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Branscum v. Berryhill

United States District Court, E.D. Kentucky, Southern Division, London

February 6, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Hanly A. Ingram, United States Magistrate Judge

         On October 31, 2014, Plaintiff Janice Faye Branscum filed a protective application for supplemental security income. D.E. 13-1 at 66, 100.[1] She dated the beginning of her disability period to October 1, 2004. Id. at 214. Branscum claimed in her initial application that she is disabled due to diabetes, kidney disease, peripheral neuropathy, and back problems. Id. at 100. The Social Security Administration denied Branscum's claims initially in December 2014 and upon reconsideration on May 21, 2015. Id. at 66.

         Meanwhile, Branscum was diagnosed in September 2015 with carpal tunnel syndrome. D.E. 13-1 at 542, 557-58. She had surgery on her left hand on December 2, 2015, followed by surgery on her right hand on June 1, 2016. Id. at 704, 760.

         On July 22, 2016, upon Branscum's request, Administrative Law Judge (“ALJ”) Dennis Hanson conducted an administrative hearing. Id. at 83-98. The ALJ heard testimony from Branscum and impartial vocational expert (“VE”) William Ellis. Id. at 66. Additional evidence was submitted after the hearing, which the ALJ considered. Id.

         Branscum was 42 years old when she filed her application. D.E. 13-1. at 73. She has “a limited education” (id.), having attended school only through the eighth grade (id. at 87). Branscum has no past relevant work experience. Id. at 73. The ALJ found that Branscum had certain severe impairments (id. at 68), but that she “has the residual functional capacity to perform light work as defined in 20 CFR 416.967(b), ” with certain limitations (id. at 70). Because there were adequate available jobs she could perform, the ALJ found Branscum was “not disabled.” Id. at 74.

         Branscum now brings this action under 42 U.S.C. §§ 405(g) and 1383(c) to obtain judicial review of the ALJ's decision denying her application for disability insurance benefits. D.E. 2. She argues that the ALJ ascribed insufficient weight to the opinion of a treating physician and that the ALJ's residual functional capacity is not based on substantial evidence. D.E. 15-1. Specifically, she argues that the ALJ erroneously underrepresented the effect of diabetes on her feet and the severity of her hand limitations as a result of carpal tunnel syndrome and hand surgeries. D.E. 15. Both parties consented to the referral of this matter to a magistrate judge. D.E. 18. This matter was thus referred to the undersigned to conduct all proceedings and order the entry of a final judgment in accordance with 28 U.S.C. § 636(c) and Federal Rule of Civil Procedure 73. D.E. 19. The Court, having reviewed the record and for the reasons stated herein, GRANTS Plaintiff's motion for summary judgment (D.E. 15), DENIES the Commissioner's motion for summary judgment (D.E. 17), and REMANDS this matter for further proceedings.

         I. The ALJ's Findings

         Under 20 C.F.R. §§ 404.1520, 416.920, an ALJ conducts a five-step analysis to evaluate a disability claim.[2] The ALJ followed these procedures in this case. See D.E. 13-1 at 67-74.

         At the first step, if a claimant is working at a substantial gainful activity, the claimant is not disabled. 20 C.F.R. § 404.1520(b). In this case, the ALJ found that Branscum was “not engaged in substantial gainful activity” since the application date. D.E. 13-1 at 68. The ALJ thus proceeded to the next step.

         At the second step, if a claimant does not have any impairment or combination of impairments which significantly limit the physical or mental ability to do basic work activities, then the claimant does not have a severe impairment and is not disabled. 20 C.F.R. § 404.1520(c). The ALJ found that Branscum did suffer several significant impairments: diabetes mellitus, peripheral neuropathy, sprains and strains, carpal tunnel syndrome, status post bilateral release surgery, Dupuytren's contracture, anxiety, and depression. D.E. 13-1 at 68.

         At the third step, if a claimant's impairments meet or equal an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, then the claimant is disabled. 20 C.F.R. § 404.1520(d). The ALJ found Branscum failed to meet this standard. D.E. 13-1 at 68-69.

         First, at this step, the ALJ considered Branscum's issues with her hands. The ALJ considered whether her conditions equal Listing 1.02 (Major Dysfunction of Joint(s) (Due to Any Cause)). D.E. 13-1 at 68. This listing requires an individual to be unable to perform fine and gross movements effectively. Although Branscum had carpal tunnel surgeries on both hands, the ALJ found “little to no evidence” of a “substantial loss of function in her arms.” Id. at 69. “She has responded well to surgery, for example.” Id. Branscum now takes issue with the ALJ's assessment of her hands; however she does so in the context of the residual functional capacity, not at step three of the disability analysis. D.E. 15-1 at 1, 10.

         Next, the ALJ considered whether Branscum's diabetes could equal one of the listed impairments. D.E. 13-1 at 69. Listing 9.00 encompasses “Endocrine Disorders” and focuses on the affected bodily system. The ALJ found that Branscum's symptoms were insufficiently severe to meet the listing. Id. For example, there was “no evidence of diabetic nephropathy or amputation of an extremity, ” no record of chronic hyperglycemia, and no evidence of severe diabetes-based complications, such as peripheral neurovascular disease. Id.

