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Carney v. Berryhill

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

March 7, 2018

STEPHANIE T. CARNEY, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          P. BRADLEY MURRAY UNITED STATES MAGISTRATE JUDGE.

         Plaintiff brings this action, pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security denying her claim for a period of disability and disability insurance benefits. 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. 23 & 24 (“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 reversed and remanded for further proceedings not inconsistent with this decision.[2]

         I. Procedural Background

         Plaintiff filed an application for a period of disability and disability insurance benefits on December 27, 2013, alleging disability beginning on September 30, 2013. (See Tr. 124-25.) Carney's claim was initially denied on March 6, 2014 (Tr. 73) and, following Plaintiff's April 3, 2014 request for a hearing before an Administrative Law Judge (“ALJ”) (see Tr. 82-83), a hearing was conducted before an ALJ on June 17, 2015 (Tr. 37-61). On December 24, 2015, the ALJ issued a decision finding that the claimant was not disabled and, therefore, not entitled to disability insurance benefits. (Tr. 21-33.) More specifically, the ALJ proceeded to the fourth step of the five-step sequential evaluation process and determined that Carney retains the residual functional capacity to perform a range of light work and her past relevant work as a caterer helper (Tr. 32; see also Tr. 30). On February 22, 2016, the Plaintiff appealed the ALJ's unfavorable decision to the Appeals Council (Tr. 15); the Appeals Council denied Carney's request for review on December 12, 2016 (Tr. 1-3). Thus, the hearing decision became the final decision of the Commissioner of Social Security.

         Plaintiff alleges disability due obesity, diabetes mellitus (type II), questionable history of fibromyalgia, questionable history of restless leg syndrome, hypertension, history of diabetic ketoacidosis, questionable history of acute sinusitis and bronchitis, and depression. The Administrative Law Judge (ALJ) made the following relevant findings:

2. The claimant has not engaged in substantial gainful activity since September 30, 2013, the alleged onset date (20 CFR 404.1571 et seq.).
The claimant has the following combinations of impairments that is severe (20 CFR 404.1520(c)):

         In application documents[, ] the claimant[, ] a forty-eight[-]year[-]old female with a general equivalent diploma (GED)[, ] initially alleged her ability to work is limited by diabetes, diabetic neuropathy, depression, leg pain, migraines, memory problem, blurred vision, pain in arms, and numbness. She reported her height as 5'5” and her weight as 171 pounds. She reported she stopped working on August 5, 2010, because the business closed; however, on September 30, 2013, she reported her conditions became severe enough to keep her from working.

         At the hearing[, ] when questioned by the undersigned[, ] the claimant testified she cannot perform any work activity that requires sitting because she can only sit for minutes at a time due to pain. She testified she has to stand up, walk around, and sometimes lay down. She testified she uses a heating pad for pain and cannot sit for hours at a time without severe pain from neuropathy and fibromyalgia. She testified she takes Neurontin three times a day, Tramadol for pain, and Celexa for depression and anxiety. She testified she has not worked since 2010 and she last worked at a dry cleaner.

         In regards to her diabetes mellitus type II, controlled with compliance, the claimant testified she was diagnosed with uncontrolled diabetes mellitus type II and she has painful neuropathy. The evidence does document[] a diagnosis if diabetes mellitus type II; however, when she presented to Meridian Medical Associates on December 19, 2013, it was noted her diabetes had been under good control. Although her examination indicated decreased pinprick and light touch in a stocking distribution, reflexes were depressed, but symmetrical, and Romberg's was slightly positive for swaying away. It further indicated she had normal gait and her cranial nerves were intact with 5/5 motor strength. She was assessed with painful peripheral neuropathy, possible element of restless leg syndrome, and history of diabetes. She was given a trial of Neurontin and it was recommended she follow up in a couple of months. The evidence indicates she returned to Meridian Medical Associates in February 2014 and reported the Neurontin was helping some, but [she] was still having pain when squatting. Her Neurontin was increased and it was recommended she follow up in three months.

