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Zanders v. Berryhill

United States District Court, S.D. Alabama, Northern Division

August 28, 2017

TANYA M. ZANDERS, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff brings this action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of a final decision of the Commissioner of Social Security denying her claims for a period of disability, disability insurance benefits, and supplemental security income. The parties have consented to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28 U.S.C. § 636(c), for all proceedings in this Court. (Doc. 21 (“In accordance with provisions of 28 U.S.C. §636(c) and Fed.R.Civ.P. 73, the parties in this case consent to have a United States magistrate judge conduct any and all proceedings in this case, . . . order the entry of a final judgment, and conduct all post-judgment proceedings.”); see also Doc. 23 (endorsed order of reference)). Upon consideration of the administrative record, Plaintiff's brief, and the Commissioner's brief, [1] it is determined that the Commissioner's decision denying benefits should be affirmed.[2]

         I. Procedural Background

         Plaintiff filed an application for a period of disability and disability insurance benefits on November 6, 2012 and protectively filed an application for supplemental security income benefits on November 27, 2012, both applications alleging disability beginning on May 30, 2009. (See Tr. 288-300.) Zanders' claims were initially denied on February 21, 2013 (Tr. 145-46 & 178-82) and, following Plaintiff's electronic request for a hearing before an Administrative Law Judge (“ALJ”) (see Tr. 183-84), a hearing was conducted before an ALJ on February 9, 2015 (Tr. 112-32). During the hearing, Zanders amended her disability onset date to November 5, 2012. (Compare Tr. 115 with Tr. 95 (“During the hearing, the claimant amended her alleged onset date of disability to November 5, 2012. This motion is granted.”)). On March 11, 2015, the ALJ issued a decision finding that the claimant was not disabled and, therefore, not entitled to any social security benefits. (Tr. 95-106). More specifically, the ALJ concluded that Zanders retains the residual functional capacity to perform a limited range of light work and, further, that in light of her residual functional capacity, she can perform her past relevant work as a fusing machine tender and a hand packager. (See Id. at 100-04; compare Id. with Tr. 129-30 (vocational expert's hearing testimony that based on the hypothetical posed, consistent with the ALJ's ultimate RFC determination, the claimant would be capable of performing her past relevant work as a fuser and hand packager)). On May 7, 2015, the Plaintiff appealed the ALJ's unfavorable decision to the Appeals Council (Tr. 89-91) and, the Appeals Council denied Zanders' request for review on August 30, 2016 (Tr. 1-4).[3] Thus, the hearing decision became the final decision of the Commissioner of Social Security.

         Plaintiff alleges disability due to anxiety, depression, paranoia, obesity, high blood pressure, headaches, back pain, hand pain, knee pain, foot pain, elbow pain, and medication side effects. The ALJ made the following relevant findings:

