DWANE L. TINSLEY, District 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) and Supplemental Security Income (SSI), under Title XVI of the Social Security Act, 42 U.S.C. § 1381-1383f. Presently pending before this Court are Plaintiff's Motion for Summary Judgement (ECF No. 12), Plaintiff's Brief in Support of Judgment on the Pleadings (ECF No. 13) and Brief in Support of Defendant's Decision (ECF No. 14).
Claimant James David Green filed applications for DIB and SSI on September 8, 2011. Claimant alleged disability beginning December 3, 2010. These claims were denied initially on March 15, 2012, and upon reconsideration on October 25, 2012. Thereafter, Claimant filed a written request for hearing on November 9, 2012. On November 20, 2013, a video hearing was held with Claimant appearing in Bluefield, West Virginia. The Administrative Law Judge (ALJ) presided over the hearing from Roanoke, Virginia.
The Order of Appeals Council dated January 28, 2015, made the following additional evidence part of the record:
Thereafter, Claimant filed a complaint with this Court pursuant to 42 U.S.C. § 405(g), seeking reversal or a remand of the ALJ's adverse decision (ECF No. 13).
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 (2015). 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) (2015). 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 particular case, the ALJ determined that Claimant satisfied the first inquiry because he has not engaged in substantial gainful activity since the alleged onset date of December 3, 2010, through the date last insured December 31, 2015 (Tr. at 90). Under the second inquiry, the ALJ found that Claimant suffers from the severe impairment of asthma/reactive airway disease, dyspnea, osteoarthritis of the joints, Sjogren's syndrome, tachycardia-bradycardia syndrome status post pacemaker placement, obstructive sleep apnea status post c-pap, obesity, learning disorder, pain disorder, affective disorder and anxiety disorder. (Id.) At the third inquiry, the ALJ concluded that Claimant did not have an impairment or combination of impairments that met or medically equaled the level of severity of any listing in Appendix 1 (Tr. at 91). The ALJ then found that Claimant has a residual functional capacity to perform work at the sedentary exertional level.
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 "must 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 July 24, 1967 (Tr. at 116). He last completed the sixth grade. (Id.) Claimant has a driver's license and a commercial driver's license (Tr. at 117). He failed his first attempt at obtaining both license but retook the test after a coworker, friends and Claimant's wife repeatedly read the materials to him (Tr. at 118-119). Claimant's wife completed the forms to apply for disability (Tr. at 119).
The medical record addressing Claimant's osteoarthritis and Sjogren's syndrome will be discussed below. The undersigned respectfully recommends the District Judge remand this matter for reconsideration including the new and material evidence regarding osteoarthritis and Sjogren's syndrome admitted by the Appeals Council. Therefore, medical records pertaining to other impairments will not be discussed at this time.
Claimant asserts that the ALJ's decision is not supported by substantial evidence (ECF No. 13). Claimant argues that the ALJ failed to properly evaluate Listing 12.05(C) for intellectual disability. Additionally, Claimant asserts that the ALJ failed to properly evaluate and consider limitations of the upper extremities. (Id.)
Additional evidence will be considered by the Appeals Council 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 Appeals Council, 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) (11
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 (4
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.'").
The Appeals Council must consider "new and material evidence" presented after the ALJ's decision "where it relates to the period on or before the date of the [ALJ's] decision." 20 C.F.R. §§ 404.970(b) and 416.1470(b). "If qualifying new evidence is presented, the Appeals Council must evaluate the entire record, including the new evidence. If it finds that the ALJ's decision is contrary to the weight of the evidence currently of record, it will then review the ALJ's decision. The Appeals Council may thereafter adopt, modify or reverse the ALJ's decision, or it may remand the case to the ALJ." Ridings v. Apfel, 76 F.Supp.2d 707, 709 (W.D. Va. 1999) (citing 20 C.F.R. §§ 404.970(b) and 404.979 (1999)).
This Court must review the record as a whole, including the new evidence, in order to determine if the Commissioner's decision is supported by substantial evidence. Wilkins v. Secretary, 953 F.2d 93, 96 (4th Cir. 1991). Although new evidence of the nature submitted by Claimant to the Appeals Council must "relate to the period on or before the date of the administrative law judge hearing decision," 20 C.F.R. §§ 404.970(b) and 416.1470(b), "[t]his does not mean that the evidence had to have existed during that period. Rather, evidence must be considered if it has any bearing upon whether the Claimant was disabled during the relevant period of time." Reichard v. Barnhart, 285 F.Supp.2d 728, 733 (S.D. W. Va. 2003); see also Wooldridge v. Bowen, 816 F.2d 157, 160 (4th Cir. 1987) ("medical evaluations made subsequent to the expiration of a claimant's insured status are not automatically barred from consideration and may be relevant to prove a previous disability").
