Cox v. Colvin

Filing 18

MEMORANDUM OPINION. Signed by Magistrate Judge Pamela Meade Sargent on 09/20/2017. (Bordwine, Robin)

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

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Civil Action No. 2:16cv00013
MEMORANDUM OPINION

By: PAMELA MEADE SARGENT
United States Magistrate Judge

I. Background and Standard of Review
Plaintiff, Benjamin W. Cox, (“Cox”), 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.
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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 Cox protectively filed applications for DIB and SSI on

July 2, 2012, alleging disability as of April 27, 2012, due to hypothyroidism;
diabetes; depression; social anxiety; obesity; swelling in the legs; right leg sciatic
nerve problems; low back pain; osteoarthritis in the back; arthritis in the neck and
hands; and liver problems. (Record, (“R.”), at 232-37, 238-39, 253.) The claims were
denied initially and on reconsideration. (R. at 80-91, 92-103, 104-16, 117-29, 136-38,
143-45, 149-51.) Cox requested a hearing before an administrative law judge,
(“ALJ”), which was held on September 4, 2014, at which Cox was represented by
counsel. (R. at 34-74, 166-67.)
By decision dated November 26, 2014, an ALJ denied Cox’s claims. (R. at 1733.) The ALJ found that Cox met the nondisability insured status requirements of

the Act for DIB purposes through December 31, 2017. (R. at 19.) The ALJ found
that Cox had not engaged in substantial gainful activity since April 27, 2012, the
alleged onset date. (R. at 19.) The ALJ found that the medical evidence established
that Cox had severe impairments, namely insulin-dependent diabetes mellitus; low
back pain; obesity; history of bilateral carpal tunnel and cubital tunnel syndrome,
status-post bilateral surgical procedures; bilateral visual disorders, including
nonproliferative diabetic neuropathy, bilateral cataracts, vitreous hemorrhage and
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diabetic macular edema; inflammatory polyarthritis, not otherwise specified; and a
combination of mental impairments with diagnoses of depressive disorder; anxiety
disorder; and personality disorder, but she found that Cox 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 19-22.)
The ALJ found that Cox had the residual functional capacity to perform a limited
range of simple, repetitive unskilled light work 2 that required lifting no more than
20 pounds maximally and 10 pounds frequently; that required no more than
occasional pushing/pulling with the upper or lower extremities, climbing of ramps
and stairs, balancing, kneeling, crawling, stooping, crouching or interacting with
co-workers and supervisors; that required no more than frequent handling, feeling
and fingering; that did not require concentrated exposure to extreme temperatures;
that did not require working around hazardous machinery, unprotected heights or
vibrating surfaces and that required no climbing of ladders, ropes and scaffolds,
interaction with the public or reading of very small print. (R. at 22-25.) The ALJ
found that Cox was unable to perform his past relevant work. (R. at 25.) Based on
Cox’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 Cox could perform, including jobs as an
assembler, a packer and an inspector/tester/sorter. (R. at 25-26.) Thus, the ALJ
concluded that Cox was not under a disability as defined by the Act, and was not
eligible for DIB or SSI benefits. (R. at 26.) See 20 C.F.R. §§ 404.1520(g)
416.920(g) (2016).

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, 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, Cox pursued his administrative appeals,
(R. at 8-11), but the Appeals Council denied his request for review. (R. at 1-7.)
Cox 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 Cox’s motion for summary
judgment filed October 27, 2016, and the Commissioner’s motion for summary
judgment filed December 28, 2016.
II. Facts 3
Cox was born in 1974, (R. at 232, 238), which classifies him as a “younger
person” under 20 C.F.R. §§ 404.1563(c), 416.963(c). He has a college education
and past relevant work as a customer service representative, an information
technology specialist and a retail sales associate. (R. at 254.) At his September 4,
2014, hearing, Cox testified that he last worked as a customer service
representative in April 2012, but had to stop working due to his health, noting that
he could not handle his pain, his anxiety was at an “extreme high,” he was
depressed, and he did not want to get out. (R. at 42-43.) He stated that he suffered
from insulin-dependent type I diabetes and had been hospitalized once in 2007
with ketoacidosis. (R. at 44.) He stated that he had used an insulin pump since
2000, but that his sugar levels continued to fluctuate, going as high as 500 a couple
of times weekly. (R. at 55-56.) He testified that he also took Metformin, which
caused bowel issues and that he had to use to restroom six to 10 times over an
eight-hour period due to diarrhea or other bowel problems. (R. at 62.) Cox further
3

