Opinion
C. A. 9:23-3597-DCC-MHC
07-30-2024
Darlene M.R.,[1] Plaintiff, v. Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
Molly H. Cherry United States Magistrate Judge
Plaintiff Darlene M.R. (Plaintiff) filed the complaint in this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the Administrative Law Judge's (ALJ's) final decision denying her claim for Disability Insurance Benefits (DIB) under the Social Security Act (Act). This case was referred to the undersigned for a report and recommendation pursuant to Local Civil Rule 73.02(B)(2)(a) (D.S.C.). For the reasons that follow, the undersigned recommends that the ALJ's decision be reversed and remanded for further administrative review.
Citations to the record refer to the page numbers in the Social Security Administration Record. See ECF No. 9.
Plaintiff applied for DIB in July 2017, alleging disability beginning on February 23, 2016. R.p. 304. Her claim was denied initially and on reconsideration. R.pp. 169, 180. Upon Plaintiff's request, an administrative hearing was held before an ALJ in June 2019. R.pp. 36-64, 187. On June 21, 2019, the ALJ issued a decision finding Plaintiff not disabled through the date of the decision. R.pp. 136-60. Plaintiff requested review by the Appeals Council. R.pp. 245. On August 28, 2020, the Appeals Council vacated the ALJ's decision and remanded the claim for further proceedings before the ALJ. R.pp. 161-68.
On January 7, 2021, an ALJ held a second hearing. R.pp. 65-100. On January 29, 2021, the ALJ issued a second unfavorable decision. R.pp. 15-35. Plaintiff again requested review by the Appeals Council, R.p. 301, which denied her request on June 22, 2201, R.p. 1. A civil action followed, and on April 8, 2022, Plaintiff's claim was remanded for further proceedings. R.p. 855.
The Appeals Council issued its own remand order on May 25, 2022. R.p. 868. On December 15, 2022, Plaintiff again appeared before an ALJ for a hearing. R.pp. 800-22. The ALJ issued a third unfavorable decision on March 28, 2023. R.p. 761-94. This appeal followed. See ECF No. 12 at 2 (citing HALLEX I-4-8-5 and explaining that Plaintiff elected to file another civil action rather than to file exceptions with the Appeals Council).
Because this Court writes primarily for the parties who are familiar with the facts, the Court dispenses with a lengthy recitation of the medical history from the relevant period. To the extent specific records or information are relevant to or at issue in this case, they are addressed within the Discussion section below.
II. APPLICABLE LAW
A. Scope of Review
Jurisdiction of this Court is pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). Under § 405(g), judicial review of a final decision regarding disability benefits is limited to determining (1) whether the factual findings are supported by substantial evidence, and (2) whether the correct legal standards were applied. 42 U.S.C. § 405(g); Walls v. Barnhart, 296 F.3d 287, 290 (4th Cir. 2002) (citing Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990)). Accordingly, a reviewing court must uphold the final decision when “an ALJ has applied correct legal standards and the ALJ's factual findings are supported by substantial evidence.” Brown v. Comm'r Soc. Sec. Admin., 873 F.3d 251, 267 (4th Cir. 2017) (internal quotation marks omitted).
“Substantial evidence” is an evidentiary standard that is not high: it is “more than a mere scintilla” and means only “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019). A reviewing court does not reweigh conflicts in evidence, make credibility determinations, or substitute its judgment for that of the ALJ. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). “Where conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the responsibility for that decision falls on the [ALJ].” Id. (alteration in original) (internal quotation marks and citation omitted). However, this limited review does not mean the findings of an ALJ are to be mechanically accepted, as the “statutorily granted review contemplates more than an uncritical rubber stamping of the administrative action.” Howard v. Saul, 408 F.Supp.3d 721, 725-26 (D.S.C. 2019) (quoting Flack v. Cohen, 413 F.2d 278, 279 (4th Cir. 1969)).
