DWANE L. TINSLEY, Magistrate Judge.
This is an action seeking review of the final decision of the Commissioner of Social Security denying the Plaintiff's application for disability insurance benefits (DIB) under the Social Security Act. The parties consented to the undersigned United States Magistrate Judge ordering the entry of final judgement. Presently pending before this Court are Plaintiff's Brief in Support of Judgment on the Pleadings (ECF No. 13) and Defendant's Brief in Support of Defendant's Decision (ECF No. 14). Benita Kay Burdette (hereinafter referred to as Claimant), applied for DIB on September 6, 2012, alleging disability beginning June 1, 2009. The claim was denied initially on January 25, 2013, and upon reconsideration on June 14, 2013. Thereafter, Claimant filed a written request for a hearing before an Administrative Law Judge (ALJ) on June 25, 2013. A hearing was held on September 11, 2014, in Charleston, West Virginia, before an ALJ. On October 9, 2014, the ALJ denied Claimant's application.
On October 9, 2014, Claimant filed a request for review of the hearing decision by the Appeals Council (AC). On December 15, 2015, the AC denied Claimant's request for review (Tr. at 1-6). The AC stated "We found no reason under our rules to review the Administrative Law Judge's decision" (Tr. at 1) and "In looking at your case, we considered the reasons you disagree with the decision and the additional evidence listed on the enclosed Order of Appeals Council" (Tr. at 2). On December 15, 2015, the AC made additional evidence received from Claimant part of the record (Tr. at 6). That evidence consists of the following exhibits:
Thereafter, Claimant filed a complaint with this Court pursuant to 42 U.S.C. § 405(g).
Under 42 U.S.C. § 423(d)(5), a claimant for disability has the burden of proving a disability. See Blalock v. Richardson, 483 F.2d 773, 774 (4th Cir. 1972). A disability is defined as the "inability to engage in any substantial gainful activity by reason of any medically determinable impairment which can be expected to last for a continuous period of not less than 12 months. . . ." 42 U.S.C. § 423(d)(1)(A).
The Social Security Regulations establish a "sequential evaluation" for the adjudication of disability claims. 20 C.F.R. § 404.1520 (2016). If an individual is found "not disabled" at any step, further inquiry is unnecessary. Id. § 404.1520(a). The first inquiry under the sequence is whether a claimant is currently engaged in substantial gainful employment. Id. § 404.1520(b). If the claimant is not, the second inquiry is whether claimant suffers from a severe impairment. Id. § 404.1520(c). If a severe impairment is present, the third inquiry is whether such impairment meets or equals any of the impairments listed in Appendix 1 to Subpart P of the Administrative Regulations No. 4. Id. § 404.1520(d). If it does, the claimant is found disabled and awarded benefits. Id. If it does not, the fourth inquiry is whether the claimant's impairments prevent the performance of past relevant work. Id. § 404.1520(e). By satisfying inquiry four, the claimant establishes a prima facie case of disability. Hall v. Harris, 658 F.2d 260, 264 (4th Cir. 1981). The burden then shifts to the Commissioner, McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983), and leads to the fifth and final inquiry: whether the claimant is able to perform other forms of substantial gainful activity, considering claimant's remaining physical and mental capacities and claimant's age, education and prior work experience. 20 C.F.R. § 404.1520(f) (2016). The Commissioner must show two things: (1) that the claimant, considering claimant's age, education, work experience, skills and physical shortcomings, has the capacity to perform an alternative job, and (2) that this specific job exists in the national economy. McLamore v. Weinberger, 538 F.2d 572, 574 (4th Cir. 1976).
In this case, the ALJ determined that Claimant satisfied the first inquiry because she has not engaged in substantial gainful activity since the amended
The sole issue before this court is whether the final decision of the Commissioner denying the claim is supported by substantial evidence. In Blalock v. Richardson, substantial evidence was defined as:
Blalock v. Richardson, 483 F.2d 773, 776 (4th Cir. 1972) (quoting Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966)). Additionally, the Commissioner, not the court, is charged with resolving conflicts in the evidence. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990). Nevertheless, the courts Amust not abdicate their traditional functions; they cannot escape their duty to scrutinize the record as a whole to determine whether the conclusions reached are rational." Oppenheim v. Finch, 495 F.2d 396, 397 (4th Cir. 1974).
A careful review of the record reveals the decision of the Commissioner in this case is not supported by substantial evidence.
Claimant was born on February 20, 1962 (Tr. at 59). Claimant obtained a GED. (Id.) Claimant testified that she is 5'10" tall and weighed 240 pounds. (Id.) Claimant lives with her husband (Tr. at 73). Claimant has her driver's license.
The medical record addressing Claimant's lower back pain, left leg pain, left arm pain and lumbar degenerative disc disease will be discussed below. The undersigned remands this matter for reconsideration as a result of the new and material evidence admitted by the AC. Therefore, medical records pertaining to other impairments will not be discussed at this time.
