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Butler v. Berryhill

United States District Court, D. South Carolina, Greenville Division

August 29, 2018

Debra Butler, Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security, Defendant.

          REPORT OF MAGISTRATE JUDGE

          Kevin F. McDonald United States Magistrate Judge.

         This case is before the court for a report and recommendation pursuant to Local Civil Rule 73.02(B)(2)(a)(D.S.C.), concerning the disposition of Social Security cases in this District, and Title 28, United States Code, Section 636(b)(1)(B).[1]

         The plaintiff brought this action pursuant to Section 205(g) of the Social Security Act, as amended (42 U.S.C. 405(g)) to obtain judicial review of a final decision of the Commissioner of Social Security denying her claim for disability insurance benefits under Title II of the Social Security Act.

         ADMINISTRATIVE PROCEEDINGS

         The plaintiff filed an application for disability insurance benefits (“DIB”) on May 28, 2013, alleging that she became unable to work on December 4, 2008. The application was denied initially and on reconsideration by the Social Security Administration. On June 25, 2014, the plaintiff requested a hearing. The administrative law judge (“ALJ”), before whom the plaintiff and William W. Stewart, an impartial vocational expert, appeared on June 10, 2016, considered the case de novo and, on August 2, 2016, found that the plaintiff was not under a disability as defined in the Social Security Act, as amended (Tr. 17-26). The ALJ's finding became the final decision of the Commissioner of Social Security when the Appeals Council denied the plaintiff's request for review on May 31, 2017 (Tr. 1-3). The plaintiff then filed this action for judicial review.

         In making the determination that the plaintiff is not entitled to benefits, the Commissioner has adopted the following findings of the ALJ:

(1) The claimant last met the insured status requirements of the Social Security Act on March 31, 2014.
(2) The claimant did not engage in substantial gainful activity during the period from her alleged onset date of December 4, 2008, through her date last insured of March 31, 2014 (20 C.F.R. § 404.1571 et seq).
(3) Through the date last insured, the claimant had the following severe impairment: degenerative disc disease (20 C.F.R. § 404.1520(c)).
(4) Through the date last insured, the claimant did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526).
(5) After careful consideration of the entire record, the undersigned finds that, through the date last insured, the claimant had the residual functional capacity to perform sedentary work as defined in 20 C.F.R. § 404.1567(a) with restrictions of lifting, carrying, pushing, and pulling ten pounds occasionally and less than ten pounds frequently; sitting six hours and standing and walking up to two hours in an eight-hour workday. No. climbing of ladders, ropes, or scaffolds; occasional climbing of ramps and stairs, kneeling, crouching, crawling, and stooping; frequent reaching with bilateral upper extremities in all directions, including overhead and handling. Furthermore, the claimant should not perform work-related activities in direct sunlight without proper eye protection, requiring more than occasional exposure to extreme temperatures or humidity, or work involving dangerous machinery or around unprotected heights.
(6) Through the date last insured, the claimant was capable of performing past relevant work as a claims technician. This work did not require the performance of work-related activities precluded by the claimant's residual functional capacity (20 C.F.R. § 404.1565).
(7) The claimant was not under a disability, as defined in the Social Security Act, at any time from December 4, 2008, the alleged onset date, through March 31, 2014, the date last insured (20 C.F.R. § 404.1520(f)).

         The only issues before the court are whether proper legal standards were applied and whether the final decision of the Commissioner is supported by substantial evidence.

         APPLICABLE LAW

         Under 42 U.S.C. § 423(d)(1)(A), (d)(5), as well as pursuant to the regulations formulated by the Commissioner, the plaintiff has the burden of proving disability, which is defined as an “inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 20 C.F.R. § 404.1505(a).

         To facilitate a uniform and efficient processing of disability claims, the Social Security Act has by regulation reduced the statutory definition of “disability” to a series of five sequential questions. An examiner must consider whether the claimant (1) is engaged in substantial gainful activity, (2) has a severe impairment, (3) has an impairment that meets or medically equals an impairment contained in the Listing of Impairments found at 20 C.F.R. Pt. 404, Subpt. P, App. 1, (4) can perform his past relevant work, and (5) can perform other work. Id. § 404.1520. If an individual is found not disabled at any step, further inquiry is unnecessary. Id. § 404.1520(a)(4).

