Lewis v. Colvin

Filing 18

MEMORANDUM OPINION. Signed by Magistrate Judge Robert S. Ballou on March 6, 2017. (sfc)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF VIRGINIA
LYNCHBURG DIVISION
SYLVIA M. LEWIS,

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Plaintiff,
v.
NANCY A. BERRYHILL,
Acting Commissioner of Social Security,1
Defendant.

Civil Action No. 6:16-cv-00001

MEMORANDUM OPINION
Plaintiff Sylvia M. Lewis (“Lewis”) filed this action challenging the final decision of the
Commissioner of Social Security (“Commissioner”) finding her not disabled and therefore
ineligible for disability insurance benefits (“DIB”) under the Social Security Act (“Act”). 42
U.S.C. §§ 401–433. Lewis’s sole claim asserts that the Administrative Law Judge (“ALJ”)
improperly gave limited weight to the opinions of her treating physician, Joseph Wombwell,
M.D. I find that the ALJ provided a sufficient explanation for the limited weight given to Dr.
Wombwell’s opinion. Accordingly, I DENY Lewis’s request for relief and GRANT the
Commissioner’s Motion for Summary Judgment. Dkt. No. 16.
STANDARD OF REVIEW
This court limits its review to a determination of whether substantial evidence exists to
support the Commissioner’s conclusion that Lewis failed to demonstrate that she was disabled

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Nancy A. Berryhill became the Acting Commissioner of Social Security on January 23, 2017. Pursuant to Rule
25(d) of the Federal Rules of Civil Procedure, I substitute Nancy A. Berryhill for Carolyn W. Colvin as the
defendant in this suit.

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under the Act.2 Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001). “Substantial evidence is such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it
consists of more than a mere scintilla of evidence but may be somewhat less than a
preponderance.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996) (internal citations omitted).
The final decision of the Commissioner will be affirmed where substantial evidence supports the
decision. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990).
CLAIM HISTORY
Lewis protectively applied for DIB on June 26, 2012, alleging that her disability began on
September 15, 2008 due to back cancer, skin cancer, high blood pressure, joint disease of knees
and ankles, lower back problems and a cyst on her ovaries. R. 39. The Commissioner denied the
application at both the initial and reconsideration levels of administrative review. R. 39–60, 61–
82. On May 20, 2014, ALJ Marc Mates held a hearing to consider Lewis’s disability claim.
R. 22–38. Lewis appeared at the hearing with her attorney, James Bowman, and the hearing
included testimony from vocational expert Gerald Wells. R. 21–38.
On July 26, 2014, the ALJ entered his decision analyzing Lewis’s claim under the
familiar five-step process3 and denied her claim for benefits. R. 10–20. The ALJ found that

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The Act defines “disability” as the “inability to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to result in death or which has lasted
or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). Disability
under the Act requires showing more than the fact that the claimant suffers from an impairment which affects his
ability to perform daily activities or certain forms of work. Rather, a claimant must show that his impairments
prevent him from engaging in all forms of substantial gainful employment given his age, education, and work
experience. See 42 U.S.C. §§ 423(d)(2), 1382c(a)(3)(B).
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The five-step process to evaluate a disability claim requires the Commissioner to ask, in sequence, whether the
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 if not, (5) whether he can perform other work.
Johnson v. Barnhart, 434 F.3d 650, 654 n.1 (4th Cir. 2001) (per curiam) (citing 20 C.F.R. § 404.1520); Heckler v.
Campbell, 461 U.S. 458, 460–62 (1983). The inquiry ceases if the Commissioner finds the claimant disabled at any
step of the process. 20 C.F.R. § 404.1520(a)(4). The claimant bears the burden of proof at steps one through four to
establish a prima facie case for disability. The burden shifts to the Commissioner at the fifth step to establish that the
claimant maintains the residual functional capacity (“RFC”), considering the claimant’s age, education, work

