Webb v. Saul, CIVIL ACTION NO. 2:19-cv-00392

Decision Date01 April 2020
Docket NumberCIVIL ACTION NO. 2:19-cv-00392
CourtU.S. District Court — Southern District of West Virginia
PartiesGLADYS FAYE WEBB, Plaintiff, v. ANDREW SAUL, Commissioner of Social Security, Defendant.

Plaintiff Gladys Faye Webb ("Claimant") seeks review of the final decision of the Commissioner of Social Security (the "Commissioner") denying her application for Supplemental Security Income under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-83f. By standing order entered on January 4, 2016, and filed in this case on May 20, 2019, this matter was referred to the undersigned United States Magistrate Judge to consider the pleadings and evidence and to submit proposed findings of fact and recommendations for disposition pursuant to 28 U.S.C. § 636(b)(1)(B). (ECF No. 3.) Presently pending before this Court are Claimant's Brief in Support of Judgment on the Pleadings (ECF No. 8) and the Commissioner's Brief in Support of Defendant's Decision (ECF No. 9).

Having fully considered the record and the arguments of the parties, the undersigned respectfully RECOMMENDS that the presiding District Judge DENY Claimant's request to reverse the Commissioner's decision (ECF No. 8), GRANT the Commissioner's request to affirm his decision (ECF No. 9), AFFIRM the final decision of the Commissioner, and DISMISS this action from the Court's docket.

A. Information about Claimant and Procedural History of Claim

Claimant was 39 years old at the time of her alleged disability onset date and 44 years old on the date of the decision by the Administrative Law Judge ("ALJ"). (See Tr. at 40-41.)2 She completed the tenth grade. (Id. at 48, 206.) She has previously been employed as a cook for a university's food service provider and as a cashier at a fast-food restaurant. (Id. at 49-50, 211.) Claimant alleges that she became disabled on January 24, 2013, due to depression, arthritis, anemia, acid reflux, vertigo, high blood pressure, "stomach problems," "bad nerves," sciatica, and "bad knees." (Id. at 201, 205.)

Claimant protectively filed her application for benefits on October 30, 2015. (Id. at 39; see id. at 188-93.) Her claim was initially denied on April 27, 2016, and again upon reconsideration on August 2, 2016. (Id. at 96-101, 110-16.) Thereafter, on August 25, 2016, Claimant filed a written request for hearing. (Id. at 117-19.) An administrative hearing was held before an ALJ on April 17, 2018, in Huntington, West Virginia, with the ALJ appearing from Baltimore, Maryland. (Id. at 31-70.) On June 22, 2018, the ALJ entered an unfavorable decision. (Id. at 12-30.) Claimant then sought review of the ALJ's decision by the Appeals Council. (Id. at 182-85.) The Appeals Council denied Claimant'srequest for review on March 21, 2019, and the ALJ's decision became the final decision of the Commissioner on that date. (Id. at 1-6.)

Claimant timely brought the present action on May 18, 2019, seeking judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g). (ECF No. 2.) The Commissioner filed an Answer (ECF No. 6) and a transcript of the administrative proceedings (ECF No. 7). Claimant subsequently filed her Brief in Support of Judgment on the Pleadings (ECF No. 8), and in response, the Commissioner filed his Brief in Support of Defendant's Decision (ECF No. 9). As such, this matter is fully briefed and ready for resolution.

B. Relevant Medical Evidence

The undersigned has considered all evidence of record, including the medical evidence, pertaining to Claimant's arguments and summarizes it here for the convenience of the United States District Judge.

1. Mental Health Treatment

On November 17, 2015, Claimant presented to her primary care physician and complained of "depressed mood, irritability, short temper, [and] poor sleep." (Tr. at 344.) She expressed that she was "worried because her son is in the military and could be deployed at any time." (Id.) She reported taking her mother's anxiety medication and requested "a referral to psychiatry for talk therapy." (Id.) Claimant's physician noted that she was fully oriented but "tearful and anxious." (Id. at 346.) Claimant was diagnosed with depression, prescribed medication, given a psychiatry referral, and directed to follow up in one month. (Id. at 347.) At the follow-up appointment on December 15, 2015, Claimant reported that she had stopped taking the medication her physician prescribed"because it made her 'feel like a zombie.'" (Id. at 340.) Her mental status was normal that day. (Id. at 343.)