Claimant asserts that the ALJ failed to accord adequate weight to the opinion of Laberta Salamacha, M.A. (ECF No. 13). Claimant argues that the ALJ's decision is not based on substantial evidence because the ALJ failed to consider Claimant's lower extremity radiculopathy and the resulting limitations in the residual functional capacity (RFC) assessment. Defendant asserts that substantial evidence supports the ALJ's decision to give little weight to Dr. Salamacha's opinion (ECF No. 14). Defendant avers that the ALJ captured all of Claimant's credible physical limitations in the RFC.
Additional evidence will be considered by the AC if it is new and material and relates to the period on or before the ALJ hearing decision. See 20 C.F.R. §§ 404.970(b) and 416.1470(b). SSA has issued HALLEX 1-3-3-6 to clarify when additional evidence is new and material. According to the HALLEX, this means the evidence is:
New evidence, which is first submitted to the AC, is part of the record which goes to the district court for review. This is true whether the Appeals Council reviews the case or not. Keeton v. Department of Health and Human Services, 21 F.3d 1064, 44 Soc. Sec. Rep. Serv. 248, Unempl. Ins. Rep. (CCH) (11th Cir. 1994).
It is not the role of the Court to search for evidence and articulate for the ALJ's decision which the ALJ himself did not articulate. See Rhinehardt v. Colvin, No. 4:12-CV-101-D, 2013 U.S. Dist. LEXIS 75948, 2013 WL 2382303, *2 (E.D.N.C. May 30, 2013) (citation omitted) ("If the ALJ fails to explain why an impairment does not meet the listing criteria, the decision is deficient."); Tanner v. Astrue, C/A No. 2:10-1750-JFA, 2011 U.S. Dist. LEXIS 105731, 2011 WL 4368547, *4 (D.S.C. Sept. 19, 2011) (stating "if the ALJ did not rationally articulate grounds for her decision, this court is not authorized to plumb the record to determine reasons not furnished by the ALJ"). In Radford v. Colvin, 734 F.3d 288 (4th Cir. 2013), 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. "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.'" Id. (quoting Florida Power & Light Co. v. Lorion, 470 U.S. 729, 744, 105 S.Ct. 1598, 84 L. Ed 2d 643 (1985)).
While the ALJ is required to weigh the relevant medical opinions, he "need not discuss every shred of evidence in the record," and is under no duty to explicitly refer to each exhibit. Reynolds v. Colvin, 2014 WL 2852242, at *21 (S.D. W.Va. Aug 19, 2014), adopted by 2014 WL 4852250 (S.D. W.Va. September 29, 2014; McGrady v. Astrue, 2011 WL 4828884, at *20 (N.D. W.Va. September 16, 2011) (quoting Mays v. Barnhart, 227 F.Supp.2d 443, 448 (E.D. Pa. 2002), aff'd 78 F. App'x 808 (3d Cir. Oct. 27, 2003)) ("[t]he ALJ is not required to give an exhaustive discussion of all the exhibits. `Consideration of all the evidence does not mean that the ALJ must explicitly refer to each and every exhibit in the record.'").
When read in combination with the applicable regulation, Wilkins v. Secretary, 953 F.2d 93 (4
Wilkins, 953 F.2d at 96 n.3; see also 20 C.F.R. § 416.1471(b) (2014). Instead, A[t]he Appeals Council must consider evidence submitted with the request for review in deciding whether to grant review `if the additional evidence is (a) new, (b) material, and (c) relates to the period on or before the date of the ALJ's decision.'" Wilkins, 953 F.2d at 95-96 (quoting Williams, 905 F.2d at 216.) Evidence is new Aif it is not duplicative or cumulative." Id. at 96 (citing Williams, 905 F.2d at 216). AEvidence is material if there is a reasonable possibility that the new evidence would have changed the outcome." Id. (citing Borders v. Heckler, 777 F.2d 954, 956 (4th Cir. 1985)).
The evidence admitted into the record by the AC relates to Claimant's alleged impairments of cervical and lumbar degenerative disc disease. These impairments must meet criteria for Listing 1.04. Listing 1.04 requires the following:
The ALJ held that Claimant has a history of low back pain "that apparently became worse in August 2011" (Tr. at 41). The ALJ found that "magnetic resonance imaging (MRI) testing of the lumbar spine performed at that time revealed degenerative disc disease at L3 to L5 with focal annulus tear and left lateral disc protrusion." (Id.) The ALJ noted that upon physical examination in October 2011, Claimant "showed that range of motion of the back was significantly limited in all directions with accompanied discomfort in the low back region." Claimant performed straight leg raises without difficulty or complaint. Claimant's muscle tone was normal and neurological examination demonstrated good strength in both lower extremities, symmetric reflexes and no sensory disturbance (Tr. at 41-42). The ALJ stated that Claimant was treated with physical therapy and was referred to pain management but she lost her insurance (Tr. at 42). After reestablishing her insurance in March 2013, an MRI of her lumbar spine, at that time, showed mild facet degenerative disease at L5-S1 unchanged. (Id.) The ALJ noted that "There was facet degenerative disease at L4-L5 with small annular tear on the left." There was no disc herniation. The ALJ stated "At L3-L4, there was a small annular tear on the left without obvious disc herniation."
