Opinion
C/A No.: 1:18-1957-RBH-SVH
08-14-2019
Arlene F. Sams, Plaintiff, v. Andrew M. Saul, Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
This appeal from a denial of social security benefits is before the court for a Report and Recommendation ("Report") pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for Disability Insurance Benefits ("DIB"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether he applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein. I. Relevant Background
A. Procedural History
On September 4, 2012, Plaintiff protectively filed an application for DIB in which she alleged her disability began on June 7, 2011. Tr. at 64, 134-37. Her application was denied initially and upon reconsideration. Tr. at 85-88, 92-93. On August 14, 2014, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Edward T. Morriss. Tr. at 25-49 (Hr'g Tr.). The ALJ issued an unfavorable decision on October 30, 2014, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 10-24. Subsequently, the Appeals Council denied Plaintiff's request for review. Tr. at 1-4. Thereafter, Plaintiff brought an action seeking judicial review of the Commissioner's decision in a complaint filed on March 30, 2016. Sams v. Colvin, No. 1:16-999-PMD-SVH, ECF No. 1. Following the parties' motion, the court entered a January 5, 2017 order remanding the case to the Commissioner for further administrative proceedings. Id. at ECF No. 16.
On May 25, 2017, the Appeals Council issued an order remanding the case to the ALJ. Tr. at 898-902. Plaintiff had a second hearing on February 1, 2018. Tr. at 877-97. The ALJ issued an unfavorable decision on May 16, 2018, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 859-76. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on July 17, 2018. [ECF No. 1].
B. Plaintiff's Background and Medical History
1. Background
Plaintiff was 48 years old at the time of the second hearing. Tr. at 880. She completed three years of college. Id. Her past relevant work ("PRW") was as an inventory management specialist in the military, but the ALJ concluded there would be no civilian equivalent to the position. Tr. at 894. She alleges she has been unable to work since June 7, 2011. Tr. at 134.
2. Medical History
On October 21, 2009, Joanne Dorn, ARNP ("N.P. Dorn"), provided restrictions for no prolonged or repetitive bending and a 25-pound lifting restriction. Tr. at 270. She stated Plaintiff had chronic low back pain. Id.
On December 10, 2009, N.P. Dorn provided the following functional limitations based on a functional assessment: occasionally lifting 35 pounds floor to waist and 25 pounds waist to shoulder. Tr. at 266, 267. She indicated Plaintiff had disqualified herself from the assessment because of pain and had failed to meet walking, lifting, bending, stooping, and crouching elements for the proposed job of laundry worker. Id.
On July 1, 2010, the Veterans Administration ("VA") issued a decision granting Plaintiff a 30% impairment rating for major depressive disorder ("MDD"), continuing a 20% impairment rating for chronic lumbar strain and urticaria, and denying entitlement to individual unemployability. Tr. at 219-25.
Plaintiff presented to Alberto Luis Torres, M.D. ("Dr. Torres"), for primary care on December 28, 2010. Tr. at 467. She complained of constant, throbbing low back pain that was exacerbated by activity and alleviated by heat, medication, and transcutaneous epidural nerve stimulation ("TENS") unit. Tr. at 468. She requested a psychiatric consultation. Id. Dr. Torres noted no abnormalities on physical exam. Tr. at 469. He instructed Plaintiff to continue analgesic medication and use of heating pad and TENS unit for back pain. Id. He declined to refer Plaintiff to a psychiatrist and indicated he could manage her depression by changing her medication as needed. Id.
Plaintiff reported severe low back pain and depression and requested a psychiatric consultation on June 24, 2011. Tr. at 450. She complained of depressed mood, lack of energy, tiredness, lack of interest in activities of daily living ("ADLs"), and wanting to sleep all the time. Id. She endorsed shooting back pain that she rated as a nine on a 10-point scale. Tr. at 451. Dr. Torres observed pain to palpation in the paravertebral muscles of Plaintiff's lumbar spine with limited flexion and extension. Id. He noted constricted affect, depressed mood, poor insight, and fair judgment, but good hygiene, cooperative behavior, normal speech, steady motor function, linear thought process, and no suicidal or homicidal ideation. Id. He ordered Triamcinolone and Ketorolac injections, prescribed a Medrol Dosepak for inflammation, requested a psychiatric consult, and recommended Plaintiff engage in exercise for 40 minutes, four-to-five times per week. Tr. at 451-52.
Plaintiff presented to David Walter Hiott, M.D. ("Dr. Hiott"), for a mental health diagnostic assessment on June 27, 2011. Tr. at 334-38. She reported a history of depression with anhedonia, lack of energy, tiredness, and lack of interest in ADLs. Tr. at 334. She indicated she was taking Citalopram occasionally, as opposed to daily, because it caused her to feel like she was in a daze. Id. She reported a history of suicidal thoughts, but denied having a suicide plan. Id. Dr. Hiott observed Plaintiff to appear somewhat unkempt, to demonstrate slight psychomotor retardation, to have a depressed mood and blunted affect, to show problems with long-term memory, and to have fair judgment and insight. Tr. at 337. He diagnosed MDD, unspecified anxiety disorder, and post-traumatic stress disorder ("PTSD") and assessed a global assessment of functioning ("GAF") score of 45-50. Tr. at 338. He discontinued Citalopram and prescribed Sertraline and Seroquel. Id.
The GAF scale is used to track clinical progress of individuals with respect to psychological, social, and occupational functioning. American Psychiatric Association: Diagnostic & Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000 ("DSM-IV-TR"). The GAF scale provides 10-point ranges of assessment based on symptom severity and level of functioning. Id. If an individual's symptom severity and level of functioning are discordant, the GAF score reflects the worse of the two. Id.
A GAF score of 41-50 indicates "serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job)." DSM-IV-TR.
On July 12, 2011, Plaintiff complained of depressed mood, inability to experience pleasure, low energy, low motivation, low self-esteem, feelings of hopelessness and helplessness, reduced activity level, and isolating behavior. Tr. at 439. She reported she woke between 8:30 and 9:00 a.m., engaged in minimal activity, and went to bed around 6:30 p.m. Id. She endorsed passive suicidal ideation, but denied specific intent or plan. Id. She reported stressors that included lack of steady employment, finances, chronic pain, unreliable transportation, and her mother's declining health because of cancer. Tr. at 440. She indicated her mood and energy level had improved slightly in response to Sertraline. Id. Erin M. Jones, LMSW, observed the following on mental status exam: appropriate appearance, grooming, and hygiene; limited engagement; normal psychomotor activity; normal speech; depressed mood; flat affect; linear, logical thought process; difficulty maintaining train of thought during discussion; and impaired insight and judgment. Tr. at 441. She assessed MDD and PTSD and a GAF score of 45-50. Id. She noted Plaintiff did not typically watch television or movies, but encouraged her to watch a movie with her son and to sit outside to watch him ride his bike. Tr. at 442.
On August 19, 2011, Plaintiff presented to James A. Hutchingson, M.D. ("Dr. Hutchingson"), for a mental disorders compensation and pension ("C&P") examination related to her request for an increased VA disability impairment rating. Tr. at 229-36. Dr. Hutchingson observed Plaintiff to "appear[] very depressed," demonstrate flat affect, be "slow to answer questions," be hypokinetic and anhedonic, "ha[ve] difficulty concentrating," and "feel[] great guilt." Tr. at 236. He stated Plaintiff was "isolative and clearly not functioning well." Id. He identified Plaintiff's symptoms as including depressed mood; anxiety; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; flattened affect; disturbance of motivation and mood; and inability to establish and maintain effective relationships. Tr. at 234-35. He confirmed Plaintiff's diagnosis of MDD. Tr. at 230. He assessed a GAF score of 50. Tr. at 231.
On August 19, 2011, Plaintiff also presented to Jason K. Trigiani, M.D. ("Dr. Trigiani"), for a thoracolumbar spine C&P exam. Tr. at 236-47. She described burning, pulsating, twitching pain in her lower back that radiated to her left calf. Tr. at 237. She stated her pain was exacerbated by activity and decreased by medication. Id. She indicated her back pain flared up three to four times per week. Id. Dr. Trigiani noted the following range of motion ("ROM") in Plaintiff's lumbar spine: forward flexion to 20/90 degrees; extension to 10/30 degrees; right lateral flexion to 30/30 degrees; left lateral flexion to 25/30 degrees; right lateral rotation to 30/30 degrees; and left lateral rotation to 30/30 degrees. Tr. at 238-39. Plaintiff was able to engage in repetitive use testing without additional limitation in ROM. Tr. at 239-40. Dr. Trigiani noted Plaintiff had functional loss in the thoracolumbar spine that included less movement than normal and pain on movement. Tr. at 240. He stated Plaintiff had pain to palpation of the entire lumbar spine, but no paraspinal tenderness. Id. He observed no guarding or muscle spasm. Id. He noted normal 5/5 strength in bilateral hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. Tr. at 241. He indicated Plaintiff did not have muscle atrophy. Id. He noted normal bilateral knee and ankle deep tendon reflexes. Tr. at 242. A sensory examination was normal in all dermatomes. Tr. at 242. A straight leg raising ("SLR") test was negative bilaterally. Id. Dr. Trigiani indicated Plaintiff had mild radicular pain in her left lower extremity. Tr. at 243. He stated Plaintiff's left L4/L5/S1/S2/S3 nerve roots were involved. Id. He assessed mild left-sided radiculopathy. Id. He indicated Plaintiff constantly used a lumbar corset brace as a normal mode of locomotion. Tr. at 244-45. He indicated imaging studies had confirmed arthritis in Plaintiff's thoracolumbar spine. Tr. at 246.
Plaintiff participated in a mental health telemedicine appointment with Dr. Hiott on August 22, 2011. Tr. at 226-29. She reported improved symptoms, but indicated she continued to wake and be unable to return to sleep on some nights. Tr. at 227. She indicated she was "not doing very much each day" and felt "overwhelmed frequently." Id. Dr. Hiott observed Plaintiff to appear "somewhat unkempt," to demonstrate psychomotor retardation, to have a depressed and anxious mood and blunted affect, and to have fair judgment and insight. Tr. at 228. Plaintiff denied recent suicidal thoughts and showed no overt evidence of psychosis. Id. She was fully oriented and her memory was intact. Id. Dr. Hiott diagnosed MDD, dysthymia, and unspecified anxiety disorder and assessed a GAF score of 45. Id. He increased Plaintiff's Zoloft to 100 mg daily, continued Seroquel, and instructed Plaintiff to continue regular individual therapy. Tr. at 229.
On October 4, 2011, Plaintiff initiated mental health treatment with Angela M. Court, M.D. ("Dr. Court"). Tr. at 409-10. She endorsed depressed mood, feelings of hopelessness and worthlessness, passive suicidal ideation without plan or intent, poor concentration, no interest in activities, low self-worth, increased sleep, and constant fatigue. Tr. at 410. She reported dizziness and lightheadedness following an increase in her Sertraline dose. Id. Dr. Court noted the following observations on mental status exam: somnolent; fair hygiene; poor eye contact; normal rate and volume, but monotone speech; depressed mood; blunted-to-flat affect; linear thought process; intact recall of information; and impaired judgment and insight. Tr. at 411. She assessed recurrent, moderate-to-severe MDD and a GAF score of 55. Tr. at 411, 412. She discontinued Quetiapine secondary to excessive sedation and indicated she would continued to monitor Plaintiff's somnolence because several of her medications could be contributing to the problem. Tr. at 411.
A GAF score of 51-60 indicates "moderate symptoms (e.g., circumstantial speech and occasional panic attacks) OR moderate difficulty in social or occupational functioning (e.g., few friends, conflicts with peers or co-workers)." DSM-IV-TR.
Plaintiff complained of excessive fatigue, low energy, and no interest or desire for activity on November 7, 2011. Tr. at 407. She reported that she had recently attended a festival with her sister, but had argued with several attendees. Tr. at 408. She indicated she typically sat at home all day in isolation and with her curtains drawn. Id. She endorsed poor concentration. Id. She stated she was unable to sleep for more than two hours at a time. Id. She denied hopelessness and suicidal thoughts, plan, or intent. Id. Dr. Court observed the following on mental status exam: somnolent; fair hygiene; poor eye contact; normal rate and volume, but monotone speech; tired mood; blunted-to-flat affect; linear thought process; intact recall of information; and impaired judgment and insight. Tr. at 409. She assessed recurrent, moderate- to-severe MDD with continued excessive fatigue and isolation. Id. She increased Plaintiff's Sertraline dose and encouraged her to continue activities as able. Id.