         A claimant must make a prima facie case of disability by showing he is unable to return to his past relevant work because of his impairments. Grant v. Schweiker, 699 F.2d 189, 191 (4th Cir. 1983). Once an individual has established a prima facie case of disability, the burden shifts to the Commissioner to establish that the plaintiff can perform alternative work and that such work exists in the national economy. Id. (citing 42 U.S.C. § 423(d)(2)(A)). The Commissioner may carry this burden by obtaining testimony from a vocational expert. Id. at 192.

         Pursuant to 42 U.S.C. § 405(g), the court may review the Commissioner's denial of benefits. However, this review is limited to considering whether the Commissioner's findings “are supported by substantial evidence and were reached through application of the correct legal standard.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). “Substantial evidence” means “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance.” Id. In reviewing the evidence, the court may not “undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner].” Id. Consequently, even if the court disagrees with Commissioner's decision, the court must uphold it if it is supported by substantial evidence. Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).

         EVIDENCE PRESENTED

         The plaintiff was 54 years old on her alleged disability onset date (December 4, 2008) and 60 years old on her date last insured (March 31, 2014). She has a high school education and past relevant work as a claims technician and a claims adjuster (Tr. 25).

         On December 4, 2008, David K. Lee, M.D., evaluated the plaintiff at her workers' compensation carrier's request for complaints of left hand pain, numbness, and tingling. The plaintiff also complained of left shoulder pain and knee problems. Dr. Lee noted that the plaintiff had fallen at work and had landed on her hands and knees. Dr. Lee found the plaintiff to have point tenderness over the first dorsal compartment in her wrist and a positive Finkelstein's test. Her knees showed some pain anteriorly with range of motion. Her left shoulder showed some tenderness anteriorly with a positive impingement sign. Dr. Lee diagnosed bilateral de Quervain's tenosynovitis, bilateral knee contusions, and left shoulder tendinitis. Dr. Lee recommended splinting, anti-inflammatory medication, occupational therapy, and an MRI. Dr. Lee indicated that the plaintiff should be restricted to light duty with no lifting over five pounds, no pushing or pulling over five pounds, ground level work only, and no repeated bending, stooping, or squatting (Tr. 834-36).

         On December 8, 2008, S. Wendell Holmes. Jr., M.D., evaluated the plaintiff for complaints of bilateral hand, knee, and shoulder pain from an incident where she slipped and fell at work. Associated complaints included pain that worsened with gripping, lifting, and general use of her hands. The plaintiff stated her anterior knee pain was getting better, but it was worsened by walking. She complained that her shoulder pain was becoming the biggest and most painful problem for her. On physical examination, she had pain over the first dorsal compartment of both hands but had full range of motion. She had minor pain on the anterior side of her knees and moderate tenderness over medial compartments. The plaintiff had full range of motion of her shoulders with mild impingement signs and mild pain with resisted abduction bilaterally. Dr. Holmes diagnosed bilateral de Quervain's tenosynovitis, resolving bilateral anterior knee contusions, and bilateral shoulder pain post fall. He administered steroid injections into her wrists and prescribed Feldene. Dr. Holmes wrote for the plaintiff to be restricted to light duties (Tr. 288-90).

         On December 9, 2008, Charles M. Butler, M.D., evaluated the plaintiff for followup of infiltrating ductal right breast carcinoma. Dr. Butler continued her on Arimidex and Effexor, and he flushed her port (Tr. 373).

         On March 19, 2009, Bhavesh R. Amin, M.D., evaluated the plaintiff for pain in her right lower extremity with associated numbness. She had a positive straight leg raise. Dr. Amin diagnosed low back pain with radiculopathy and abdominal pain and swelling. He ordered an MRI of the lumbosacral spine and gave the plaintiff a prescription for Naproxen (Tr. 352).

         On March 27, 2009, the plaintiff had an MRI of her lumbosacral spine, which was unremarkable (Tr. 356).

         On April 9, 2009, the plaintiff had a CT scan of her abdomen that showed a small hernia just to the right of midline above her umbilicus. It also showed a much larger right-sided abdominal wall hernia that extended into the right anterior pelvic quadrant as well as a gallstone (Tr. 354-55).