         The ALJ then discussed whether Branscum could meet Listing 11.14 (Peripheral Neuropathies) in regard to her diabetes symptoms. The ALJ found “little evidence of the required disorganization of motor function, as the claimant is able to sustain movement, gait, and station.” D.E. 13-1 at 69.

         Branscum argues the ALJ understated the severity of her diabetes-related foot issues. D.E. 15-1 at 1, 6-10. However, Branscum does not identify any specific impairment listing as being equivalent to her impairments. Instead, she appears to take issue with the ALJ's residual functional capacity in relation to her feet. See id.

         The ALJ also found no sufficiently severe mental health issues. D.E. 13-1 at 69-70. Branscum does not challenge this finding.

         If, as here, a claimant is found to be not disabled at step three, the ALJ must determine the claimant's residual functional capacity (“RFC”), which is the claimant's ability to do physical and mental work activities on a sustained basis despite limitations from the impairments. 20 C.F.R. § 404.1520(e). The ALJ determined that Branscum has the RFC to perform light work as defined in 20 C.F.R. § 416.976(b),

except that she can only occasionally climb ramps or stairs, stoop, kneel, crouch, or crawl. The claimant can only frequently balance, and frequently handle, finger, or feel bilaterally. She can never climb ladders, ropes, or scaffolds. She can never be exposed to unprotected heights or dangerous moving machinery. The claimant can understand and remember work place instructions, and can complete work place tasks in a normal amount of time with regular breaks every two hours. She can frequently interact with supervisors, coworkers, and the public; and can adapt to occasional work place changes.

D.E. 13-1 at 70.

         Branscum argues that the ALJ's RFC calculation underestimates her actual disability concerning her hands and, presumably, her feet. D.E. 15-1.

         At the fourth step, if a claimant's impairments do not prevent her from doing past relevant work (given the ALJ's residual functional capacity), she is not disabled. 20 C.F.R. § 404.1520(f). Here, the ALJ found that Branscum “has no past relevant work.” D.E. 13-1 at 72.

         At the fifth step, if a claimant's impairments (considering her RFC, age, education, and past work) do not prevent her from doing other work that exists in the national economy, she is not disabled. 20 C.F.R. § 404.1520(g). The ALJ found Branscum was not disabled at this step. D.E. 13-1 at 73-74. The ALJ explained that the vocational expert testified that Branscum could “perform the requirements of representative light and unskilled occupations with a Specific Vocational Preparation (SVP) level of two, ” such as ticket taker, rental clerk, and mail clerk- jobs with significant numbers of openings in Kentucky. Id. at 73. Branscum was therefore “not disabled” as defined by the regulations. Id. at 74.

         Accordingly, on August 30, 2016, the ALJ issued a decision finding that Branscum was not disabled and was therefore ineligible for supplemental security income. D.E. 13-1 at 74. The Appeals Council declined to review the ALJ's decision on October 25, 2017. Id. at 1-4. She filed this action in federal court on December 27, 2017. D.E. 2.

         II. General Legal Standards

         Under the Social Security Act, a “disability” is defined as “the inability to engage in ‘substantial gainful activity' because of a medically determinable physical or mental impairment of at least one year's expected duration.” Cruse v. Comm'r of Soc. Sec., 502 F.3d 532, 539 (6th Cir. 2007). Judicial review of the denial of a claim for Social Security benefits is limited to determining whether the ALJ's findings are supported by substantial evidence and whether the correct legal standards were applied. Rogers v. Comm'r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007). “Substantial evidence” is “more than a scintilla of evidence but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Cutlip v. Sec'y of Health & Human Servs., 25 F.3d 284, 286 (6th Cir. 1994). The substantial evidence standard “presupposes that there is a zone of choice within which decision makers can go either way, without interference from the court.” Mullen v. Bowen, 800 F.2d 535, 545 (6th Cir. 1986) (en banc) (quotes and citations omitted).

         In determining the existence of substantial evidence, courts must examine the record as a whole. Id. (citing Kirk v. Sec'y of Health & Human Servs., 667 F.2d 524, 535 (6th Cir. 1981), cert. denied, 461 U.S. 957 (1983)). However, courts are not to conduct a de novo review, resolve conflicts in evidence, or make credibility determinations. Id. (citations omitted); see also Bradley v. Sec'y of Health & Human Servs., 862 F.2d 1224, 1228 (6th Cir. 1988). Rather, if the ALJ's decision is supported by substantial evidence, it must be affirmed even if the reviewing court would decide the matter differently, and even if substantial evidence also supports the opposite conclusion. See Her v. Comm'r of Soc. Sec., 203 F.3d 388, 389-90 (6th Cir. 1999); see also Casey v. Sec'y of Health & Human Servs., 987 F.2d 1230, 1233 (6th Cir. 1993); Mullen, 800 F.2d at 545; Kinsella v. Schweiker, 708 F.2d 1058, 1059 (6th Cir. 1983).

