Lewis v. Berryhill

• Citation: 858 F.3d 858
• Decision Date: 02 June 2017
• Docket Number: No. 15-2473,15-2473
• Parties: Stacy L. LEWIS, Plaintiff-Appellant, v. Nancy A. BERRYHILL, Acting Commissioner, Social Security Administration, Defendant-Appellee.
• Court: United States Courts of Appeals. United States Court of Appeals (4th Circuit)

858 F.3d 858

Stacy L. LEWIS, Plaintiff-Appellant,

v.Nancy A. BERRYHILL, Acting Commissioner, Social Security Administration, Defendant-Appellee.

No. 15-2473

United States Court of Appeals, Fourth Circuit.

Argued: January 24, 2017

Decided: June 2, 2017

ARGUED: Gregory Dolin, UNIVERSITY OF BALTIMORE SCHOOL OF LAW, Baltimore, Maryland, for Appellant. Jay C. Hinsley, SOCIAL SECURITY ADMINISTRATION, Baltimore, Maryland, for Appellee. ON BRIEF: Meghan E. Ellis, Third Year Law Student, UNIVERSITY OF BALTIMORE SCHOOL OF LAW, Baltimore, Maryland, for Appellant. Rod J. Rosenstein, United States Attorney, OFFICE OF THE UNITED STATES ATTORNEY, Baltimore, Maryland; Aparna V. Srinivasan, Special Assistant United States Attorney, SOCIAL SECURITY ADMINISTRATION, Baltimore, Maryland, for Appellee.

Before AGEE, KEENAN, and THACKER, Circuit Judges.

Vacated and remanded with instructions by published opinion. Judge Agee wrote the opinion, in which Judge Keenan and Judge Thacker joined.

AGEE, Circuit Judge:

Stacy L. Lewis appeals the district court's decision upholding the Social Security Administration's denial of her application for disability insurance benefits and supplemental security income. Because the administrative law judge ("ALJ") did not give appropriate weight to the opinions of Lewis' treating physicians and failed to adequately explain his decision to deny her benefits, we vacate the judgment of the district court and remand for further proceedings.

I.

On October 4, 2010, Lewis filed applications for disability insurance benefits and supplemental security income with the Acting Social Security Commissioner (the "Commissioner"), alleging a disability beginning on March 9, 2009, due to obesity

, degenerative disc disease, degenerative joint disease / thoracic outlet syndrome, diabetes mellitus, lupus, and depression with complaints of anxiety. Because the Commissioner denied Lewis' initial application and request for reconsideration, Lewis requested a hearing before an ALJ. The hearing was granted, but the ALJ denied Lewis' applications. Lewis then requested review by the Appeals Council, which was denied. At that point, the ALJ's decision became the final decision of the Commissioner.

Subsequently, Lewis filed a complaint in district court against the Commissioner pursuant to 42 U.S.C. § 405(g). Considering the parties' cross-motions for summary judgment, a United States magistrate judge¹ issued a letter opinion observing that "Ms. Lewis is correct that, if the ALJ had credited her testimony, he likely would have concluded that she is unable to work." J.A. 15. Nevertheless, the magistrate judge ultimately denied Lewis' motion, granted the Commissioner's motion, and affirmed the Commissioner's final decision denying benefits.

Lewis timely appealed, and this Court has jurisdiction pursuant to 28 U.S.C. § 1291 and 42 U.S.C. § 405(g).

A.

To provide context for our consideration of this case, we begin with an overview of the sequential evaluation that ALJs must follow when making disability determinations. The relevant Social Security Administration regulations set forth a comprehensive five-step process:

[T]he ALJ asks at step one whether the claimant has been working; at step two, whether the claimant's medical impairments meet the regulations' severity and duration requirements; at step three, whether the medical impairments meet or equal an impairment listed in the regulations; at step four, whether the claimant can perform her past work given the limitations caused by her medical impairments; and at step five, whether the claimant can perform other work.

Mascio v. Colvin , 780 F.3d 632, 634 (4th Cir. 2015) ; see also 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The claimant bears the burden to make the requisite showing during the first four steps. Monroe v. Colvin , 826 F.3d 176, 179–80 (4th Cir. 2016). If the claimant fails to carry that burden at any step, she is determined not to be disabled. If the claimant does meet her burden of proof, the burden then shifts to the Commissioner at step five. Id. at 180. The Commissioner does not contest that Lewis met her burden as to steps one and two, so we focus on steps three through five as those are most relevant to the issues before us.

