Arakas v. Comm'r, Soc. Sec. Admin.
| Decision Date | 14 December 2020 |
| Docket Number | No. 19-1540,19-1540 |
| Citation | 983 F.3d 83 |
| Parties | Esin E. ARAKAS, Plaintiff - Appellant, v. COMMISSIONER, SOCIAL SECURITY ADMINISTRATION, Defendant - Appellee. |
| Court | U.S. Court of Appeals — Fourth Circuit |
ON BRIEF: Robertson H. Wendt, Jr., FINKEL LAW FIRM, LLC, North Charleston, South Carolina; Sarah H. Bohr, BOHR & HARRINGTON, LLC, Atlantic Beach, Florida, for Appellant. Eric Kressman, Regional Chief Counsel, Victor Pane, Supervisory Attorney, Annie Kernicky, Special Assistant United States Attorney, Corey Fazekas, Office of the General Counsel, SOCIAL SECURITY ADMINISTRATION, Philadelphia, Pennsylvania; Sherry A. Lydon, United States Attorney, OFFICE OF THE UNITED STATES ATTORNEY, Columbia, South Carolina, for Appellee.
Before GREGORY, Chief Circuit Judge, and WYNN and HARRIS, Circuit Judges.
Reversed and remanded by published opinion. Judge Wynn wrote the opinion, in which Chief Judge Gregory and Judge Harris joined.
Plaintiff Esin Arakas appeals from the district court's order affirming the Social Security Administration's denial of her application for disability insurance benefits. Arakas argues that the administrative law judge ("ALJ") made several errors in discrediting her subjective complaints of pain and fatigue and in according little weight to the opinion of her treating physician.
We agree that the ALJ erred and conclude, based on our review of the record, that Arakas was legally disabled during the relevant period. Accordingly, we reverse and remand for a calculation of disability benefits.
On April 23, 2010, Arakas filed an application for Social Security Disability Insurance ("SSDI") benefits, alleging disability based on various conditions including fibromyalgia
, carpal tunnel syndrome, and degenerative disc disease. After her claim was denied initially in 2010 and upon reconsideration in 2011, she requested a hearing, which was held on June 15, 2012 before an ALJ. Arakas originally alleged that her disability began on November 11, 1996, but she later amended the onset date to January 1, 2010.
On August 28, 2012, the ALJ denied Arakas's claim. The Social Security Administration ("SSA")’s Appeals Council summarily denied review. Arakas then filed suit in the United States District Court for the District of South Carolina pursuant to 42 U.S.C. § 405(g).
On September 23, 2015, the district court reversed and remanded the case, instructing the Commissioner to make findings of fact regarding an opinion letter submitted to the Appeals Council by Dr. Frank Harper, Arakas's long-time treating physician, in support of her application. See Arakas v. Colvin , No. 4:14-CV-457-TER, 2015 WL 5602577, at *6–7 (D.S.C. Sept. 23, 2015). Accordingly, the Appeals Council ordered a remand, and another ALJ held a second hearing on February 24, 2017. That ALJ again denied Arakas's claim.
On August 31, 2017, Arakas commenced the instant suit in the District of South Carolina. On January 24, 2019, a magistrate judge issued a Report and Recommendation, which recommended affirming the Commissioner's decision.
On February 6, 2019, Arakas filed objections to the magistrate judge's conclusions that the ALJ's findings regarding her fibromyalgia
and subjective complaints were made through proper analysis and supported by substantial evidence. On March 21, 2019, the District Court adopted the magistrate judge's Report and Recommendation and affirmed the Commissioner's decision. See Arakas v. Berryhill , No. 4:17-CV-02338-TMC, 2019 WL 1292458, at *5 (D.S.C. Mar. 21, 2019). Arakas timely appealed.
The Social Security Act defines "disability" as the "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). To determine whether a claimant is disabled, ALJs use the "five-step sequential evaluation process" set forth in 20 C.F.R. § 404.1520(a)(4).
At step 1, the ALJ must determine whether the claimant has been working. 20 C.F.R. § 404.1520(a)(4). Step 2 asks whether the claimant's medically determinable impairments meet the regulations’ severity and duration requirements. If the claimant has been working, or if the claimant's impairments do not meet the severity and duration requirements, the ALJ must find the claimant not disabled. Id. Otherwise, the ALJ proceeds to step 3—determining whether any of the claimant's impairments, independently or in combination, meets or equals an impairment listed in the regulations, in terms of severity. If any of the claimant's impairments matches a listed impairment, the claimant is disabled. Id.
