Opinion
C/A No. 0:19-1905-MGL-PJG
07-07-2020
Scottie Williams, Plaintiff, v. Andrew Saul, Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
This social security matter is before the court for a Report and Recommendation pursuant to Local Civil Rule 83.VII.02 (D.S.C.). The plaintiff, Scottie Williams, brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) to obtain judicial review of a final decision of the defendant, Commissioner of Social Security ("Commissioner"), denying his claims for Disability Insurance Benefits ("DIB"). Having carefully considered the parties' submissions and the applicable law, the court concludes that the Commissioner's decision should be reversed and that the case should be remanded for further consideration as explained below.
SOCIAL SECURITY DISABILITY GENERALLY
Under 42 U.S.C. § 423(d)(1)(A) and (d)(5), as well as pursuant to the regulations formulated by the Commissioner, the plaintiff has the burden of proving disability, which is defined as an "inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 20 C.F.R. § 404.1505(a); see also Blalock v. Richardson, 483 F.2d 773 (4th Cir. 1973). The regulations require the Administrative Law Judge ("ALJ") to consider, in sequence:
(1) whether the claimant is engaged in substantial gainful activity;20 C.F.R. § 404.1520(a)(4). If the ALJ can make a determination that a claimant is or is not disabled at any point in this process, review does not proceed to the next step. Id.
(2) whether the claimant has a "severe" impairment;
(3) whether the claimant has an impairment that meets or equals the requirements of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 ("the Listings"), and is thus presumptively disabled;
(4) whether the claimant can perform his past relevant work; and
(5) whether the claimant's impairments prevent him from doing any other kind of work.
The court observes that effective August 24, 2012, ALJs may engage in an expedited process which permits the ALJs to bypass the fourth step of the sequential process under certain circumstances. 20 C.F.R. § 404.1520(h).
Under this analysis, a claimant has the initial burden of showing that he is unable to return to his past relevant work because of his impairments. Once the claimant establishes a prima facie case of disability, the burden shifts to the Commissioner. To satisfy this burden, the Commissioner must establish that the claimant has the residual functional capacity, considering the claimant's age, education, work experience, and impairments, to perform alternative jobs that exist in the national economy. 42 U.S.C. § 423(d)(2)(A); see also McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983); Hall v. Harris, 658 F.2d 260, 264-65 (4th Cir. 1981); Wilson v. Califano, 617 F.2d 1050, 1053 (4th Cir. 1980). The Commissioner may carry this burden by obtaining testimony from a vocational expert. Grant v. Schweiker, 699 F.2d 189, 192 (4th Cir. 1983).
ADMINISTRATIVE PROCEEDINGS
In January 2013, Williams applied for DIB, alleging disability beginning July 1, 2012. Williams's application was denied initially and upon reconsideration, and he requested a hearing before an ALJ. A hearing was held on January 4, 2018, at which Williams appeared and testified and was represented by Amy Hertza, Esquire. After hearing testimony from a vocational expert, the ALJ issued a decision on May 23, 2018 finding that Williams was not disabled from the alleged onset date of July 1, 2012 through the date last insured of March 31, 2018. (Tr. 16-34.)
Williams was born in 1963 and was fifty-four years old on the date last insured. He has a high school education and past relevant work experience as a forklift operator, a logistics container coordinator, a material handler, and a warehouse foreman. (Tr. 269.) Williams alleged disability due to complex regional pain syndrome and depression. (Tr. 268.)
In applying the five-step sequential process, the ALJ found that Williams had not engaged in substantial gainful activity since his alleged onset date of July 1, 2012 through his date last insured of March 31, 2018. The ALJ also determined that, through the date last insured, Williams's cervical and lumbar degenerative disc disease, degenerative joint disease of the left shoulder with adhesive capsulitis, reflex sympathetic disease/chronic regional pain syndrome, and recurrent headaches were severe impairments. However, the ALJ found that, through the date last insured, Williams 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 (the "Listings"). The ALJ further found that, through the date last insured, Williams retained the residual functional capacity to
perform less than the full range of light work as defined in 20 CFR 404.1567(b) except the claimant should perform no lifting or carrying over 20 pounds occasionally and 10 pounds frequently, and should not lift over 10 pounds with his left upper extremity. He could occasionally reach overhead, perform gross
handling and push/pull with the left upper extremity. The claimant should never crawl or climb ladders, ropes or scaffolds. The claimant should have no exposure to hazards to unprotected heights, vibration and dangerous machinery.(Tr. 22.) The ALJ found that, through the date last insured, Williams was unable to perform any past relevant work, but that considering Williams's age, education, work experience, and residual functional capacity, there were jobs that existed in significant numbers in the national economy that Williams could have performed. Accordingly, the ALJ found that Williams was not disabled from the alleged onset date of July 1, 2012 through the date last insured of March 31, 2018.
The Appeals Council denied Williams's request for review on May 3, 2019, thereby making the decision of the ALJ the final action of the Commissioner. (Tr. 1-5.) This action followed.