If the claimant fails to demonstrate she has a disability that meets or medically equals a listed impairment at step three, the ALJ must assess the claimant's residual functional capacity ("RFC") before proceeding to step four, which is "the most [the claimant] can still do despite [her physical and mental] limitations [that affect h[er] ability to work]." 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1). That determination requires the ALJ to "first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions listed in the regulations." Mascio , 780 F.3d at 636 (internal quotations omitted); see also SSR 96-8p, 1996 WL 374184, at *1 (July 2, 1996). Once the function-by-function analysis is complete, an ALJ may define the claimant's RFC "in terms of the exertional levels of work, sedentary, light, medium, heavy, and very heavy." SSR 96-8p, 1996 WL 374184, at *1. See generally 20 C.F.R. §§ 404.1567, 416.967 (defining "sedentary, light, medium, heavy, and very heavy" exertional requirements of work).

When assessing the claimant's RFC, the ALJ must examine "all of [the claimant's] medically determinable impairments of which [the ALJ is] aware," 20 C.F.R. §§ 404.1525(a)(2), 416.925(a)(2), "including those not labeled severe at step two." Mascio , 780 F.3d at 635. In addition, he must "consider all [the claimant's] symptoms, including pain, and the extent to which [her] symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence," 20 C.F.R. §§ 404.1529(a), 416.929(a). "When the medical signs or laboratory findings show that [the claimant has] a medically determinable impairment(s) that could reasonably be expected to produce [her] symptoms, such as pain, [the ALJ] must then evaluate the intensity and persistence of [the claimant's] symptoms so that [the ALJ] can determine how [her] symptoms limit [her] capacity for work." 20 C.F.R. §§ 404.1529(c)(1), 416.929(c)(1).

After assessing the claimant's RFC, the ALJ continues with the fourth step, where the claimant must establish she is unable to perform past work. Mascio , 780 F.3d at 635. If she meets her burden as to past work, the ALJ proceeds to step five.

"At step five, the burden shifts to the Commissioner to prove, by a preponderance of the evidence, that the claimant can perform other work that ‘exists in significant numbers in the national economy,’ considering the claimant's residual functional capacity, age, education, and work experience." Id. (quoting 20 C.F.R. §§ 416.920(a)(4)(v), 416.960(c)(2), 416.1429 ). "The Commissioner typically offers this evidence through the testimony of a vocational expert responding to a hypothetical that incorporates the claimant's limitations." Id. If the Commissioner meets this burden, the claimant is deemed not disabled and her benefits application is denied. Id.

B.

Following this regulatory assignment of the burden of proof and evidentiary standards, we summarize the evidence before the ALJ as it relates to this appeal, including testimony and medical records, and then describe the ALJ's reasoning in denying Lewis benefits.

At the time of the ALJ hearing on August 22, 2013, Lewis was 38 years old. She testified that she has a B.S. in criminal justice and an employment history that included residential counselor at Maryland Sherriff's Youth Ranch, deli worker, and store clerk. She reported that she stopped working as a residential counselor on March 9, 2009, when she was slated to be switched to an afternoon shift that would have exacerbated her diabetes

. She claims she has been unable to work since then because of her combined medical impairments.

Lewis reports a myriad of severe medical impairments, which include insulin-dependent diabetes

, with no neuropathy or end-organ failure, as well as lupus

for which she takes prednisone as she experiences symptom flares, though it has been in remission since August 2012. She has a bulge on one of her lumbar disks, which causes her to walk with a limp at times and to experience tingling and numbing down the back of her left leg. In addition, Lewis has autoimmune anemia, which is generally under control. She further experiences non-exertional pain in her left arm from thoracic outlet syndrome that causes her left hand to have tremors and to go numb. Lewis describes the pain as "stabbing, burning, tingling pain" and "throbbing pain" in her back, as well as pain that is "constant in [her] arm," and prevents her from sleeping at night. A.R. 56. She also has mental impairments, including depression and anxiety, for which she takes medication.

These severe medical impairments significantly limit her ability to do basic work activities. Lewis stated she can lift approximately five pounds with her left hand and fifteen to twenty pounds with her right, but can sit for no more than thirty minutes before experiencing pain in her shoulder and the back of her neck. She has a driver's license and her own car, which she "can drive short distances, about five to 10 miles" at least five times per week, but she can only go grocery shopping with assistance. A.R. 52.

In addition to Lewis' testimony, the ALJ called a vocational expert ("VE") to testify at the administrative hearing. In questioning the VE, the ALJ described a hypothetical individual possessing the same limitations as Lewis. The VE testified that such a hypothetical person could not perform any of Lewis' past relevant work. However, the VE testified that there were jobs in the national economy that such a person could perform and specifically identified jobs of call-out operator, surveillance monitor, and charge account clerk.

When questioned by...