The relevant time period for deciding Cox’s claims is from April 27, 2012, the alleged
onset date, to November 26, 2014, the date of the ALJ’s decision. To the extent that medical
records outside the scope of the relevant time period are included herein, it is for clarity of the
record.
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stated that his diabetes caused frequent urinary urges, causing him to use the
restroom three to four times in an eight-hour period. (R. at 61.)
Cox also stated that he suffered from diabetic retinopathy and macular
edema, and he testified that he could not read small print. (R. at 45.) However, he
stated that he did not wear reading glasses or contact lenses and that his ability to
watch television was “fairly decent.” (R. at 45.) He testified that he had
spondylosis of the back, but had been diagnosed with only low back pain. (R. at
45.) Cox stated that he underwent surgery for carpal tunnel syndrome in 2011 and
that he continued to experience swelling, numbness and tingling of the hands. (R.
at 46.) Nonetheless, he testified that he was not then receiving any treatment for
this condition. (R. at 46.) Cox testified that the hand swelling caused difficulty
gripping and grasping objects. (R. at 57-58.) He described the sensation in his
hands as “needles” and “bee stings.” (R. at 58.) Cox testified that he had
neuropathy in his feet and that he tried to stay off of them and keep them elevated
three to four hours throughout the day. (R. at 46-47.) He stated that he had been
doing this since May or June 2012. (R. at 47.) He stated that the sensation in his
feet was similar to that in his hands, but he also had a burning sensation. (R. at 58.)
Cox stated that he could not take anything for pain other than Tylenol because he
was in renal failure, for which he had been treated since 2009 or 2010. (R. at 48.)
Cox stated that he had been told to cut back on the amount of protein in his diet
and to only take Tylenol. (R. at 49.) Cox testified that a kidney specialist had
advised to “keep a close eye and monitor[] it.” (R. at 49.)
Cox further testified that he suffered from depression, for which he had
never been hospitalized. (R. at 49, 54.) He testified that the last time he took
mental health medications was in April 2012 because he could not afford them.
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(R. at 54-55.) He stated that he had been in counseling since 2010. (R. at 43, 60.)
Cox stated that he had anxiety or panic attacks, during which his heart raced and he
did not want to be around people. (R. at 59.) He stated that he left his home “very
rarely,” noting that he usually stayed in his bedroom “resting or something.” (R. at
59.) He described his depressive symptoms to include tiredness, increased appetite,
feeling really sad, crying a lot and having no motivation to get out of bed. (R. at
59.) Cox noted that four or five times weekly he would not get out of bed to
shower and dress. (R. at 59-60.) Cox stated that, in April 2012, he was
experiencing a lot of work-related stress, noting that breaks were being taken
away, and he was allowed only a lunch break in a 10-hour period. (R. at 61.) He
further stated there was a lot of negativity. (R. at 61.)
Cox testified that he had lived with his parents since losing his house in
November 2012. (R. at 52.) He stated that he usually stayed home, sitting around
or lying in bed. (R. at 51-52.) Cox stated that he took care of a fish aquarium, but a
friend bought the supplies for him. (R. at 52.) He denied performing any household
activities due to pain in his low back, legs and knees. (R. at 53.) Cox further
testified that he became short of breath with exertion, estimating he could walk 20
feet before becoming short of breath, stand for 10 minutes and sit for about 20
minutes. (R. at 53-54.) Cox estimated that he could lift five pounds. (R. at 54.) He
testified that being on his feet too long caused low back pain, and if he did not sit
down, his legs got weak and shaky. (R. at 56-57.) He also stated that his feet would
swell after being on them for five to 10 minutes and that he suffered swelling in his
legs and ankles daily, all as a result of his improperly functioning kidneys. (R. at
57.) Cox testified that bending at the waist was “extremely painful” and that
stooping, squatting and kneeling were “very difficult,” as they increased his pain,
and he had to pull himself back up. (R. at 58-59.)
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Vocational expert John Newman also was present and testified at Cox’s
hearing. (R. at 64-72.) Newman classified Cox’s past work as a customer service
representative as sedentary4 and semi-skilled, as a retail sales associate, as
performed by Cox, as medium5 and unskilled and as an information technology
specialist as medium and skilled. (R. at 66.) Newman was asked to consider a
hypothetical individual such as Cox, who could perform simple, repetitive
unskilled work that required lifting and carrying no more than 20 pounds
occasionally, up to 10 pounds frequently, standing, walking and sitting up to six
hours in an eight-hour day, occasionally pushing and pulling with the upper and
lower extremities to the lift/carry amounts, occasionally climbing ramps and stairs,
balancing, kneeling, crawling, stooping and crouching, frequently handling, feeling
and fingering objects, who needed to avoid concentrated exposure to extreme
temperatures, hazardous machinery, unprotected heights, climbing ladders, ropes
and scaffolds and working on vibrating surfaces, who could have no interaction
with the general public and no more than occasional interaction with supervisors
and co-workers and who would have to avoid reading very small print. (R. at 6667.) Newman testified that such an individual could not perform Cox’s past
relevant work, but could perform other jobs existing in significant numbers in the
national economy, including those of an assembler, a packer, a laundry folder and
an inspector/sorter. (R. at 67-68.) Newman testified that the same hypothetical
4

Sedentary work involves lifting no more than 10 pounds at a time and occasionally
lifting or carrying items 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).
5

Medium work involves lifting items weighing up to 50 pounds at a time with frequent
lifting or carrying of objects weighing up to 25 pounds. If someone can perform medium work,
he also can perform sedentary and light work. See 20 C.F.R. §§ 404. 1567(c), 416.967(c) (2016).
-7-

individual, but who would miss more than two workdays monthly, could not
perform any work due to an unacceptable rate of absenteeism. (R. at 68-69.)
Newman next testified that the individual in the first hypothetical, but who would
be limited to handling and fingering objects less than one-third of an eight-hour
workday due to diabetic neuropathy and carpal tunnel symptoms, could not
perform any work. (R. at 69-70.) Newman next testified that the first hypothetical
individual, but who was seriously limited in the ability to deal with work stresses,
functioning independently and demonstrating reliability, could not perform
competitive employment. (R. at 70-71.) Next, Newman testified that an individual
with the restrictions set out in Paula Meade’s May 25, 2014, physical assessment,
with the exception of a changed restriction from an ability to never climb, stoop,
kneel, crouch and crawl to an ability to rarely perform these activities and an
ability to occasionally balance, could not perform any jobs. (R. at 71.) Lastly,
Newman testified that an individual who would be off-task greater than 10 percent
of the workday could not maintain substantial gainful activity. (R. at 72.)
In rendering her decision, the ALJ reviewed records from Wellmont Health
System; Clinch Valley River Health Services; Lonesome Pine Hospital; Holston
Medical Group; Holston Valley Ambulatory Surgery Center; Anne B. Jacobe,
LCSW; Solutions Counseling; B. Wayne Lanthorn, Ph.D., a licensed clinical
psychologist; Dr. Matthew Beasey, M.D.; Holston Valley Medical Center; Wise
County Social Services; The Regional Eye Center; Paula Meade, FNP; Karen
Odle, LPC; Mary Beth Bentley, FNP; The Health Wagon; Dr. Andrew Bockner,
M.D., a state agency physician; Dr. Richard Surrusco, M.D., a state agency
physician; Howard S. Leizer, Ph.D., a state agency psychologist; and Dr. R.S.
Kadian, M.D., a state agency physician.

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As for Cox’s alleged physical impairments, by way of background, the
record reveals that he has been treated for type I diabetes since he was nine years
old. (R. at 696.) He also has undergone numerous diagnostic tests, including x-rays
of the cervical spine, taken on January 25, 2010, which showed no significant
degenerative changes, and x-rays of the lumbar spine, dated February 24, 2010,
which showed mild degenerative spondylosis, but no acute abnormality. (R. at
1277, 1297.) These lumbar x-rays also showed slight wedging of the T11 and T12
vertebral bodies. (R. at 1277.) An MRI of the lumbar spine, dated February 26,
2010, showed T11 and T12 compressions and degenerative changes, but no
definite neural impingement. (R. at 1272-73.) An MRI of the thoracic spine, dated
March 17, 2010, showed mild compression deformities of the T11 and T12 levels
of the spine, which appeared to be chronic, but no acute abnormality was evident.
(R. at 1264.) An MRI of the lumbar spine, dated December 15, 2010, showed mild
lumbar spondylosis without significant interval change. (R. at 1182-83.) An
ultrasound of the abdomen, also dated December 15, 2010, showed echogenic
liver, consistent with steatosis. 6 (R. at 1188.) An August 25, 2011, abdominal CT
scan showed progression in hepatomegaly and hepatic steatosis, but stable
splenomegaly; atrophy of the medial segment of the left lobe of the liver and
caudate lobe, of unclear significance; and age-advanced pancreatic atrophy. (R. at
1101, 1567.) August 26, 2011, x-rays of the cervical spine were normal. (R. at
1099.) Based on Cox’s complaints of headaches, a CT scan, taken on September 2,
2011, strongly suggested chronic bilateral mastoiditis and chronic otitis media, but,
otherwise, was unremarkable. (R. at 1093.) A CT guided liver biopsy, performed
on October 31, 2011, revealed findings consistent with hepatic steatohepatitis/fatty
liver disease. (R. at 936-38.)
6

