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Combest v. Commissioner Social Security Administration

United States District Court, D. Maryland

June 22, 2016

Diana Lynn Combest
v.
Commissioner, Social Security Administration;

          Stephanie A. Gallagher United States Magistrate Judge.

         Dear Counsel:

         On April 16, 2015, Plaintiff Diana Lynn Combest petitioned this Court to review the Social Security Administration's final decision to deny her claims for Supplemental Security Income and Disability Insurance Benefits. (ECF No. 1). I have considered the parties' cross-motions for summary judgment and Plaintiff's reply memorandum. (ECF Nos. 16, 19, 21). I find that no hearing is necessary. See Loc. R. 105.6 (D. Md. 2014). This Court must uphold the decision of the Agency if it is supported by substantial evidence and if the Agency employed proper legal standards. See 42 U.S.C. §§ 405(g); 1383(c)(3); Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). Under that standard, I will deny both motions, reverse the Commissioner's decision in part, and remand the case to the Commissioner for further consideration. This letter explains my rationale.

         Ms. Combest filed claims for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") on January 24, 2012 and January 11, 2012, respectively. (Tr. 205-217). In both claims, she alleged a disability onset date of March 1, 2008, which she later amended to August 5, 2012. (Tr. 22, 44). Her claims were denied initially and on reconsideration. (Tr. 65-86, 87-110). A hearing was held on December 16, 2013, before an Administrative Law Judge ("ALJ"). (Tr. 42-64). Following the hearing, the ALJ determined that Ms. Combest was not disabled within the meaning of the Social Security Act during the relevant time frame. (Tr. 22-36). The Appeals Council denied her request for review, making the ALJ's decision the final, reviewable decision of the Agency. (Tr. 1-6).

         The ALJ found that Ms. Combest suffered from the following severe impairments: status post cervical disc surgery; degenerative disc disease of the cervical and lumbar spine with resulting lumbago and cervicalgia; cervical radiculopathy and stenosis; lumbosacral neuritis; and major depressive disorder, rule out bipolar disorder and anxiety. (Tr. 24-25). Despite these impairments, the ALJ determined that Ms. Combest retained the residual functional capacity ("RFC") to:

perform light work as defined in 20 CFR §§ 404.1567(b) and 416.967(b) except she can only occasionally climb stairs, ramps, ladders, ropes and scaffolds. The claimant can have only occasional interaction with supervisors and can understand, remember and carryout [sic] simple and detailed instructions.

(Tr. 29). After considering the testimony of a vocational expert ("VE"), the ALJ determined that Ms. Combest could perform her past relevant work as a housekeeper, and that, therefore, she was not disabled. (Tr. 36).

         Ms. Combest raises two primary arguments on appeal. First, she argues that the ALJ improperly evaluated whether her impairments met or equaled Listing 1.04A by failing to identify the relevant listing, consider material evidence, and apply the proper standard. Pl. Mem. at 8-30. Second, Ms. Combest contends that the ALJ's RFC assessment does not comply with the Fourth Circuit's recent decision in Mascio v. Colvin, 780 F.3d 632 (4th Cir. 2015). I agree that Mascio warrants remand. Both arguments are discussed below.

         I will begin with Ms. Combest's unsuccessful argument regarding Listing 1.04A. At step three of the five-step sequential evaluation, the ALJ determined that Ms. Combest's impairments did not meet or medically equal the severity of any of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 26). Her decision specifically addressed physical Listing 1.04. To meet Listing 1.04, a claimant must have a disorder of the spine, resulting in compromise of a nerve root, with either: A) evidence of nerve root compression; B) spinal arachnoiditis; or C) lumbar spinal stenosis. 20 C.F.R. Pt. 404, Subpt. P, App. 1 § 1.04. Each subsection also delineates symptoms for establishing that severity requirement. Id. In her decision, the ALJ stated:

Specifically, I considered all of the claimant's cervical and lumbar spine impairments under Listing 1.04, and concluded that the claimant does not have the requisite neurological deficits to satisfy the severity requirements of this listed impairment. In particular, the claimant's MRIs only revealed spondylitic narrowing, foraminal stenosis and diffuse disc osteophyte and her medical record is void of evidence indicating nerve root compression characterized by neuro-anatomic distribution of pain, spinal arachnoiditis, or lumbar spinal stenosis resulting in an inability to ambulate effectively. Further, physical examinations revealed the claimant displayed a normal gait without the use of an assistive device. Accordingly, I conclude that the claimant does not have an impairment or combination of impairments that meets or medically equals Listing 1.04.

(Tr. 26) (citations omitted). Ms. Combest argues this finding is deficient in three ways. First, she claims the ALJ "failed entirely to identify Listing 1.04A, " despite "ample evidence" of nerve root compression to implicate that subsection. Pl. Mem. at 10. Second, she claims the ALJ mischaracterized the evidence of record pertaining to her MRI findings, and ignored material evidence showing that Ms. Combest's impairments met the requisite element of Listing 1.04A. Id. at 13-15; Pl. Reply at 5. Third, she claims "the ALJ was under the mistaken belief that the inability to ambulate effectively . . . is a requirement of Listing 1.04A, " and thus required Ms. Combest to produce more evidence than required. Pl. Mem. at 16. I disagree.