On December 29, 2011, Robert W. Rectenwald, M.D. ("Dr. Rectenwald"), reviewed Plaintiff's VA records as a follow up to the C&P exams and to provide an opinion as to whether Plaintiff met the requirements for a finding of individual unemployability. Tr. at 397. He specified he was not commenting on Plaintiff's mental health issues. Tr. at 398. He opined that Plaintiff "should be able to perform sedentary to mildly physical labor without stooping/squatting or lifting carrying more than twenty pounds." Id. He further stated Plaintiff "should be able to perform work from the waist up." Id.
On February 3, 2012, Plaintiff reported depression, low energy, poor sleep, fatigue, little interest, and isolation. Tr. at 385. She complained that the increased dose of Sertraline had caused shaking, yawning, and teeth chattering. Id. She denied suicidal and homicidal thoughts. Id. She endorsed conflict with her brother. Id. Dr. Court observed the following on mental status exam: somnolent; fair hygiene; okay eye contact; normal rate and volume, but monotone speech; tired mood; blunted-to-flat affect; linear thought process; intact recall of information; and impaired judgment and insight. Tr. at 386. She assessed recurrent, moderate-to-severe MDD with continued excessive fatigue and isolation. Id. She reduced Plaintiff's Sertraline dose to 100 mg daily, added Ritalin, and encouraged Plaintiff to engage in activities as able. Id. She assessed a GAF score of 55. Tr. at 387.
On March 20, 2012, Plaintiff reported increased energy since starting Ritalin. Tr. at 379. She continued to endorse anger and irritability, but indicated it had been better controlled. Id. She denied hopeless, suicidal, and homicidal thoughts. Id. Dr. Court observed the following on mental status exam: fair hygiene, but wearing a ball cap because of self-consciousness related to hair loss; good eye contact; normal rate and volume, but monotone speech; constricted affect; linear thought process; intact recall of information; and improved judgment and insight. Tr. at 380. She increased Plaintiff's Ritalin dose. Tr. at 381.
On May 1, 2012, Plaintiff reported improved sleep, increased energy, and feeling better. Tr. at 376. She denied hopeless, suicidal, and homicidal thoughts and plan. Id. Dr. Court noted the following findings on mental status exam: alert; fair hygiene; good eye contact; normal rate and volume, but monotone speech; constricted affect; linear thought process; intact recall of information; and improved judgment and insight. Tr. at 377. She assessed mild, recurrent MDD and continued Plaintiff's medications. Tr. at 377-78.
On June 14, 2012, Plaintiff reported intermittent low back pain and rated it as a six on a 10-point scale. Tr. at 368. Dr. Torres observed no spinal tenderness or cyanosis, edema, or clubbing in Plaintiff's extremities and no gross neurological deficit. Tr. at 369-70.
On July 10, 2012, Plaintiff reported feeling "down" as a result of grieving her mother, who had recently passed away. Tr. at 364. She indicated she had been isolating in her room and sleeping all day. Id. She reported having decreased energy, no interest, and hopeless thoughts. Id. She denied suicidal and homicidal ideation and plan. Id. Dr. Court observed the following on mental status exam: alert; fair hygiene; good eye contact; normal rate and volume of speech, but monotone; constricted affect; linear thought process; intact recall of information; fair judgment; and fair insight. Tr. at 365. She assessed recurrent, moderate MDD with increased depression following mother's recent passing. Id. She increased Plaintiff's Ritalin dose and encouraged her to continue her other medications as prescribed and activities as able. Id.
Plaintiff presented to Dr. Court for mental health follow up on August 28, 2012. Tr. at 354-56. She reported pain, but indicated her mood had improved. Tr. at 354-55. She stated she had been more energized and had engaged in some cleaning, but indicated she was "still not getting out much" and was "not identifying anything she want[ed] to be doing." Tr. at 355. Plaintiff denied arguments, confrontations, hopeless thoughts, and suicidal or homicidal ideation or intent. Id. Dr. Court observed the following on mental status examination: alert with fair hygiene; good eye contact; normal rate and volume of speech, but monotone; constricted affect; linear thought process; instant recall of information; fair judgment; and fair insight. Tr. at 355-56. She assessed recurrent, mild MDD and a GAF score of 55. Tr. at 356. She increased Plaintiff's Ritalin and continued her other medications. Id.
Plaintiff followed up with Dr. Torres on August 30, 2012. Tr. at 349. She reported chronic low back pain that she rated as a five-to-six on a 10-point scale. Id. She indicated her pain increased with exercise and decreased with rest and lying down. Id. Dr. Torres noted pain at palpation in the paravertebral muscles of Plaintiff's thoracolumbar spine, limited flexion and extension, pain at palpation in the left sacroiliac ("SI") joint, no muscle wasting, good ROM in the joints, and normal curvature in the spine. Tr. at 351. He observed Plaintiff to demonstrate normal gait and balance. Id. He assessed acute-on-chronic low back pain and prescribed Ibuprofen 800 mg, Ketoroloac and Solu-Cortef injections, and a TENS unit. Id. He recommended Plaintiff continue to use her back brace, use a heating pad, engage in 40 minutes of exercise four to five times weekly, and follow an 1800-calorie diet. Id.
State agency psychological consultant Camilla Tezza, Ph.D. ("Dr. Tezza"), reviewed the evidence and completed a psychiatric review technique ("PRT") on October 22, 2012. Tr. at 54-55. She considered listings 12.04 for affective disorders and 12.07 for somatoform disorders. Id. She assessed mild restriction of ADLs, moderate difficulties in maintaining social functioning, and moderate difficulties in maintaining concentration, persistence, or pace. Tr. at 55. She provided the following explanation:
Longitudinal review indicates moderate impairment in social and mild-to-moderate impairment in CPP. Although it is felt that the clmt could perform tasks of at least moderate complexity, her vulnerability to depressive episodes and to associated neurovegetative sxs suggests that simple routine tasks might be a better recommendation. The clmt does appear to be capable of more than simple routine work in future should her depressive sxs remain in remission.Id. Dr. Tezza also completed a mental residual functional capacity ("RFC") assessment and indicated Plaintiff was moderately limited in the following abilities: to carry out detailed instructions, to maintain attention and concentration for extended periods; to work in coordination with or in proximity to others without being distracted by them; to complete a normal workday and workweek without interruptions from psychologically-based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods; to interact appropriately with the general public; and to get along with coworkers or peers without distracting them or exhibiting behavioral extremes. Tr. at 59-61. She provided the following additional explanation:
Based on the evidence cited on the PRT, it is expected that the clmt—
1) is able to understand, remember and carry out simple instructionsTr. at 60. A second state agency psychological consultant, Olin Hamrick, Jr., Ph.D. ("Dr. Hamrick"), indicated similar findings on a PRT and mental RFC assessment on April 8, 2013. Compare Tr. at 54-55 and 59-61, with Tr. at 73-74 and 78-80.
2) is able to understand and remember detailed instructions but may have difficulty carrying out detailed instructions
3) can maintain attention and concentration for at least two hour blocks of time throughout a regular work day
4) can tolerate and work cooperatively with coworkers, but may perform better if substantial interaction with coworkers is not required
5) can accept feedback from supervisors
6) may perform better if substantial interaction with the public is not required
7) can sustain an ordinary routine without special supervision
8) may perform better if tasks are routine or are already familiar to her
9) may miss an occasional day or half-day of work due to psych sx or need to attend a MH appt.
10) can attend work regularly and avoid workplace hazards.
On November 8, 2012, Plaintiff reported recent chest pain she believed to be stress-induced. Tr. at 548. She complained of significant stress related to her living situation. Id. She stated she was no longer using Doxepin on school nights because she had been too tired to wake and get her son ready, resulting in him being late for school on 16 occasions. Id. She endorsed down mood and hopeless thoughts, but denied suicidal ideation, plan, or intent. Id. She reported attending church for support. Id. Dr. Court observed the following on mental status examination: fair hygiene, good eye contact, normal psychomotor activity; normal rate and volume, but monotone speech; linear thought processes; intact recall of information; and fair judgment and insight. Tr. at 550. She discontinued Ritalin based on Plaintiff's complaints of chest pain and added Bupropion. Id.
On November 26, 2012, x-rays of Plaintiff's lumbar spine were unremarkable. Tr. at 838.
On December 21, 2012, state agency medical consultant Katrina B. Doig, M.D. ("Dr. Doig"), reviewed the evidence and assessed the following physical RFC: occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or walk for a total of about six hours in an eight-hour workday; sit for a total of about six hours in an eight-hour workday; never climb ladders, ropes or scaffolds; occasionally climb ramps or stairs, stoop, kneel, crouch, and crawl; and avoid even moderate exposure to hazards. Tr. at 56-59. A second state agency medical consultant, Stephen Wissman, M.D. ("Dr. Wissman"), assessed the same physical RFC on April 8, 2013. Compare Tr. at 56-59, with Tr. at 75-78.
On January 3, 2013, Plaintiff reported doing poorly with continued depressed mood, anhedonia, tiredness, and poor concentration. Tr. at 544. She denied suicidal ideation and plan. Id. She indicated she was taking her medication as prescribed, but Dr. Court noted the refill history did not support Plaintiff's report. Id. Dr. Court observed the following on mental status exam: fair hygiene; good eye contact; normal psychomotor activity; normal rate and tone, but monotone speech; down mood; constricted affect; occasional hopeless thoughts; linear thought process; intact information recall; and fair insight and judgment. Tr. at 545-46. She assessed recurrent, moderate MDD with continued depressed mood and financial and living situation stressors and provided a GAF score of 55. Tr. at 546. She increased Bupropion SA to 200 mg daily and encouraged Plaintiff to use her medications more consistently. Id.
On February 28, 2013, Plaintiff reported depressed mood, anhedonia, lack of motivation, increased distractibility, poor concentration, impaired memory, fatigue, hopeless thoughts, and fleeting suicidal ideation. Tr. at 537. Dr. Court observed the following on mental status exam: slight odor and disheveled appearance; intermittent eye contact; normal rate and volume, but monotone speech; down mood; constricted affect; linear thought process; intact recall of information; and fair judgment and insight. Tr. at 538. She assessed moderate, recurrent MDD with continued depressed mood and financial and living stressors. Tr. at 539. She added a prescription for Lamotrigine 25 mg for depression and encouraged Plaintiff use her medications consistently and to continue activities as able. Id.
On April 8, 2013, Plaintiff reported no change in her mental status. Tr. at 825. She endorsed feelings of hopelessness, anxiety, restlessness, depression, variable energy, and impaired concentration. Id. She denied side effects from the increased dose of Lamotrigine. Id. Dr. Court noted fair hygiene and grooming, down mood, constricted affect, monotone speech, intermittent eye contact, and fair insight and judgment, but the remainder of the mental status exam was normal. Tr. at 826. She increased Plaintiff's Lamotrigine dose to 50 mg twice daily and continued Sertraline and Bupropion. Tr. at 826-27. She assessed a GAF score of 55. Tr. at 827.
On April 9, 2013, Plaintiff presented to General Theophilus Little, M.D. ("Dr. Little"), for severe posterior cervical pain extending into her shoulders and causing numbness in her hands. Tr. at 820. She denied upper extremity weakness. Id. Dr. Little observed tenderness and muscle spasm in Plaintiff's posterior cervical muscles and trapezius. Tr. at 822. Plaintiff reported pain on rotation of her head to the right. Id. Dr. Little noted normal flexion and extension of Plaintiff's neck, normal upper extremity motor function, negative Tinel's test, mild swelling of the fingers and tenderness of the proximal interphalangeal ("PIP") joints of both hands, no tenderness of the metacarpophalangeal ("MCP") joints in either hand, and normal wrist exam. Tr. at 823. He continued Plaintiff on 800 mg of ibuprofen three times daily and ordered magnetic resonance imaging ("MRI") of her cervical spine. Id.
On May 1, 2013, the MRI showed mild discogenic-type degenerative changes at C2-3, C4-5, and C5-6 with no significant central canal or neural foraminal stenosis. Tr. at 703.
On May 16, 2013, the VA notified Plaintiff that she was entitled to a higher level of disability due to being unemployable. Tr. at 828. It found Plaintiff to be totally and permanently disabled due to her service-connected disabilities effective June 23, 2011. Id. It assigned an impairment rating of 70% for MDD, 40% for chronic lumbar strain, 10% for urticaria, and 10% for radiculopathy of the left lower extremity associated with chronic lumbar strain. Tr. at 832.