1. The claimant meets the insured status requirements of the Social Security Act through December 31, 2015.
2. The claimant has not engaged in substantial gainful activity since November 5, 2012, the amended onset date (20 CFR 404.1571 et seq., and 416.971 et seq.).
3. The claimant has the following severe impairments: depression, anxiety, Raynaud's syndrome, and obesity (20 CFR 404.1520(c) and 416.920(c)).
. . .
4. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926).
. . .
The severity of the claimant's mental impairments, considered singly and in combination, do not meet or medically equal the criteria of listings 12.04 and 12.06. In making this finding, the undersigned has considered whether the “paragraph B” criteria are satisfied. To satisfy the “paragraph B” criteria, the mental impairments must result in at least two of the following: marked restriction of activities of daily living; marked difficulties in maintaining social functioning; marked difficulties in maintaining concentration, persistence, or pace; or repeated episodes of decompensation, each of extended duration. A marked limitation means more than moderate but less than extreme. Repeated episodes of decompensation, each of extended duration, means three episodes within 1 year, or an average of once every four months, each lasting for at least 2 weeks.
In activities of daily living, the claimant has mild restriction. During the psychological assessment under Dr. Tocci, the claimant had an appropriate appearance. She also independently bathed and dressed herself, feed herself, used the toilet, prepared meals, performed household chores, cared for her children, drove a car, shopped in stores, attended church, managed her own finances, read the Bible, and played volleyball. Thus, the claimant demonstrated the mental ability to initiate, sustain, and complete activities independent of direction or supervision. While the claimant's impairments may interfere with complex activities, the claimant's performance of a simple routine remained appropriate, effective and sustainable.
In social functioning, the claimant has moderate difficulties. The claimant demonstrated cooperative behavior, normal speech, good eye contact, and responsive facial expressions during her assessment with Dr. Tocci, even though her mood was “gloomy”. She also displayed a pleasant and cooperative behavior during her assessments with Dr. Travis. The claimant further interacted with her children, regularly attended church, and shopped in stores. Thus, the undersigned determined she has retained the ability to communicate clearly, demonstrate cooperative behaviors, and sustain some social contact with others, based upon the preponderance of the evidence.
With regard to concentration, persistence or pace, the claimant has moderate difficulties. The claimant did incorrectly calculate change during the examination with Dr. Tocci. However, her orientation, concentration/attention, memory, fund of information, abstract thinking, thought processes, and insight/judgment remained intact. She also demonstrated having average intelligence. During treatment records, she denied problems with attention and concentration. Therefore, given such evidence, the undersigned determined the claimant could sustain the focus, attention, and concentration necessary to permit the timely and appropriate completion of tasks commonly found in routine and repetitive, not detailed or complex, work settings.
As for the episodes of decompensation, the claimant has experienced no episodes of decompensation, which have been of extended duration. The record revealed no extended psychiatric hospitalizations or frequent altering of psychotropic medications during this period of adjudication. Thus, there was no loss of adaptive functioning manifested by the claimant's inability to perform activities of daily living, maintain social relationships, or maintain concentration, persistence, or pace. Therefore, the undersigned determined the claimant has not had any episodes of decompensation within one year, or an average of once every four months, each lasting for at least 2 weeks, to support this functional limitation.
The above finding[s] are supported by the opinion of the state agency medical consultant, whose opinion is supported by the record and is entitled to great weight.
. . .
The limitations identified in the “paragraph B” criteria are not a residual functional capacity assessment but are used to rate the severity of mental impairments at steps 2 and 3 of the sequential evaluation process. The mental residual functional capacity assessment used at steps 4 and 5 of the sequential evaluation process requires a more detailed assessment by itemizing various functions contained in the broad categories found in paragraph B of the adult mental disorders listings in 12.00 of the Listing of Impairments. Therefore, the following residual functional capacity assessment reflects the degree of limitation the undersigned has found in the “paragraph B” mental function analysis.
5. After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b). The claimant cannot climb ladders, ropes or scaffolds. She cannot kneel, crouch or crawl. She should avoid all exposure to cold, unprotected heights and hazardous machinery. The claimant can perform simple, routine and repetitive tasks involving simple work related decisions with few, if any, work place changes. She should avoid all direct contact with the general public. Work can be around co-workers but with only occasional interaction with co-workers.
In making this finding, the undersigned has considered all symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence, based on the requirements of 20 CFR 404.1529 and 416.929 and SSRs 96-4p and 96-7p. The undersigned has also considered opinion evidence in accordance with the requirements of 20 CFR 404.1527 and 416.927 and SSRs 96-2p, 96-5p, 96-6p and 06-3p.
In considering the claimant's symptoms, the undersigned must follow a two-step process in which it must first be determined whether there is an underlying medically determinable physical or mental impairment(s)-i.e., an impairment(s) that can be shown by medically acceptable clinical and laboratory diagnostic techniques-that could reasonably be expected to produce the claimant's pain or other symptoms.
Second, once an underlying physical or mental impairment(s) that could reasonably be expected to produce the claimant's pain or other symptoms has been shown, the undersigned must evaluate the intensity, persistence, and limiting effects of the claimant's symptoms to determine the extent to which they limit the claimant's functioning. For this purpose, whenever statements about the intensity, persistence, or functionally limiting effects of pain or other symptoms are not substantiated by objective medical evidence, the undersigned must make a finding on the credibility of the statements based on a consideration of the entire case record.
. . .