Steatosis refers to fatty degeneration. See DORLAND’S ILLUSTRATED MEDICAL
DICTIONARY, (“Dorland’s”), 1579 (27th ed. 1988).
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The record also shows that Cox treated his diabetes, hypothyroidism,
hypertension and hyperlipidemia with Holston Medical Group from January 3,
2012, to April 20, 2012. Over this time, some mild edema of the lower extremities
was noted, but Cox consistently had a normal gait and normal strength and muscle
tone in the extremities, as well as normal foot examination. (R. at 754, 819, 830,
870, 882, 886.) Cox was obese, with his weight during this time period recorded as
being from 298 to 307 pounds. (R. at 753, 819, 830, 869, 886, 893.) Blood pressure
readings were 172/86, (R. at 893), 148/76, (R. at 830), 138/82, (R. at 886), 160/90,
(R. at 881), 122/82, (R. at 819), and 140/80. (R. at 869.) He denied symptoms of
peripheral neuropathy, gastrointestinal complaints and numbness and tingling in
the legs. (R. at 753, 827-28, 881, 883.) Over this time, Cox did complain of stress,
headaches, right hip pain and some back pain. (R. at 883, 886, 893.) On March 8,
2012, Cox received injections for lower back and hip pain. (R. at 887-88.) X-rays
of the hips were mostly unremarkable, and x-rays of the lumbar spine showed only
mild spondylosis, mild compression deformity at the T12 vertebra, minimal
discogenic abnormalities at the L3-L4 and T11-T12 levels of the spine and mild
anterior wedging of the T11 vertebra. (R. at 889, 891.) Cox reported more than
once that he was not taking his medications as directed. (R. at 828, 883.) He
reported that he was doing well with CPAP treatment. (R. at 866, 893.) Over this
time, Cox was consistently alert and oriented with a normal mood and affect, as
well as intact insight and judgment. (R. at 754, 830, 882, 886, 894.) On January 3,
2012, Dr. Michael Nannenga, M.D., noted that Cox had diabetic nephropathy, but
on March 22, 2012, hepatic function testing was normal. (R. at 755, 828.) On
March 30, 2012, Cox’s microalbumin levels and microalbumin/creatinine ratio
were high, but TSH levels were normal. (R. at 913, 921.) Cox was diagnosed with
diabetic nephropathy, hypertension, hyperlipidemia, hypothyroidism, elevated liver
enzymes, nonalcoholic steatohepatitis, microalbuminuria, uncontrolled type I
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diabetes, neuropathy, neck pain, migraine headaches, hip pain, sciatica and lower
back pain. (R. at 754, 820, 831, 887.) Cox was continued on medications and
advised to exercise and lose weight. (R. at 754, 821-22, 831-32, 870.) On April 20,
2012, Cox reported that he would be looking for a new job because his employer
would not accommodate his limitations due to diabetes and severe sleep apnea. (R.
at 866.)
Cox saw Paula Hill Meade, FNP at The Health Wagon, to establish his status
as a new patient, on October 1, 2012. (R. at 1543-45.) His nonfasting blood sugar
level was 261. (R. at 1544.) On examination, Cox was pleasant, cooperative and in
no acute distress. (R. at 1544.) He exhibited some elbow tenderness and right hip
tenderness with painful range of motion of the hip. (R. at 1544.) There was no
clubbing, cyanosis or edema of the extremities, and peripheral pulses were within
normal limits. (R. at 1544.) Cranial nerves were grossly intact, and Cox was alert
and oriented with good eye contact and clear speech. (R. at 1544.) The remainder
of the examination was normal, including a foot exam. (R. at 1544.) Cox reported
that he had been without all medications since May, except for Synthroid and
insulin. (R. at 1544.) While he reported arthritic pain in his upper extremity joints,
he noted that he responded well to Mobic. (R. at 1544.) Meade diagnosed Cox with
benign essential hypertension, diabetes, not stated as uncontrolled, and generalized
osteoarthritis. (R. at 1544.) She prescribed Lisinopril and Mobic. (R. at 1544.) On
October 18, 2012, Cox saw Teresa Gardner, another FNP at The Health Wagon,
for a follow-up appointment. (R. at 1541-42.) His blood pressure was 147/81, he
weighed 314 pounds, and his nonfasting blood sugar level was 262. (R. at 1541.)
Cox reported painful upper extremity joints and neck pain due to not taking Mobic
because of lack of resources. (R. at 1541.) On physical examination, Cox was
pleasant, cooperative and in no acute distress. (R. at 1541.) Frontal and maxillary
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sinuses were tender to percussion, and he exhibited right elbow and right hip
tenderness with painful range of motion of the hip, but there was no clubbing,
cyanosis or edema of the extremities, and peripheral pulses were within normal
limits. (R. at 1541.) Cox was alert and oriented with grossly intact cranial nerves,
he made good eye contact, and he had clear speech. (R. at 1541.) Cox was
diagnosed with diabetes, not stated as uncontrolled, and acute sinusitis. (R. at
1542.) When Cox returned to Gardner on November 12, 2012, his blood pressure
was 156/84, he weighed 313 pounds, and his nonfasting blood sugar level was 232.
(R. at 1539.) Gardner encouraged Cox to lose weight. (R. at 1539.)
On December 6, 2012, Dr. Richard Surrusco, M.D., a state agency
physician, completed a physical residual functional capacity assessment of Cox,
finding that he could perform light work with a limited ability to frequently
push/pull with the upper extremities. (R. at 87-89.) Dr. Surrusco found that Cox
could occasionally climb ladders, ropes or scaffolds, but could perform all other
postural activities frequently. (R. at 87-88.) He further opined that Cox was limited
to handling objects frequently with both hands. (R. at 88.) He indicated no visual
or communicative limitations, but found that Cox must avoid concentrated
exposure to vibration, fumes, odors, dusts, gases, poor ventilation and hazards. (R.
at 88-89.) Dr. Surrusco concluded that Cox could perform his past relevant work as
a dispatcher. (R. at 91.)
Cox continued to treat with various healthcare providers at The Health
Wagon through June 5, 2013. Over this time, his blood pressure readings were
190/90, 149/72 and 163/88, and his nonfasting blood sugar levels were 187, 224
and 126. (R. at 1522, 1525, 1534.) Cox continued to lose weight during this time,
with a recorded weight of 307 pounds on June 5, 2013. (R. at 1522.) Physical
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examinations were essentially normal, except for tenderness to percussion of the
frontal and maxillary sinuses, bilateral elbow tenderness and right hip tenderness
with painful range of motion. (R. at 1522, 1525, 1534.) There was no clubbing,
cyanosis or edema of the extremities, peripheral pulses were normal, cranial nerves
were grossly intact, and Cox exhibited good eye contact and clear speech. (R. at
1522, 1525-26, 1534.) On June 5, 2013, a foot examination was normal. (R. at
1522.) Over this time, Cox was diagnosed with diabetes without mention of
complication and not uncontrolled; unspecified essential hypertension; chronic
nonalcoholic liver disease; hypothyroidism; acquired trigger finger; unspecified
tachycardia; unspecified hematuria; and proteinuria. (R. at 1522, 1526, 1535.) Cox
was continued on medications and advised to lose weight. (R. at 1523, 1535.)
Dr. R.S. Kadian, M.D., a state agency physician, completed another physical
residual functional capacity assessment of Cox on June 14, 2013. (R. at 112-13.)
His assessment mirrored that of Dr. Surrusco from December 4, 2012, except he
found that Cox had no environmental limitations. (R. at 112-13.) Dr. Kadian
concluded that, despite his limitations, Cox could perform his past work as a
dispatcher. (R. at 114.)
On July 3, 2013, Cox returned to The Health Wagon, complaining of
worsened thyroid symptoms over the previous three to four weeks, including
crying spells, nightmares, temperature sensitivity, low energy and depressed mood.
(R. at 1520.) He reported that he had discontinued his thyroid medications
approximately six weeks previously for one to two weeks, and he noted that he
would run out of medications soon, but had no money to obtain refills. (R. at
1520.) Cox reported fatigue, blurred vision in the right eye, shortness of breath
with exertion, painful shoulder, neck, low back, knees and hips, decreased
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sensation in the extremities with tingling, numbness and burning in the feet related
to position, a burning sensation in the liver after meals and back pain with walking,
which had worsened over the previous three to four weeks. (R. at 1521.) On
examination, Cox was pleasant and cooperative and in no acute distress. (R. at
1520.) He exhibited bilateral elbow tenderness and tenderness of the right hip with
painful range of motion of the hip, but there was no clubbing, cyanosis or edema of
the extremities, and peripheral pulses were normal. (R. at 1520.) Gardner
diagnosed unspecified hematuria and unspecified hypothyroidism. (R. at 1520.)
On October 18, 2013, Cox saw Becky Mullins, a nurse practitioner at The Health
Wagon, at which time his blood pressure was 148/89, he weighed 329 pounds, and
his fasting blood sugar level was 151. (R. at 1515.) Cox reported no changes since
his prior visit other than increased fatigue. (R. at 1516.) He further reported blood
sugar levels from the 120s to 150s, with no significant highs or lows. (R. at 1516.)
He denied blurred vision, diminished visual acuity or floaters, cold intolerance,
difficulty sleeping, dizziness, excessive sweating or thirst, frequent urination, heat
intolerance, shortness of breath with rest or exertion, fluid accumulation in the
legs, abdominal pain and swollen joints. (R. at 1516.) Cox did complain of painful
joints, lower back pain and stiffness, but he denied decreased extremity sensation,
foot pain, leg pain or cramping, ulceration of the feet, difficulty walking, foot pain,
gait abnormality, headache, irritability, loss of strength, memory loss, tingling and
numbness. (R. at 1516-17.) Cox also denied anxiety, depressed mood, eating
disorder, loss of appetite, stressors and suicidal thoughts. (R. at 1517.) On
examination, Cox was pleasant, alert and in no acute distress. (R. at 1515.) He had
full range of motion of the neck, a normal spine examination, no lumbosacral
tenderness, no clubbing, cyanosis or edema of the extremities, normal peripheral
pulses, normal gait and normal motor strength in all extremities. (R. at 1515.) He
was alert and oriented with intact cognitive function, good eye contact, good
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insight and judgment, clear speech, thought content free of suicidal ideation or
delusions and logical and goal-directed thought processes. (R. at 1515.) Mullins
diagnosed Cox with benign essential hypertension, diabetes, not stated as
uncontrolled, and unspecified hypothyroidism. (R. at 1515.) His medications were
refilled, and he was advised to start a diet and exercise regimen. (R. at 1516.)
Cox presented to the emergency department at Lonesome Pine Hospital on
October 28, 2013, with complaints of seeing red spots with his right eye with no
history of injury. (R. at 1432-42.) He denied eye pain, but noted blurred vision of
the right eye. (R. at 1434.) Cox appeared uncomfortable, but alert and in no acute
distress. (R. at 1435.) No hemorrhages were noted, and there was no corneal
abrasion or foreign body. (R. at 1435.) Cox exhibited no extremity tenderness or
edema, and his mood and affect were normal. (R. at 1435.) Cox was diagnosed
with eye floaters. (R. at 1437.) A CT scan of the head was performed, and Cox was
referred to an ophthalmologist. (R. at 1435.)
Cox continued to receive treatment at The Health Wagon from December 3,
2013, to March 4, 2014. His blood pressure readings over this time were 142/85,
157/93 and 139/84, and his blood sugar levels were 183, 271, 253 and 510. 7 (R. at
1502, 1504, 1506, 1513.) Cox’s weight ranged from 321 to 333 pounds. (R. at
1502, 1504, 1506, 1513.) When Cox saw Mary Beth Bentley, FNP, on January 20,
2014, he did not report any symptoms, including depression or anxiety, and he was
in no acute distress. (R. at 1508-09.) A physical examination was unremarkable,
including a full range of motion of the neck, no extremity edema, normal motor
strength and normal sensory exam. (R. at 1508.) Cox was alert and oriented with
intact cognitive function, good eye contact, good judgment and insight, clear
7