On May 23, 2013, Plaintiff reported a slight improvement in mood, some improvement in energy, leaving her home more often, and taking short walks. Tr. at 815. She endorsed periods of hopeless thoughts and overall depressed mood, but denied suicidal thoughts, plan, or intent. Id. Dr. Court's observations on mental status exam were consistent with prior findings. Tr. at 816. She increased Plaintiff's Lamotrigine prescription to 50 mg in the morning and 100 mg at bedtime. Id.
On June 7, 2013, Plaintiff complained of unrefreshing sleep and indicated she desired to sleep all the time. Tr. at 809. She also reported depressed mood, occasional palpitations, and a rash. Id. Dr. Boyle noted a patch of erythema in Plaintiff's right inguinal area and indicated she was depressed. Tr. at 810. She prescribed an antifungal cream and continued Plaintiff's other medications. Id.
On July 9, 2013, Plaintiff complained of increased family stressors following her uncle's death. Tr. at 800. She reported hopeless thoughts and restless sleep, but denied suicidal thoughts, plan, or intent. Id. Dr. Court's observations on mental status exam were consistent with prior exams. Tr. at 801. She continued Plaintiff's medications and assessed a GAF score of 55. Tr. at 802.
On August 20, 2013, Plaintiff participated in a mental telehealth visit with Floyd Sallee, M.D. ("Dr. Sallee"). Tr. at 792. She reported feeling more tired over the prior weeks. Id. She stated she had felt increased grief over her mother's death following her uncle's passing in July. Id. Plaintiff complained of depressed mood, restless sleep, reduced appetite, anhedonia, no energy, and poor concentration. Id. Dr. Sallee observed the following on mental status exam: fair hygiene and grooming; intermittent eye contact; slow moving with psychomotor retardation; slow rate and volume with monotone speech; depressed mood; sad and constricted affect; linear and logical thoughts process; intact recall; and fair judgment and insight. Tr. at 794. Plaintiff denied suicidal and homicidal ideations and auditory and visual hallucinations. Id. Dr. Sallee increased Lamotrigine to 200 mg per day. Tr. at 795.
On August 20, 2013, Plaintiff complained of a frontal headache and blurred vision. Tr. at 787. She indicated she woke during the night with left arm and hand pain, noticed recent left arm weakness, and felt as if she were dragging her left foot. Tr. at 789. Dr. Boyle noted positive Phalen's sign in Plaintiff's left upper extremity, microvesicles and scaling on her feet, and depressed affect. Tr. at 790. She assessed headache secondary to hypertension and left arm and hand pain possibly related to carpal tunnel syndrome. Id. She ordered a left wrist splint, referred Plaintiff for an eye exam, and instructed her to take Amlodipine at bedtime and Hydrochlorothiazide in the morning for hypertension, Motrin for headaches, and to engage in a regular walking routine. Id.
On October 16, 2013, Plaintiff complained of feeling tired and not sleeping well. Tr. at 764. She reported decreased energy, "okay" concentration, and increased appetite and denied hopeless or suicidal thoughts and side effects from medication. Id. Dr. Court noted the following findings on mental status exam: fair hygiene and grooming; intermittent eye contact; normal psychomotor activity; normal rate and volume, but monotone speech; linear thought process; intact recall; and fair insight and judgment. Tr. at 765. She increased Plaintiff's Doxepin prescription to 20 mg and instructed her to take it one hour prior to bedtime. Tr. at 766. She assessed a GAF score of 55. Id.
Plaintiff presented to Deena J. Flessas, M.D. ("Dr. Flessas"), at the Goose Creek VA Clinic for an initial psychiatric visit on January 15, 2014. Tr. at 759. She indicated her medication was working and her energy level had improved. Tr. at 760. She reported being more social and attending church with a friend, as well as spending time and talking with her son more often. Id. Dr. Flessas observed Plaintiff to have "ok" mood and reserved affect, but noted no other abnormalities on mental status exam. Tr. at 761. She continued Plaintiff's medications and encouraged her to attend group therapy at the clinic. Id.
On April 22, 2014, Plaintiff reported she enjoyed attending a women's support group at her church. Tr. at 755. She indicated she had no friends and felt like should could not trust people. Id. She endorsed early waking at 4 a.m. on three days per week. Id. She reported suicidal ideation two weeks prior. Id. She denied problems with medications. Id. Dr. Flessas observed 6/10 mood and constricted affect, but noted no other abnormalities on mental status exam. Tr. at 757. She continued Plaintiff's medications and encouraged her to attend a group therapy session at the clinic. Id.
Plaintiff attended a group therapy session on April 22, 2014. Tr. at 754. Ashley Tate Hatton, Psy. D. ("Dr. Hatton") and Sarah B. Stevens, Ph.D. ("Dr. Stevens"), noted no abnormalities on mental status exam. Id. They indicated Plaintiff participated, sharing ideas and engaging in activities. Tr. at 754-55.
On May 12, 2014, Plaintiff complained of "feel[ing] tired all the time." Tr. at 751. She reported isolation, limited social interaction, limited engagement in activities, anxiety, road rage, feeling depressed most of the time, and preferring to remain at home. Id. Sondra R. Bryant, LMSW ("S.W. Bryant"), indicated Plaintiff's medications were somewhat helpful. Id. Plaintiff agreed to participate in monthly therapy sessions. Id. S.W. Bryant observed Plaintiff to have a tired mood and constricted affected, but noted no other abnormalities on mental status exam. Tr. at 752.
On May 28, 2014, Plaintiff presented to the emergency room ("ER") at the Charleston VA Medical Center with complaints of numbness and tingling in her right middle three fingers, as well as a tender lump on her posterior spine. Tr. at 740. X-rays of Plaintiff's cervical spine showed straightening of the cervical spine; moderate C2-3, C4-5, and C5-6 disc space narrowing with mild adjacent endplate spurring; no vertebral height loss; normal Atlantodental inverval; no prevertebral soft tissue swelling; moderate right-sided osseous neural foraminal narrowing at C6-7; and moderate-to-severe left-sided osseous neural foraminal narrowing at C6-7. Tr. at 743-44. Plaintiff reported improved symptoms following Toradol injection. Tr. at 743. The attending physician discharged Plaintiff with prescriptions for a nonsteroidal anti-inflammatory drug ("NSAID") and low-dose Elavil. Id.
Plaintiff followed up with S.W. Bryant on June 9, 2014. Tr. at 730. She reported feeling "extremely tired" and sleeping the entire prior day and all morning prior to the 1:20 p.m. visit. Id. She felt her medication was causing extreme drowsiness. Id. She reported isolation, limited social interaction, limited engagement in activities, anxiety, and road rage. Id. She stated she felt depressed most of the time and preferred to remain in her home. Id. S.W. Bryant observed Plaintiff to demonstrate a tired mood and constricted affect, but to have no other abnormalities on mental status exam. Tr. at 731.
On July 9, 2014, Plaintiff complained of right arm pain and numbness, decreased right hand grip, and right shoulder pain radiating to her fingers. Tr. at 1686. Candace C. Chidester, M.D. ("Dr. Chidester"), observed tenderness to the back of Plaintiff's neck, painful cervical abduction, tenderness to palpation in her right shoulder, decreased right hand grip, and increased pain upon turning her neck. Tr. at 1688. She prescribed Vicodin and Flexeril and referred Plaintiff for an x-ray of her right shoulder and an MRI of her cervical spine. Tr. at 1689.
On July 10, 2014, an MRI of Plaintiff's cervical spine showed mild S-shaped cervicothoracic scoliosis; mild congenital narrowing of the cervical spinal canal; mild-to-moderate spondylosis at C2-3, C4-5, and C5-6; and degenerative disc disease, mild-to-moderate broad-based disc/osteophyte complex, moderate right and mild left foraminal narrowing, and slight broad cord flattening at C4-5. Tr. at 835.
Plaintiff complained of pain on July 29, 2014. Tr. at 1679. She indicated her pain affected her mood and sleep. Id. She stated she avoided socializing because she did not trust most people, including her family members. Id. Rukhsana W. Mirza, M.D. ("Dr. Mirza"), observed Plaintiff to have low and sad mood and constricted affect, but no other abnormalities on mental status exam. Tr. at 1680. He diagnosed MDD and borderline personality traits with a need to rule out borderline personality disorder. Tr. at 1680-81. He continued Plaintiff's medications and instructed her to follow up with Dr. Flessas in four weeks. Tr. at 1681.
Plaintiff followed up with S.W. Bryant the same day. Tr. at 1681. S.W. Bryant helped Plaintiff to process her feelings related to pain issues. Tr. at 1682. She assessed a GAF score of 55 and recommended Plaintiff attend group therapy. Tr. at 1683, 1684.
Plaintiff presented to orthopedic surgeon Michael S. Wildstein, M.D. ("Dr. Wildstein"), for consultation regarding neck and arm pain on August 14, 2014. Tr. at 1203. She described sharp pain that radiated from her neck through her right shoulder and arm. Id. She stated her pain was exacerbated by right arm movement. Id. She rated the pain as a constant 10 on a 10-point scale. Id. Dr. Wildstein observed Plaintiff to be in moderate distress; decreased and painful ROM of the right shoulder; 4/5 strength of the right upper extremity; and negative Hoffman's, L'Hermite's, and Spurling's maneuvers. Tr. at 1203-04. He assessed cervical spondylosis with radiculopathy. Tr. at 1204. He recommended conservative options, including physical therapy and injections and prescribed a Medrol Dosepak. Tr. at 1205.
On August 20, 2014, Plaintiff reported improved sleep, but declined mood. Tr. at 1673. She complained of "a lot of pain issues" and continued to isolate at home and spend most of her time "resting" in bed. Id. Dr. Flessas encouraged Plaintiff to avoid staying in bed all day, to engage in activities, to socialize with others, and to attend a support group. Id. She observed decreased mood and mildly constricted affect, but noted no other abnormalities on mental status exam. Tr. at 1675. She instructed Plaintiff to taper and discontinue Lamotrigine and increased Bupropion from 200 mg to 300 mg for mood and energy. Id.
Plaintiff reported improved mood on September 12, 2014. Tr. at 1669. She indicated her sleep and energy had improved after another provider discontinued one of her medications. Id. S.W. Bryant provided behavioral activation and cognitive behavioral therapy. Id. She encouraged Plaintiff to increase activities and engage socially. Id. She assessed a GAF score of 55. Tr. at 1671.
Plaintiff attended a neurosurgical consultation with Zachary G. Wright, M.D. ("Dr. Wright"), on September 23, 2014. Tr. at 1199. Dr. Wright observed Plaintiff to demonstrated signs of pain when she attempted to grip with her right hand. Tr. at 1200. He noted 4+ right hand strength, 2+ deep tendon reflexes, and intact sensation. Id. He discussed surgery to relieve nerve root compression, but Plaintiff indicated a desire to continue conservative measures. Id. Dr. Wright recommended physical therapy, cervical traction, and injections. Id.
Plaintiff reported improved mood on October 27, 2014. Tr. at 1659. She indicated her pain had decreased, allowing her to get out and feel less depressed. Id. S.W. Bryant encouraged Plaintiff to increase activities, engage socially, and attend group counseling. Id. She assessed a GAF score of 55. Tr. at 1661.
On December 8, 2014, Dr. Flessas observed Plaintiff to appear sleepy and not very engaged. Tr. at 1647. Plaintiff reported being in a lot of pain and spending most of her time sleeping. Id. Dr. Flessas discussed increasing Bupropion from 150 mg to 300 mg for mood and energy and increasing Sertaline from 100 mg to 200 mg for mood and anxiety. Id. Plaintiff agreed to the change. Id. Dr. Flessas assessed a GAF score of 60. Tr. at 1649.
Plaintiff presented to S.W. Bryant the same day. Tr. at 1651. She indicated she was receiving little benefit from treatment and medications. Tr. at 1652. She reported frustration, fatigue, depressed mood, low motivation, little energy, and constant, chronic pain. Id. S.W. Bryant noted that Plaintiff had minimal social interaction and activity and indicated her increased pain had caused increased depression and feelings of helplessness. Id. She assessed a GAF score of 55. Tr. at 1654.
On December 9, 2014, Plaintiff reported one-to-two weeks of pain relief from cervical epidural steroid injection ("ESI") and relief from traction, but only during use. Tr. at 1644. Patricia Mathias, PA-C ("P.A. Mathias"), recommended continued conservative treatment and noted that Plaintiff was scheduled for another ESI on January 29, 2015. Tr. at 1645. She recommended Plaintiff use NSAIDs, muscle relaxers, and daily traction. Id.