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Lewis was insured at the time of the alleged disability onset and that she suffered from the severe
impairments of hypertension, obstructive sleep apnea, degenerative joint disease of both knees,
and obesity. R. 10–13. The ALJ found that these impairments, either individually or in
combination, did not meet or medically equal a listed impairment. R. 13–14. The ALJ then
concluded that Lewis retained the residual functional capacity (“RFC”) to perform light work.4
Specifically, the ALJ found that Lewis was limited to lifting and carrying 20 pounds
occasionally and 10 pounds frequently, standing and walking for 4 hours in an 8 hour workday,
and sitting for 6 hours in an 8 hour workday. R. 14. The ALJ further concluded that Lewis could
only occasionally climb stairs, balance, kneel or crawl, and that she must avoid exposure to
hazards, wetness, and extreme cold. Id.
The ALJ determined that Lewis would be unable to return to her past relevant work as a
sandwich maker, laborer, or picking line worker, but that Lewis could perform jobs that exist in
significant numbers in the national economy, such as cafeteria cashier, gate guard, and routing
clerk. R. 19–20. The ALJ therefore concluded that Lewis was not disabled. R. 20. Lewis
appealed the ALJ’s decision and the Appeals Council denied her request for review on
November 2, 2015. R. 1–3.
ANALYSIS
Lewis argues that the ALJ improperly discounted the medical opinion of Dr. Wombwell,
the orthopedic surgeon who served as her treating physician from February 2010 to January
2014, during which time he treated her on ten occasions. On January 24, 2014, Dr. Wombwell

experience, and impairments, to perform available alternative work in the local and national economies. 42 U.S.C. §
423(d)(2)(A); Taylor v. Weinberger, 512 F.2d 664, 666 (4th Cir. 1975).
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An RFC is an assessment, based upon all the relevant evidence, of what a claimant can still do despite her
limitations. 20 C.F.R. § 404.1545. Descriptions and observations of a claimant’s limitations by her and by others
must be considered along with medical records to assist the Commissioner in deciding to what extent an impairment
keeps a claimant from performing particular work activities. Id. The Social Security Administration classifies jobs as
sedentary, light, medium, heavy, and very heavy. 20 C.F.R. § 404.1567(a).

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completed a checkbox Medical Source Statement describing Lewis’s prognosis as “poor.”
R. 571–74. Specifically, Dr. Wombwell found that Lewis “may require knee replacements,” that
she is unable to stand or walk during an 8 hour workday, that she can only occasionally lift 5–10
pounds, and that she is entirely unable to bend, squat, crawl, or climb. Id.
The state agency physicians who reviewed Lewis’s medical history and records in 2012
determined that Lewis could stand for 4 hours each day, occasionally bend and squat, and
occasionally lift or carry up to 20 pounds. R. 55, 77. The ALJ relied upon the opinions of Dr.
Wombwell and the state agency physicians to develop Lewis’s RFC, giving only “limited
weight” to the findings of Dr. Wombwell, but “significant weight to the assessments of the State
agency consultants.” R. 17–18.
Regarding Dr. Wombwell’s opinion, the ALJ wrote:
The undersigned gives limited weight to Dr. Wombwell’s
assessments, as the limitations noted above are overly restrictive
and inconsistent with and unsupported by the objective findings
noted throughout the medical evidence of record, which indicate
that the claimant has no instability of knee joints, her treatment has
been limited to medication and injections as needed, she has 5/5
strength throughout her extremities, and she has nearly full
extension of her knees. Additionally, as recently as May 2014, the
claimant’s primary care practitioner advised her to do activity as
tolerated.
Id. The ALJ further credited the opinions of the state agency medical consultants because they
were “consistent with and supported by the evidence of record, as a whole.” R. 17.
The ALJ must assess every medical opinion received into evidence. See 20 C.F.R.
§ 404.1527(c). Under the social security regulations, an ALJ must give the opinion of a treating
source controlling weight if he finds the opinion “well-supported by medically acceptable
clinical and laboratory diagnostic techniques” and “not inconsistent with the other substantial
evidence in [the] case record.” 20 C.F.R. § 404.1527(c)(2). The ALJ must further give “good
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reasons” for not affording controlling weight to a treating physician’s opinion. 20 C.F.R.
§ 416.927(c)(2); Brown v. Astrue, No. 2:09CV266, 2010 WL 2382857, at *6 (E.D. Va. May 6,
2010). The ALJ may assign little or no weight to the medical opinion of a treating physician if
the ALJ provides sufficient consideration of the factors set forth in 20 C.F.R § 404.1527.5
The ALJ thoroughly reviewed Lewis’s medical records and summarized her treatment
history, including Dr. Wombwell’s treatment notes from each of Lewis’s visits. The detailed
review of the medical evidence of record demonstrates that the ALJ developed a full awareness
of Lewis’s treatment history with Dr. Wombwell when deciding the proper weight to assign to
Dr. Wombwell’s opinion.
The ALJ’s explanation for the weight given to Dr. Wombwell’s medical opinion satisfies
the ALJ’s obligation to “build an accurate and logical bridge from the evidence to his
conclusion.” Monroe v. Colvin, 826 F.3d 176, 189 (4th Cir. 2016). In Monroe, the ALJ failed to
“specify what ‘objective evidence’ or what aspects of [the claimant’s] ‘treatment history’ he was
referring to.” Id. at 191. The ALJ’s failure to do so rendered his analysis “incomplete” because it
“preclude[d] meaningful review.” Id. Thus, after Monroe, an ALJ’s conclusory finding that a
treating physician’s opinion is inconsistent with the medical record does not, without more,
constitute a complete analysis. See id. (“Without more specific explanation of the ALJ’s reasons
for the differing weights he assigned various medical opinions, neither we nor the district court
can undertake meaningful substantial-evidence review.”).

