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Thomas v. Berryhill

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

March 29, 2019




         Plaintiff Vada Jean Thomas brings this matter under 42 U.S.C. § 405(g) seeking judicial review of an administrative decision of the Acting Commissioner of Social Security. The Court, having reviewed the record and the cross motions for summary judgment filed by the parties, will REVERSE and REMAND the Commissioner's decision because for further explanation on the ALJ's finding related to whether the claimant met the criteria in listing 1.04. Otherwise, the ALJ's determination on listing 12.06 is supported by substantial evidence and Thomas has failed to demonstrate that she meets the criteria for listing 12.08.

         I. Standard for Determining Disability

         Under the Social Security Act, a disability is defined as “inability to engage in 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.” 42 U.S.C. § 423(d)(1)(A). In determining disability, an Administrative Law Judge (“ALJ”) uses a five-step analysis. See Jones v. Comm'r of Soc. Sec., 336 F.3d 469, 474 (6th Cir. 2003). Step One considers whether the claimant is still performing substantial gainful activity; Step Two, whether any of the claimant's impairments are “severe”; Step Three, whether the impairments meet or equal a listing in the Listing of Impairments; Step Four, whether the claimant can still perform past relevant work; and, if necessary, Step Five, whether significant numbers of other jobs exist in the national economy which the claimant can perform. As to the last step, the burden of proof shifts from the claimant to the Commissioner. Id.; see also Preslar v. Sec'y of Health & Human Servs., 14 F.3d 1107, 1110 (6th Cir. 1994).

         II. Procedural and Factual History

         Thomas filed an application for disability insurance benefits (DIB) and supplemental security income (SSI) on June 21, 2013, alleging disability as of March 30, 2010. [TR 607-16]. Thomas alleged disability due to major depression, post-traumatic stress disorder, cervical disc disease, osteoarthritis, short-term memory loss, and very limited use of her left arm. [TR 629]. Thomas's claim was denied initially and upon review. [TR 466-69, 531-44].

         A. Relevant Medical Evidence

         In 2012, Thomas was treated three times at Quantum Healthcare. [TR 722-31]. Physical examinations at Quantum revealed that Thomas suffered from back and shoulder pain, decreased range of motion, difficulty standing up after sitting and squatting, and a depressed mood. [Id.].

         In 2013, Thomas was treated at the Little Flower Clinic for back pain and depression. [TR 758-63]. An x-ray of Thomas's back revealed narrowing of two vertebrae, which suggested that Thomas suffered from degenerative disc disease. [TR 747].

         Plaintiff had two consultative exams with Dr. Barry Burchett, who diagnosed Thomas with chronic back, hip, and shoulder pain, and potential depression. [TR 739, 742, 749]. Additionally, Dr. William Rigby diagnosed Thomas with PTSD, panic disorder, and major depression. [TR 750-51, 754-55].

         Moreover, state agency psychologist Laura Cutler, Ph.D., found that Thomas could understand, remember, and carry out simple detailed instructions, could sustain attention for extended two-hour segments for detailed tasks, could tolerate occasional contact with coworkers and supervisors in nonpublic settings, and could adapt to routine changes as needed. [TR 447]. The assessment of state agency psychologist Jermaine Robertson, Ph.D., was largely in accord with Dr. Cutler's assessment. [TR 486].

         Thomas submitted two function reports and a pain questionnaire as part of her application for benefits. [TR 644-57, 674-82]. On the questionnaire, Thomas reported daily “sharp, burning, knifelike” pain in her back, hips, knees, left shoulder, and neck that began after a car accident in 2005. [TR 644-45]. Thomas reported difficulty with walking, travel, regular housework, and yard work, among other difficulties. [TR 646]. Thomas also reported difficulty with using her left arm and reported that she spent a significant amount of time sitting. [TR 647-48]. Thomas's second questionnaire contained similar information but emphasized Thomas's mental health issues and limitations. [TR 674-82].

         In 2014, state agency physician Dr. Amanda Lange reviewed the record evidence and concluded that, while Thomas had exertional and postural limitations, she could occasionally lift and carry up to twenty pounds, could stand or walk with normal breaks for about six hours in an eight-hour workday, and could frequently stoop, kneel, crouch, and crawl. [TR 483]. Still, Dr. Lange noted that Thomas was limited in reaching to the left overhead. [Id.].

         Moreover, Thomas received additional treatment from Quantum Healthcare in 2014. [TR 773, 776, 778, 781, 783]. On February 25, 2014, Thomas reported that her anxiety and depression were well controlled by using the prescription medication Lexapro. [TR 783]. In September 2014, Thomas reported that she slept well at night and that she was still taking prescription medication Lexapro, but that she continued to have some shoulder pain. [TR 773].

         In November 2014, Thomas had surgery on her left shoulder to remove a cyst and for rotator cuff repair. [Tr 791-847]. Post-surgery, Thomas reported that her pain was controlled and that her depression had improved. [TR 767]. Still, Thomas reported some continued left hip pain. [Id.].

         In 2015, Thomas was assessed by Dr. Robert Hoskins, M.D., and Dr. Michele Amburgey, Ph.D., related to her disability claim. [TR 869-76, 890-95]. Dr. Hoskins reported that Thomas had a somewhat unsteady gait and had difficulty squatting, sitting, and standing from the chair in the office. [TR 894]. Additionally, Dr. Hoskins noted that Thomas had a strong limp after taking a few steps. [Id.]. As a result of his examination, Dr. Hoskins stated that he “[could not] think of a job that she could keep given the history. [Id.]. Similarly, Dr. Amburgey's assessment rated Thomas's ability to function as poor in several areas, including understanding and remembering detailed instructions, maintaining attention and concentration for extended periods, and performing at a consistent pace, among others. [TR 875].

         B. Hearing Before ALJ

         After her claims were denied initially and were denied upon reconsideration, Thomas pursued her claims at an administrative hearing before ALJ Roger L. Reynolds on September 28, 2015. [TR 383-411]. Thomas was represented by an attorney at the administrative hearing. At the hearing, Thomas testified that she had previously worked as a charge nurse. [TR 387]. Thomas testified that she was unable to work beginning in 2010 because she was experiencing a lot of pain and was having problems with her memory. [TR 388].

         Additionally, Thomas testified that she underwent surgeries on her left shoulder in November 2014 and July 2015. [TR 390-91]. Thomas explained that the pain in her left shoulder had improved since her surgeries and that, although she still does not have much range of motion, she can raise her left ...

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