On January 14, 2015, Plaintiff indicated the ESIs relieved neck pain, but only lasted a few weeks. Tr. at 1640. She complained of headaches. Id. Plaintiff's blood pressure was elevated, but Dr. Chidester noted no other abnormalities on physical exam. Tr. at 1642. Dr. Chidester indicated Plaintiff's headaches were worse when her blood pressure was elevated. Id. She added Lisinopril 10 mg for hypertension, referred Plaintiff to a pain group and aquatherapy, and refilled Flexeril. Id.
Dino P. Massoglia, M.D. ("Dr. Massoglia"), administered an ESI at Plaintiff's C5-6 level on January 29, 2015. Tr. at 1073-74.
Plaintiff presented to neurosurgeon Abhay K. Varma, M.D. ("Dr. Varma"), for cervical spondylosis with pain in her neck and right upper extremity on March 24, 2015. Tr. at 1614. Dr. Varma noted full, but painful ROM of Plaintiff's cervical spine; 5/5 strength in her left upper extremity; global weakness in her right upper extremity, secondary to pain; marked restriction of right shoulder abduction; positive shoulder impingement; and 5/5 strength of the bilateral lower extremities. Tr. at 1615. He referred Plaintiff for an MRI of the right shoulder and instructed her to continue physical therapy and ESIs. Id.
On April 7, 2015, Plaintiff complained that her pain exacerbated her depression. Tr. at 1606. S.W. Bryant noted some depression, but a mental status exam was otherwise normal. Tr. at 1608. She encouraged Plaintiff to attend a group for coping with pain and managing depression. Id. She assessed a GAF score of 55. Id.
Plaintiff presented to Dr. Flessas the same day. Tr. at 1612. She reported her pain continued to be present, but she was managing it a little better. Id. She indicated she was attempting to spend more time away from her bed. Id. Dr. Flessas observed 4/10 mood and constricted affect, but noted no other abnormalities on mental status exam. Tr. at 1613-14. She continued Plaintiff's medications, encouraged her to attend a support group, and assessed a GAF score of 60. Tr. at 1614.
On May 6, 2015, an MRI of Plaintiff's right upper extremity showed a large partial thickness tear of the bursal side of the rotator cuff tendon. Tr. at 1071-72.
Dr. Massoglia administered a cervical ESI at Plaintiff's C5-6 level on June 11, 2015. Tr. at 1066-68.
Plaintiff followed up with Dr. Varma on June 23, 2015. Tr. at 1588. She complained of painful ROM of her right shoulder, limited right upper extremity function, and inability to sleep on her right side. Id. She indicated her neck pain was less intense following the ESI. Id. Dr. Varma noted full, but painful ROM of Plaintiff's cervical spine; 5/5 strength in her left upper extremity; global weakness in her right upper extremity, secondary to pain; marked restriction of right shoulder abduction; positive shoulder impingement; and 5/5 strength of the bilateral lower extremities. Id. He recommended continued ESIs and referred Plaintiff back to her primary care provider for management of right rotator cuff tear. Tr. at 1589.
On August 11, 2015, Plaintiff reported feeling poorly and having little energy or motivation. Tr. at 1571. Dr. Flessas noted 2/10 mood and constricted affect, but no other abnormalities on mental status exam. Tr. at 1572. She continued Plaintiff's medications, encouraged her to participate in group activities through the VA Center, and assessed a GAF score of 60. Tr. at 1573.
Plaintiff also presented to S.W. Bryant for therapy. Tr. at 1566. She complained of health and pain issues that had increased her anxiety. Id. She indicated she had been isolating and had avoided activities outside her home on most days. Id. S.W. Bryant noted depressed mood and affect and signs of anxiety, but indicated no other abnormalities on mental status exam. Tr. at 1568. She assessed a GAF score of 55. Id.
On November 13, 2015, Plaintiff complained of "a lot of pain" in her back, leg, and right shoulder. Tr. at 1552. She indicated she did not have much energy, was not exercising, and was spending most of her time in bed. Id. She reported daily compliance with Bupropion and Sertaline, but stated she was only taking Doxepin on the weekend because she feared oversleeping and causing her son to miss his bus. Id. Dr. Flessas noted that Plaintiff had not attended any group therapy sessions since her last visit. Id. She observed 4/10 mood and constricted affect, but noted no other abnormalities on mental status exam. Tr. at 1553. She encouraged Plaintiff to avoid sleeping during the day. Tr. at 1552. She assessed a GAF score of 60. Tr. at 1554.
Plaintiff presented to S.W. Bryant for counseling the same day. Tr. at 1554. She complained of pain that prevented her from performing personal care and household chores and of increased depressive mood. Tr. at 1555. S.W. Bryant encouraged Plaintiff to pursue some social interaction and activity. Id. She assessed a GAF score of 55. Tr. at 1557.
Plaintiff participated in ten physical therapy sessions for partial tear of her right rotator cuff between November 30, 2015, and January 14, 2016. Tr. at 1522. She indicated physical therapy had greatly improved her function. Tr. at 1523.
Darryl R. Pauls, M.D. ("Dr. Pauls"), administered a steroid and anesthetic injection to Plaintiff's right shoulder on December 10, 2015. Tr. at 1058-59.
Plaintiff presented to P.A. Mathias for neurosurgery follow up on January 26, 2016. Tr. at 1514. She denied neck pain and indicated her right shoulder pain had significantly improved with physical therapy. Id. P.A. Mathias observed bilateral grip weakness on exam. Id. She instructed Plaintiff to follow up on an as-needed basis. Id.
On February 4, 2016, Plaintiff reported a recent altercation with her neighbor who was angry because Plaintiff had parked her car in a space for a week without moving it. Tr. at 1511. She indicated her mood had improved slightly following the holidays. Id. Dr. Flessas encouraged Plaintiff to participate in group therapy, but Plaintiff was reluctant based on a past negative experience. Tr. at 1512. She recommended switching Sertraline to Duloxetine for mood, anxiety, and nerve pain, "[g]iven little improvement with mood." Id. Dr. Flessas noted 4/10 mood and depressed affect, but indicated no other abnormalities on mental status exam. Tr. at 1513. She assessed a GAF score of 60. Id.
On March 2, 2016, Plaintiff reported continued difficulty with socializing and engaging in activity. Tr. at 1498. She indicated she only left her home to attend doctors' visits. Id. S.W. Bryant noted signs of depression and anxiety on mental status exam, but otherwise normal findings. Tr. at 1499. She assessed a GAF score of 55. Tr. at 1500.
On April 1, 2016, Plaintiff indicated she was not tolerating Metformin well. Tr. at 1489. She noted decreased mood and constricted affect, but no other abnormalities on mental status exam, and otherwise normal findings. Tr. at 1490. Dr. Flessas encouraged Plaintiff to speak with her primary care provider about discontinuing Metformin and to engage in a walking routine. Tr. at 1489. She assessed a GAF score of 60. Tr. at 1491.
Plaintiff also attended therapy with S.W. Bryant. Tr. at 1491. She complained of a lot of pain. Id. She reported depressed mood, poor memory, tiredness, and lack of energy. Tr. at 1492. S.W. Bryant noted signs of depression and anxiety on mental status exam and assessed a GAF score of 55. Tr. at 1493, 1494.
On May 12, 2016, Plaintiff reported right leg numbness and tingling. Tr. at 1478. Dr. Chidester noted no abnormalities on physical exam, aside from elevated blood pressure at 140/80 mm/Hg. Tr. at 1481. X-rays of Plaintiff's lumbar spine showed mild degenerative disc disease at the L4-5 and L5-S1 levels. Tr. at 1057. Dr. Chidester reviewed lab work and assessed new onset diabetes and degenerative joint disease of the spine. Tr. at 1482.
On June 3, 2016, Plaintiff reported significant pain and fluctuating mood. Tr. at 1465. She indicated she had been engaging in minimal activity. Id. S.W. Bryant indicated mostly normal findings on mental status exam, aside from problematic short- and long-term memory. Id. She discussed with Plaintiff her transition to a new therapist and encouraged her to interact socially and increase activity. Tr. at 1463, 1465. She assessed a GAF score of 65. Tr. at 1465.
A GAF score of 61-70 indicates "some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, [and] has some meaningful interpersonal relationships." DSM-IV-TR.
Plaintiff presented to Molly M. Lussier, APRN ("N.P. Lussier"), for a mental health diagnostic assessment on June 13, 2016. Tr. at 1454. She complained of excessive sleep, fatigue, feelings of helplessness and uselessness, anhedonia, isolation, poor attention and concentration, and impaired short-term memory. Tr. at 1455. She denied suicidal ideation, but endorsed a history of suicidal thoughts and plans. Id. N.P. Lussier observed the following on mental status exam: lethargic appearance; fair grooming and hygiene; calm, cooperative behavior; steady gait; clear speech at decreased rate; dysphoric mood; blunted affect; slowed, but concrete thought processes; intact associations; fully oriented; poor attention/concentration; appropriate fund of knowledge; and limited insight and judgment. Tr. at 1460. She indicated she would prescribe a mood stabilizer at Plaintiff's next visit if her mood had not significantly improved. Id.
Plaintiff presented to Patricia Pomeroy, Psy.D., LMSW ("Dr. Pomeroy"), for an initial counseling session on June 17, 2016. Tr. at 1450. She complained of anxiety, depression, lack of motivation, lack of physical activity, social isolation, irritability, and lack of energy. Tr. at 1449. Dr. Pomeroy encouraged Plaintiff to research gyms near her home and to walk for 15 to 20 minutes per day at her apartment complex's exercise facility. Tr. at 1450. She noted slightly delayed speech, depressed and anxious mood, flat affect, fair-to-good judgment, and poor insight, but indicated no other abnormalities on mental status exam. Tr. at 1451-52. Dr. Pomeroy indicated Plaintiff had severe and pervasively debilitating depression. Tr. at 1452. She stated treatment would "likely progress slowly due to the severity and duration of [Plaintiff's] illness." Id.
On June 24, 2016, Plaintiff complained that Metformin caused stomach upset. Tr. at 1443. Dr. Chidester noted no abnormalities on physical exam. Tr. at 1446. She agreed to discontinue Metformin in exchange for Plaintiff's promise to continue following a diet and exercising. Tr. at 1447.
On July 20, 2016, Plaintiff complained of reduced motivation, poor health, and little energy. Tr. at 1431. She reported feeling discouraged and frustrated by multiple health problems. Id. She denied going out regularly or engaging in regular exercise. Id. She indicated she kept her blinds drawn in her apartment. Id. She stated she had difficulty making friends. Id. Dr. Pomeroy encouraged Plaintiff to open her blinds for brief periods each day , to look into joining a gym near her home, and to practice deep breathing exercises. Id. She observed Plaintiff to have slightly delayed speech, depressed and discouraged mood, flat affect, fair-to-good judgment, and poor insight, but noted no other abnormalities on mental status exam. Tr. at 1433.
On July 25, 2016, an MRI of Plaintiff's lumbar spine showed no significant degenerative disc disease and no concerns for transiting or exiting nerve root impingement. Tr. at 1055-57.
Plaintiff reported improved mental symptoms on July 28, 2016. Tr. at 1425. She endorsed improved energy and motivation since discontinuing Metformin. Id. However, she indicated she continued to struggle to complete tasks and organize thoughts. Id. She reported stable mood and improved sleep and denied suicidal and homicidal ideations and delusions. Id. N.P. Lussier observed the following on mental status exam: lethargic appearance; fair grooming and hygiene; calm, cooperative behavior; steady gait; clear, decreased rate of speech; somewhat dysphoric mood; restricted affect; normal thought processes; intact associations; fully oriented; poor attention/concentration; and limited insight and judgment. Tr. at 1427. She encouraged Plaintiff to move her second dose of Bupropion to midday to help with attention and sleep. Tr. at 1428.
Plaintiff reported no change in mental health symptoms on August 22, 2016. Tr. at 1402. N.P. Lussier noted Plaintiff was more motivated to engage in activities, but was anxious about going out on her own. Tr. at 1402-03. She observed the following on mental status exam: fatigued appearance; fair grooming and hygiene; calm, cooperative behavior; steady, slow gait and station; clear, soft speech with decreased rate; dysphoric mood; restricted affect; no hallucinations or delusions; no suicidal or homicidal ideation; normal thought processes; intact associations; fully oriented; poor attention/concentration; and limited insight and judgment. Tr. at 1404. She encouraged Plaintiff to move her second dose of Bupropion to 11:00 a.m. and to continue with counseling. Tr. at 1405.