         An ALJ must identify the relevant listings and compare each of the criteria to the evidence of the claimant's symptoms when there is "ample evidence in the record to support a determination" that the claimant's impairments meet or equal a listing. Cook v. Heckler, 783 F.2d 1168, 1172-73 (4th Cir. 1986). Remand is not warranted "in circumstances where it is clear from the record which listing or listings . . . were considered, " and the court can still "readily determine whether there was substantial evidence to support the ALJ's Step Three conclusion." Id.; Schoofield v. Barnhart, 220 F.Supp.2d 512, 522 (D. Md. 2002). In the instant case, the record implicated Listing 1.04; accordingly, the ALJ expressly identified that listing and said that "her medical record is void of evidence" indicative of any of the Listing's subsections. (Tr. 26). It is clear from the opinion that the ALJ considered all three subsections. I also find substantial evidence to support her conclusion, since the ALJ cited Ms. Combest's MRIs, the medical record, and Ms. Combest's physical examinations, as discussed below. (Tr. 26).

         Ms. Combest claims the ALJ failed to recognize evidence of nerve root compression that implicated Listing 1.04A. Specifically, she points to two MRI findings: an MRI from January 19, 2011, which revealed, "[d]iffuse disc osteophyte complex partially effacing the ventral CSF, minimally abutting the ventral cord" at the C4-C5 and C5-C6 levels; and an MRI from July 2, 2012, which revealed "diffuse bulging annulus and osteophyte complex indenting the ventral aspect of the thecal sac and the spinal cord" at the C3-C4 and C5-C6 levels. Pl. Mem. at 14 (citing Tr. 373, 466) (emphasis in original). Ms. Combest also points to her cervical radiculopathy, which the ALJ acknowledged as a severe impairment but did not mention in her 1.04 analysis. Pl. Mem. at 19-20. However, the ALJ analyzed the Listing appropriately.[1] She identified the MRI evidence, stating that "the claimant's MRIs only revealed spondylitic narrowing, foraminal stenosis and diffuse disc osteophyte." (Tr. 26). Ms. Combest argues that such language "mischaracterizes" the evidence, but I agree with the Commissioner's contention that Ms. Combest has not shown how these findings "amount to a compromise of a nerve root or the spinal cord with evidence of nerve root compression." Pl. Mem. at 13; Def. Mem. at 15 (emphasis in original). Ms. Combest cites Beauchamp v. Colvin, Civil No. 14-01899, 2015 U.S. Dist. LEXIS 153842, at *11 (E. D. La. Oct. 20, 2015) where the court found that evidence of a disc protrusion "which abutted the exiting L3 nerve root . . . satisfied the first requirement" of Listing 1.04. Pl. Reply at 3 (citing Beauchamp, 2015 U.S. Dist. LEXIS 153842, at *11). However, Ms. Combest omits the fact that the record in Beauchamp also contains evidence of "neural canal compromise." Id. at *11. She also cites Brown v. Astrue, Civil No. 3:11-723 JFA/JRM, 2012 U.S. Dist. LEXIS 88294, at *8 (D.S.C. June 6, 2012), where the court remanded a case "pursuant to Listing 1.04A where a cervical MRI also used the language . . . ‘abutting' and ‘indentation' in describing the nature of the plaintiff's spinal cord injury." Pl. Reply at 4. But again, the MRI in that case also showed "spinal cord compression." Id. at *23 (emphasis added). Such proof of compromise and compression is absent in Ms. Combest's MRI findings. (Tr. 373, 466). Ms. Combest argues the ALJ should have expressly analyzed why such evidence did not support nerve root compression, but the claimant bears the burden of demonstrating that her impairment meets a listing. Pl. Reply at 3; Radford v. Colvin, 734 F.3d 288, 291 (4th Cir. 2013). Given that Ms. Combest has failed to establish nerve root compression, I will not discuss the additional evidence she puts forth pertaining to the elements of Listing 1.04A.[2]

         Ms. Combest also claims "the ALJ was under the mistaken belief that the inability to ambulate effectively . . . is a requirement of Listing 1.04A, " and thus expected Ms. Combest to produce more evidence than required. Pl. Mem. at 16. The Commissioner contends that "it is reasonable to assume that the ALJ was referring to [L]isting 1.04C, " of which the inability to ambulate effectively is a plain requirement. 20 C.F.R. Pt. 404, Subpt. P, App. 1 § 1.04; Def. Mem. at 17. I agree with the Commissioner. It is clear that the ALJ synthesized her identification of Listing 1.04 and discussed the listing in its entirety. It is also clear the phrase "resulting in an inability to ambulate effectively" is a prepositional phrase modifying "lumbar spinal stenosis, " the triggering symptom of Listing 1.04C. 20 C.F.R. Pt. 404, Subpt. P, App. 1 § 1.04C; (Tr. 26). The ALJ supported her decision that Ms. Combest does not meet or equal all of Listing 1.04 with substantial evidence, and, for the reasons explained above, this Court will not disturb her conclusion.

         Ms. Combest next makes several arguments related to the Fourth Circuit's recent decision in Mascio. Specifically, she argues that the ALJ erred by: (1) failing to explain why her finding of a moderate limitation in concentration, persistence, or pace did not translate into additional limitations in her RFC; (2) using boilerplate language that purports to determine her RFC prior to weighing her credibility; and (3) giving little weight to Nurse ...


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