         Although[] the claimant has been diagnosed with diabetes mellitus type II, the evidence documents several instances where her diabetes was controlled. Her physical examinations have been unremarkable and there is no evidence of cerebrovascular accidents, renal failure, polydipsia, or polyuria, generally associated with uncontrolled diabetes mellitus, which certainly suggests the impairment[] is well controlled. If the claimant were to remain compliant with all treatment recommendations, dietary modifications, exercise, and medications[, ] her diabetes would continue to be controlled. Therefore, the evidence does not show this impairment has significantly limited or is likely to significantly limit the claimant's ability to do basic work activities.

         In regards to her questionable history of fibromyalgia[, ] the evidence documents a diagnosis of fibromyalgia; however, there are no follow up appointments for this impairment. The evidence does not document any widespread pain in the joints, muscles, tendons, or nearby soft tissues associated with fibromyalgia. Nor does the evidence document at least 11 positive tender points found bilaterally both above and below the waist. Furthermore, there are no objective tests or signs to confirm the severity of any observable problem of fibromyalgia. Therefore, the evidence does not document any objective findings for this impairment nor does it show this impairment has significantly limited or is likely to significantly limit the claimant's ability to do basic work activities.

         In regards to her history of diabetic ketoacidosis, acute, the evidence documents [that] she presented to The Clinic PC on March 30, 2015, with complaints of vomiting, sweating, and fatigue[]. Her examination indicated she was well appearing, well-nourished [and] in no distress. She was oriented times three and her mood and affect was normal. Examination of her abdomen and extremities w[as] unremarkable; however, it was noted since she has [had] ketoacidosis before it was recommended she go to the emergency room, but she refused. She was encouraged to continue her current medication[s] and dietary modification[s]. Approximately[] a month later[, ] on April 26, 2015, she presented to Anderson Regional Medical Hospital and was admitted for diabetic ketoacidosis. It was noted she was vomiting and severely dehydrated; therefore, she was placed in intensive care and started on normal saline and an insulin drip. Within two days she was gradually weaned off the insulin drip and became stable enough to be discharged. She was discharged in stable condition with instructions to follow up with her treating physician in a week. She followed up at The Clinic PC on June 10, 2015, and her examination was unremarkable. She was assessed with fatigue, pain in back, depression, and anxiety.

         With her questionable history of acute sinusitis and bronchitis, the evidence documents she presented to The Clinic PC in January 2013 with complaints of a sore throat, bilateral ear pain, weakness/fatigue, hurting all over, neck pain, and cough. Her examination indicated her lungs were clear and her eyes, ears, nose, and throat were normal. She was assessed with sinusitis, acute[, ] and treated with medication []. She returned in October 2013 with a sore throat and again she was diagnosed with sinusitis, acute. On April 22, 2015, she returned to The Clinic PC reporting cough and congestion and hurting in her chest at times. She reported chronic leg pain and headaches. Her physical examination indicated she was well appearing, well-nourished [and] in no acute distress. She was oriented times three with normal mood and affect. Her lungs were clear to auscultation and percussion and her extremities did not exhibit any deformities, cyanosis, or edema. She was assessed with acute sinusitis, acute bronchitis, pain in back, and depression. There is nothing to show the claimant required any medications on a continuous basis or corticosteroids for this impairment. Furthermore, there is no indication the claimant's acute sinusitis and bronchitis caused long-term complications such as severe shortness of breath, chronic obstructive pulmonary disease, or respiratory failure.

         In making this finding, the undersigned has considered the four broad functional areas set out in the disability regulations for evaluating mental disorders and in section 12.00C of the Listing of Impairments. These four broad functional areas are known as the “paragraph B” criteria.

         The next functional area is social functioning. In this area, the claimant has no limitation. The claimant can communicate clearly, demonstrate cooperative behaviors, initiate and sustain social contacts and participate in group activities.

         The fourth functional area is episodes of decompensation. In this area, the claimant has experienced no episodes of decompensation which have been of extended duration.

         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 broad categories found in paragraph B of the adult mental disorders listings in 12.00 of the Listing of Impairments. Therefore, the following residual ...


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