B. Social Security Disability Evaluation Process
To be considered “disabled” within the meaning of the Social Security Act, a claimant must show that he has an impairment or combination of impairments which prevent him from engaging in all substantial gainful activity for which he is qualified by his age, education, experience, and functional capacity, and which has lasted or could reasonably be expected to last for a continuous period of not less than twelve months. See 42 U.S.C. § 423. The Social Security Administration established a five-step sequential procedure in order to evaluate whether an individual is disabled for purposes of receiving benefits. See 20 C.F.R. §§ 404.1520, 416.920; see also Mascio v. Colvin, 780 F.3d 632, 634-35 (4th Cir. 2015) (outlining the questions asked in the five-step procedure). The burden rests with the claimant to make the necessary showings at each of the first four steps to prove disability. Mascio, 780 F.3d at 634-35. If the claimant fails to carry his burden, he is found not disabled. Lewis v. Berryhill, 858 F.3d 858, 861 (4th Cir. 2017). If the claimant is successful at each of the first four steps, the burden shifts to the Commissioner at step five. Id.
At the first step, the ALJ must determine whether the claimant has engaged in substantial gainful activity since his alleged disability onset date. 20 C.F.R. §§ 404.1520(b), 416.920(b). At step two, the ALJ determines whether the claimant has an impairment or combination of impairments that meet the regulations' severity and duration requirements. Id. §§ 404.1520(c), 416.920(c). At step three, the ALJ considers whether the severe impairment meets the criteria of an impairment listed in Appendix 1 of 20 C.F.R. part 404, subpart P (the “Listings”) or is equal to a listed impairment. If so, the claimant is automatically eligible for benefits; if not, before moving on to step four, the ALJ assesses the claimant's residual functional capacity (RFC). Id. §§ 404.1520(d), (e), 416.920(d), (e); Lewis, 858 F.3d at 861.
The RFC is “the most the claimant can still do despite physical and mental limitations that affect her ability to work.” Mascio, 780 F.3d at 635 (internal quotation marks and citations omitted).
At step four, the ALJ determines whether, despite the severe impairment, the claimant retains the RFC to perform his past relevant work. 20 C.F.R. §§ 404.1520(e), (f), 416.920(e), (f). If the ALJ finds the claimant capable of performing his past relevant work, he is not disabled. Id. §§ 404.1520(f), 416.920(f). If the requirements to perform the claimant's past relevant work exceed his RFC, then the ALJ goes on to the final step.
At step five, the burden of proof shifts to the Social Security Administration to show that the claimant can perform other jobs existing in significant numbers in the national economy, considering the claimant's age, education, work experience, and RFC. Id. §§ 404.1520(g), 416.920(g); Mascio, 780 F.3d at 634-35. Typically, the Commissioner offers this evidence through the testimony of a vocational expert answering hypotheticals that incorporate the claimant's limitations. Mascio, 780 F.3d at 635. “If the Commissioner meets her burden, the ALJ finds the claimant not disabled and denies the application for benefits.” Id.
III. ADMINISTRATIVE FINDINGS
The ALJ employed the statutorily-required five-step sequential evaluation process to determine whether Plaintiff was disabled from the alleged onset date of February 23, 2016, through the last date insured. R.pp. 764-87. The ALJ found, in pertinent part:
1. The claimant last met the insured status requirements of the Social Security Act on December 31, 2021.
2. The claimant did not engage in substantial gainful activity during the period from her alleged onset date of February 23, 2016, through her date last insured of December 31, 2021 (20 CFR 404.1571, et seq.).
3. Through the date last insured, the claimant had the following severe impairments: cervical degenerative disc disease status post fusion with radiculopathy, status post right rotator cuff and right bicep tear repairs, right upper extremity radiculopathy, and fibromyalgia (20 CFR 404.1520(c))
4. Through the date last insured, the claimant did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525 and 404.1526)....
5. After careful consideration of the entire record, I find that, through the date last insured, the claimant had the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a) except that the claimant could frequently sit, stand, and walk and could occasionally reach overhead with her right upper extremity. The claimant could perform frequent handling and fingering, can occasionally climb ramps and stairs but never climb ladders, ropes, or scaffolds. The claimant could frequently stoop and occasionally kneel, crouch, and crawl. She had to avoid concentrated exposure to workplace hazards....
6. Through the date last insured, the claimant was capable of performing past relevant work as a secretary, DOT #201.362-030, SVP 6, sedentary, and accounting clerk, DOT #216.482-010, SVP 5, sedentary. This work did not require the
performance of work-related activities precluded by the claimant's residual functional capacity (20 CFR 404.1565)....