Regarding the requirement of 42 U.S.C. § 405(g) that the claimant show good cause for not submitting the evidence earlier, that provision should be interpreted as applying to evidence first submitted to the district court, not to evidence that was submitted to the Commissioner during the administrative proceedings. As the Fourth Circuit stated, there is no requirement that a claimant show good cause in seeking to present new evidence to the Appeals Council. Wilkins v. Secretary, Dep't of HHS, 953 F.2d 93, 96 n. 3 (4
Claimant's functional report states that he "sometimes can't hardly button buttons [or] put on socks" (Tr. at 382). He stated that his wife takes his socks off and cuts his fingernails and toenails (Tr. at 409). He reported that his arms and hands hurt. He stated that he shakes and that due to the shaking he loses food off his fork when feeding himself and he has to keep a cup half full. (Id.) He stated that he can't lift anything and has trouble getting in and out of the tub. The pain keeps him awake and describes the pain as constant and severe. Claimant reported that he can only lift 5 pounds (Tr. at 386). He stated that he is unable to carry groceries due to the pain.
Claimant's treating physician William A. Merva, M.D., reported impressions of essential tremor, arthralgias/possible fibromyalgia and insomnia (Tr. at 490). On August 3, 2011, Claimant's treating rheumatologist, Wassim Saikali, M.D., reported that Claimant tested positive with ANA
On August 30, 2011, and October 31, 2011, Dr. Saikali reported seeing Claimant for a follow-up visit for his osteoarthritis and Sjogren's syndrome (Tr. at 506). Claimant complained of pain and stiffness in the joints of his hands and knees. Upon examination, Dr. Saikali reported "degenerative nodules in the second and third DIP and PIPs." Dr. Saikali's progress notes dated February 7, 2012, reported that upon exam he found Claimant to have "Mild tenderness over the second and third PIP" (Tr. at 548).
On May 5, 2012, Dr. Merva saw Claimant for follow-up visit for his headaches, insomnia and joint pain (Tr. at 555). Dr. Merva reported that Claimant was experiencing most of the pain in his legs and hips. Dr. Merva reported that Claimant did not exhibit a tremor and that Claimant's prescription for Corgard was working for his tremor. (Id.)
On May 8, 2012, Dr. Saikali saw Claimant for a follow-up visit regarding his osteoarthritis and "probable Sjogren's" (Tr. at 547). Claimant complained of pain in his joints. Dr. Saikali reported "No swelling in the wrists or elbows." On August 20, 2012, Dr. Saikali saw Claimant for a follow-up visit for his "inflammatory arthritis and Sjogren's syndrome" (Tr. at 802). Claimant reported experiencing pain and discomfort associated with stiffness and soreness in the joints in his hands, knees, neck, shoulders and arm. Claimant reported being stiff in the morning for half an hour in his hands and wrists. (Id.) Dr. Saikali's impression listed inflammatory arthritis, osteoarthritis and possible Sjogren's syndrome. Bloodwork collected on August 20, 2012, reflected that Claimant tested positive for ANA (Tr. at 808). On September 17, 2012, Frederick W. Barker, M.D. reported upon consultation that Claimant's extremities showed "Trace edema" (Tr. at 774).
On February 14, 2013, Ruth Rhodes, PA-C, reported seeing Claimant for follow-up on inflammatory osteoarthritis, Sjrogen syndrome and osteoarthritis (Tr. at 810). Claimant reported occasional joint pain and stiffness in his hands and knees "but overall is doing well." (Id.) Ms. Rhodes reported that upon examination Claimant did not have hot or swollen joints. She reported that Claimant had full range of motion of the upper extremities.
