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Pinckney v. Berryhill

United States District Court, D. South Carolina

June 22, 2017

Katrina Tonecia Pinckney, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security, Defendant.


          Richard Mark Gergel, United States District Judge

         Plaintiff has brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the final decision of the Commissioner of Social Security denying her claim for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). In accordance with 28 U.S.C. § 636(b) and Local Civil Rule 73.02 DSC, this matter was referred to a United States Magistrate Judge for pre-trial handling. The Magistrate Judge issued a Report and Recommendation ("R & R") on June 2, 2017, recommending that the Commissioner's decision be affirmed. (Dkt. No. 19). Plaintiff filed objections to the R & R and the Commissioner filed a response. (Dkt. No. 21, 22). As explained below, the Court reverses the decision of the Commissioner and remands the matter to the agency for further action consistent with this order.

         Legal Standard

         The Magistrate Judge makes only a recommendation to this Court. The recommendation has no presumptive weight, and the responsibility to make a final determination remains with the Court. Mathews v. Weber, 423 U.S. 261 (1976). The Court is charged with making a de novo determination of those portions of the Report and Recommendation to which specific objection is made. The Court may accept, reject, or modify, in whole or in part, the recommendation of the Magistrate Judge. 28 U.S.C. § 636(b)(1).

         The role of the federal judiciary in the administrative scheme established by the Social Security Act is a limited one. The Act provides that the "findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive." 42 U.S.C. § 405(g). "Substantial evidence has been defined innumerable times as more than a scintilla, but less than preponderance." Thomas v. Celebrezze, 331 F.2d 541, 543 (4th Cir. 1964). This standard precludes de novo review of the factual circumstances that substitutes the Court's findings of fact for those of the Commissioner. Vitek v. Finch, 438 F.2d 1157 (4th Cir. 1971). Although the federal court's review role is a limited one, "it does not follow, however, that the findings of the administrative agency are to be mechanically accepted. The statutorily granted right of review contemplates more than an uncritical rubber stamping of the administrative action." Flack v. Cohen, 413 F.2d 278, 279 (4th Cir. 1969). Further, the Commissioner's findings of fact are not binding if they were based upon the application of an improper legal standard. Coffman v. Bowen, 829 F.2d 514, 519 (4th Cir. 1987).

         Under the regulations of the Social Security Administration, the Commissioner is obligated to consider all medical evidence and the opinions of all medical sources, including treating physicians. 20 C.F.R. § 404.1527(b). This includes the duty to "evaluate every medical opinion we receive." Id. § 404.1527(c). Under what is commonly referred to as Treating Physician Rule, the Commissioner is required to give special consideration to the opinions of treating physicians of the claimant, based on the view that "these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of [the claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations." Id. § 404.1527(c)(2). Under some circumstances, the opinions of the treating physicians are to be accorded controlling weight. Even where the opinions of the treating physicians of the claimant are not accorded controlling weight, the Commissioner is obligated to weigh those opinions in light of a broad range of factors, including the examining relationship, the treatment relationship, length of treatment, nature and extent of the treatment relationship, supportability of the opinions in the medical record, consistency, and whether the treating physician was a specialist. Id., §§ 404.1527(c)(1)-(5). The Commissioner is obligated to weigh the findings and opinions of treating physicians and to give "good reasons" in the written decision for the weight given to a treating source's opinions. SSR 96-2P, 61 Fed. Reg. 34490, 34492, 1996 WL 374185 (July 2, 1996). Further, all medical opinions must be weighed under the standards of the Treating Physician Rules, including non-treating and non-examining physicians. §§ 404.1527(c), (e)(1)(ii).

         When evaluating a claim of disability under the Social Security Act, the Commissioner is obligated to determine the claimant's severe and non-severe impairments and assess whether, despite any such combination of impairments, the claimant retains the residual functional capacity to perform sustained work on a regular and continuous basis. The lowest level of functional capacity for sustained work is sedentary work. Such work generally requires the capacity to sit 6 hours in an 8 hour workday, to stand up to 2 hours in an eight hour day, and to lift no more than 10 pounds at a time. SSR 96-9P, 1996 WL 374185 (July 2, 1996).


         It is important to note at the outset the profound work-related limitations the Administrative Law Judge ("ALJ") concluded were present in this claim for disability benefits. The ALJ determined that Plaintiff retained the residual functional capacity ("RFC") for less than the full range of sedentary work. Tr. 19-22. The Commissioner recognizes that a RFC of less than the full range of sedentary work "reflects very serious limitations resulting from an individual's medical impairments(s)" and is "expected to be relatively rare." SSR 96-9P, 1996 WL 374185, at * 1. This level of function is the lowest level possible without a claimant being found disabled under the Social Security Act. This "rare" determination was reached by the ALJ only after providing "little weight" to the opinions of Plaintiff s primary treating physician, Dr. Jeff Kramer, and making findings regarding Plaintiffs capacity to sit during a normal work day and Dr. Kramer's treatment notes which are not supported by substantial evidence in the record.

         The ALJ concluded that Plaintiff suffered from multiple severe impairments, including lupus, depression and anxiety. The Commissioner recognizes that lupus is "a chronic inflammatory disease that can affect any organ or body system" and can result in severe fatigue, malaise, anemia, mood disorders, anxiety, inflammatory arthritis, and severe pain. 20 CFR Pt. 404, Subpt. P, App. 1, Listing 14.02(1)(a). A lupus patient's condition can be "highly variable" and requires a careful, individualized assessment. Id. In light of these potential signs and symptoms, lupus can have a profound and disabling affect on a individual's capacity to sustain work 8 hours a day, 5 days a week.

         The Court sets forth below significant deficiencies in the ALJ's decision in this matter, each which independently require reversal and remand.

         A. The ALJ's finding that Dr. Kramer's opinions are inconsistent with the doctor's treatment notes is not supported by substantial evidence in the record.

         In support of the ALJ's conclusion that the opinions of Plaintiff s primary care physician, Dr. Kramer were entitled to "little weight, " the ALJ found that opinions Dr. Kramer provided in response to a February 2014 questionnaire were "inconsistent with [his] treatment notes." Tr. 21. By way of background, Dr. Kramer, an internal medicine physician, was intimately involved in the management of Plaintiff s complicated medical problems during the entire period in question in this appeal. Over the period extending from October 1, 2012 until May 13, 2014, Dr. Kramer examined and treated Plaintiff on at least nine occasions, more than any other medical provider. Plaintiff was also treated for her lupus during this period by a rheumatologist, Dr. William Edwards. Notably, Dr. Edwards declined to provide a disability assessment for Plaintiff, explaining that this was an area in which he deferred to other providers. Tr. 334. Dr. Kramer thereafter completed a detailed functional assessment of Plaintiff s capacity to work, considering all of her multiple impairments, and the opinions offered in this assessment were the ones in which the ALJ accorded "little weight" because they were allegedly inconsistent with his treatment notes.

         In his responses to the February 2014 questionnaire, Dr. Kramer documented that as a result of her lupus Plaintiff suffered from non-erosive arthritis, anemia, severe fatigue, severe joint pain, malaise, mood disorders, and inflammatory arthritis. Tr. 343-344. He opined that she could sit no more than 15 minutes at a time and stand no more than 5 minutes at a time. Tr. 345. He indicated that she could not sit or stand/walk as much as 2 hours in an 8 hour day. Id. He further indicated she would need frequent breaks throughout the day and was incapable of even low stress work, explaining that this was because of "severe pain from ...

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