NICKAL v. BERRYHILL, 1:16-cv-00088

Background

Mellissa Nickal applied for DIB and SSI (alleged onset July 4, 2010); ALJ denied benefits in July 2014 and Appeals Council denied review in Dec. 2015.
ALJ found severe impairments: post‑right L5‑S1 laminectomy, lumbar radiculopathy/myofascial pain, mild sacroiliac and pubic symphysis osteoarthritis, and obesity; no listing met.
ALJ determined an RFC for sedentary work with sit/stand option, occasional push/pull/climbing/stooping limits, frequent stooping, no climbing ladders, and cane use outside; could not perform past work but could perform other jobs per vocational expert.
After the ALJ decision, Plaintiff submitted a Physical RFC Questionnaire from treating physician Dr. Amy Woolwine (dated Sept. 16, 2014) opining markedly greater limitations (e.g., sitting ≤2 hours/day, standing <2 hours/day, no right‑hand use, >4 absences/month).
A Functional Capacity Evaluation performed Jan. 21, 2014 indicated inability to sustain an 8‑hour sedentary workday due to fatigue and low manual/finger dexterity scores.
The Appeals Council incorporated Dr. Woolwine’s opinion into the record but denied review; the magistrate judge found that the new opinion creates material conflict and evidentiary gaps warranting remand.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether Appeals Council’s inclusion of Dr. Woolwine’s post‑decision RFC requires remand	Woolwine’s opinion fills evidentiary gaps, corroborates the FCE, conflicts with ALJ’s RFC, and is treating‑physician evidence covering period before ALJ decision	Commissioner argued Woolwine was not a treating physician and opinion post‑dates the ALJ decision / is unpersuasive or extreme	Held: Remand required — Appeals Council accepted new, material, conflicting evidence that a factfinder must evaluate and reconcile before a substantial‑evidence determination can stand
Whether ALJ performed required function‑by‑function RFC analysis for hand/ fingertip dexterity (Mascio issue)	ALJ failed to analyze handling/fingering despite FCE low dexterity scores, treatment records of hand pain, and VE testimony that frequent right‑hand handling/fingering precludes available jobs	Implicitly: ALJ’s RFC need not list functions that are irrelevant or uncontested; no specific treating opinion required to limit handling/fingering	Held: ALJ did not adequately address hand limitations; remand appropriate for function‑by‑function analysis because the record contains contradictory evidence
Credibility / symptom evaluation	Nickal argued ALJ erred in rejecting her symptom testimony without legally sufficient reasons	Commissioner defended ALJ credibility findings based on lack of corroborating medical opinions and inconsistencies	Held: Court did not reach merits because remand required on medical‑opinion and Mascio grounds; credibility issue left for ALJ on remand

Key Cases Cited

Hines v. Barnhart, 453 F.3d 559 (4th Cir. 2006) (federal review of SSA denial limited to substantial‑evidence standard)
Mastro v. Apfel, 270 F.3d 171 (4th Cir. 2001) (RFC must reflect claimant’s capacity for sustained work and follows step‑three analysis)
Meyer v. Astrue, 662 F.3d 700 (4th Cir. 2011) (appeals council’s consideration of new evidence is reviewed by examining whole record; remand if new evidence is uncontradicted and dispositive)
Wilkins v. Sec. Health & Human Servs., 953 F.2d 93 (4th Cir. 1991) (newly submitted evidence incorporated by Appeals Council becomes part of record for judicial review)
Mascio v. Colvin, 780 F.3d 632 (4th Cir. 2015) (ALJ must perform function‑by‑function RFC analysis when record contains contradictory evidence about specific work‑related functions)
Richardson v. Perales, 402 U.S. 389 (1971) (definition of substantial evidence standard in administrative proceedings)