United States District Court, D. South Carolina
V. Hodges United States Magistrate Judge
appeal from a denial of social security benefits is before
the court for a final order pursuant to 28 U.S.C. §
636(c), Local Civ. Rule 73.01(B) (D.S.C.), and the order of
the Honorable Margaret B. Seymour dated April 28, 2016,
referring this matter for disposition. [ECF No. 6]. The
parties consented to the undersigned United States Magistrate
Judge's disposition of this case, with any appeal
directly to the Fourth Circuit Court of Appeals. [ECF No. 5].
files this appeal pursuant to 42 U.S.C. § 405(g) of the
Social Security Act (“the Act”) to obtain
judicial review of the final decision of the Commissioner of
Social Security (“Commissioner”) denying the
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 she applied the proper legal
standards. For the reasons that follow, the court reverses
and remands the Commissioner's decision for further
proceedings as set forth herein.
November 13, 2012, Plaintiff protectively filed an
application for DIB in which he alleged his disability began
on April 8, 2008. Tr. at 63 and 131-36. His application was
denied initially and upon reconsideration. Tr. at 85-88 and
90-95. On April 1, 2015, Plaintiff had a hearing before
Administrative Law Judge (“ALJ”) Ann G. Paschall.
Tr. at 29-49 (Hr'g Tr.). The ALJ issued an unfavorable
decision on June 9, 2015, finding that Plaintiff was not
disabled within the meaning of the Act. Tr. at 8-28.
Subsequently, the Appeals Council denied Plaintiff's
request for review, making the ALJ's decision the final
decision of the Commissioner for purposes of judicial review.
Tr. at 1-6. Thereafter, Plaintiff brought this action seeking
judicial review of the Commissioner's decision in a
complaint filed on April 25, 2016. [ECF No. 1].
Plaintiff's Background and Medical History
was 59 years old at the time of the hearing. Tr. at 34. He
completed the second grade. Tr. at 148. His past relevant
work (“PRW”) was as a weaver. Tr. at 47. He
alleges he has been unable to work since April 8, 2008. Tr.
presented to Benjamin C. Pinner, M.D. (“Dr.
Pinner”), for evaluation of hypothyroidism,
hypertension, and hyperlipidemia on January 28, 2008. Tr. at
287. Dr. Pinner indicated Plaintiff's hypothyroidism was
controlled with Synthroid and his hypertension was controlled
by diet. Id. He stated Plaintiff's cholesterol
was not at its goal. Id.
February 18, 2008, Plaintiff reported moderate pain after
sustaining an on-the-job injury to his right fourth toe. Tr.
at 284. Dr. Pinner diagnosed an ulcer, prescribed Lortab and
a 10-day course of Doxycycline, gave Plaintiff a work excuse,
and instructed him to return in four days. Tr. at 285-86. On,
February 28, 2008, Dr. Pinner observed Plaintiff to have a
small ulceration medially and erythema extending proximally
to the base of the toe. Tr. at 278. He prescribed a four-day
course of Doxycycline. Id.
complained of dizziness and tinnitus on February 19, 2009.
Tr. at 273 and 274. Dr. Pinner observed no abnormalities on
examination. Tr. at 274-75. He prescribed Antivert for
vertigo, Synthroid for hypothyroidism, Lisinopril for
hypertension, and Prilosec for gastroesophageal reflux
disease (“GERD”). Tr. at 275-76.
followed up for hypertension, hypothyroidism, and GERD on
July 12, 2010. Tr. at 269. He complained of back pain. Tr. at
270. A physical examination was unremarkable. Tr. at 270-71.
Dr. Pinner recommended Plaintiff restart Synthroid for
hypothyroidism. Tr. at 271. He prescribed Triamterene-HCTZ
for hypertension and Omeprazole for GERD. Id.
September 13, 2010, Plaintiff reported chest pain and
cramping in his lower back and leg. Tr. at 267. Dr. Pinner
observed Plaintiff to have some lower paraspinal muscle
tenderness. Tr. at 268. He stated he suspected
Plaintiff's cramping pain may be a side effect of his
blood pressure medication. Id. He discontinued
Triamterene-HCTZ and prescribed Procardia XL. Id.
followed up with Dr. Pinner regarding hypertension and
hypothyroidism on September 15, 2011. Tr. at 261. A physical
examination was unremarkable. Tr. at 261-62. However, Dr.
