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Ballard v. Berryhill

United States District Court, E.D. Oklahoma

March 2, 2017

DIANE BALLARD, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, [1] Defendant.

          OPINION AND ORDER

          STEVEN P. SHREDER UNITED STATES MAGISTRATE JUDGE.

         The claimant Diane Ballard requests judicial review of a denial of benefits by the Commissioner of the Social Security Administration pursuant to 42 U.S.C. § 405(g). She appeals the Commissioner's decision and asserts the Administrative Law Judge (“ALJ”) erred in determining she was not disabled. For the reasons set forth below, the Commissioner's decision is herby REVERSED and the case REMANDED for further proceedings.

         Social Security Law and Standard of Review

         Disability under the Social Security Act is defined as the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment[.]” 42 U.S.C. § 423(d)(1)(A). A claimant is disabled under the Social Security Act “only if h[er] physical or mental impairment or impairments are of such severity that [s]he is not only unable to do h[er] previous work but cannot, considering h[er] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy[.]” Id. § 423 (d)(2)(A). Social security regulations implement a five-step sequential process to evaluate a disability claim. See 20 C.F.R. §§ 404.1520, 416.920.[2]

         Section 405(g) limits the scope of judicial review of the Commissioner's decision to two inquiries: whether the decision was supported by substantial evidence and whether correct legal standards were applied. See Hawkins v. Chater, 113 F.3d 1162, 1164 (10th Cir. 1997). Substantial evidence is “‘more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'” Richardson v. Perales, 402 U.S. 389, 401 (1971), quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938); see also Clifton v. Chater, 79 F.3d 1007, 1009 (10th Cir. 1996). The Court may not reweigh the evidence or substitute its discretion for the Commissioner's. See Casias v. Secretary of Health & Human Services, 933 F.2d 799, 800 (10th Cir. 1991). But the Court must review the record as a whole, and “[t]he substantiality of evidence must take into account whatever in the record fairly detracts from its weight.” Universal Camera Corp. v. NLRB, 340 U.S. 474, 488 (1951); see also Casias, 933 F.2d at 800-01.

         Claimant's Background

         The claimant was born December 15, 1959, and was fifty-four years old at the time of the administrative hearing (Tr. 203). She has a high school education and certified nursing assistant training, and has worked as a certified nurses' aide and kennel manager (Tr. 77, 223). The claimant alleges that she has been unable to work since an amended onset date of April 29, 2013, due to mood disorder, degenerative disc disease, anxiety, depression, insomnia, shoulder muscle spasms, nervousness, and problems concentrating (Tr. 65, 241).

         Procedural History

         On May 4, 2013, the claimant filed her current application for supplemental security income benefits under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-85. Her application was denied. ALJ James Bentley conducted an administrative hearing and determined that the claimant was not disabled in a written opinion dated December 24, 2014 (Tr. 42-60). The Appeals Council denied review, so the ALJ's written opinion is the Commissioner's final decision for purposes of this appeal. See 20 C.F.R. § 416.1481.

         Decision of the Administrative Law Judge

         The ALJ made his decision at step five of the sequential evaluation. He found that the claimant retained the residual functional capacity (“RFC”) perform medium work as defined in 20 C.F.R. § 416.967(c), except that she was limited to frequent stooping and crawling, and occasional contact with coworkers, supervisors, and the general public (Tr. 46). The ALJ further found the claimant could understand, remember, and manage most simple and more complex instructions and tasks; could adequately adjust socially and emotionally into most settings; and could perform goal-oriented work, but could not perform at a production rate (Tr. 46). The ALJ concluded that although the claimant could not return to her past relevant work, she was nevertheless not disabled because there was work that she could perform in the national economy, e. g., janitor, laundry worker, and dining room attendant (Tr. 59-60).

         Review

         The claimant contends that the ALJ erred by failing to: (i) account for her non-severe impairment of shoulder muscle spasms at steps four and five, (ii) perform a proper credibility determination, (iii) properly determine the mental and physical demands of her past relevant work, and (iv) apply the Medical-Vocational Guidelines (the “Grids”) to find her disabled. The Court finds the claimant's second proposition persuasive, and the decision of the Commissioner must therefore be reversed and the case remanded to the ALJ for further proceedings.

         The ALJ determined that the claimant had the severe impairments of lumbar degenerative disc disease, early onset dysthymia, anxiety disorder not otherwise specified, and dependent personality traits, but that her alleged impairments of endometriosis and shoulder muscle spasms were non-severe (Tr. 15-18). The medical record as to her physical impairments reveals that physician assistants at Stigler Choctaw Health Clinic managed the claimant's pain medications (Tr. 289-343, 434-42, 464-535). Physician assistant Gwen Hendrix's treatment notes from July 2009 through May 2011 reflect that the claimant's lumbar region was frequently tender to palpation, and that she had intermittent decreased range of motion in her back (Tr. 339-40, 477-512). Ms. Hendrix prescribed opioid and nonsteroidal anti-inflammatory pain medications through June 13, 2011, when she informed the claimant that she needed to obtain her pain medication from an outside provider (Tr. 338-43, 477-532). There are no treatment notes related to the claimant's back between August 2011 and January 2013 (Tr. 296-336). On June 12, 2013, Ms. Hendrix noted the claimant had decreased range of motion in her back, pain with all movement, and tenderness in her lumbar region (Tr. 440-41). She referred the claimant for a lumbar spine MRI, the results of which revealed a shallow, broad-based disc bulge with a small posterior disc protrusion at ¶ 1-2, ...


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