7. The claimant was not under a disability, as defined in the Social Security Act, at any time from February 23, 2016, the alleged onset date, through December 31, 2021, the date last insured (20 CFR 404.1520(f)).R.pp. 766-87.
The ALJ found the following conditions to be non-severe: migraine headaches, joint stiffness of the left knee, Dupuytren's contracture of the right hand, right carpal tunnel syndrome, lumbar disc herniation, sudden onset right foot drop, depression, and generalized anxiety disorder. R.pp. 76769.
IV. DISCUSSION
Plaintiff argues that remand is warranted for several reasons. First, she argues that the ALJ's findings at step 2 were not supported by substantial evidence. ECF No. 12 at 18-20. Second, she argues that the ALJ failed to consider the combined effects of her multiple impairments. Id. at 21-23. She also contends that the RFC assessment is not supported by substantial evidence because the ALJ failed to properly evaluate the medical opinion evidence and her subjective complaints. Id. at 23-39. For the reasons that follow, the undersigned concludes that remand is warranted.
A. RFC Assessment Generally
“RFC is an assessment of an individual's ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis.” Titles II & XVI: Assessing Residual Functional Capacity in Initial Claims, Social Security Ruling (SSR) 96-8p, 1996 WL 374184 at *7 (S.S.A. July 2, 1996). A claimant's RFC, which represents “the most [she] can still do despite [her] limitations,” must be based on all the relevant evidence in the case record and should account for all of the claimant's medically determinable impairments, including those that are not severe. Id.; 20 C.F.R. §§ 404.1545(a), 416.945(a).
Social Security Rulings, or “SSRs,” are “interpretations by the Social Security Administration of the Social Security Act.” Pass v. Chater, 65 F.3d 1200, 1204 n.3 (4th Cir. 1995). They do not carry the force of law but are “binding on all components of the Social Security Administration,” 20 C.F.R. § 402.35(b)(1), as well as on ALJs when they are adjudicating Social Security cases. See Bray v. Comm'r of Soc. Sec. Admin., 554 F.3d 1219, 1224 (9th Cir. 2009).
In evaluating an RFC, an ALJ must “consider all of the claimant's ‘physical and mental impairments, severe and otherwise, and determine, on a function-by-function basis, how they affect h[er] ability to work.'” Thomas v. Berryhill, 916 F.3d 307, 311 (4th Cir. 2019) (quoting Monroe v. Colvin, 826 F.3d 176, 188 (4th Cir. 2016)). “‘Only after such a function-by-function analysis may an ALJ express RFC in terms of the exertional levels of work' of which [s]he believes the claimant to be capable.” Dowling v. Comm'r of Soc. Sec. Admin., 986 F.3d 377, 387 (4th Cir. 2021) (quoting Monroe, 826 F.3d at 179).
The RFC assessment must include a narrative discussion describing how all the relevant evidence supports each conclusion and must cite “specific medical facts (e.g., laboratory findings) and non-medical evidence (e.g., daily activities, observations).” SSR 96-8p, 1996 WL 374184 at *7. “The RFC assessment must always consider and address medical source opinions. If the RFC assessment conflicts with an opinion from a medical source, the adjudicator must explain why the opinion was not adopted.” Id. “The RFC assessment must include a discussion of why reported symptom-related functional limitations and restrictions can or cannot reasonably be accepted as consistent with the medical and other evidence.” Id.
In assessing the RFC, the ALJ must explain how any material inconsistencies or ambiguities in the record were resolved, SSR 96-8p, 1996 WL 374184 at *7, and she must “build an accurate and logical bridge from the evidence to his conclusions,” Monroe, 826 F.3d at 189 (quoting Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000)). Consequently, “a proper RFC analysis has three components: (1) evidence, (2) logical explanation, and (3) conclusion.” Thomas, 916 F.3d at 311. The ALJ's logical explanation is just as important as the ALJ's discussion of evidence and his conclusion. Id. “[R]emand may be appropriate where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite contradictory evidence in the record, or where other inadequacies in the ALJ's analysis frustrate meaningful review.” Mascio, 780 F.3d at 636 (citations and internal quotation marks omitted).