The 183 and 510 readings were fasting levels, while the other two were nonfasting.
-15-

speech, thought content free of suicidal ideation or delusions and logical and goaldirected thought processes. (R. at 1508.) A physical examination on February 3,
2014, yielded the same results. (R. at 1506.) On February 25, 2014, Cox had trace
edema to the legs, but he reported that he had run out of insulin. (R. at 1504.) The
rest of the physical examination was unremarkable, and a mental status
examination also was normal, including intact cognitive function, good judgment
and insight, full range mood and affect, no hallucinations, no suicidal ideation or
delusions and logical and goal-directed thought processes. (R. at 1504.) Over this
time, Cox was diagnosed with diabetes; unspecified essential hypertension;
nonspecific abnormal liver function study results; mixed hyperlipidemia; and
hypothyroidism. (R. at 1504-06, 1508.) He was continued on medications and
advised to lose weight. (R. at 1505-06, 1508-09.)
Meade completed a letter, dated April 17, 2014, on behalf of the Wise
County Department of Social Services, finding that Cox was permanently disabled
due to diabetes mellitus with nephropathy, hypertension and hypothyroidism. (R. at
1398.) Cox continued to see Meade in April and May 2014. Over this time, his
blood pressure was 139/83 and 132/81, and his nonfasting blood sugar level was
262 and 219. (R. at 1495, 1497.) He weighed 317 to 319 pounds. (R. at 1495,
1497.) During this time, Cox had normal physical examinations, with the exception
of trace edema to the legs. (R. at 1495, 1497.) Mental status examinations were
unremarkable. (R. at 1495, 1497.) On April 22, 2014, a foot examination also was
normal. (R. at 1497.) On May 6, 2014, Cox reported that his disability application
had been denied the previous week, he was going to run out of his medications,
and he was extremely stressed. (R. at 1495.) Cox’s diagnoses remained the same,
and he was continued on medications. (R. at 1497-98.)