Plaintiff subsequently attended a counseling session with Dr. Pomeroy. Tr. at 1407. She reported continued social isolation, depression, and avoidance. Id. Dr. Pomeroy encouraged Plaintiff to use the fitness facility in her apartment complex, to open her blinds for longer periods each day, and to socialize more often. Tr. at 1407-08. She observed Plaintiff to have depressed and discouraged mood, slightly blunted affect, fair-to-good judgment, and poor insight, but noted no other abnormalities on mental status exam. Tr. at 1409.
On September 26, 2016, Plaintiff reported no change in her mental symptoms, but indicated she generally felt unwell. Tr. at 1380. N.P. Lussier observed the following on mental status exam: fatigued appearance; good grooming and hygiene; calm and cooperative behavior; steady and slow gait and station; clear and soft speech with decreased rate; less dysphoric, calmer mood; restricted affect; no hallucinations or delusions; no suicidal or homicidal ideation; no evidence of paranoia; normal thought processes; intact associations; fully oriented; poor attention/concentration; and limited judgment and insight. Tr. at 1382. She continued Plaintiff's prescriptions and encouraged her to continue counseling. Tr. at 1383.
Plaintiff attended a session with Dr. Pomeroy the same day. Tr at 1385. She reported that she had enrolled in one in-person and one online class that were scheduled to start in January. Id. Dr. Pomeroy encouraged Plaintiff to participate in more activities and socialize more often. Id.
On October 26, 2016, Plaintiff reported no change in her mental symptoms, but indicated her dizziness had resolved. Tr. at 1365. She considered counseling to be helpful and indicated she had been a little more active. Id. She stated she continued to feel lonely, but denied suicidal and homicidal ideations and hallucinations. Id. N.P. Lussier observed the following on mental status exam: appears fatigued; good grooming and hygiene; calm, cooperative behavior; steady, slow gait and station; soft, clear speech with decreased rate; less dysphoric, calmer mood; restricted affect; normal thought processes; fully oriented; poor attention/concentration; and limited judgment and insight. Tr. at 1366-67. She made no changes to Plaintiff's medications. Id.
Plaintiff also attended a session with Dr. Pomeroy. Tr. at 1369. She stated she had struggled with opening her blinds, but felt better after doing so because the sunlight had improved her mood. Tr. at 1370. Dr. Pomeroy encouraged Plaintiff to initiate conversations and increase her physical activity. Id. She indicated Plaintiff's mood was slightly better and more optimistic. Id.
On December 7, 2016, Plaintiff reported improved sleep, but indicated she continued to feel fatigued on some days. Tr. at 1347. She stated she felt abandoned by her friends and was dreading Christmas. Id. She denied suicidal and homicidal ideations and hallucinations. Id. N.P. Lussier observed the following on mental status exam: fatigued appearance; slow and steady gait; calm and cooperative behavior; clear speech with improved rate and flow; somewhat irritable mood; restricted affect; normal thought process; intact associations; fully oriented; poor attention/concentration; and limited judgment and insight. Tr. at 1348-49. She made no changes to Plaintiff's medications. Tr. at 1350.
Plaintiff followed up for counseling with Dr. Pomeroy the same day. Tr. at 1351. She reported that she had registered for a course to begin in January. Tr. at 1352. Dr. Pomeroy indicated Plaintiff's mood was "not good," her affect was blunted, her judgment was fair-to-good, and her insight was poor-to-fair, but otherwise noted normal findings on mental status exam. Tr. at 1353. She stated Plaintiff was progressing well in treatment. Tr. at 1354.
On January 11, 2017, Plaintiff reported improved symptoms. Tr. at 1337. She indicated she was getting out more, but continued to feel anxious around crowds. Id. She stated she found the holidays difficult, but was able to prepare and enjoy a small meal with her son. Id. She reported improved sleep, despite some racing of her brain that prevented her from resting. Id. She planned to start exercising. Id. N.P. Lussier observed less psychomotor retardation on physical exam. Tr. at 1339. She described Plaintiff's mood as somewhat anxious, but mostly euthymic and her affect as restricted. Id. She stated Plaintiff's attention/concentration was "fair, improving." Id. She continued to assess Plaintiff as having limited insight and judgment. Id. She continued Plaintiff's medications and encouraged her to try two Doxepin for sleep. Tr. at 1340.
Plaintiff attended counseling with Dr. Pomeroy the same day. Tr. at 1340. She reported having taken a trip to Walmart prior to Christmas. Tr. at 1342. She indicated she felt frustrated in the parking lot, but used coping mechanisms, and was able to shop and engage in a conversation while waiting to check out. Id. Plaintiff indicated she was scheduled to attend her first college course that evening. Id. Dr. Pomeroy noted fair-to-good judgment and poor-to-fair insight, but indicated no other abnormalities on mental status exam. Tr. at 1343-44. She noted Plaintiff was setting goals, identifying objectives, and following through, but would likely progress slowly because of the severity and duration of her illness. Tr. at 1344.
On February 13, 2017, Plaintiff reported worsened mental health symptoms and increased back pain that limited her abilities to stand and walk. Tr. at 1319. She complained of increased frustration, irritability, and withdrawal. Id. She denied suicidal and homicidal ideation. Id. N.P. Lussier observed Plaintiff to have a stiff and labored gait and station and to appear "bent over." Tr. at 1321. She noted the following abnormalities on mental status exam: irritable and dysphoric mood; restricted affect; impaired attention/concentration; and limited insight and judgment. Id. She increased Duloxetine to target Plaintiff's mood and pain and continued her other medications. Tr. at 1322.
On March 14, 2017, Plaintiff complained of worsening back pain. Tr. at 1305. She reported pain with lumbar flexion and decreased lumbar ROM and rated her pain as a seven on a 10-point scale. Id. Dawn C. Mills, MSN, ANP ("N.P. Mills"), observed no abnormalities on physical exam. Tr. at 1308.
Plaintiff reported feeling less down and more motivated on March 27, 2017. Tr. at 1295. She indicated she was attending a business class, despite her discomfort, and walking around her neighborhood more frequently. Id. She denied suicidal and homicidal ideation and hallucinations. Id. N.P. Lussier indicated mostly normal findings on mental status exam, aside from somewhat dysphoric mood, restricted affect, impaired attention/concentration, and limited insight and judgment. Tr. at 1297. She assessed recurrent, moderate MDD, continued Plaintiff's medications, and added Melatonin to help with sleep. Tr. at 1298.
On May 30, 2017, Plaintiff reported worsened mental health symptoms. Tr. at 1275. She complained of anhedonia, feelings of helplessness, frequent sadness, feeling fatigued, racing thoughts, and sleep disturbance. Id. She denied suicidal and homicidal ideation and hallucinations. Id. N.P. Lussier observed the following abnormalities on mental status exam: dark circles around eyes; decreased and soft speech; dysphoric mood; restricted affect; impaired attention/concentration; and limited judgment and insight. Tr. at 1277. She recommended Plaintiff taper and stop Duloxetine, increase Bupropion to 450 mg, continue Melatonin and Doxepin, and consider family counseling. Tr. at 1278.
On July 11, 2017, Plaintiff reported no change in symptoms. Tr. at 1269. She continued to report isolation, anhedonia, fatigue, difficulty making decisions, and worry. Tr. at 1269-70. She denied suicidal and homicidal ideations and hallucinations. Tr. at 1270. N.P. Lussier noted the following abnormalities on mental status exam: dark circles around eyes; soft and decreased rate of speech; dysphoric mood; restricted affect; impaired attention/concentration; and limited judgment and insight. Tr. at 1271. She assessed moderate-to-severe recurrent MDD. Tr. at 1272. She continued Plaintiff's medications, but indicated she might need to decrease Bupropion at a later time because it seemed to be elevating Plaintiff's blood pressure and heartrate. Id.
On August 22, 2017, Plaintiff continued to struggle with fatigue, attention, anhedonia, early waking, and worsening chronic pain. Tr. at 1266. She denied suicidal and homicidal ideation and hallucinations. Id. N.P. Lussier observed the following abnormalities on mental status exam: dark circles around eyes; soft and decreased rate of speech; dysphoric mood; restricted affect; impaired attention/concentration; and limited insight and judgment. Tr. at 1267-68. She discontinued Melatonin, but continued Plaintiff's other medications. Tr. at 1268-69.
On September 26, 2017, Plaintiff presented to N.P. Mills for routine follow up. Tr. at 1260-61. Ms. Mills noted no abnormalities on physical exam. Tr. at 1264.
Plaintiff reported worsened mental health symptoms on October 13, 2017. Tr. at 1243. She indicated she had recently been involved in a car accident. Id. She reported daily fatigue, poor attention, forgetfulness, excess worry, anhedonia, and pain. Id. She denied suicidal and homicidal ideation and hallucinations. Id. N.P. Lussier noted the following abnormalities on mental status examination: dark circles around Plaintiff's eyes; slow gait; general psychomotor retardation; dysphoric mood; restricted affect; impaired attention/concentration; and limited insight and judgment. Tr. at 1245. She prescribed Levothyroxine and continued Plaintiff's other medications. Tr. at 1246.
On November 29, 2017, Plaintiff complained her body was giving out. Tr. at 1216. She reported pain in her neck and upper and lower back, as well as dizziness. Tr. at 1217. N.P. Mills noted no abnormalities on physical exam. Tr. at 1220. X-rays of Plaintiff's cervical spine showed multilevel degenerative disc disease with mild foraminal narrowing at the left C4-5 and C5-6 levels. Tr. at 1047. X-rays of Plaintiff's thoracic spine showed mild thoracic spine scoliosis with minimal mid-thoracic degenerative disc disease. Tr. at 1048.
Plaintiff reported worsened mental health symptoms on November 29, 2017. Tr. at 1223. She complained of fatigue, anhedonia, and feeling ill. Id. N.P. Lussier observed Plaintiff to appear lethargic, be dressed casually, demonstrate fair grooming and hygiene, and to have dark circles around her eyes. Tr. at 1225. She noted slow gait and general psychomotor retardation and indicated Plaintiff was speaking softly and at a decreased rate. Id. She described Plaintiff's mood as dysphoric and her affect as restricted. Id. She stated Plaintiff's attention and concentration were impaired and she had limited judgment and insight. Id. Nevertheless, Plaintiff denied suicidal and homicidal ideations, showed no signs of paranoia, denied hallucinations or delusions, was fully oriented, and had normal thought processes. Id. N.P. Lussier recommended Plaintiff taper and stop Bupropion, stop Levothyroxine, and start Escitalopram. Id.
C. The Administrative Proceedings
1. The Administrative Hearing
a. Plaintiff's Testimony
i. August 14, 2014 Hearing
Plaintiff testified she last worked part-time as a substitute teacher in 2011. Tr. at 29, 30. She stated she had previously served in the Army from 2000 to 2007. Id. She indicated she had worked in a supply unit, where her job duties included operating a forklift and lifting more than 25 pounds. Tr. at 44-45.
Plaintiff testified she had stopped working because of back pain that prevented her from sitting and standing for long periods. Tr. at 30-31. She stated she had developed neck pain more recently that limited her ability to use her right arm. Tr. at 31. She indicated she experienced headaches because of high blood pressure that occurred two to three times per week and were relieved one to two hours after taking medication. Tr. at 32. She stated she experienced dizziness, lightheadedness, and insomnia as side effects of medication. Tr. at 33. She testified that carpal tunnel syndrome caused difficulty writing, typing, bathing, grooming, and dressing with her right hand. Tr. at 41.
Plaintiff stated she felt daily pain in her neck and back that was exacerbated by increased activity. Tr at 34-35. She estimated she could lift and carry 10 pounds, stand in one place for 15 minutes, walk for 10 minutes, and sit for 15 minutes without exacerbating her pain. Tr at 35-36.
Plaintiff testified that she lived with her 12-year-old son. Id. She stated she awoke around 8:30 or 9:00 a.m. on a typical morning, prepared her breakfast, took her medications, and remained awake until around 11:00 a.m. Id. She indicated she would typically lie down for two to three hours because her medication made her feel drowsy and disoriented. Tr. at 37-38.