STANDARD OF REVIEW
Pursuant to 42 U.S.C. § 405(g), the court may review the Commissioner's denial of benefits. However, this review is limited to considering whether the Commissioner's findings "are supported by substantial evidence and were reached through application of the correct legal standard." Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996); see also 42 U.S.C. § 405(g); Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). Thus, the court may review only whether the Commissioner's decision is supported by substantial evidence and whether the correct law was applied. See Brown v. Comm'r Soc. Sec. Admin., 873 F.3d 251, 267 (4th Cir. 2017); Myers v. Califano, 611 F.2d 980, 982 (4th Cir. 1980). "Substantial evidence" means "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance." Craig, 76 F.3d at 589; see also Pearson v. Colvin, 810 F.3d 204, 207 (4th Cir. 2015). In reviewing the evidence, the court may not "undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]." Craig, 76 F.3d at 589; see also Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Accordingly, even if the court disagrees with the Commissioner's decision, the court must uphold it if it is supported by substantial evidence. Blalock, 483 F.2d at 775.
ISSUES
Williams raises the following issues for this judicial review:
I. The ALJ failed to properly consider Williams['s] medical condition pursuant to Social Security Ruling 03-02p[.](Pl.'s Br., ECF No. 15.)
II. The ALJ failed to properly assess medical source opinion evidence[.]
III. Evaluation of subjective symptomology of the Plaintiff[.]
DISCUSSION
The court notes that numerous social security regulations and social security rulings (SSRs) have changed effective March 27, 2017. However, these changes specifically state that they are applicable to claims filed on or after March 27, 2017. See, e.g., 20 C.F.R. §§ 404.1513, 404.1527. Because the instant claim was filed before that time, all references in the instant Report and Recommendation are to the prior versions of the regulations and SSRs in effect at the time Williams's application for benefits was filed, unless otherwise specified.
Although Williams raises several issues on appeal, for the reasons that follow the court finds that remand is required to properly consider and assess the medical source opinion evidence from Dr. John B. Bieltz. Specifically, upon careful review of the parties' arguments, the ALJ's decision as a whole, and the record, the court is simply unable to determine whether the ALJ's decision is supported by substantial evidence based on several of the errors identified by Williams on appeal.
The law applicable to Williams's application provides that regardless of the source, the Commissioner will evaluate every medical opinion received. 20 C.F.R. § 404.1527(c). Typically, the Social Security Administration accords greater weight to the opinion of treating medical sources because treating physicians are best able to provide "a detailed, longitudinal picture" of a claimant's alleged disability. See id. However, "the rule does not require that the testimony be given controlling weight." Hunter v. Sullivan, 993 F.2d 31, 35 (4th Cir. 1992) (per curiam). Instead, a treating physician's opinion is evaluated and weighed "pursuant to the following non-exclusive list: (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 v. Barnhart, 434 F.3d 650, 654 (4th Cir. 2005) (citing 20 C.F.R. § 404.1527). Any other factors that may support or contradict the opinion should also be considered. 20 C.F.R. § 404.1527(c)(6). In the face of "persuasive contrary evidence," the ALJ has the discretion to accord less than controlling weight to such an opinion. Mastro v. Apfel, 270 F.3d 171, 178 (4th Cir. 2001). Further, "if a physician's opinion is not supported by clinical evidence or if it is inconsistent with other substantial evidence, it should be accorded significantly less weight." Id. (quoting Craig, 76 F.3d at 590).
Upon review of the record and the parties' briefs, the court is unable to determine whether the ALJ's evaluation of this evidence is supported by substantial evidence. At issue are two opinions issued by Dr. Bieltz: one in January 2013 following a review of Williams's medical records and a consultative examination, and one in July 2015 after seeing Williams on three occasions that year. The ALJ summarized both of these opinions as follows:
In January 2013, John Bieltz, DO saw the claimant for evaluation at Thomson Orthopedics and Sports Medicine and diagnosed reflex sympathetic dystrophy of left elbow. He had full range of motion and good strength of right arm with no neurological deficits. His left wrist was in slightly flexed position with some contractures in fingers with stiffness/pain with movement. He was referred for pain management for possibly more aggressive blocks. Dr. B[ie]ltz stated from an
orthopedic standpoint, there was nothing that could be done. He recommended more aggressive physical medicine and rehabilitation and pain management. He opined the claimant was not able to return to any type of manual labor that required use of two arms. He could do sedentary work with the right upper extremity only. However, his pain levels were fairly high and would be hard to concentrate for significant time frame. He stated the claimant's impairment was not a ratable impairment (Exhibit 3F).(Tr. 24, 26.)
. . . .