-16-

Meade completed a physical assessment of Cox on May 25, 2014, finding
that he could lift and/or carry items weighing up to 10 pounds occasionally and up
to five pounds frequently due to a history of chronic low back pain. (R. at 145658.) She further found that he could stand and/or walk for a total of 30 minutes in
an eight-hour workday, but could do so for only 15 minutes without interruption,
noting that his history of diabetic neuropathy prevented prolonged sitting or
prolonged walking. (R. at 1456.) Likewise, Meade found that Cox could sit for a
total of 30 minutes in an eight-hour workday, but could do so for only 15 minutes
without interruption due to obesity, chronic low back pain and diabetic neuropathy.
(R. at 1457.) She found that he could never climb, stoop, kneel, balance, crouch or
crawl due to his chronic lumbago and diabetic neuropathy. (R. at 1457.) Meade
found that Cox’s abilities to reach, to handle, to feel, to push/pull, to see and to
speak were affected by his impairments due to his diabetic retinopathy and a visual
disturbance of the left eye due to hemorrhage. (R. at 1457.) She found that Cox
could not work around moving machinery, temperature extremes, chemicals, dust,
fumes and humidity. (R. at 1458.) She attributed these restrictions to Cox’s history
of sleep apnea and breathing difficulties. (R. at 1458.) She also noted that Cox’s
neuropathic pain was increased. (R. at 1458.) Meade opined that Cox would miss
more than two workdays monthly. (R. at 1458.)
Cox continued to treat at The Health Wagon through August 21, 2014. On
May 28, 2014, Cox reported continued spots before his eyes and floaters and a
history of diabetic neuropathy with increased pain and burning in the lower
extremities, which he rated as a 10 on a 10-point scale. (R. at 1492.) He reported
fever, lightheadedness and sleep disturbance. (R. at 1493.) On examination, Cox
was alert and in no distress, and there was no clubbing or cyanosis of the
extremities, but trace edema to the legs, and peripheral pulses were normal
-17-

throughout. (R. at 1492.) He had a normal gait and normal extremity motor
strength. (R. at 1492.) Cox was alert and oriented with intact cognitive function,
good eye contact, good judgment and insight, full range mood and affect, no
auditory or visual hallucinations, clear speech, thought content free of suicidal
ideation or delusions and logical and goal-directed thought processes. (R. at 1492.)
In addition to his previous diagnoses, Cox was diagnosed with diabetes with
neurological manifestations, and he was advised on foot care. (R. at 1492.) Cox’s
blood pressure readings over this time were 143/84, 124/81 and 135/76, and his
blood sugar levels were 412, 123 and 209. 8 Cox’s weight ranged from 317 to 320
pounds. (R. at 1484, 1487, 1490.) On June 24, 2014, Cox reported that his blood
sugar had been well-controlled with no significantly high readings, and he reported
well-controlled blood pressure. (R. at 1488.) At that time, he complained of low
back pain at times, as well as tingling and numbness, but he denied all other
symptoms, including anxiety, depressed mood and suicidal thoughts. (R. at 1488.)
Physical examination, as well as mental status examination, were completely
unremarkable. (R. at 1487.) Cox was continued on medications. (R. at 1487-88.)
On August 21, 2014, Bentley completed a mental assessment of Cox,
finding that he had a good ability to understand, remember and carry out simple
job instructions, to maintain personal appearance and to behave in an emotionally
stable manner. (R. at 1478-80.) She opined that Cox had a fair ability to follow
work rules, to relate to co-workers, to use judgment, to interact with supervisors, to
function independently, to maintain attention and concentration, to understand,
remember and carry out both detailed and complex job instructions and to
demonstrate reliability. (R. at 1478-79.) She found that he had a fair to poor ability
to relate predictably in social situations and a poor ability to deal with work
8

The 209 reading was the only nonfasting level.
-18-

stresses due to poor coping abilities and a poor ability to deal with the public. (R.
at 1478-79.) She found that Cox would miss more than two workdays monthly.
(R. at 1480.) Bentley based these findings on Cox’s allegations of having a poor
rapport with co-workers, social anxiety, prior increased hostility and antisocial
behavior in social situations. (R. at 1478-79.) She further noted that Cox’s various
health issues compromised his ability to work and participate in social activities.
(R. at 1480.) On this same day, Bentley opined that Cox’s condition met or equaled
§ 6.02(C)(2) of the Listing of Medical Impairments for impaired renal functioning.
(R. at 1482.)
Cox received treatment at The Regional Eye Center from October 2013
through July 2014. (R. at 1400-15, 1444-48, 1470-76.) Cox saw Dr. Eric K. Smith,
M.D., on October 29, 2013, following an emergency room visit the previous
evening due to the sudden appearance of a black spot in the central vision of his
right eye. (R. at 1413.) Cox advised Dr. Smith that this had worsened since the
prior evening and that his peripheral vision had begun to decrease. (R. at 1413.)
Dr. Smith diagnosed Cox with background diabetic retinopathy in both eyes with
vitreous hemorrhage of the right eye and cataracts in both eyes. (R. at 1414.) By
November 26, 2013, visual acuity was 20/50 in the right eye and 20/25 in the left.
(R. at 1411.) Dr. Smith noted improving hemorrhage in the right eye, and he
referred Cox to Dr. Williamson for a panretinal photocoagulation, (“PRP”),
evaluation. (R. at 1412.) Cox saw Dr. Keith Williamson, M.D., on January 7, 2014,
noting no changes in his condition. (R. at 1408.) Visual acuity in the left eye was
improved to 20/20, but there continued to be hemorrhage in the right eye. (R. at
1409.) Dr. Williamson diagnosed proliferative diabetic retinopathy of the right eye
with hemorrhage and nonproliferative diabetic retinopathy of the left eye. (R. at
1409.) Dr. Williamson performed a PRP treatment on the right eye and advised
-19-