Plaintiff testified that she performed household chores, but had modified her routine. Tr. at 39. She stated she typically prepared quick and easy or microwaveable foods because she could not stand for long periods to cook. Id. She indicated she did laundry once or twice a week. Id. She testified she no longer washed dishes by hand. Id. She stated her son assisted with chores. Id. She indicated she drove to medical appointments and to pick up groceries. Id.
Plaintiff testified she had some difficulty remembering and concentrating, but indicated she had been able to watch a two-hour movie. Tr. at 36. She stated she could remember things she read if they captured her attention. Tr. at 37. She indicated her depressive symptoms caused her to remain in her house most of the time. Tr. at 40-41. She denied attending church and social activities. Tr. at 41. She stated she avoided leaving the house and neglected to perform household chores on three or four days per week. Tr. at 48.
Plaintiff testified that she had received several Cortisone injections that relieved her pain for "a couple of hours" at a time. Tr. at 42. She indicated she used a back brace and a TENS unit. Tr. at 45. She stated she would be unable to perform a desk job because she would frequently need to alternate positions and her pain would prevent her from completing her work. Tr. at 43.
ii. February 1, 2018 Hearing
Plaintiff testified she was unable to work because of pain in her left shoulder and low back pain that radiated into her bilateral legs. Tr. at 881. She stated the left was worse than the right. Tr. at 886. She indicated steroid injections in her neck had not relieved her pain or level of functioning. Tr. at 884. She stated she experienced symptoms of depression that included lack of energy, social isolation, lack of motivation, suicidal thoughts, and feelings of failure. Tr. at 882. She indicated her depression worsened her pain and her pain worsened her depression. Tr. at 887.
Plaintiff testified the VA had assessed a 70% impairment rating for MDD and a 40% impairment rating for her back. Tr. at 882-83. She indicated she had an overall impairment rating of 100% from the VA. Tr. at 883.
Plaintiff testified she could perform light housework. Tr. at 885. She stated her back pain caused her to spend time lying in the bed or on the couch during the day. Tr. at 885-86. She indicated she used a TENS unit and a heating pad. Tr. at 886. She stated her pain affected her ability to concentrate. Id. She indicated she was inactive for most of a typical day. Tr. at 888. She testified she shopped for groceries with her son's assistance and drove to the grocery store, medical appointments, and to drop her son off as needed. Tr. at 892.
Plaintiff stated she believed Dr. Hutchingson had served as her psychiatrist when she was receiving services in Beaufort, but she had subsequently transferred care to the VA in Charleston. Tr. at 890.
b. Vocational Expert Testimony
Vocational Expert ("VE") Tonetta Watson-Coleman reviewed the record and testified at the hearing on February 1, 2018. Tr. at 893-96. The ALJ described a hypothetical individual of Plaintiff's vocational profile who could perform light work with no climbing of ladders and occasional climbing of ramps and stairs, stooping, kneeling, crouching and crawling. Tr. at 895. He further indicated the individual would be limited to understanding, remembering, and carrying out simple instructions, occasional interaction with coworkers and supervisors, and no ongoing public interaction. Id. The VE testified that the hypothetical individual could perform jobs at the light exertional level with a specific vocational preparation ("SVP") of two as a merchandise labeler, Dictionary of Occupational Titles ("DOT") number 209.587-034, with 1,218,000 positions in the national economy and 26,000 positions in the state economy, a final inspector, DOT number 727.687-054, with 449,000 positions in the national economy and 12,000 positions in the state economy, and a routing clerk, DOT number 222.687-022, with 573,000 positions in the national economy and 8,000 positions in the state economy. Id.
The ALJ next asked the VE to assume the same factors in the first hypothetical question, but to further assume the individual would require an average of two hours of unscheduled work breaks during an eight-hour workday. Tr. at 896. He asked if the individual would be able to perform the jobs identified in response to the first question. Id. The VE stated the individual would be unable to retain or maintain employment. Id.
2. The ALJ's Findings
In his decision dated May 16, 2018, the ALJ made the following findings of fact and conclusions of law:
1. The claimant last met the insured status requirements of the Social Security Act on June 30, 2016.
2. The claimant did not engage in substantial gainful activity during the period from her alleged onset date of June 7, 2011, through her date last insured of June 30, 2016 (20 CFR 404.1571 et seq.).
3. Through the date last insured, the claimant had the following severe impairments: degenerative disc disease and depression (20 CFR 404.1520(c)).
4. Through the date last insured, the claimant did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525 and 404.1526).
5. After careful consideration of the entire record, I find that, through the date last insured, the claimant had the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) with: occasional stooping, kneeling, crouching, and crawling; and, no climbing ladders/scaffolds/ropes. She would be limited to understanding, remembering, and carrying out simple instructions with no ongoing public interaction.
6. Through the date last insured, the claimant was unable to perform any past relevant work (20 CFR 404.1565).
7. The claimant was born on April 20, 1969 and was 47 years old, which is defined as younger individual age 18-49, on the date last insured (20 CFR 404.1563).Tr. at 864-71. II. Discussion
8. The claimant has at least a high school education and is able to communicate in English (20 CFR 404.1564).
9. Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant is "not disabled," whether or not the claimant has transferable job skills (See SSR 82-41 and 20 CFR Part 404, Subpart P, Appendix 2).
10. Through the date last insured, considering the claimant's age, education, work experience, and residual functional capacity, there were jobs that existed in significant numbers in the national economy that the claimant could have performed (20 CFR 404.1569 and 404.1569(a)).
11. The claimant was not under a disability, as defined in the Social Security Act, at any time from June 7, 2011, the alleged onset date, through December 31, 2016, the date last insured (20 CFR 404.1520(g)).
Plaintiff alleges the Commissioner erred for the following reasons:
1) the ALJ failed to explain the weight he accorded to the opinion evidence of record; and
2) the ALJ's RFC analysis is not supported by substantial evidence.
The Commissioner counters that substantial evidence supports the ALJ's findings and that the ALJ committed no legal error in her decision.
A. Legal Framework
1. The Commissioner's Determination-of-Disability Process
The Act provides that disability benefits shall be available to those persons insured for benefits, who are not of retirement age, who properly apply, and who are under a "disability." 42 U.S.C. § 423(a). Section 423(d)(1)(A) 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 at least 12 consecutive months.42 U.S.C. § 423(d)(1)(A).
To facilitate a uniform and efficient processing of disability claims, regulations promulgated under the Act have reduced the statutory definition of disability to a series of five sequential questions. See, e.g., Heckler v. Campbell, 461 U.S. 458, 460 (1983) (discussing considerations and noting "need for efficiency" in considering disability claims). An examiner must consider the following: (1) whether the claimant is engaged in substantial gainful activity; (2) whether she has a severe impairment; (3) whether that impairment meets or equals an impairment included in the Listings; (4) whether such impairment prevents claimant from performing PRW; and (5) whether the impairment prevents her from doing substantial gainful employment. See20 C.F.R. § 404.1520. These considerations are sometimes referred to as the "five steps" of the Commissioner's disability analysis. If a decision regarding disability may be made at any step, no further inquiry is necessary. 20 C.F.R. § 404.1520(a)(4) (providing that if Commissioner can find claimant disabled or not disabled at a step, Commissioner makes determination and does not go on to the next step).
The Commissioner's regulations include an extensive list of impairments ("the Listings" or "Listed impairments") the Agency considers disabling without the need to assess whether there are any jobs a claimant could do. The Agency considers the Listed impairments, found at 20 C.F.R. part 404, subpart P, Appendix 1, severe enough to prevent all gainful activity. 20 C.F.R. § 404.1525. If the medical evidence shows a claimant meets or equals all criteria of any of the Listed impairments for at least one year, she will be found disabled without further assessment. 20 C.F.R. § 404.1520(a)(4)(iii). To meet or equal one of these Listings, the claimant must establish that her impairments match several specific criteria or are "at least equal in severity and duration to [those] criteria." 20 C.F.R. § 404.1526; Sullivan v. Zebley, 493 U.S. 521, 530 (1990); see Bowen v. Yuckert, 482 U.S. 137, 146 (1987) (noting the burden is on claimant to establish his impairment is disabling at Step 3).
In the event the examiner does not find a claimant disabled at the third step and does not have sufficient information about the claimant's past relevant work to make a finding at the fourth step, he may proceed to the fifth step of the sequential evaluation process pursuant to 20 C.F.R. § 404.1520(h).
A claimant is not disabled within the meaning of the Act if she can return to PRW as it is customarily performed in the economy or as the claimant actually performed the work. See 20 C.F.R. Subpart P, § 404.1520(a), (b); Social Security Ruling ("SSR") 82-62 (1982). The claimant bears the burden of establishing her inability to work within the meaning of the Act. 42 U.S.C. § 423(d)(5).
Once an individual has made a prima facie showing of disability by establishing the inability to return to PRW, the burden shifts to the Commissioner to come forward with evidence that claimant can perform alternative work and that such work exists in the regional economy. To satisfy that burden, the Commissioner may obtain testimony from a VE demonstrating the existence of jobs available in the national economy that claimant can perform despite the existence of impairments that prevent the return to PRW. Walls v. Barnhart, 296 F.3d 287, 290 (4th Cir. 2002). If the Commissioner satisfies that burden, the claimant must then establish that she is unable to perform other work. Hall v. Harris, 658 F.2d 260, 264-65 (4th Cir. 1981); see generally Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987) (regarding burdens of proof).
2. The Court's Standard of Review
The Act permits a claimant to obtain judicial review of "any final decision of the Commissioner [] made after a hearing to which he was a party." 42 U.S.C. § 405(g). The scope of that federal court review is narrowly-tailored to determine whether the findings of the Commissioner are supported by substantial evidence and whether the Commissioner applied the proper legal standard in evaluating the claimant's case. See Richardson v. Perales, 402 U.S. 389, 390 (1971); Walls, 296 F.3d at 290 (citing Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990)).
The court's function is not to "try these cases de novo or resolve mere conflicts in the evidence." Vitek v. Finch, 438 F.2d 1157, 1157-58 (4th Cir. 1971); see Pyles v. Bowen, 849 F.2d 846, 848 (4th Cir. 1988) (citing Smith v. Schweiker, 795 F.2d 343, 345 (4th Cir. 1986)). Rather, the court must uphold the Commissioner's decision if it is supported by substantial evidence. "Substantial evidence" is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson, 402 U.S. at 390, 401; Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005). Thus, the court must carefully scrutinize the entire record to assure there is a sound foundation for the Commissioner's findings and that her conclusion is rational. See Vitek, 438 F.2d at 1157-58; see also Thomas v. Celebrezze, 331 F.2d 541, 543 (4th Cir. 1964). If there is substantial evidence to support the decision of the Commissioner, that decision must be affirmed "even should the court disagree with such decision." Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).
B. Analysis
1. Weighing of Opinion Evidence
Plaintiff argues the ALJ failed to explain the weight he gave to the opinion evidence of record. [ECF No. 13 at 18]. The Commissioner maintains the ALJ adequately explained the weight he accorded to the opinion statements. [ECF No. 14 at 8].
"Medical opinions are statements from acceptable medical sources that reflect judgments about the nature and severity of your impairment(s), including your symptoms, diagnosis and prognosis, what you can still do despite impairment(s), and your physical or mental restrictions." 20 C.F.R. § 404.1527(a)(1). The applicable regulations direct ALJs to accord controlling weight to treating physicians' medical opinions that are well supported by medically-acceptable clinical and laboratory diagnostic techniques and that are not inconsistent with the other substantial evidence of record. 20 C.F.R. §§ 404.1527(c)(2). If the record contains no opinion from a treating physician or if the ALJ declines to accord controlling weight to a treating physician's opinion, the ALJ must proceed to weigh all the other medical opinions of record based on the factors in 20 C.F.R. § 404.1527(c), which include "(1) whether the physician has examined the applicant, (2) the treatment relationship between the physician and the applicant, (3) the supportability of the physician's opinion, (4) the consistency of the opinion with the record, and (5) whether the physician is a specialist." Johnson, 434 F.3d at 654 (citing 20 C.F.R. § 404.1527).