In January 2015, the claimant returned to Dr. Bieltz, and was seen on three occasions through July 2015, and diagnosed with complex regional pain syndrome, atypical left shoulder pain and hypertension. He had history of three injection/blocks with no reported improvement in his pain. He had little use of his left arm and was on heavy pain medication that affected his concentration and ability to drive. In July 2015, Dr. Bieltz completed a medical source statement and diagnosed reflex sympathetic dystrophy/complex regional pain syndrome, type 1 with persistent complaints of pain. He reported symptoms including burning, aching, increased sensitivity to touch, joint stiffness, restricted mobility, muscle spasm, muscle pain, impaired sleep and chronic fatigue, all failed to respond to treatment. Dr. B[ie]ltz indicated problems with anxiety and side effects from medications including drowsiness, sedation and inability to concentrate. He stated the claimant could walk 2-3 city blocks. He could sit 2 hours at one time and 4 hours in an 8-hour workday; stand 2 hours at one time and about 2 hours in an 8-hour workday. He would need to alternate sitting, standing and walking, shift at will and required periods of walking around every 30 minutes and would need to take unscheduled breaks due to pain, paresthesia and numbness. He had no problems with prolonged sitting. He could lift/carry less than 10 pounds frequently, 10 pounds occasionally and should never lift or carry more than 20 pounds. The claimant could occasionally twist, bend or stoop and could rarely crouch or squat. He could use his right hand 100% of the time for grasping, turning, twisting objects, fine manipulation and reaching in front of or overhead, but could use his left hand 0% of the time. He stated the claimant would be off-task 25% or more of the time, and was incapable of even low stress work. He would have good days and bad days, and would likely be absent more than 4 days per month. Further, he must wear an arm sling, as he was unable to use the left arm for anything (Exhibit 16F).
Williams raises several issues with regard to the ALJ's evaluation of this opinion evidence that renders the court unable to determine whether it is supported by substantial evidence. First, in weighing the opinion evidence the ALJ fails to indicate what weight he gave to Dr. Bieltz's 2013 opinion. Additionally, in the paragraph weighing the opinion evidence the ALJ states, "I note none of the claimant's treating or examining physicians have offered any opinion regarding disability." (Tr. 31.) Clearly there are opinions from treating and examining physicians regarding Williams's limitations that, if accepted, may suggest he is entitled to disability benefits. To the extent this statement suggests otherwise, it does not appear to be supported. To the extent that the ALJ is indicating that no examining or treating physician specifically opined that Williams is disabled, it is unclear how this impacts the ALJ's evaluation of the opinion evidence because as the ALJ later acknowledges, the issue of whether the claimant is disabled is an issue that is reserved to the Commissioner. Finally, the ALJ discounts Dr. Bieltz's July 2015 opinion for several reasons. The Commissioner concedes Williams's argument that the first reason offered by the ALJ was erroneous. Specifically, the Commissioner concedes that the ALJ erred in finding that the opinion was internally inconsistent and therefore that reason was not a proper basis to discount the opinion. Although the ALJ offered several other reasons that appear to be supported by the record, the cumulative effect of the above errors warrants remand.
In summary, while the ALJ appears to offer several valid reasons to discount Dr. Bieltz's July 2015 opinion, there appear to be two unsupported reasons, and the ALJ fails to specifically assign any weight to Dr. Bieltz's first opinion. Accordingly, the court is unable to determine whether the ALJ's evaluation of the opinion evidence is supported by substantial evidence and meaningful review is frustrated. See 20 C.F.R. § 404.1527(c); Mascio v. Colvin, 780 F.3d 632, 636-37 (4th Cir. 2015) (holding remand may be appropriate when the courts are left to guess at how the ALJ arrived at the conclusions and meaningful review is frustrated); see also Monroe, 826 F.3d at 189 (remanding where the ALJ failed to "build an accurate and logical bridge from the evidence to his conclusion") (citation omitted); cf. Mastro, 270 F.3d at 178 (stating that "if a physician's opinion is not supported by clinical evidence or if it is inconsistent with other substantial evidence, it should be accorded significantly less weight") (internal quotation marks and citation omitted). Therefore, the court is constrained to recommend that this matter be remanded for further consideration of the opinion evidence.
The court expresses no opinion as to whether further consideration of the opinion evidence by the ALJ should necessarily lead to a finding that the opinion at issue is entitled to additional weight or that Williams is ultimately entitled to benefits. Further analysis and discussion may well not change the ALJ's conclusion on this point.
In light of the court's recommendation that this matter be remanded for further consideration, the court need not address Williams's remaining arguments, as they may be rendered moot on remand. See Boone v. Barnhart, 353 F.3d 203, 211 n.19 (3d Cir. 2003) (remanding on other grounds and declining to address claimant's additional arguments). Moreover, if necessary, Williams may present his remaining argument concerning the ALJ's alleged errors on remand.
RECOMMENDATION
Based on the foregoing, the court recommends that the Commissioner's decision be reversed pursuant to sentence four of 42 U.S.C. § 405(g) and that the case be remanded to the Commissioner for further consideration as discussed above. July 7, 2020
Columbia, South Carolina
/s/_________
Paige J. Gossett
UNITED STATES MAGISTRATE JUDGE
The parties' attention is directed to the important notice on the next page.
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).