that, if this did not resolve the problem, he would refer Cox for retinal injections.
(R. at 1409.)
On February 26, 2014, Cox reported that his vision was some better, but he
continued to see a few spots and a lot of floaters. (R. at 1406.) Fresh vitreous
hemorrhage was discovered on examination. (R. at 1407.) Dr. Williamson
scheduled Cox for the second half of the PRP treatment. (R. at 1407, 1447.) On
March 27, 2014, Cox reported continued, but improved, spots. (R. at 1403.) He
reported that his right eye became “hazier” as the day progressed and that it was
very sensitive to light. (R. at 1403.) Cox’s visual acuity was 20/50 in the right eye
and 20/25 in the left. (R. at 1403.) An early cataract was noted in the right eye,
along with fresh vitreous hemorrhage. (R. at 1404.) Dr. Williamson diagnosed mild
nonproliferative diabetic retinopathy in the left eye, but moderate diabetic
proliferative retinopathy in the right eye. (R. at 1404.) On May 5, 2014, Cox’s
visual acuity remained unchanged, an early cataract was noted in the right eye, and
there was a small amount of hemorrhage in the right eye. (R. at 1400-01.)
Moderate proliferative diabetic retinopathy with mild edema in the right eye also
was noted. (R. at 1401.) Cox agreed to undergo an evaluation for retinal injections.
(R. at 1401.)
On June 2, 2014, Cox saw Dr. Brandon Lee, M.D., who recommended
intravitreal injections for three months to try to improve his vision. (R. at 1445.)
Examination showed a small amount of hemorrhage, moderate proliferative
diabetic retinopathy of the right eye and cataracts in both eyes, but which were not
affecting his vision. (R. at 1445.) On July 22, 2014, Dr. Williamson performed the
retinal injection. (R. at 1472-74.) Cox complained of experiencing random right
eye pain and distorted and blurry vision in the right eye, and he reported difficulty
-20-

reading fine print. (R. at 1472.) There was a small amount of hemorrhage. (R. at
1473.) Dr. Williamson diagnosed diabetic macular edema. (R. at 1473.) Although
Cox returned for another retinal injection on August 19, 2014, Dr. Lee found that
Cox’s vision and edema had improved. (R. at 1550-52.) Therefore, no injection
was administered. (R. at 1552.)
As for Cox’s mental health treatment, the record shows that he received
counseling at Solutions Counseling from June 2010 to August 2012 for his
symptoms of depression. On January 5, 2012, Cox reported moderate depression,
anxiety, irritability and anger and panic attacks, as well as mildly decreased
attention and concentration, but no crying spells or suicidal ideation. (R. at 978.)
On mental status examination, Anne Jacobe, a licensed clinical social worker,
found that Cox had a depressed and irritable mood with anxious affect, but intact
orientation and thought process, no paranoia/delusions and fair insight and
judgment. (R. at 978.) Jacobe diagnosed Cox with moderate, recurrent major
depressive disorder and agoraphobia with panic attacks. (R. at 978.) By January
18, 2012, Cox reported “doing some better.” (R. at 977.) He continued to report
moderate depression and anxiety and mildly decreased concentration, but no
irritability/anger, no panic attacks, no crying spells and no suicidal or homicidal
ideation. (R. at 977.) Jacobe found that Cox had a depressed mood and anxious,
but appropriate, affect, intact orientation, racing thoughts, no paranoia/delusions
and fair judgment/insight. (R. at 977.) On January 31, 2012, Cox continued to
report moderate depression and anger and moderately decreased attention and
concentration, but he denied anxiety, panic attacks and suicidal or homicidal
ideation. (R. at 976.) Jacobe found that Cox’s mood was depressed and irritable,
but orientation and thought process were intact, he had no paranoia/delusions, and
judgment/insight was good. (R. at 976.) On February 16, 2012, Cox again reported
-21-

“doing some better,” noting decreased stress at work. (R. at 975.) He continued to
report moderate depression, anxiety and irritability, moderately decreased attention
and concentration, but no crying spells, panic attacks or suicidal or homicidal
ideation. (R. at 975.) Jacobe found that Cox had an irritable mood and anxious
affect with intact orientation and thought process, no paranoia/delusions and fair
judgment/insight. (R. at 975.) On March 15, 2012, Cox reported increased stress.
(R. at 973.) On mental status examination, Jacobe found that Cox had a depressed
mood and anxious affect, but intact orientation and thought process. (R. at 973.)
On March 29, 2012, Jacobe found that Cox had a depressed and irritable mood
with an anxious affect and racing thoughts, but intact orientation, no
paranoia/delusions and fair judgment/insight. (R. at 972.) Cox reported “doing
some better” when he saw Jacobe on April 12, 2012. (R. at 971.) However, he
noted continued work stressors. (R. at 971.) He had an anxious affect, but intact
orientation and thought process, no paranoia/delusions and fair insight and
judgment. (R. at 971.) On April 25, 2012, Cox reported increased work stressors
and reported working 50 hours weekly. (R. at 970.) Cox reported moderate
depression and panic attacks. (R. at 970.) Jacobe found that Cox had a depressed
mood and anxious affect, but intact orientation and thought process, no
paranoia/delusions and fair judgment/insight. (R. at 970.)
On May 18, 2012, Cox reported that he had quit his job earlier in the week
and planned to file for disability benefits. (R. at 969.) He stated, “I couldn’t take
it,” and he noted he planned to sue his employer for failing to accommodate his
health issues. (R. at 969.) Cox reported moderate depression, anxiety and anger,
but no crying spells or panic attacks and “ok” attention/concentration. (R. at 969.)
Jacobe found that Cox had a depressed and irritable mood with anxious affect and
racing thoughts, but intact orientation, no paranoia/delusions and fair
-22-

judgment/insight. (R. at 969.) On May 24, 2012, Cox reported that he had been
applying for jobs, but it was “frustrating.” (R. at 968.) He reported severe anxiety.
(R. at 968.) Jacobe found that Cox had a depressed and irritable mood with anxious
affect and racing thoughts, but intact orientation, no paranoia/delusions and fair
judgment/insight. (R. at 968.) On June 7, 2012, Cox reported that he continued to
search for work, but it was hard. (R. at 967.) Jacobe found that Cox had a
depressed and irritable mood with anxious and appropriate affect, intact orientation
and thought process, no paranoia/delusions and fair judgment/insight. (R. at 967.)
On June 21, 2012, Cox again reported severe anxiety and decreased
attention/concentration. (R. at 966.) Jacobe found Cox had a depressed mood and
anxious affect. (R. at 966.) On July 12, 2012, he reported less stress since quitting
his job. (R. at 964.) He further reported that he had run out of all medications, but
he had received help from a church. (R. at 964.) Cox reported only mild depression
and anxiety. (R. at 964.) Jacobe found that Cox had a depressed and irritable mood
with anxious affect, intact orientation and thought process, no paranoia/delusions
and fair judgment/insight. (R. at 964.) Jacobe’s diagnoses of Cox remained
unchanged. (R. at 964.)
Also on July 12, 2012, Jacobe also completed a mental assessment of Cox,
finding that he had a good ability to follow work rules, to relate to co-workers, to
deal with the public, to use judgment, to interact with supervisors and to
understand, remember and carry out simple job instructions. (R. at 959-61.) She
further found that Cox had a fair ability to deal with work stresses, to function
independently, to understand, remember and carry out detailed job instructions, to
maintain personal appearance and to demonstrate reliability. (R. at 959-60.)
Jacobe found that Cox had a poor or no ability to understand, remember and carry
out complex job instructions, to behave in an emotionally stable manner and to
-23-