         On April 14, 2009, Dr. Butler evaluated the plaintiff for followup of infiltrating ductal right breast carcinoma. Dr. Butler continued Arimidex and noted that the plaintiff wished to taper off of Effexor (Tr. 372).

         On April 15, 2009, Dr. Lee evaluated the plaintiff for followup of bilateral knee, wrist, and shoulder pain. Dr. Lee diagnosed bilateral de Quervain's tenosynovitis, bilateral knee contusions, and bilateral shoulder contusions. The plaintiff reported receiving some injections by Dr. Holmes that had helped but were starting to wear off. She reported feeling some clicking and popping in both knees, and she continued to feel a sharp pain in both shoulders. Dr. Lee ordered occupational and physical therapy and started her on Lyrica (Tr. 839).

         On April 16, 2009, Dr. Amin evaluated the plaintiff and reviewed her recent diagnostic tests. Dr. Amin diagnosed back pain and hernias. He referred her for a surgical consultation (Tr. 351).

         On April 30, 2009, Dr. Holmes evaluated the plaintiff in followup for bilateral shoulder pain with the left worse than the right. Physical examination showed 160 degrees of elevation both sides, actively and passively. She had positive Hawkins and Neer impingement signs bilaterally. She had weak external rotation and scaption of left worse than right. She had bilateral trigger thumbs. Dr. Holmes diagnosed bilateral shoulder pain and weakness. He ordered an MRI of both shoulders to rule out rotator cuff injury (Tr. 287).

         On May 6, 2009, Anil J. Kudchadkar, M.D., evaluated the plaintiff for recurrent incisional hernia and gallstone disease. She reported several weeks of right upper quadrant pain. Dr. Kudchadkar noted that the plaintiff was obese. He diagnosed gallstone disease and abdominal hernia with recurrent incisional hernia, and he ordered diagnostic testing (Tr. 350).

         On May 14, 2009, the plaintiff had an abdominal ultrasound, which showed cholelithiasis with a single large calculus without evidence of cholecystitis and slight dilation of the common bile duct measuring approximately six millimeters (Tr. 353).

         On May 21, 2009, Dr. Lee evaluated the plaintiff for followup of pain in her wrists, knees, and shoulders. Physical examination showed pain along the first dorsal compartment of her thumb and positive impingement signs of her shoulders. Dr. Lee diagnosed bilateral de Quervain's tenosynovitis, bilateral knee contusions, and bilateral shoulder impingement. Dr. Lee ordered formal hand therapy and an MRI of both shoulders (Tr. 840).

         On June 3, 2009, the plaintiff had a mammogram, which showed benign heterogeneously dense fibroglandular tissue (Tr. 380-81).

         On August 6, 2009, the plaintiff underwent a repair of recurrent incarcerated incisional hernia with Peridex mesh (Tr. 347-48).

         On August 25, 2009, Dr. Butler evaluated the plaintiff for followup of infiltrating ductal right breast carcinoma. She complained of continued hot flashes and hair loss. Dr. Butler continued Arimidex and flushed the plaintiff's port (Tr. 371).

         On August 27, 2009, Dr. Lee evaluated the plaintiff for followup of bilateral wrist and hand pain. Physical examination showed pain along the first dorsal compartment, a positive Finkelstein's test, and a nodule on the A1 pulley. Dr. Lee diagnosed bilateral de Quervain's tenosynovitis and left thumb trigger. Dr. Lee recommended surgery to which the plaintiff agreed (Tr. 841).

         On September 18, 2009, the plaintiff underwent a right wrist de Quervain's tenosynovitis release (Tr. 326-27). On September 29, 2009, Dr. Lee evaluated the plaintiff for followup of the release surgery. The plaintiff indicated that she was doing better. Dr. Lee removed her sutures and placed her in a Velcro thumb spica splint. He ordered occupational therapy for her wrist and indicated that shoulder surgery might be required (Tr. 842). On October 27, 2009, the plaintiff had continued complaints of left wrist and trigger thumb discomfort. Dr. Lee diagnosed status-post right de ...


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