         III. The ALJ's Weighing of Podiatrist Dr. Jensen-Stanley's Opinion

         Branscum argues that the ALJ “failed to properly apply the treating physician standard when weighing treating podiatrist Dr. Jensen-Stanley's opinion.” D.E. 15-1 at 1.

         Under the regulations as they existed in 2016, “if the opinion of the treating physician as to the nature and severity of a claimant's conditions is ‘well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence in the case record,' then it will be accorded controlling weight.” Rogers v. Comm'r of Soc. Sec., 486 F.3d 234, 242 (6th Cir. 2007) (quoting Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004)). The ALJ must provide “good reasons” for discounting a treating physician's opinion, and the reasons must be “sufficiently specific” so any reviewers will know the ALJ's reasoning for ascribing a particular weight to the opinion. Id.

         In her brief, Branscum describes consultations and treatments with Dr. Jensen-Stanley that occurred on April 22, 2015, August 19, 2015, October 21, 2015, January 13, 2016, and May 26, 2016. D.E. 15-1 at 2-6. Dr. Jensen-Stanley filled out a two-page Physical Impairment Questionnaire about Branscum on July 5, 2016. D.E. 13-1 at 775-76. Branscum argues the ALJ gave this opinion insufficient weight. D.E. 15-1 at 6-10. Dr. Jensen-Stanley's questionnaire notes that Branscum has insulin-dependent diabetes and suffers “numbness to feet, painful nails.” D.E. 13-1 at 775. According to the questionnaire, Branscum would not need extra break time to recline or lie down during a hypothetical 8-hour workday. Id. She can walk one to two city blocks without rest or significant pain. Id. She can stand or walk for 15 minutes out of every hour. Id. She can sit for four hours during the work day and stand or walk for one hour during the work day. Id. She can frequently lift objects weighing less than ten pounds, and occasionally lift ten- or twenty-pound objects. Id. at 776. Dr. Jensen-Stanley reported that Branscum is not a malingerer. Id.

         The ALJ made the following statement regarding this questionnaire:

This [treating source statement] limited the claimant to sitting four hours a day, and standing and walking to one hour. It limited the claimant to lifting or carrying only less than ten pounds frequently, and ten to twenty pounds occasionally. The undersigned accords this opinion partial weight. The modest treatment records do not support such exertional limitations, but the record does reflect that the claimant can lift or carry at the light level.

D.E. 13-1 at 72 (citation omitted).

         According to Branscum, “The ALJ accepted Dr. Jensen-Stanley's lifting limitations but rejected the walking/standing limitations, stating the ‘record[s] do not support such exertional limitations . . . .'” D.E. 15-1 at 7. Branscum faults this “brief, conclusory” explanation as being “unsupported by substantial evidence” and inconsistent with the treating-physician rule. Id. The pivotal question is whether the ALJ improperly discounted Dr. Jensen-Stanley's opinion that Branscum could sit for only four hours during the work day and stand or walk for only one hour during the work day.

         Section 416.927 of the regulatory code describes how the Commission is to evaluate medical opinion evidence.[3] “Generally, ” treating sources are given “more weight” than non-treating sources. 20 C.F.R. § 416.927(c)(2). The regulation informs claimants, “If we find that a treating source's medical opinion on the issue(s) of the nature and severity of your impairment(s) is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in your case record, we will give it controlling weight.” Id. However, there may be “good reasons” for declining to ascribe “controlling weight.” Id. Such reasons include how well the opinion is supported by relevant evidence (id. § 416.927(c)(3)) and how consistent the opinion is with “the record as a whole” (id. § 416.927(c)(4)). The “substantial evidence” standard has already been discussed.

         Here, the ALJ provided the following explanation for ascribing only partial weight to the relevant opinion: “The modest treatment records do not support [Dr. Jensen-Stanley's] exertional limitations[.]” D.E. 13-1 at 72.

         Prior to making this statement, the ALJ noted other evidence which suggested that Branscum could sit more than four hours a day and stand more than one hour a day. First, the ALJ noted Branscum's testimony that her feet and legs are “affected by neuropathy” and that “her feet swell if they are not elevated.” D.E. 13-1 at 71. However, the ALJ found that the reported intensity of her claimed impairments were “not entirely consistent with the medical evidence” in the record. Id. Turning to Dr. Jensen-Stanley's own treatment records, the ALJ noted that Branscum showed “no gait abnormalities” in April 2015 and August 2015. Id.

         Further, the diabetes that caused the foot issues was “relatively under control with conservative treatment.” Id. The ALJ also relied on the opinion of a state agency medical consultant:

P. Saranga, M.D., opined that the claimant could perform light work; could frequently perform postural activities, but could only occasionally climb ladders; and would need to avoid exposure to hazards. The undersigned accords this opinion preponderant weight. It is consistent with the longitudinal medical evidence of record that shows a variety of testing but ...

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