relate predictably in social situations. (R. at 959-60.) She found that his ability to
maintain attention and concentration depended on his blood sugar levels. (R. at
959.) Jacobe supported these findings by stating that Cox’s anxiety/social phobia
impacted his ability to deal with new situations and new people, and his health
issues impacted all other areas. (R. at 959.) In particular, she noted that his
diabetes, anxiety, depression and self-worth issues impacted his focus and
concentration, and his blood sugar levels affected his mood. (R. at 960-61.) Jacobe
concluded that Cox would be absent more than two workdays monthly due to his
impairments or treatment. (R. at 961.)
On July 26, 2012, Cox returned to Jacobe and continued to see her through
November 13, 2012. Over this time, Cox’s stressors included his mother’s
hospitalization, transportation difficulties, increased physical pain, difficulty
obtaining his medications, some family conflict and losing his home. (R. at 1007,
1054, 1056-57.) On August 9, 2012, Cox reported severe anxiety and depression,
on August 30, 2012, he reported increased symptoms of depression, and on
November 13, 2012, he reported severe anxiety and severe panic attacks in crowds.
(R. at 1007, 1054, 1057.) Over this time, Cox consistently had a depressed mood
and anxious affect, intact orientation and thought process, no paranoia/delusions
and fair judgment/insight. (R. at 1007-08, 1054-57.)
On December 6, 2012, Dr. Andrew Bockner, M.D., a state agency physician,
completed a Psychiatric Review Technique form, (“PRTF”), on Cox, finding that,
despite a diagnosis of depression, he was capable of all ranges of work and that
any mental symptoms could not be purely attributed to a mental diagnosis. (R. at
85-86.) Thus, Dr. Bockner concluded that Cox did not have a mental medically
determinable impairment at that time. (R. at 86.)
-24-

Howard S. Leizer, Ph.D., a state agency psychologist, completed another
PRTF of Cox on June 14, 2013. (R. at 110-11.) Like Dr. Bockner, Leizer
concluded that Cox was capable of all ranges of work and any mental symptoms
could not be purely attributed to a mental diagnosis. (R. at 111.) Thus, he further
concluded that no mental medically determinable impairment could be established
at that time. (R. at 111.)
On February 25, 2014, B. Wayne Lanthorn, Ph.D., a licensed clinical
psychologist, completed a psychological evaluation of Cox, at the referral of his
attorney. (R. at 1062-69, 1386-96.) Cox stated that he lived with his parents, with
whom he socialized almost exclusively. (R. at 1388, 1390.) He reported working
puzzles, watching television, spending some time on the internet and reading. (R.
at 1063, 1390.) He reported rarely leaving home. (R. at 1063, 1390.) On mental
status examination, Cox’s affect was generally flat and blunt, but he was fidgety
and somewhat jumpy. (R. at 1063, 1390.) He made good eye contact, and rapport
was reasonably established. (R. at 1063, 1390.) Overall, his mood was described as
a combination of anxiety and depression. (R. at 1063, 1390.) Cox was able to recall
four of five words presented earlier, and he correctly performed Serial 7 testing.
(R. at 1063, 1390.) He gave higher order and correct interpretations to two of three
commonly used adages, and he correctly spelled “world” both forward and
backward. (R. at 1063, 1390.) Cox displayed no clinical signs of a thought
disorder, ongoing psychotic processes, delusional thinking or hallucinations of any
type. (R. at 1064, 1391.) He denied suicidal or homicidal ideation, plans or intent,
and he indicated no such previous attempts. (R. at 1064, 1391.) Cox reported
feeling like crying or crying when alone occasionally. (R. at 1064, 1391.) He
indicated that he had “pretty good” concentration and that his memory was “soso.” (R. at 1064, 1391.) He denied any significant problems with anxiety or tension
-25-

at home, but reported that he had difficulty with anxiety out in public for many
years. (R. at 1064, 1391.)
Lanthorn administered the Wechsler Adult Intelligence Scale – Fourth
Edition, (“WAIS-IV”), the results of which were deemed valid. (R. at 1064-65.)
Cox achieved a full-scale IQ score of 92, placing him in the borderline range of
intellectual functioning. (R. at 1065, 1392.) Lanthorn also administered the
Minnesota Multiphasic Personality Inventory – 2, (“MMPI-2”), the results of
which also were deemed valid. (R. at 1066-67, 1393-94.) This indicated a
probability of serious psychological and emotional problems often characteristic of
severe and chronic behavioral problems. (R. at 1066, 1393.) It further indicated
that Cox was experiencing moderate to severe emotional distress and that he had a
tendency to be impatient, irritable and angry. (R. at 1066, 1393.) Results indicated
that Cox had difficulty with concentration, was forgetful, had memory problems,
was very introverted and withdrawn from others and disliked having people around
him. (R. at 1067, 1394.)
Lanthorn concluded that Cox was functioning in the average range of overall
intellectual functioning. (R. at 1067, 1394.) Lanthorn noted that Cox showed the
signs of social anxiety disorder. (R. at 1068, 1395.) He further noted that Cox had
a distinct flattened affect and a sort of detachment and aloofness about him,
leading to a diagnosis of schizoid personality disorder. (R. at 1068, 1395.) While
Cox had depressive symptomotology, Lanthorn opined that it did not rise to the
level of a diagnosis. (R. at 1068, 1395.) Lanthorn deemed Cox’s prognosis “rather
guarded,” and he strongly encouraged him to continue with psychotherapeutic
intervention. (R. at 1068, 1395.)

-26-

On March 5, 2014, Lanthorn completed a mental assessment of Cox, finding
that he had an unlimited or very good ability to understand, remember and carry
out simple and detailed job instructions, a good ability to understand, remember
and carry out complex job instructions, a fair ability to follow work rules, to deal
with work stresses, to function independently, to maintain attention and
concentration, to maintain personal appearance, to behave in an emotionally stable
manner and to demonstrate reliability and a poor or no ability to relate to coworkers, to deal with the public, to use judgment, to interact with supervisors and
to relate predictably in social situations. (R. at 1059-61, 1383-85.) Lanthorn
supported these findings with Cox’s diagnoses of social anxiety disorder and
schizoid personality disorder. (R. at 1059, 1383.) He opined that Cox would be
absent from work more than two days monthly. (R. at 1061, 1384.)
On February 17, 2014, Cox began seeing Karen Odle, a licensed
professional counselor at Clinch River Health Services, Inc. (R. at 1452-54.) His
presenting problems were depression and social anxiety, but he reported no prior
hospitalizations. (R. at 1452, 1454.) On mental status examination, Cox was
cooperative with normal motor activity, appropriate affect with depressed mood,
he had normal speech and thought processes with no abnormalities of thought
content, he had no suicidal or homicidal ideations, he was fully oriented, and his
remote memory was impaired, but his cognitive function, abstraction, judgment
and insight were intact. (R. at 1453.) When Cox returned to Odle for counseling on
March 10, 2014, he reported moderate depression, mild anxiety, mild insomnia,
mildly decreased appetite, moderately decreased energy, mild irritability/anger and
no suicidal or homicidal ideations. (R. at 1451.) On mental status examination,
Cox had a euthymic affect, intact orientation and thought process, no
paranoia/delusions and good judgment/insight. (R. at 1451.) On June 9, 2014, Cox
-27-