B. Evaluation of Subjective Complaints
A claimant's statements are among the evidence the ALJ must consider and reconcile with the RFC assessment. “[A]n ALJ follows a two-step analysis when considering a claimant's subjective statements about impairments and symptoms.” Lewis, 858 F.3d at 865-66 (citing 20 C.F.R. §§ 404.1529(b)-(c), 416.929(b)-(c)). “First, the ALJ looks for objective medical evidence showing a condition that could reasonably produce the alleged symptoms.” Id. at 866 (citing 20 C.F.R. §§ 404.1529(b), 416.929(b)). The ALJ proceeds to the second step only if the claimant's impairments could reasonably produce the symptoms she alleges. See 20 C.F.R. §§ 404.1529(c)(1), 416.929(c)(1) .
At the second step, the ALJ is required to “evaluate the intensity, persistence, and limiting effects of the claimant's symptoms to determine the extent to which they limit the claimant's ability to perform basic work activities.” Lewis, 858 F.3d at 866 (citing 20 C.F.R. §§ 404.1529(c), 416.929(c)). The ALJ must “evaluate whether the [claimant's] statements are consistent with objective medical evidence and the other evidence.” Titles II & XVI: Evaluation of Symptoms in Disability Claims, SSR 16-3P, 2017 WL 5180304, at *6 (S.S.A. Oct. 25, 2017).
“Other evidence” includes “statements from the individual, medical sources, and any other sources that might have information about the individual's symptoms, including agency personnel, as well as the factors set forth in [the] regulations.” SSR 16-3P, 2017 WL 5180304, at *6; see also 20 C.F.R. §§ 404.1529(c)(3) (listing factors to consider, such as claimant's daily activities; the location, duration, frequency, and intensity of pain or other symptoms; factors that precipitate and aggravate the symptoms; medication and other treatment taken or received to relieve pain or other symptoms; any measures other than treatment the individual uses or has used to relieve pain or other symptoms; and any other factors concerning an individual's functional limitations and restrictions due to pain or other symptoms).
Pursuant to SSR 16-3p, the ALJ must explain which of the claimant's symptoms the ALJ found “consistent or inconsistent with the evidence in [the] record and how [the ALJ's] evaluation of the individual's symptoms led to [the ALJ's] conclusions.” 2017 WL 5180304, at *8. The ALJ must evaluate the “individual's symptoms considering all the evidence in [the] record.” Id. Importantly, the ALJ is not to evaluate the claimant's symptoms “based solely on objective medical evidence unless that objective medical evidence supports a finding that the individual is disabled.” SSR 16-3p, 2017 WL 5180304, at *5; see Arakas v. Comm'r, Soc. Sec. Admin., 983 F.3d 83, 98 (4th Cir. 2020) (“We also reiterate the long-standing law in our circuit that disability claimants are entitled to rely exclusively on subjective evidence to prove the severity, persistence, and limiting effects of their symptoms.”).
On appeal, Plaintiff argues that the ALJ's conclusions regarding her subjective complaints are not supported by substantial evidence because the ALJ broadly rejected her complaints without any meaningful discussion or explanation, and the ALJ failed to consider Plaintiff's qualifying statements regarding the extent to which she can perform her activities of daily living. ECF No. 12 at 26-29. In response, the Commissioner argues that the ALJ properly evaluated Plaintiff's subjective complaints and that the “path of the ALJ's reasoning is traceable.” ECF No. 16 at 2022. Upon review, the undersigned is constrained to agree with Plaintiff.
The ALJ first assessed the following RFC for Plaintiff:
After careful consideration of the entire record, I find that, through the date last insured, the claimant had the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a) except that the claimant could frequently sit, stand, and walk and could occasionally reach overhead with her right upper extremity. The claimant could perform frequent handling and fingering, can occasionally climb ramps and stairs but never climb ladders, ropes, or scaffolds. The claimant could frequently stoop and occasionally kneel, crouch, and crawl. She had to avoid concentrated exposure to workplace hazards.R.p. 771.
The ALJ then explained, “In making this finding, I have considered all symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence, based on the requirements of 20 CFR 404.1529 and SSR 163p. I also considered the medical opinion(s) and prior administrative medical finding(s) in accordance with the requirements of 20 CFR 404.1520c.” R.p. 771.