On August 7, 2013, Dr. Saikali saw Claimant for a follow-up visit for Sjogren's syndrome and osteoarthritis (Tr. at 811). Dr. Saikali reported:
The medical records admitted into evidence included treatment notes by William A. Merva, M.D., dated October 31, 2013 (Tr. at 723). Dr. Merva stated that Claimant's "essential tremors came back in a major way." (Id.) Jack C. Meshal, M.D. saw Claimant on February 28, 2011, and reported that claimant "has had chest pain going into the left arm with diaphoresis" and that Claimant's extremities show 1+ edema (Tr. at 744). On May 10, 2011, August 9, 2011, December 29, 2011, February 13, 2012, September 11, 2012, July 9, 2012, November 5, 2012, and April 26, 2013, Dr. Meshal reported that Claimant was experiencing "chest pain going into the left arm with some diaphoresis" and that his extremities "show trace edema" (Tr. at 735). Dr. Meshal's treatment notes on May 14, 2013, August 6, 2013, and November 4, 2013, reported that Claimant's extremities showed traces of edema (Tr. at 729).
The ALJ found that Claimant suffered from severe impairments including osteoarthritis of the joints and Sjogren's syndrome (Tr. at 90). However, the ALJ held that the impairment or combination of impairments did not medically equal the severity of one of the listed impairments in Supbart P, Appendix 1 (Tr. at 91). Regarding osteoarthritis, the ALJ held that "the objective evidence simply fails to indicate that the claimant has functional loss based on musculoskeletal impairment" (Tr. at 91-92).
In the ALJ's residual functional capacity (RFC) assessment, Claimant's was restricted to "Never reach overhead with his left upper extremity" (Tr. at 95). The ALJ stated that Claimant "reported he stopped work due to heart problems and pain in his legs, feet, back and arms as well as chest pain" (Tr. at 96). The ALJ stated "the claimant indicated he had pain in his left shoulder and that it limited his ability to raise his left arm." (Id.) The ALJ's decision stated "In terms of pain, the claimant reported it was constant especially in his joints and that he was on medication for it and that it increased with activity." The ALJ stated that Claimant indicated having difficulty holding a pencil, that he could not open jars with is left hand and that he experiences pain in the right hand due to an old chainsaw accident. (Id.) Ultimately, the ALJ found that the medical evidence of record did not support Claimant's alleged functional limitation in regards to osteoarthritis of the joints and Sjogren's syndrome. The ALJ stated that he took Claimant's alleged functional limitations into account within the RFC and reduced it accordingly.
The ALJ's discussion on Claimant's osteoarthritis and Sjogren's syndrome included the following:
This Court must review the record as a whole, including the new evidence, to determine whether substantial evidence supports the ALJ's findings. The additional records, marked as Exhibits 28F, 29F and 30F, were admitted into evidence by the Appeals Council. The evidence is new and material. As the new evidence was submitted to the AC, good cause is not required. A portion of the contents of the newly admitted evidence pertains directly to Claimant's continued complaints and treatment for osteoarthritis and Sjogren's syndrome. As such, there is a reasonable possibility that the newly admitted evidence would have changed the outcome of the ALJ's decision. Therefore, the ALJ's decision is not supported by substantial evidence as he has not reviewed the record as a whole.
In evaluating the opinions of treating sources, the Commissioner generally must give more weight to the opinion of a treating physician because the physician is often most able to provide "a detailed, longitudinal picture" of a claimant's alleged disability. See 20 C.F.R. §§ 404.1527(c)(2)(i) and 416.927(c)(2)(i) (2015). Thus, a treating physician's opinion is afforded "controlling weight only if two conditions are met: (1) that it is supported by clinical and laboratory diagnostic techniques and (2) that it is not inconsistent with other substantial evidence." Ward v. Chater, 924 F.Supp. 53, 55 (W.D. Va. 1996); see also, 20 C.F.R. §§ 404.1527(c)(2) and 416.927(c)(2) (2015). Under §§ 404.1527(c)(2)(ii) and 416.927(c)(2)(ii), the more knowledge a treating source has about a claimant's impairment, the more weight will be given to the source's opinion. Sections 404.1527(c)(3), (4) and (5) and 416.927(c)(3), (4) and (5) add the factors of supportability, consistency and specialization. Additionally, the regulations state that the Commissioner "will always give good reasons in our notice of determination or decision for the weight we give your treating source's opinion." §§ 404.1527(c)(2) and 416.927(c)(2).