Effective March 27, 2017, the Social Security Administration rescinded SSR 96-2p, and it no longer applies the "treating physician rule." Rescission of SSR 96-2p, 96-5p, and 06-3p, 82 Fed. Reg. 15,263 (March 27, 2017); 20 C.F.R. § 404.1520c (2017). The undersigned will review the ALJ's decision under the old rules codified by 20 C.F.R. § 404.1527 because the new regulation is not retroactive and Plaintiff filed her claim before it took effect. See 82 Fed. Reg. 15,263 (stating the rescissions of SSR 96-2p, 96-5p, and 06-3p were effective for "claims filed on or after March 27, 2017"); see also 20 C.F.R. § 404.1520c (stating "[f]or claims filed before March 27, 2017, the rules in § 404.1527 apply").
a. Dr. Hutchingson's Opinion
On August 19, 2011, Dr. Hutchingson indicated Plaintiff had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. Tr. at 232. He opined Plaintiff was "not employable at [the] time secondary to her severe depression" that "significantly interfere[d] with her occupational and social functioning." Id. However, he stated, "[t]here [was] a very good chance that she [would] return to full functioning in several months with appropriate treatment." Tr. at 236.
Dr. Hutchingson provided a follow up note on January 9, 2012. Tr. at 421. He explained "[d]epression leaves someone unable to think clearly, concentrate, get out of bed, deal with any significant stress, eat, sleep, and just generally perform ADLs." Id. He opined "Ms. Sams was completely unemployable at the time of my exam in August based upon the severity of the above symptoms." Id.
Plaintiff argues the ALJ disregarded Dr. Hutchingson's opinion as being based on her subjective reports and unsupported by other objective evidence without considering the evidence supporting the opinion or providing his reasons for reaching such a conclusion. [ECF No. 13 at 19].
The Commissioner argues the ALJ declined to give controlling weight to Dr. Hutchingson's opinion because he considered it to lack substantial support from the other objective evidence of record. [ECF No. 14 at 9]. He maintains the ALJ cited specific evidence that demonstrated Plaintiff's improvement and contradicted Dr. Hutchingson's opinion. Id. at 9-10.
The ALJ addressed Dr. Hutchingson's opinion as follows:
I give little weight to Dr. James Hutchingson's opinion from August 2011 that the claimant's severe depression significantly interfered with her occupational and social functioning and that she was unemployable as far as this established a permanent limitation (Exhibit 1F and 4F). The doctor's assessment was based primarily on the claimant's subjective symptoms, which, for reasons stated in detail above, are not reliable. The lack of substantial support from the other objective evidence of record renders the opinion less persuasive.Tr. at 869. The ALJ found Plaintiff's subjective symptoms to be unreliable because the record contained "no indication that [she] required emergency treatment or inpatient hospitalization for [depression]." Tr. at 867. He noted Plaintiff had reported her medications were helpful in June 2011, "reported feeling better in terms of her depression" in May 2012, "reported feeling better, doing some cleaning at home, and feeling more energized" in August 2012, "reported getting out more in May 2013," stated "her medications were working" in January 2014, "was doing well and had been spending time with her son" in April 2014, endorsed improved mood in October 2014, and "had made clinically significant progress toward her treatment goals" in December 2014. Tr. at 867-68. The ALJ stated findings of severe depression were "primarily made by a social worker and nurse practitioner, who are not considered 'acceptable medical sources'" and whose "assessment of severe depression [was] not supported by the clinical findings." Tr. at 868. He noted "Dr. Flessias [sic], a treating psychiatrist, reported fairly normal findings on exam and assigned the claimant a GAF score of 60 during the same period (Exhibit 12F)." Id. He acknowledged Plaintiff's treatment notes documented her reports of fatigue, isolation, irritability, and anhedonia," but pointed out that her "provider advised her to avoid staying in bed all day, stay busy, engage in more activities outside the home, and interact with others (Exhibit 12F)." Id.
Because Dr. Hutchingson had an examining relationship, but not a treatment relationship with Plaintiff, the ALJ was required to consider the examining relationship, the supportability of Dr. Hutchingson's opinion in his examination notes, the consistency of his opinion with the other evidence of record, and his specialization as a psychiatrist. See Johnson, 434 F.3d at 654; 20 C.F.R. § 404.1527(c). The ALJ's decision reflects no consideration of Dr. Hutchingson's specialization. See Tr. at 867-68. Although the ALJ concluded that Dr. Hutchingson's opinion was "based primarily on the claimant's subjective symptoms," he did not explain this conclusion or address Dr. Hutchingson's findings on evaluation. See id.
The ALJ cited evidence of inconsistency between Dr. Hutchingson's opinion and the other evidence of record, but his findings of inconsistency were not well-supported. He indicated Plaintiff's medications were working in June 2011 (Tr. at 867), but the record does not support this conclusion. When Plaintiff reported to Dr. Hiott on June 27, 2011, she reported depression with anhedonia, lack of energy, tiredness, and lack of interest in ADLs, and Dr. Hiott observed her to appear somewhat unkempt, to demonstrate slight psychomotor retardation, to have a depressed mood and blunted affect, to show problems with long-term memory, and to have fair judgment and insight. Tr. at 334, 337. She reported Citalopram caused her to feel like she was in a daze (Tr. at 334), and Dr. Hiott discontinued the medication. Tr. at 338. She had also requested a psychiatric consultation and reported to Dr. Torres three days prior to her appointment with Dr. Hiott her depressed mood, lack of energy, tiredness, lack of interest in ADLs, and wanting to sleep all the time. Tr. at 450.
"'An ALJ has the obligation to consider all relevant medical evidence and cannot simply cherrypick facts that support a finding of nondisability while ignoring evidence that points to a disability finding.'" Lewis v. Berryhill, 858 F.3d 858, 869 (4th Cir. 2017) (quoting Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010). In Lewis, the court noted that there was evidence of significant abnormal findings "[i]n the same medical records containing the 'normal' findings relied upon by the ALJ." Id.
Similarly, in this case, the ALJ cited evidence of Plaintiff's improved functioning while ignoring evidence of declined functioning in the same and subsequent records. The ALJ referenced Plaintiff's improved symptoms in May 2012, but ignored evidence of increased depression, isolation, decreased energy, lack of interest, and hopeless thoughts during her next visit. Tr. at 364. He cited Plaintiff's improved functioning in August 2012, but ignored her indication during the same visit that she was "still not getting out much." Tr. at 355. He also neglected to consider evidence of impaired functioning during Plaintiff's next four mental health visits. See Tr. at 537 (indicating depressed mood, anhedonia, lack of motivation, increased distractibility, poor concentration, impaired memory, fatigue, hopeless thoughts, and fleeting suicidal ideation), 538 (observing slight odor and disheveled appearance, intermittent eye contact, monotone speech, down mood, and constricted affect on mental status exam), 544 (complaining of feeling poorly with depressed mood, anhedonia, tiredness, and poor concentration), 548 (reporting down and hopeless mood and stress-induced chest pain), 825 (endorsing no change, feelings of hopelessness, anxiety, restlessness, depression, variable energy, and impaired concentration).
The ALJ noted Plaintiff was "getting out more" in May 2013, but failed to consider evidence of declined functioning in June, July, August, and October 2013. See Tr. at 764 (endorsing decreased energy, poor sleep, and increased appetite), 792 (complaining of feeling more tired, increased grief, depressed mood, restless sleep, reduced appetite, anhedonia, no energy, and poor concentration), 794 (observing intermittent eye contact, psychomotor retardation, slow and monotone speech, depressed mood, and sad, constricted affect on mental status exam), 800 (noting hopeless thoughts and restless sleep), 809 (reporting unrefreshing sleep, desire to sleep all the time, depressed mood, and occasional palpitations).
The ALJ referenced signs of improved mood and functioning in January, April, October, and December 2014, but ignored evidence to the contrary during those and other visits in 2014. He indicated Plaintiff was doing well and had been spending time with her son in April 2014 (Tr. at 867), but he ignored references in the same notes to Plaintiff having no friends, feeling like she could not trust others, and experiencing recent suicidal ideation. See Tr. at 755. He failed to reconcile his conclusion with Plaintiff's reports in May, June, July, and August 2014 of feeling tired all the time, isolating, having limited social interaction, engaging in limited activities, experiencing road rage, feeling depressed most of the time, and preferring to remain at home. Tr. at 730, 751, 1673, 1679. He referenced a mental health note in December 2014 that indicated Plaintiff had made clinically significant progress toward her treatment goals, but ignored evidence on the same day that Plaintiff appeared sleepy and not very engaged; reported being in a lot of pain and spending most of her time sleeping; endorsed frustration, fatigue, depressed mood, low motivation, and little energy; and complained of little benefit from treatment and medications. Tr. at 1647, 1652.
The above-cited evidence in addition to the assessments of moderate-to-severe and severe depression from Dr. Court, Dr. Hiott, N.P. Lussier, and Dr. Pomeroy support Dr. Hutchingson's assessment of severe depression. See, e.g., Tr. at 228, 386, 411, 1460, 1452. Dr. Hutchingson's indication that Plaintiff had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood is consistent with much of the evidence referenced above. Finally, his explanation that "[d]epression leaves someone unable to think clearly, concentrate, get out of bed, deal with any significant stress, eat, sleep, and just generally perform ADLs" appears to be consistent with the symptoms documented in Plaintiff's treatment notes.
To the extent the ALJ discounts assessments of severe depression from Plaintiff's providers who were not acceptable medical sources, the undersigned notes that a provider does not have to be an acceptable medical source to assess the severity of an impairment previously diagnosed by an acceptable medical source. See Social Security Ruling ("SSR") 06-03p, 2006 WL 2329939, at *1 (Aug. 9, 2006) (providing that only acceptable medical sources can establish the existence of a medically-determinable impairment, provide medical opinions, and be considered treating sources whose medical opinions may be entitled to controlling weight).
Because the ALJ's weighing of Dr. Hutchingson's opinion does not reflect proper consideration of his specialization, the supportability of his opinion in his record, or the consistency of his opinion with the other evidence of record, the undersigned recommends the court find that substantial evidence does not support the ALJ's decision to give it little weight.
b. Dr. Rectenwald's Opinion
Plaintiff argues the ALJ failed to credit the restrictions for no squatting or stooping despite giving "weight" to Dr. Rectenwald's assessment. [ECF No. 13 at 21]. The Commissioner maintains the ALJ gave some weight to Dr. Rectenwald's opinion, but significant weight to Dr. Doig, who indicated Plaintiff was capable of occasional stooping. [ECF No. 14 at 10-11].
The ALJ stated he had considered Dr. Rectenwald's opinion "that the claimant's lumbar spine condition caused her to be unable to squat, stoop, or lift more than 20 pounds" and had "give[n] weight to [it] as it is supported by the objective evidence of record." Tr. at 869. Thus, he accorded unspecified weight to Dr. Rectenwald's opinion. The ALJ acknowledged that Dr. Rectenwald was neither a treating or examining physician and had only reviewed Plaintiff's medical records "as a compensation and pension examiner for the Department of Veterans Affairs." Id. He incorporated the 20-pound lifting restriction Dr. Rectenwald indicated into the RFC assessment by restricting Plaintiff to light work, but included a provision for occasional, as opposed to "no" stooping and crouching. See Tr. at 866.
The Commissioner correctly points out that the ALJ's rejection of the provision for no stooping or squatting is consistent with his decision to accord significant weight to the state agency consultants' opinions. See Tr. at 56-59, 75-78. The state agency consultants indicated Plaintiff was capable of occasional stooping and crouching. See Tr. at 57, 76. The ALJ gave "significant weight" to the opinions of the state agency medical consultants, finding them to be supported by "[Plaintiff's] treatment history, findings upon examination, and [Plaintiff's] activities of daily living as described throughout this decision." Id.
Although the ALJ failed to explain his reason for rejecting Dr. Rectenwald's restriction for no stooping/squatting, Plaintiff was not prejudiced, as the jobs identified in the ALJ's decision required no stooping or crouching. See 209.587-034, MARKER, DOT (4th ed., revised 1991), 1991 WL 671802; 727.687-054, FINAL INSPECTOR, DOT (4th ed., revised 1991), 1991 WL 679672; 222.687-022, ROUTING CLERK, DOT (4th ed., revised 1991), 1991 WL 672133 (all providing "Crouching: Not Present—Activity or condition does not exist" and "Stooping: Not Present—Activity or condition does not exist"). Thus, any error on the part of the ALJ in failing to explain his reason for rejecting Dr. Rectenwald's opinion that Plaintiff was unable to engage in stooping and squatting was harmless. See Tanner v. Commissioner of Social Sec., 602 F. App'x 95, 101 (4th Cir. 2015) (unpublished) (concluding that reversal for the ALJ's failure to expressly discuss or assign weight to a medical source statement would be futile because the RFC assessment and the medical opinion were "largely consistent" and it was "highly unlikely . . . that a remand to the agency would change the Commissioner's finding"); Mickles v. Shalala, 29 F.3d 918, 921 (4th Cir. 1991) (providing that an error is harmless if the ALJ would have reached the same result notwithstanding the error). Therefore, the undersigned recommends the court find the ALJ did not err in evaluating Dr. Rectenwald's opinion.