If unable to make a conclusive determination at the end of step 3, the ALJ must then assess the claimant's Residual Functional Capacity, which is the most work-related activity the claimant can do despite all of her medically determinable impairments and the limitations they cause. See Mascio v. Colvin , 780 F.3d 632, 635 (4th Cir. 2015) ; 20 C.F.R. § 404.1545(a). To assess the claimant's Residual Functional Capacity, the ALJ must first identify the claimant's "functional limitations or restrictions" and assess the claimant's "ability to do sustained work-related" activities "on a regular and continuing basis"—i.e. , "8 hours a day, for 5 days a week, or an equivalent work schedule." SSR 96-8p, 1996 WL 374184, at *1 (July 2, 1996). The ALJ may then express the claimant's Residual Functional Capacity "in terms of the exertional levels of work[:] sedentary, light, medium, heavy, and very heavy." Id.
After the Residual Functional Capacity assessment, the ALJ proceeds to step 4, which asks whether the claimant can still perform past relevant work despite the limitations identified. 20 C.F.R. § 404.1520(a)(4). If the claimant is capable of doing so, she is not disabled. Id. Otherwise, the ALJ proceeds to step 5.
At this final step, the ALJ must determine whether the claimant can perform other work considering her Residual Functional Capacity, age, education, and work experience. Id. Here, the ALJ typically relies on a vocational expert's testimony. Mascio , 780 F.3d at 635. If able to perform other work, the claimant is not disabled. If unable, the claimant is disabled. 20 C.F.R. § 404.1520(a)(4).
The burden of proof lies with the claimant during the first four steps but shifts to the Commissioner at step 5. Lewis v. Berryhill , 858 F.3d 858, 861 (4th Cir. 2017).
Arakas was 50 years old when she first applied for disability insurance benefits in 2010. She has a high school degree, and she completed specialized job training in real estate sales in 2005. Between 1997 and 2009, Arakas worked full-time as a dining room manager at a restaurant. She has also worked briefly as a real estate salesperson and a caterer. Due to her alleged disability, Arakas stopped working full-time as of January 1, 2010, although she performed some part-time work for a catering company in 2010 and as a cashier at a restaurant in 2017.
For many years, Arakas has suffered from several medical conditions that limit her ability to perform gainful work activity. The most significant is fibromyalgia
, "a disorder of unknown cause" characterized by "chronic widespread soft-tissue pain" particularly in "the neck, shoulders, back, and hips, which is aggravated by use of the affected muscles" and "accompanied by weakness, fatigue, and sleep disturbances." Stedman's Medical Dictionary 331870 (2014). Fibromyalgia Sarchet v. Chater , 78 F.3d 305, 306 (7th Cir. 1996).
Dr. Harper, a rheumatologist, treated Arakas for her fibromyalgia
and other pain-causing conditions from November 11, 1996 to February 24, 2017. In 1996, Dr. Harper diagnosed her with fibromyalgia, based on his findings of "exquisitely tender trigger points" throughout her neck and shoulder muscles, hips, knees, and upper, mid, and lower back—"in accordance with the diagnostic criteria of the American College of Rheumatology." A.R. 357–58, 502.1 He found no other abnormalities, such as muscle weakness, abnormal reflexes, or limited range of motion—a finding consistent with fibromyalgia.
Dr. Harper's treatment notes indicate that since 1996, Arakas has suffered from chronic, diffuse myalgias (muscle pain), stiffness, and fatigue—particularly in her neck, back, hips, and legs—with waxing and waning severity. He observed that physical exertion and lack of sleep aggravated her symptoms. He also consistently noted that she showed a full range of motion of the joints and no signs of active joint inflammation
, both of which are typical of fibromyalgia. Over the years, Dr. Harper prescribed physical therapy and various medications for Arakas's fibromyalgia, including antidepressants that help control neuropathic pain (imipramine and Cymbalta ) and narcotic painkillers (Darvocet and Lorcet /Lortab ). He also provided tender-point injections and referred her for a cervical epidural block when her pain symptoms were severe.
For many years, Arakas has also suffered from degenerative disc disease
in her cervical spine, which has caused persistent and often severe neck and shoulder pain. She was diagnosed with the condition in 2009 based on an MRI, which showed hypolordosis (loss of the normal curve) of the cervical spine, bulging discs, and mild right foraminal narrowing (tightening or narrowing of the small openings along the spine that nerves pass through). Dr. Charles Jervey, a neurologist who examined Arakas after Dr. Harper's referral, found tenderness in her neck and considerable tightness of the right posterolateral muscles, as well as signs of cervical dystonia (muscle spasm). Over the years, Dr. Harper also documented severe pain, muscle spasms, and tenderness in Arakas's neck and shoulder muscles...
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