Claimant had her initial evaluation with a psychiatrist on March 7, 2016. (Id. at 349.) She reported that she had experienced depression for the preceding two years "following her oldest son moving out and joining the Army." (Id.) She related depressed mood, "sleep disturbance with early and middle insomnia," low energy, "increased appetite particularly in the evenings with weight gain," lack of motivation, "anhedonia, and intermittent hopelessness." (Id.) She also reported increased anxiety. (Id.) Her mental status examination was normal aside from a "worried and down" mood and affect. (Id. at 351.) She was diagnosed with depression, prescribed medication, and referred to a psychotherapist. (Id. at 351-52.)

At an April 4, 2016 follow-up appointment with her psychiatrist, Claimant reported "feeling better and estimate[d] that overall her symptoms are ~40% improved." (Id. at 353.) She stated that she "[s]till has some low days and still experiences generalized worries." (Id.) She also stated that she "[s]truggles with motivation but does get out of the house now more days than not." (Id.) She reported no side effects from her medication. (Id.) Her mental status examination that day was normal, and the psychiatrist observed that Claimant was smiling. (Id. at 355.) The psychiatrist increased Claimant's dosage of medication. (Id. at 356.)

Claimant returned to her psychiatrist on September 19, 2016, and reported that her "mood has improved considerably" and that she was "[t]olerating [her] medication well and feels it is helping." (Id. at 539.) However, she reported that she "[c]ontinues to have poor quality sleep and low daytime energy" and complained of fatigue. (Id.) Her mental status examination was normal. (Id. at 541.) Claimant's psychiatristrecommended that Claimant continue taking her medication and noted that Claimant was "[o]btaining benefit from pharmacotherapy but if does not obtian [sic] full response will re-visit psychotherapy as adjunctive treatment." (Id. at 543.)

Claimant presented to a new psychiatrist for a routine follow-up appointment on July 3, 2017. (Id. at 530.) She reported that she was "doing well with depresion [sic] and anxiety" and that her prescribed medication "has helped both." (Id. at 533.) She reported getting six to eight hours of sleep each night. (Id.) Her mental status examination was normal that day, and the psychiatrist observed that she "[a]ppears happy" and "easily smiled." (Id. at 535.) The psychiatrist summarized, "Depression and anxiety well controlled on medication. . . . Overall the patient's risk is felt to be a minimal concern." (Id. at 535-36.) Claimant was instructed to continue her medication, and the psychiatrist noted that there was "[n]o need for therapy at the moment." (Id. at 536.) She was directed to follow up in six months. (Id.)

2. Treatment for Back Pain

On October 2, 2014, Claimant presented to an urgent care clinic, complaining of pain in the right side of her lower back that radiated down her leg. (Id. at 448.) She described the pain as "[m]oderate" and stated that she "helped a friend move furniture and exacerbated [her] low back pain." (Id.) She also explained that she had a history of "sciatic nerve pain." (Id.) Upon physical examination, Claimant's gait and stance and lower-back range of motion were normal, and she had "[f]ull strength against resistance." (Id. at 449.) There was "[p]araspinous tenderness noted," and pain upon movement. (Id.) Her "lower extremity motor function" and "[p]atellar reflexes" were normal. (Id.) She was given a pain injection and prescribed medication, and she was instructed to apply ice and a warm compress and follow up with her primary care physician. (Id.)

Claimant again presented to an urgent care clinic on January 8, 2015, complaining of a back injury after a fall. (Id. at 457.) A physical examination was normal, except for "[p]araspinous tenderness" in the lower back and tenderness in the "[r]ight posterior hip." (Id. at 458.) Claimant was diagnosed with a lumbar sprain and given an injection for the pain. (Id.) She was also prescribed pain medication and a muscle relaxer. (Id.)

On May 13, 2016, Claimant presented to an urgent care clinic, complaining of low back pain that radiated into her right leg. (Id. at 476.) She stated that it began after helping her father dig up and plant flowers a few days prior. (Id.) She reported that she had "chronic back pain." (Id.) Upon physical examination, Claimant had a reduced range of motion in her lower back "due to pain," as well as "[p]araspinous tenderness" and a muscle spasm." (Id. at 477.) She was given a steroid injection and prescribed pain medication and a muscle relaxer. (Id. at 477-78.)

3. Treatment for Knee and Leg Pain

On January 5, 2015, Claimant reported to her primary care physician that she was suffering from "increased arthritic pain" in her "shoulders, hips, wrists, and knees." (Id. at 323.) She requested switching to ibuprofen to treat it and acknowledged that "her arthritis would improve if she loses weight." (Id.) Her gait and station were observed to be normal that day. (Id. at 325.) Claimant was given a prescription for ibuprofen and scheduled to return for a follow-up appointment to address her "arthritis and chronic conditions." (Id. at 326.) At the follow-up appointment on June 10, 2015, Claimant stated that her knee pain was "[w]orsening" and was...

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