2. RFC Assessment
Plaintiff argues the ALJ failed to explain how the RFC assessment accounted for her moderate limitations in concentration, persistence, or pace and mild difficulties in adapting or managing herself. [ECF No. 13 at 22]. She maintains the ALJ did not follow the special technique for evaluating mental impairments and based all his findings regarding her mental limitations on a form she completed in 2012. Id. at 23. She contends the ALJ did not consider all her impairments cumulatively. Id. at 23.
The Commissioner argues the ALJ accommodated all of Plaintiff's credibly-established functional limitations in the RFC assessment. [ECF No. 14 at 11-12]. He maintains the ALJ's limitation to simple instructions with no ongoing public interaction is supported by his discussion of the longitudinal record relating to Plaintiff's concentration, persistence, or pace. Id. at 14.
The regulations require the Social Security Administration ("SSA") to use a special technique for evaluating the severity of mental impairments at each level of the administrative review process. 20 C.F.R. 404.1520a(a). The adjudicator "must first evaluate [the claimant's] pertinent symptoms, signs, and laboratory findings to determine whether [she] has a medically-determinable mental impairment." 20 C.F.R. § 404.1520a(b)(1). If the adjudicator determines the claimant has a medically-determinable mental impairment, he "must specify the symptoms, signs, and laboratory findings that substantiate the presence of the impairment(s) and document [his] findings." Id. He "must then rate the degree of functional limitation resulting from the impairment(s)" in the areas of understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing oneself. 20 C.F.R. § 404.1520a(b)(2). If the adjudicator assesses a degree of limitation that is consistent with severe mental impairment, but that neither meets or is equivalent in severity to a listing, he must account for the mental impairment in assessing the claimant's RFC. 20 C.F.R. § 404.1520a(d). The ALJ is required to document application of the special technique in his decision. 20 C.F.R. § 404.1520a(e). His decision should "show the significant history, including examination and laboratory findings, and the functional limitations that were considered in reaching a conclusion about the severity of the mental impairment(s)" and "must include a specific finding as to the degree of functional limitation in each of the functional areas." 20 C.F.R. § 404.1520a(e)(4).
A claimant's RFC represents the most she can still do despite her limitations. 20 C.F.R. § 404.1545(a). It must be based on all the relevant evidence in the case record and should account for all the claimant's medically-determinable impairments. Id. In assessing Plaintiff's functional limitations, the ALJ was "require[d] to consider multiple issues and all relevant evidence to obtain a longitudinal picture of [Plaintiff's] overall degree of functional limitation." 20 C.F.R. § 404.1520a(c)(1). The regulation specifically directs the ALJ to "consider all relevant and available clinical signs and laboratory findings, the effects of [Plaintiff's] symptoms, and how [Plaintiff's] functioning may be affected by factors including, but not limited to, chronic mental disorders, structured settings, medication, and other treatment." Id. The ALJ is further instructed to "rate the degree of [Plaintiff's] functional limitation based on the extent to which [Plaintiff's] impairment(s) interfere with [her] ability to function independently, appropriately, effectively, and on a sustained basis," which may involve consideration of "the quality and level of [her] overall functional performance, any episodic limitations, the amount of supervision or assistance [she] require[s], and the settings in which [she is] able to function." 20 C.F.R. § 404.1520a(c)(2).
Pursuant to 20 C.F.R. § 404.1523(c), the ALJ is to "consider the combined effect of all [the claimant's] impairments without regard to whether any such impairment, if considered separately would be of sufficient severity." The RFC assessment must include a narrative discussion describing how all the relevant evidence in the case record supports each conclusion and must cite "specific medical facts (e.g., laboratory findings) and non-medical evidence (e.g., daily activities, observations)." SSR 96-8p, 1996 WL 374184, at *7 (1996). The ALJ must determine the claimant's ability to perform work-related physical and mental abilities on a regular and continuing basis. Id., at *2. He must explain how any material inconsistencies or ambiguities in the record were resolved. Id., at *7. "[R]emand may be appropriate . . . where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite contradictory evidence in the record, or where other inadequacies in the ALJ's analysis frustrate meaningful review." Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (citing Cichocki v. Astrue, 729 F.3d 172, 177 (2d Cir. 2013)).
a. Moderate Limitations in Concentration, Persistence, or Pace and Mild Limitation in Adapting or Managing Oneself
Here, the ALJ determined depression was among Plaintiff's severe impairments. Tr. at 864. In evaluating her depression using the special technique, he assessed moderate limitation in understanding, remembering, or applying information; moderate limitation in interacting with others; moderate limitation in concentration, persistence or pace; and mild limitation in adapting or managing oneself. Tr. at 865. The ALJ included the following mental restrictions in the RFC assessment: "She would be limited to understanding, remembering, and carrying out simple instructions with no ongoing public interaction." Tr. at 866. He indicated he had "considered [Plaintiff's] depression with symptoms of decreased memory/concentration, irritability, and social isolation in limiting her to work involving simple instructions with no ongoing public interaction," but "[could not] find [her] allegations that she was incapable of all work activity to be consistent with the evidence." Tr. at 869.
The ALJ included no specific restrictions in the RFC assessment to accommodate moderate limitation in Plaintiff's abilities to concentrate, persist, and maintain pace and mild limitation in her abilities to adapt and manage herself. The restriction to understanding, remembering, and carrying out simple instructions was presumably intended to address the moderate restriction the ALJ assessed in understanding, remembering, or applying information and the restriction to no ongoing public interaction was presumably intended to address the moderate restriction he assessed in interacting with others.
"This area of mental functioning refers to the abilities to learn, recall, and use information to perform work activities." 20 C.F.R. Pt. 404, Subpt. P, App'x 1, § 12.00(E)(1).
"This area of mental functioning refers to the abilities to relate to and work with supervisors, co-workers, and the public." 20 C.F.R. Pt. 404, Subpt. P, App'x 1, § 12.00(E)(2).
Evaluation of a claimant's ability to concentrate, persist, or maintain pace required consideration of her "abilities to focus attention on work activities and stay on task at a sustained rate." 20 C.F.R. Pt. 404, Subpt. P, App'x 1, § 12.00(E)(3). Examples of this area of functioning include, but are not limited to, the following:
[i]nitiating and performing a task that you understand and know how to do; working at an appropriate and consistent pace; completing tasks in a timely manner; ignoring or avoiding distractions while working; changing activities or work settings without being disruptive; working close to or with others without interrupting or distracting them; sustaining an ordinary routine and regular attendance at work; and working a full day without needing more than the allotted number or length of rest periods during the day.Id. The record contains consistent evidence of impaired functioning in this area. Plaintiff reported reduced motivation that often resulted in her spending most of her days in her home and even in bed. See, e.g., Tr. at 234- 35, 408, 439, 537, 1552, 1647, 1673. She described and her providers noted evidence of distractibility and poor concentration. See, e.g., Tr. at 236, 537, 549, 792, 825, 1410. She also complained of, and her providers documented evidence of, impaired memory. See, e.g., Tr. at 334, 337, 537, 1455, 1465, 1492. Plaintiff's providers noted psychomotor retardation and slow speech during multiple visits. See, e.g., Tr. at 228, 337, 794, 1225, 1245. Given evidence of impairment to this area of functioning and the ALJ's assessment of moderate limitation, he erred in failing to include additional restrictions to accommodate it in the RFC assessment.
Evaluation of a claimant's ability to adapt or manage oneself "refers to the abilities to regulate emotions, control behavior, and maintain well-being in a work setting." 20 C.F.R. Pt. 404, Subpt. P, App'x 1, § 12.00(E)(4). Examples of this area of functioning include, but are not limited to, the following: "[r]esponding to demands; adapting to changes; managing your psychologically based symptoms; distinguishing between acceptable and unacceptable work performance; setting realistic goals; making plans for yourself independently of others; maintaining personal hygiene and attire appropriate to a work setting; and being aware of normal hazards and taking appropriate precautions." Id. Plaintiff's providers occasionally observed her to present with poor hygiene. See Tr. at 228, 337, 538. The record demonstrates that Plaintiff typically reacted by isolating from others when presented with increased stressors, including pain. See, e.g., Tr. at 439-40, 1465, 1552, 1679. Given evidence of impairment to this area of functioning and the ALJ's assessment of mild limitation, he erred in failing to include additional restrictions to accommodate it in the RFC assessment.
b. Combined Effect of Impairments
The ALJ found that degenerative disc disease was a severe impairment (Tr. at 864) that could reasonably be expected to cause Plaintiff's alleged symptom of pain (Tr. at 867), but a review of his decision does not show that he considered whether the functional effects of Plaintiff's depression were increased by pain. See Tr. at 866-69. In Walker v. Bowen, 889 F.2d 47, 50 (4th Cir. 1989), the court explained "[i]t is axiomatic that disability may result from a number of impairments which, taken separately, might not be disabling, but whose total effect, taken together, is to render claimant unable to engage in substantial gainful activity." Therefore, "the [Commissioner] must consider the combined effect of a claimant's impairments and must not fragmentize them" and "must adequately explain his or her evaluation of the combined effects of the impairments." Id. (citing Reichenbach v. Heckler, 808 F.2d 309 (4th Cir. 1985); DeLoatche v. Heckler, 715 F.2d 148 (4th Cir. 1983); Oppenheim v. Finch, 495 F.2d 396 (4th Cir. 1974); Hicks v. Gardner, 393 F.2d 299 (4th Cir. 1968); Griggs v. Schweiker, 545 F. Supp. 475 (S.D.W.Va. 1982).
The record demonstrates that much of Plaintiff's decline in mental functioning coincided with her reports of increased pain. See, e.g., 1465, 1552, 1566, 1647, 1651, 1673, 1679. This would suggest that pain caused by degenerative disc disease exacerbated Plaintiff's depression and caused more significant functional limitation than that caused by depression alone. By having failed to consider the effect of pain on Plaintiff's depression, the ALJ did not adequately consider the combined effect of her impairments in assessing her RFC.
In light of the foregoing, the undersigned recommends the court find the ALJ's failure to assess Plaintiff's capacity to perform relevant functions renders his decision unsupported by substantial evidence and requires remand. See Mascio, 780 F.3d at 636. III. Conclusion and Recommendation
The court's function is not to substitute its own judgment for that of the ALJ, but to determine whether the ALJ's decision is supported as a matter of fact and law. Based on the foregoing, the court cannot determine that the Commissioner's decision is supported by substantial evidence. Therefore, the undersigned recommends, pursuant to the power of the court to enter a judgment affirming, modifying, or reversing the Commissioner's decision with remand in Social Security actions under sentence four of 42 U.S.C. § 405(g), that this matter be reversed and remanded for further administrative proceedings.
IT IS SO RECOMMENDED. August 14, 2019
Columbia, South Carolina
/s/
Shiva V. Hodges
United States Magistrate Judge
The parties are directed to note the important information in the attached
"Notice of Right to File Objections to Report and Recommendation."
Notice of Right to File Objections to Report and Recommendation
The parties are advised that they may file specific written objections to this Report and Recommendation with the District Judge. Objections must specifically identify the portions of the Report and Recommendation to which objections are made and the basis for such objections. "[I]n the absence of a timely filed objection, a district court need not conduct a de novo review, but instead must 'only satisfy itself that there is no clear error on the face of the record in order to accept the recommendation.'" Diamond v. Colonial Life & Acc. Ins. Co., 416 F.3d 310 (4th Cir. 2005) (quoting Fed. R. Civ. P. 72 advisory committee's note).
Specific written objections must be filed within fourteen (14) days of the date of service of this Report and Recommendation. 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b); see Fed. R. Civ. P. 6(a), (d). Filing by mail pursuant to Federal Rule of Civil Procedure 5 may be accomplished by mailing objections to:
Robin L. Blume, Clerk
United States District Court
901 Richland Street
Columbia, South Carolina 29201
Failure to timely file specific written objections to this Report and Recommendation will result in waiver of the right to appeal from a judgment of the District Court based upon such Recommendation. 28 U.S.C. § 636(b)(1); Thomas v. Arn, 474 U.S. 140 (1985); Wright v. Collins, 766 F.2d 841 (4th Cir. 1985); United States v. Schronce, 727 F.2d 91 (4th Cir. 1984).