The claimant alleged back pain, Raynaud's syndrome, and depression have continued to affect her ability to work. She stated her constant and severe (an 8 on a 10 point scale) back pain was the most limiting impairment. She claimed the onset of her back pain occurred in 2009. She reported a 3 to 4 year history of radiation of the pain into and numbness of the left leg. In addition, the claimant testified that Raynaud's syndrome has affected both of her hands ramping[] pain and an inability to extend her right ring finger; these symptoms have been present for the past 5 to 6 years. She also testified that she has problems with gripping things over the last five to six months, along with an inability to open jars. The claimant stated she has had an 8 to 9 year history of daily numbness in her feet; she attributed this symptom [] to Raynaud's syndrome. Furthermore, the claimant testified that she has been depressed for [the] last six to seven years. She stated her mental symptoms consisted of social isolation, avoidance of public places, fear of driving, crying episodes, hearing voices (for four to five years occurring three to four times per week), and sleep difficulties (sleeping a total of four to five hours per day). She stated her sleep problems stemmed from her physical allegations and the need to check on her autistic son at night. The claimant testified that she has taken medications for anxiety and depression, and she admitted that these medications have helped her symptoms “a lot.”
As to limitations, the claimant testified that she has been limited to lifting a gallon of milk for the last four years. She also alleged she could only walk 15 minutes and sit 15 to 20 minutes.
The claimant testified that she lived in a trailer with her three children, the youngest child being six years old. On a typical day, she testified to doing the following activities: waking up, getting the kids up for school, driving/dropping the kids off at school, going back home, cleaning the kitchen and doing the dishes, reading the Bible for 10 to 15 minutes, and crying while thinking upon things from her past. She claimed her sister did her hair, because she experienced elbow pain. She reported her mother and grandmother often prepared meals. She, however, admitted she cooked chicken and rice on the Friday prior to the hearing. The claimant testified that she shopped once per week (in the mornings to avoid people), washed light dishes, and washed/ironed clothes. She claimed her daughter primarily swept, mopped, and vacuumed. She alleged she last swept/mopped one year ago (2014). The claimant testified that she attended a two-hour church service every Sunday and Bible study on Wednesdays, once or twice each month. The claimant also stated she attended choir practice on a Saturday each month and sang in the choir once per month. She reported she has attended the same church since she was five or six years old, and she stated that she has felt confortable around the church members.
At the outset, the claimant's routine daily activities are consistent with the residual functional capacity. The claimant admitted to living with and being the primary caretaker of her minor children. She stated she prepared their meals, provided them with clean clothes, played with them, and drove them to school. She also performed light household chores, including washing dishes, cleaning the kitchen, making the beds, washing clothes, and cleaning the bathroom. She even admitted that she shopped in stores, read the Bible, for 10 to 15 minutes, counted change, handled a savings account, used a checkbook, played volleyball, walked, and traveled. The claimant also socialized amongst others while attending two-hour church services every Sunday and Bible study on[c]e or twice per month. She further completed a disability form by understanding and concentrating on each question and recalling situations before providing the appropriate answers. Overall, these daily activities suggested the claimant could sustain work within the realms of the residual functional capacity. Thus, such evidence undermined the claimant's assertion of not being able to work entirely.
Pursuant to Social Security Ruling 02-1p, the undersigned did consider the physical effects of obesity and its potential to contribute to musculoskeletal, respiratory, and cardiovascular impairments. However, the record reflected no[] significant deficits compromising the claimant's body systems or her ability to work. She weighed 178 pounds at 64 inches with a body mass index of 30.55. Although the treating physician, Dr. Travis, noted right elbow tenderness on examination, the claimant maintained a full range of motion of all joints with good muscle mass (bilaterally) and no signs of atrophy or deformities. Thus, such evidence did not substantiate the claimant's debilitating back pain radiating to her left leg, in which Dr. Travis only prescribed a non-narcotic medication, Tramadol, for pain relief. The claimant also did not provide testimony regarding any knee complaints, and Dr. Travis' examination did not support this allegation either. The claimant's heart had a regular rate and rhythm, and her lungs remained clear to auscultation and percussion. The record essentially reflected no evidence of residuals from hypertension, including no stroke or any cardiovascular-related events. There were also no recurring crises or advancing organ damage related to uncontrolled blood pressure. In fact, the claimant's hypertension warranted only conservative treatment with medication. Hence, the record suggested obesity has not eliminated the claimant's ability to perform routine movement and necessary physical activities within a light work environment with the above-noted limitations addressed in the residual functional capacity. Thus, the residual functional capacity stated herein would accommodate the claimant's obesity, in spite of her physical allegations.
Given the claimant's allegations of bilateral hand numbness, the record reflected no clear interpretation of the electromyogram and nerve conduction studies. Dr. Ubogu provided no summarization of his findings to substantiate carpal tunnel syndrome or neuropathy occurring in the claimant's bilateral hands. Thus, there was essentially no evidence to warrant manipulative limitations or signs of atrophy. In fact, Dr. Ubogu noted the claimant had no neurological diagnosis. An examination revealed negative Tinel's sign and no sensory deficits [and] full range of motion. Examinations have shown full range of motion of all joints, all muscles functioning well and no atrophy. Thus, there is no medically determinable impairment due to carpal tunnel syndrome or numbness of the hands.
Although the claimant alleged she has exhibited crying spells, hearing voices, self-isolation, anxiety, and a depressed mood, she testified to having good outcomes with psychotropic medications. She stated her medications have “helped a lot”. Treatment records support this testimony. In November 2014, the claimant noted that she was less depressed and less anxious and she was doing “OK” with medication. A mental status examination by the claimant's mental health counselor also reflects the claimant's appropriate appearance, adequate affect/mood, calm motor activity, adequate judgment and insight, and normal thoughts with no deficits in orientation or speech. There was also no evidence or mention of any hallucinations during the examination. In fact, the claimant denied having any psychological problems when she later visited Dr. Travis. She also presented a pleasant and cooperative demeanor with good hygiene. The above evidence implied the claimant's medication regiment was effective at controlling her mental symptoms. She has denied ...

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