and
tone in Vaughn’s upper extremities. All this evidence supports the ALJ’s finding
that Vaughn’s impairment did not meet or equal the Listing at § 1.04(A).
Vaughn also argues that the ALJ erred by failing to give full consideration to
the findings of Dr. Blackwell. (Plaintiff’s Brief at 13-16.) The ALJ noted that he
was giving “some weight” to the opinions of Dr. Blackwell. (R. at 501.) In
particular, the ALJ adopted Dr. Blackwell’s opinions that Vaughn’s work-related
activities should be limited to walking and standing no more than two hours in an
eight-hour workday, sitting no more than six hours in an eight-hour workday and
being able to shift positions every 20 minutes. (R. at 501.) The only opinion of Dr.
Blackwell’s that the ALJ rejected was his opinion that Vaughn could lift 15 pounds
frequently and 35 pounds occasionally and that Vaughn should avoid squatting,
stooping, crouching and crawling. (R. at 501.) The ALJ, instead, found that
Vaughn could lift only 10 pounds frequently and 20 pounds occasionally. (R. at
497, 501.) The ALJ also placed restrictions on Vaughn’s ability to reach, handle
and finger and kneel, crawl, crouch, stoop, balance or climb ramps or stairs, but he
did not prohibit these activities. (R. at 497, 501.) The ALJ stated that he adopted
greater restrictions on Vaughn’s ability to lift than those of Dr. Blackwell based on
the credibility of Vaughn’s testimony regarding his symptoms and the limiting
effects of his symptoms. (R. at 501.) Vaughn’s testimony supports this restriction. I
also note that the state agency physician’s residual functional capacity evaluation
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supports the lesser restrictions on Vaughn’s ability to squat, stoop, crouch and
crawl.
Based on the above-stated reasons, I find that the substantial evidence
supports the Commissioner’s decision that Vaughn was not disabled. An
appropriate Order and Judgment will be entered.
DATED:

August 14, 2017.
/s/

Pamela Meade Sargent

UNITED STATES MAGISTRATE JUDGE

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