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Vanadore v. Berryhill

United States District Court, D. South Carolina

July 8, 2019

Columbus Keith Vanadore, Plaintiff,
v.
Nancy Berryhill, Acting Commissioner of Social Security, Defendant.

          ORDER

          RICHARD MARK GERGEL, UNITED STATES DISTRICT JUDGE

         Plaintiff has brought this action pursuant to 42 U.S.C. § 405(g) seeking judicial review of the final decision of the Commissioner of Social Security denying his application for Disability Insurance Benefits ("DIB"). 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 11, 2019, recommending that the Court reverse the decision of the Commissioner and remand the claim to the agency for further administrative action. (Dkt. No. 17). The Commissioner has advised the Court that she would file no objections to the R & R. (Dkt. No. 19). As set forth more fully below, the Court reverses the decision of the Commissioner and remands with instructions to award benefits from November 23, 2012.

         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 medical sources, including treating physicians. 20 C.F.R. § 404.1545. The regulation, known as the "Treating Physician Rule," imposes a duty on the Commissioner to "evaluate every medical opinion we receive." Id. § 404.1527(c). The Commissioner "[g]enerally ... give[s] more weight to opinions from .. . treating sources" 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). Further, the Commissioner "[g]enerally . .. give[s] more weight to the opinion of a source who has examined [the claimant] than to the opinion of a source who has not examined [the claimant]." Id. § 404.1527(c)(1).

         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 specifically identified factors, including the examining relationship, the nature and extent of the treatment relationship, supportability of the opinions in the medical record, consistency, and whether the treating physician is 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 (July 2, 1996).

         The opinions of non-examining sources and state agency medical consultants must be weighed under the same standards of the Treating Physician Rule, including the source's "medical specialty and expertise . . ., the supporting evidence in the case record, supporting explanations .. . and other factors relevant to the weighing of opinions." Id. §§ 404.1527(e)(2)(h). The Commissioner further pledges that the opinions of non-examining sources will be evaluated on "the degree to which these opinions consider all the pertinent evidence . . ., including the opinions of treating and other examining sources." Id. §§ 404.1527(c)(3).[1]

         It is well-settled in this Circuit that "medical evaluations made after a claimant's insured status has expired are not automatically barred from consideration and may be relevant to prove a disability before the claimant's DLL"[2] Bird v. Commissioner of Social Sec. Admin., 699 F.3d 337, 340 (4th Cir. 2012). As the Bird court explained, "post-DLI medical evidence generally is admissible in a SSA disability determination in such instances in which the evidence permits an inference of linkage with the claimant's pre-DLI condition." Id. at 341.

         Factual Background

         This is the second appeal in this claim to come before the Court. Plaintiff asserts an onset date of March 31, 2009, and his date last insured was December 31, 2014. Tr. 671, 673. In the initial appeal, the record was somewhat complicated by the fact that the Plaintiff, due to the lack of insurance and personal resources, had no regular treating physician and received the limited medical care he did obtain from a free medical clinic and at local emergency rooms. These records documented complaints of chronic neck and back pain, as well as chronic wrist pain and depression. The Social Security Administration referred Plaintiff for an examination by Dr. Harish Mangipudi, a regular Social Security examiner, to obtain a comprehensive assessment of the claimant's capacity to function in the workplace. In his examination of February 16, 2013, Dr. Mangipudi documented Plaintiffs history of chronic low back, cervical and shoulder pain following a motor vehicle accident two years earlier. Plaintiffs neck pain was described as "sharp stabbing" and back pain as "dull, throbbing." Dr. Mangipudi documented that Plaintiff "is not able to ambulate without being in pain, unable to bend due to pain, unable to squat due to pain, able to sit for 30 minutes then has to readjust." Tr. 392. He noted that Plaintiff could ambulate without assistance but his gait was abnormal and "was unable to bend and squat without difficulty." He also documented the presence of cervical and low back paraspinal tenderness. Tr. 393.

         Dr. Mangipudi conducted a physical assessment of Plaintiff using the American Medical Association Guide to the Evaluation of Permanent Impairments and found significant abnormalities in the flexion and rotation of the cervical spine, flexion and extension in the lumbar spine, abduction, elevation and rotation of the shoulder, and flexion and deviation of the wrist. Tr. 395. He concluded, based on "today's examination and objective evidence gathered from the Social Security disability file, that Plaintiff is "unable to stand for a full workday" but was "able to sit for a full work day." Tr. 394.

         The Administrative Law Judge ("ALJ") found in the initial decision in this case that although Plaintiff had multiple severe mental and physical impairments, including degenerative changes in his lumbar spine without herniation, lower back muscle strain, cervical spondylosis, carpal tunnel syndrome, anxiety disorder, and depression, he retained the residual functional capacity to perform less than the full range of light work. Tr. 58, 61. On appeal, this Court noted the narrow difference between the parties, with the Commissioner arguing that Plaintiff could still perform light work (at less than full scope) and the Plaintiff arguing that he was limited to sedentary work. This was noted by the Court to be a critical difference since if Plaintiff could not perform light work (most relevant here being unable to stand 6 hours in an eight hour day), he would be rendered disabled under Social Security regulations from the time of his fiftieth birthday, on November 23, 2012. (Dkt. No. 22 at 7).

         In order to reach the conclusion in the first administrative decision that Plaintiff was capable of performing light work, it was necessary for the ALJ to disregard the findings and opinions of Dr. Mangipudi, the testimony of the Plaintiff, and notes and findings related to Plaintiffs back and neck abnormalities in the administrative record. The Court found that the ALJ's evaluation of Dr. Mangipudi's records and opinions was "replete with error," noting that he had failed to give any weight to Dr. Manipudi as an examining physician, ignored supporting evidence of Dr. Mangipudi's opinion in his examination and office notes, and had basically substituted his medical opinion for that of Dr. Mangipudi. (Id. at 9). The ALJ was instructed on remand to evaluate Dr. ...


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