Under §§ 404.1527(c)(1) and 416.927(c)(1), more weight generally is given to an examiner than to a non-examiner. Sections 404.1527(c)(2) and 416.927(c)(2) provide that more weight will be given to treating sources than to examining sources (and, of course, than to non-examining sources). The Fourth Circuit Court of Appeals has held that "a non-examining physician's opinion cannot by itself, serve as substantial evidence supporting a denial of disability benefits when it is contradicted by all of the other evidence in the record." Martin v. Secretary of Health, Education and Welfare, 492 F.2d 905, 908 (4th Cir. 1974); Hayes v. Gardener, 376 F.2d 517, 520-21 (4th Cir. 1967). Thus, the opinion "of a non-examining physician can be relied upon when it is consistent with the record." Smith v. Schweiker, 795 F.2d 343, 346 (4th Cir. 1986).
The ALJ is not required in all cases to give the treating physician's opinion greater weight than other evidence in determining whether a claimant is disabled under the Act. Johnson v. Barnhart, 434 F.3d 650, n. 5 (4
Moreover, a treating physician's opinion can never bind the ALJ on issues reserved to the ALJ, such as a claimant's RFC or whether a claimant is able to work. These decisions are solely the responsibility of the ALJ because they are administrative findings that are dispositive of a case; they are not medical issues. See 20 C.F.R. §§ 404.1527(d)(1)-(3) and 416.927(d)(1)-(3); Social Security Ruling (SSR) 96-5p, 1996 WL 374183 at *2 (S.S.A.).
In weighing a medical opinion, an ALJ will consider the examining relationship; the treatment relationship, including the length of treatment, the frequency of examination and the nature and extent of the treatment relationship; the relevant evidence, including medical signs and laboratory findings, supporting the opinion; the consistency of an opinion with the record as whole; the specialization of the treating physician; and any other factors which tend to support or contradict the opinion. 20 C.F.R. §§ 404.1527(c)(1)-(6) and 416.927(c)(1)-(6). An ALJ does not need to address each individual factor in making his decision, but should sufficiently demonstrate his analysis of the relevant evidence. See Pinson v. McMahon, Civil Action No. 3:07-1056-PMD-JRM, 2009 WL 763553, at *10 (D.S.C. Mar. 19, 2009).
The report of a non-examining, non-treating physician should be discounted and is not substantial evidence when contradicted by all other evidence in the record. Millner v. Schweiker, 725 F.2d 243, 245 (4
A reviewing court cannot determine if an ALJ's findings are supported by substantial evidence unless he explicitly indicates the weight he gave to all of the relevant evidence. Gordon v. Schweiker, 725 F.2d 231, 235 (4th Cir. 1984). In the present matter, the ALJ did not state what weight, if any, was given to treating physicians Dr. Saikali, Dr. Merva and Dr. Mershal. The ALJ gave weight to the reviewing physicians as follows:
The ALJ failed to address and analyze the factors listed in 20 C.F.R. § 404.1527(c) and 416.927(c), discussed supra, in determining the weight given to Claimant's treating physicians for osteoarthritis and Sjogren's syndrome. The Court cannot conclude the decision is supported by substantial evidence without, at a minimum, weighing the Claimant's treating physicians' opinions for his osteoarthritis and Sjogren's syndrome. The ALJ failed to demonstrate the consideration and analysis of the treating physicians' length of treatment, nature and extent of treatment, frequency of examination and specialization.
The undersigned respectfully recommends that the District Judge find that the ALJ failed to consider and analyze all the factors listed in Social Security Regulations in determining the proper weight to give treating source opinions. Although the ALJ gave great weight to the opinions of reviewing Medical Experts, the ALJ failed to provide a thorough treating source analysis. Additionally, the undersigned respectfully suggests the District Judge find that the ALJ's decision is not supported by substantial evidence of record. This Court makes no recommendation as to Claimant's remaining arguments. These issues may be addressed on remand.
For the reasons set forth above, it is hereby respectfully
The parties are notified that this Proposed Findings and Recommendation is hereby
Failure to file written objections as set forth above shall constitute a waiver of de novo review by the District Court and a waiver of appellate review by the Circuit Court of Appeals. Snyder v. Ridenour, 889 F.2d 1363, 1366 (4th Cir. 1989); Thomas v. Arn, 474 U.S. 140, 155 (1985); Wright v. Collins, 766 F.2d 841, 846 (4th Cir. 1985); United States v. Schronce, 727 F.2d 91, 94 (4th Cir. 1984). Copies of such objections shall be served on opposing parties, Judge Faber and this Magistrate Judge.
The Clerk is directed to file this Proposed Findings and Recommendation and to transmit a copy of the same to counsel of record.