Pinner reduced Plaintiff's dosage of Synthroid after
reviewing lab test results. Tr. at 260.
December 19, 2011, Plaintiff complained of chest pain that
radiated to his back and worsening hypertension. Tr. at 258.
He reported fatigue and dyspnea. Id. Dr. Pinner
indicated Plaintiff's symptoms sounded musculoskeletal,
but he encouraged Plaintiff to schedule calcium scoring
because of his risk factors for coronary artery disease. Tr.
at 259. A chest x-ray showed Plaintiff to have poor
inspiration, but was otherwise normal. Id. An
electrocardiogram (“EKG”) was also normal.
Id. Lab tests indicated Plaintiff's thyroid
medication was working properly. Id.
August 21, 2012, Plaintiff complained that his hypertension
was worsening and had caused him to experience headaches and
chest pain. Tr. at 253. He reported his energy had decreased
over the prior three-month period and that he had felt more
anxious. Id. He complained of paresthesias.
Id. Dr. Pinner described Plaintiff as having an
anxious mood and affect, but noted no other abnormalities on
examination. Tr. at 253- 54. He prescribed Xanax to be taken
as needed and changed Plaintiff's hypertension medication
from Procardia to Exforge. Tr. at 254.
presented to Dr. Pinner on September 17, 2012, for
hypertension and associated headache. Tr. at 251. Dr. Pinner
noted no abnormalities on examination. Tr. at 251-52. He
encouraged Plaintiff to work on reducing his weight to
control his blood pressure and cholesterol. Tr. at 252.
April 8, 2013, Plaintiff followed up for hypertension and
hypothyroidism. Tr. at 321. He reported a sore throat,
increasing fatigue, and generalized muscle aches.
Id. Dr. Pinner noted no abnormalities on
examination. Tr. at 321-22.
April 29, 2013, an x-ray of Plaintiff's right knee showed
a small joint effusion and mild degenerative changes of the
medial and patellofemoral compartments. Tr. at 300. An x-ray
of his left knee indicated minimal degenerative change of the
medial knee joint compartment. Tr. at 302. An x-ray of
Plaintiff's back showed mild disc degenerative changes at
the T12-L1 and L5-S1 levels. Tr. at 301.
presented to Branham Tomarchio, M.D. (“Dr.
Tomarchio”), for a consultative examination on May 18,
2013. Tr. at 304-09. Plaintiff described chronic pain in his
lumbar spine that was associated with some numbness and
weakness in his lower extremities and burning in his legs.
Tr. at 306. He also endorsed some pain in his knees and neck.
Id. He reported abilities to dress and feed himself;
to stand for 30 minutes at a time; to walk for two miles; to
sit for 30 minutes; to lift 50 pounds; and to engage in
activities of daily living (“ADLs”) that included
driving, sweeping, mopping, vacuuming, washing dishes,
shopping, climbing stairs, and mowing grass. Id. Dr.
Tomarchio observed Plaintiff to ambulate from the office into
the examination room; to shake his hand with a firm grip; to
sit in the interview chair without difficulty; to rise to
move to the examination chair without difficulty; and to hear
and speak normally. Tr. at 308. He noted Plaintiff's
spine showed no evidence of deformity and was not tender to
palpation. Id. Plaintiff's extremities showed no
evidence of edema, cyanosis, or clubbing. Id. His
joints demonstrated no redness, swelling, or effusion.
Id. He had 5/5 grip strength bilaterally.
Id. Plaintiff demonstrated normal fine and gross
manipulative skills. Id. He had normal range of
motion (“ROM”) throughout his spine and
extremities. Id. He was able to walk and squat
without difficulty. Id. Plaintiff had normal motor
strength and reflexes and his muscles showed no atrophy.
Id. Dr. Tomarchio assessed chronic back pain, but
indicated Plaintiff had “no objective evidence of
significant functional capacity deficit.” Tr. at 309.
agency consultant Debra C. Price, Ph. D. (“Dr.