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When a treating physician’s medical opinion is not given controlling weight, an ALJ is to consider the following
factors when assigning weight to the opinion: (1) the length of treatment and frequency of examination; (2) the
nature and extent of the treatment relationship; (3) the opinion’s support by medical evidence; (4) the opinion’s
consistency with the record as a whole; and (5) the treating physician’s specialization. 20 C.F.R. § 404.1527(c)(2)–
(5). Although the regulations require consideration of these factors, the ALJ is not required to specifically address
each one in his opinion. See Henley v. Astrue, No. 3:11-cv-488, 2012 WL 2804846, at *4 (W.D.N.C. July 10, 2012).

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Here, the ALJ found Dr. Wombwell’s opinion inconsistent with and unsupported by the
record and cited to specific aspects of Lewis’s treatment history that supported this conclusion.
R. 18. Specifically, the ALJ pointed to evidence showing that Lewis “has no instability of the
knee joints, her treatment has been limited to medication and injections as needed, she has 5/5
strength throughout her extremities, and she has nearly full extension of her knees.” Id. Indeed,
Dr. Wombwell’s checkbox form opinion that Lewis was unable to stand or walk at all during an
eight-hour workday is contradicted by his examination notes finding near normal range of
motion and no instability in either knee. See R. 315, 316, 576–77, 581. Additionally, the ALJ
noted that Lewis returned to work in September 2013 as a production worker, which
demonstrated that “she believed herself capable of working during the relevant timeframe.”
R. 18. Although Lewis ultimately quit that job four months later, the Commissioner can consider
work done by the claimant after the alleged onset of disability as tending to show that the
claimant was not then disabled. Sigmon v. Califano, 617 F.2d 41, 42–43 (4th Cir. 1980).
The ALJ sufficiently linked evidence in the record to his decision to give Dr.
Wombwell’s opinion limited weight. The ALJ has provided a sufficient bridge between the
evidence and his conclusions such that I, sitting as a reviewing judge, am not required to mine
the medical record to search for the inconsistencies between Dr. Wombwell’s opinion and those
of the state agency consultants. See Knapp v. Colvin, No. 7:15-CV-348, 2016 WL 4447836, at
*4 (W.D. Va. Aug. 1, 2016) (“Without this analysis, I am left to mine the record for facts to
support the ALJ’s conclusions and essentially fill in the blanks the ALJ left in his analysis. This I
cannot do.”). The ALJ’s opinion allows a reviewing court to analyze the record with respect to
the particular ailments and symptoms that Dr. Wombwell and the state consultants relied upon in
making their differing determinations of Lewis’s RFC.

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Lewis’s argument is really an invitation to re-weigh the evidence and assign a different
weight to the opinion of Dr. Wombwell, which I will not do. The ALJ set out in detail Dr.
Wombwell’s medical examinations and treatment of Lewis, including the possibility that she
may one day need a knee replacement. The court’s role is limited to determining whether the
ALJ’s decision is supported by substantial evidence. Here, the ALJ thoroughly considered the
entire medical record and explained his decision to give the state physicians’ opinions greater
weight by pointing to specific evidence in the medical record. In determining Lewis’s RFC, the
ALJ interpreted the medical record consistently with the opinions of the state agency physicians.
Accordingly, the ALJ’s opinion allows for meaningful review, and upon such review, I find that
substantial evidence supports the ALJ’s decision to give diminished weight to Dr. Wombwell’s
medical opinion.
CONCLUSION
For the reasons set forth above, Lewis’s request for relief is DENIED, and the
Commissioner’s motion for summary judgment is GRANTED. An order will follow.
Entered: March 6, 2017

Robert S. Ballou
Robert S. Ballou
United States Magistrate Judge

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