reported moderate depression, mild hyperinsomnia, mildly decreased appetite,
mildly decreased energy, mild irritability/anger and no suicidal or homicidal
ideations. (R. at 1450.) On mental status examination, Cox had a depressed mood
with euthymic affect, intact orientation and thought process, no paranoia/delusions
and good judgment/insight. (R. at 1450.) He reported that his family environment
was causing increased stress. (R. at 1450.) He also reported that he continued to
transport a friend to medical appointments and other activities. (R. at 1450.)
Odle completed a mental assessment of Cox on July 2, 2014, finding that he
had no limitations on his abilities to follow work rules, to function independently
and to understand, remember and carry out simple job instructions. (R. at 146062.) She found that he was mildly limited in his abilities to maintain attention and
concentration, to understand, remember and carry out detailed job instructions and
to maintain personal appearance. (R. at 1460-61.) Odle found that Cox was
moderately limited in his abilities to relate to co-workers, to deal with the public,
to use judgment, to interact with supervisors, to understand, remember and carry
out complex job instructions, to behave in an emotionally stable manner and to
relate predictably in social situations. (R. at 1460-61.) Odle also found that Cox
was markedly limited in his abilities to deal with work stresses and to demonstrate
reliability. (R. at 1460-61.) She opined that he would be absent from work more
than two days monthly. (R. at 1462.) Odle did not specify any medical or clinical
findings to support these findings.
Cox returned to Odle for counseling on July 14, 2014, at which time he
reported mild depression and anxiety, mild difficulty going to sleep, mildly
decreased energy and no suicidal or homicidal ideations. (R. at 1464.) Odle found
that his mood was depressed with subdued affect, he had intact orientation and
-28-

thought process, no paranoia/delusions and good judgment/insight. (R. at 1464.)
He reported going out with a friend on evenings working on computers. (R. at
1464.) He further reported that living at home with his parents continued to be very
stressful. (R. at 1464.) Cox again saw Odle on August 18, 2014, at which time he
reported moderate depression, mild insomnia, moderately decreased energy, mild
irritability/anger and no suicidal or homicidal ideations. (R. at 1673.) On mental
status examination, he had a depressed mood with a subdued affect, intact
orientation and thought process, no paranoia/delusions and good judgment/insight.
(R. at 1673.) He reported doing “ok” mentally. (R. at 1673.)
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
-29-

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
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 her findings and her 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 she sufficiently explains her rationale and if the record
supports her findings.

-30-

Cox 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.) Cox also argues that the ALJ
erred by failing to find that his condition met or equaled § 6.02(C)(2) of the Listing
of Impairments. (Plaintiff’s Brief at 8-9.)
I find that the ALJ did, in fact, err in her analysis of whether Cox’s
impairments met or equaled § 6.02(C)(2) of the Listing of Impairments. Although
the Commissioner stated in her Brief that no such listing exists, this is only partly
true. While there currently is no such section contained in the Listing of
Impairments, a review of the Social Security Administration’s website reveals that
this Listing was in effect at the time of the ALJ’s decision in this case.9
Specifically, § 6.02 dealt with impairment of renal function, and § 6.02(C)(2)
required the following:
Impairment of renal function, due to any chronic renal disease that has
lasted or can be expected to last for a continuous period of at least 12
months. With: … Persistent elevation of serum creatinine to 4 mg per
deciliter (dL) (100 ml) or greater or reduction of creatinine clearance
to 20 ml per minute or less, over at least 3 months, with one of the
following … Persistent motor or sensory neuropathy. …
The record in this case shows that Cox has suffered from type I diabetes
since he was at least nine years old. He has been monitored and treated
continuously for his diabetes and myriad accompanying conditions during the

9

Listing § 6.02(C)(2) was in effect from December 18, 2007, through December 8, 2014.
See https://secure.ssa.gov/poms.nsf/lnx/0434126009 (last visited Sept. 20, 2017).
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relevant time period. The record also shows that Cox has been diagnosed with
diabetic nephropathy 10 as well as peripheral neuropathy.
The Fourth Circuit has held that an ALJ must provide an explanation for his
findings from which a reviewing court may determine whether substantial
evidence supports those findings. See Cook v. Heckler, 783 F.2d 1168, 1173 (4th
Cir. 1986). In Cook, the court held that the ALJ should have identified the relevant
listed impairments and then compared each of the listed criteria to the evidence of
the claimant’s symptoms. See 783 F.2d at 1173. Likewise, in Radford v. Colvin,
734 F.3d 288, 295 (4th Cir. 2013) (quoting Fla. Power & Light Co. v. Lorian, 470
U.S. 729, 744 (1985)), the Fourth Circuit stated that “[a] necessary predicate to
engaging in substantial evidence review is a record of the basis for the ALJ’s
ruling…. The record should include a discussion of which evidence the ALJ found
credible and why, and specific application of the pertinent legal requirements to the
record evidence….” If the reviewing court has no way of evaluating the basis for
the ALJ’s decision, then ‘the proper course, except in rare circumstances, is to
remand to the agency for additional investigation or explanation.’” Here, with
regard to whether Cox’s conditions met or equaled Listing § 6.02(C)(2), the ALJ
stated as follows: “[A]lthough suggested by the claimant’s providers, the claimant
has not shown that his impairments meet or equal Listing 6.02. …” (R. at 21.) The
ALJ conducted no further analysis on this issue, nor did she specify the content of
Listing 6.02. The ALJ offered nothing to reveal why she was making her decision,
and there was no specific application of the pertinent legal requirements to the
evidence of record. I find that such a conclusory and perfunctory analysis of
10

Diabetic nephropathy is a serious kidney-related complication of type I and type II
diabetes, which may progress to kidney failure. See www.mayoclinic.org/diseasesconditions/diabetic-nephropathy/home/ovc-20212103 (last visited Sept. 20, 2017).
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whether Cox’s conditions met or equaled this Listing, precludes this court from
undertaking a meaningful review of the finding that Cox’s conditions did not
satisfy the Listing. Given this finding, I further find it unnecessary to address
Cox’s remaining argument on appeal at this time.
Based on the above-stated reasons, I find that the substantial evidence does
not exist in the record to support the ALJ’s finding that Cox was not disabled. An
appropriate Order and Judgment will be entered remanding Cox’s claim to the
Commissioner for further development.
DATED:

September 20, 2017.
/s/

Pamela Meade Sargent

UNITED STATES MAGISTRATE JUDGE

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