Price”), reviewed the evidence and completed a
psychiatric review technique form (“PRTF”) on
June 4, 2013. Tr. at 56-57. She considered Listings 12.02 for
organic mental disorders and 12.06 for anxiety-related
disorders and found that Plaintiff had mild restriction of
ADLs and difficulties in maintaining social functioning;
moderate difficulties in maintaining concentration,
persistence, or pace; and no episodes of decompensation that
were of extended duration. Id. Dr. Price found that
Plaintiff was moderately limited in his abilities to
understand, remember, and carry out detailed instructions; to
maintain attention and concentration for extended periods; 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. Tr. at 58-60. She stated Plaintiff's
symptoms and impairments were severe, “but would not
preclude the performance of simple, repetitive work
tasks.” Tr. at 60. She indicated Plaintiff could
understand and remember simple instructions; carry out short
and simple instructions; maintain concentration and attention
for at least two hours; respond appropriately to coworkers,
supervisors, and the general public; and be aware of normal
hazards and take appropriate precautions. Id.
25, 2013, Plaintiff complained of a gradual onset of fatigue
that had been occurring in a persistent pattern for months.
Tr. at 317. He reported generalized muscle aches and pain in
his bilateral knees and lower back. Id. Dr. Pinner
observed Plaintiff to be anxious; to be tender to palpation
over his left sacroiliac joint; and to have a coarse right
knee. Tr. at 318. He prescribed Diclofenac Sodium for pain
and Cymbalta for mood. Id. He recommended Plaintiff
avoid exposure to the sun. Id.
reported weight gain, fatigue, and dry skin on August 26,
2013. Tr. at 335. Dr. Pinner noted no abnormal findings on
examination. Tr. at 335-36. He discontinued Diclofenac Sodium
and prescribed Feldene for osteoarthritis in Plaintiff's
knee. Tr. at 336. He increased Plaintiff's dosage of
Cymbalta from 30 to 60 milligrams and refilled his
prescriptions for Exforge and Synthroid. Id.
October 14, 2014, Plaintiff complained of hypertension, pain
in his shoulders and knee, and depression. Tr. at 356. Dr.
Pinner noted no abnormalities on examination. Tr. at 357. He
diagnosed shoulder bursitis. Id. He refilled
Plaintiff's prescription for Hydrocodone and indicated he
could take the medication up to four times a day.
reported anxiety that was accompanied by insomnia and sleep
disturbance on March 5, 2015. Tr. at 352. He complained of
pain in his left shoulder that was radiating toward his upper
back. Id. Dr. Pinner observed Plaintiff to have
reduced ROM in his bilateral shoulders. Tr. at 353.
Chapman of the Newberry County Adult Literacy Council drafted
a letter on January 8, 2013, that indicated Plaintiff was
enrolled in an Adult Basic Reading class from May 5, 2009,
through February 2, 2012. Tr. at 166. She stated Plaintiff
was able to increase his reading level from a first to a
second grade level with one-and-a-half hours of one-on-one
tutoring per week. Id.
administered on January 14, 2013, showed Plaintiff to be
reading on a third grade level. Tr. at 170.
March 24, 2014, Robert V. Shea, Jr., indicated in a sworn
statement that he had served as a volunteer with the Newberry
Literacy Society and had worked with Plaintiff during one to
two hour sessions that took place twice a week for a period
of six months to a year. Tr. at 223. He stated Plaintiff had
difficulty learning words and recognizing known words in
sentences. Id. He noted Plaintiff put forth good
effort, but had a limited aptitude. Id. He stated
Plaintiff's reading and writing skills were so limited
that he would consider him illiterate. Tr. at 223-24.
Plaintiff's Testimony At the hearing on April 1, 2015,
Plaintiff testified he was in special education classes and
withdrew from school at the age of 15. Tr. at 34. He stated
he attended a literacy class as an adult, but remained unable
to read. Tr. at 35. He indicated he had obtained a
driver's license because the test was administered
testified he started working at American Fiber and Finishing
when he was 16 years old. Tr. at 36. He indicated he worked
as a weaver because his reading problems did not prevent him
from performing the job. Id. He stated his employer
closed down. Id. He indicated he had some physical
problems performing his job before the job ended. Tr. at 37.
He stated he looked for other work, but denied having worked
anywhere since April 4, 2008. Id.
testified he experienced pain in his knees, lower back, and
shoulders. Tr. at 37. He indicated his back pain was
exacerbated by bending and standing for too long. Tr. at 38.
He stated he could walk for 15 minutes before he needed to
stop and rest. Id. He indicated he could stand for
less than 15 minutes at a time. Id. He testified he
was unable to sit for a long period, but admitted that he had
sat in the car for ...