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Ward v. Berryhill

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

September 6, 2017

BERNAL WARD, 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. (Docs. 17 & 18 (“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.”)). 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 October 31, 2013, and that same day filed an application for supplemental security income. Both applications alleged disability beginning on June 5, 2013. (See Tr. 131-43). Ward's claims were initially denied on January 24, 2014 (Tr. 79-85) and, following Plaintiff's written request for a hearing before an Administrative Law Judge (“ALJ”) (see Tr. 86), a hearing was conducted before an ALJ on February 25, 2015 (Tr. 39-62). On July 13, 2015, the ALJ issued a decision finding that the claimant was not disabled and, therefore, not entitled to a period of disability and disability insurance benefits. (Tr. 23-32). More specifically, the ALJ concluded that Ward retains the residual functional capacity to perform a limited range of light work and, therefore, is capable of performing those jobs identified by the vocational expert (“VE”) during the administrative hearing. (See Id. at 27-32; compare Id. with Tr. 56-60 (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 those light jobs identified)). On August 25, 2015, the Plaintiff appealed the ALJ's unfavorable decision to the Appeals Council (Tr. 16-19) and, the Appeals Council denied Ward's request for review on October 27, 2016 (Tr. 1-3). In the decision denying review, the Appeals Council clearly indicated that it was denying Plaintiff's claims for both disability insurance benefits and supplemental security income (see Id. at 3). Thus, the hearing decision became the final decision of the Commissioner of Social Security.

         Plaintiff alleges disability due to chronic congestive heart failure, cardiomyopathy, hypertension, cervical disc protrusion, lumbago, osteoarthritis, fibromyalgia, headaches, obesity, depression, and anxiety. The ALJ made the following relevant findings:

1. The claimant meets the insured status requirements of the Social Security Act through December 31, 2017.
2. The claimant has not engaged in substantial gainful activity since June 5, 2013, the alleged onset date (20 CFR 404.1571 et seq.).
3. The claimant has the following severe impairments: chronic systolic congestive heart failure, cardiomyopathy, hypertension, cervical disc protrusion, lumbago, osteoarthritis, fibromyalgia, headache, obesity, depression and anxiety (20 CFR 404.1520(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 and 404.1526).
. . .
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. The claimant provides care and supervision for a minor child. She cares for her personal needs without assistance. The claimant prepares frozen dinners and sandwiches. She does laundry, irons, and [performs] household chores over the course of 2-3 days. The claimant drives, and shops for food, clothing, and household necessities once per month.
In social functioning, the claimant has mild difficulties. The claimant spends time with her family and attends church services weekly.
With regard to concentration, persistence or pace, the claimant has moderate difficulties. The claimant can maintain a household budget by paying bills and handling a savings account, checkbook, or money orders. She reported difficulty completing tasks, but states she could follow written and spoken instructions “good”. Notes from Cahaba Mental Health Center in 2014 showed treatment for depression and anxiety. She denied side effects due to her medications. The claimant indicated she was taking 16 hours of classes, and had stable mood.
As for the episodes of decompensation, the claimant has experienced no episodes of decompensation, which have been of extended duration. The claimant has not required inpatient care due to a psychiatric impairment.
Because the claimant's mental impairments do not cause at least two “marked” limitations or one “marked” limitation and “repeated” episodes of decompensation, each of extended duration, the “paragraph B” criteria are not satisfied.
. . .
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) except the claimant can occasionally operate hand and foot controls with the left upper and lower extremities, and occasionally reach overhead with the left upper extremity. She can occasionally climb ramps and stairs, but never climb ladders and scaffolds. The claimant can occasionally stoop, kneel, crouch and crawl. She should never work at unprotected heights or with moving mechanical parts. She is limited to simple tasks, and can tolerate few gradually introduced changes in a routine work setting. The claimant can tolerate ordinary work pressures, but should avoid excessive workloads, rapid changes, and multiple demands.
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 SSRs 96-4p and 96-7p. The undersigned has also considered opinion evidence in accordance with the requirements of 20 CFR 404.1527 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 testified that she stopped working in June 2013, and withdrew from school in September 2014 due to fibromyalgia. She reported pain in the neck, back and arms, and rated the pain an 8 on a scale of 0-10. The claimant described low back pain that radiates down the left leg. She can walk for 100 feet, stand for 15-20 minutes, and sit for 20-30 minutes. The claimant lies down for 3-4 hours each day. Her medications cause drowsiness. The claimant reported panic attacks that last three minutes, and depressive symptoms. She described chest pain that radiates down the left arm, and numbness in her legs. The claimant does household chores and shops for groceries with her children. She prepares sandwiches or microwave meals.
The longitudinal medical evidence of record does not fully support the claimant's allegation of disability. Magnetic resonance imaging (MRI) of the lumbar spine in September 2012 did not show degenerative disc disease or neural impingement. Nerve conduction studies (NCS) of the bilateral lower extremities were normal. Physical exam in March 2013 by Dr. Ronnie Chu showed normal gait and station. The claimant moved all extremities well, and had full range of motion. She was treated with Flexeril and Toradol for pain. The claimant was diagnosed with lumbago, and referred to physical therapy. In July 2013, Dr. Chu indicated the claimant's back pain was not improving with physical therapy. MRI of the cervical, thoracic, and lumbar spine in July 2013 was normal.
Records from Dr. Hector Caballero in February 2013 indicated that the claimant's headaches were partially controlled with Cymbalta. She also reported back pain that radiated into the lower extremities, but there was no objective evidence of lumbosacral stenosis or radiculopathy. ...

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