The ALJ found that "MRI testing of the cervical spine revealed left paracentral/left foraminal disc protrusions at the C5-C6 and C6-C7 levels producing narrowing of the left neural foramina, but no significant spinal stenosis." (Id.) Upon physical examination in July 2013, Claimant performed positive straight leg raising on the left but no sensory loss. The ALJ held that "The claimant apparently received a lumbar injection at that time, but there is no further evidence of treatment until October 2013 (Exhibit 8F) when examination showed full lower extremity muscle strength, normal spine range of motion and negative straight leg raising." (Id.)
The ALJ found that Claimant experienced some left upper extremity weakness, but no sensation or reflex loss. The ALJ provided that Claimant "apparently received a short course of physical therapy at that time (Exhibit 11F) but again lost her insurance." The pain management specialist reported that Claimant ambulated without difficulty.
The ALJ held that "The claimant received cervical, lumbar and hip injections in 2014 [] apparently without significant relief of pain. There is no evidence of any treatment or musculoskeletal examinations since May 2014, and no evidence that the claimant's spinal impairments meet the criteria of this listing." (Id.)
In discussing Claimant's credibility, the ALJ held:
Claimant argues that the ALJ "failed to discuss much of the record that supported the Plaintiff's alleged limitations resulting from her lumbar disc disease and radiculopathy (ECF No. 13). Claimant asserts:
In response, Defendant asserts that there is no requirement that an ALJ must discuss every piece of medical evidence (ECF No. 14). The ALJ found that Claimant saw her treating physician on October 2013, March 2014 and June 2014 for follow-up from thyroid cancer and denied any anxiety or depression or concentration issues." (Id.)
The Appeals Council admitted Claimant's medical records from Capital Neurology dated September 17, 2014, as Exhibit 25 F (Tr. at 637-638). Claimant's treating neurologist, Rida Mazagri, M.D., provided a summary of an evaluation of Claimant conducted on September 17, 2014. Dr. Mazagri stated:
Claimant was seen by Rida Mazagri, for hip joint pain on October 11, 2013 (Tr. at 527). The radiology report stated the impression was "negative left hip." (Id.) Dr. Mazagri noted that Claimant reported pain in her left arm, back, neck and left leg. Claimant's x-ray did not show any major arthritic change (Tr. at 521). Dr. Mazagri stated that Claimant walked with mild limping, favoring her left leg. She has restriction of neck movement in rotation and side bending, more so on the left side. (Id.) Claimant's straight leg raising was negative. The plan stated that Claimant would benefit from continuing treatment with Dr. Saldanha at the Pain Management Clinic with possible nerve block. (Id.) On October 16, 2013, Dr. Mazagri reported the same findings as on October 11, 2013 (Tr. at 521).
The ALJ did not state what amount of weight was given to Claimant's neurologist, Dr. Mazagri. Although the ALJ is not required to discuss every piece of evidence and every opinion, the ALJ simply cannot ignore evidence which contradicts his findings. The Appeals Council admitted Claimant's additional medical records from Dr. Mazagri with Capital Neurology, dated September 17, 2014, as Exhibit 25F. The additional evidence admitted by the Appeals Council reflect the duration of Claimant's symptoms and ongoing treatment.
The ALJ did not review the record as a whole and did not review Exhibit 25F. The additional records were admitted into evidence by the Appeals Council, therefore, it is considered new and material pursuant to HALLEX 1-3-3-6. Exhibit 25F is dated September 17, 2014, therefore according to HALLEX 1-3-3-6, the exhibit relates to the period on or before the date of the hearing decision, October 9, 2014. This Court must review the record as a whole, including the new evidence, to determine whether substantial evidence supports the ALJ's findings. The contents of the new evidence pertains to Claimant's cervical and lumbar degenerative disc disease which was relevant to the issues in this case.
The additional evidence may have affected the ALJ's determination that Claimant's severe impairments of cervical and lumbar degenerative disc disease do not meet a Listing (Tr. at 41). Additionally, there is a reasonable possibility that the additional evidence admitted into the record may have affected the weight given by the ALJ to medical opinions and may have prompted the ALJ to address any weight given to Dr. Mazagri.
For the reasons set forth above, the undersigned hereby find that this Court shall
The Clerk of this court is directed to provide copies of this ORDER to all counsel of record.