The ALJ summarized Plaintiff's testimony from her hearings as follows:
During her first hearing, held on June 5, 2019, the claimant testified that she experienced ongoing symptoms of pain in her neck due to a cervical discectomy, reporting that she experienced ongoing upper back spasms. Additionally, the claimant testified that she underwent a prior right rotator cuff and bicep repair procedure, reporting that she occasionally wore a shoulder brace due to ongoing symptoms of pain in her right shoulder. Due to her back and shoulder problems, the claimant reported that she could not lift or carry much with her right arm, reporting that she could only lift a gallon of milk with the left arm. The claimant also testified that she had trouble kneeling, climbing stairs, and walking as well. In addition to her physical conditions, the claimant testified that she experienced symptoms of depression and anxiety, reporting that she had trouble sleeping at night, trouble concentrating, and fatigue. In terms of daily activities, the claimant reported that she spent time with family members, that she napped every day, and that she could only complete chores with her left arm, reporting that she did not wash laundry or cook. The claimant also testified that she often went several days at a time without washing her hair or shaving her legs due to her symptoms of pain.
The claimant testified again on December 15, 2022; at which time she was 57 years old. She lives with her husband, who is disabled and no longer works. The claimant's representative argued that she met the requirements of listing 1.21 addressing soft tissue injury. The claimant is able to drive if necessary but stated that she tries to limit her driving due to neck issues. She alleged that since her February 2016 workplace accident, she has been in pain and depressed and has undergone two failed surgeries. She described her pain as chronic but varied as to where it is located by day. The claimant reported pain in her neck, arm, back, and head. She reported history of cervical spine surgery in November 2016 and shoulder surgery and October 2017. The claimant stated that she is depressed due to her inability to work and perform her usual activities of daily living. She reported recent diagnosis with fibromyalgia and foot drop. She indicated left side spasm. The claimant reported some difficulty obtaining treatment as her injury was a Worker's Compensation case. Regarding her medication, the claimant alleged taking OxyContin three times a day, ibuprofen as needed, Valium for muscle spasms, Xanax for anxiety, and Cymbalta for depression and pain. She stated that due to elevated liver levels, her doctor suggested she try to go without Lyrica and ibuprofen but stated that she is unable to get by without ibuprofen. Socially, the
claimant reported smoking five or fewer cigarettes per day. In describing a typical day, the claimant reported difficulty sleeping due to anxiety and due to arm pain and spasm. She naps as needed during the day. She reported upset stomach in the morning secondary to stress and use of fiber. The claimant has four adult children and four grandchildren but stated that she sees them only rarely due to Covid. She stated that her husband, who she indicated is disabled due to failed back surgery, does the primary cooking and cleaning but also testified that they have a housekeeper for the bathrooms, floors, and dusting. The claimant is able to use the Internet but stated that she has difficulty keeping her head down to look at her laptop or phone. She uses the Internet for playing games and rarely to go on social media. The claimant's husband orders groceries online for delivery. She denied other social activities. While the claimant has indicated that she does not leave the house unless she must, she would not agree to a video or telephone hearing. She alleged reduced concentration and memory.R.pp. 772-73.
Review of the record suggests that, although the ALJ specifically cites Plaintiff's December 2022 testimony at the beginning of the second paragraph, the ALJ was summarizing Plaintiff's testimony from both the January 2021 hearing and the December 2022 hearing. See R.pp. 65-100, 795-824.
The ALJ then found:
After careful consideration of the evidence, I find that the claimant's medically determinable impairments could reasonably be expected to cause some of her alleged symptoms; however, the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record for the reasons explained in this decision.R.p. 773 (emphasis added). The ALJ then went on to summarize the medical records in the record before making the following finding:
The claimant [sic] has considered and analyzed the claimant's subjective statements about her impairments and symptoms pursuant to SSR 16-3P. I have looked for objective medical evidence showing the condition that could reasonably produce alleged symptoms, such as pain. I have also evaluated the intensity, persistence, and limiting effects of the claimant's symptoms to determine the extent to which they limit the claimant's ability to work. In making this determination, I must and have examined the entire case record, including the objective medical evidence; the claimant's statements about the intensity, persistence, and limiting effects of symptoms; statements and other information provided by medical sources and other persons; and any other relevant evidence in the individual's case record.R.pp. 773-79. The ALJ does not, however, explain why or how the ALJ found Plaintiff's statements concerning the intensity, persistence and limiting effects of these symptoms to be not entirely consistent with the medical evidence and other evidence in the record.
SSR 16-3p expressly provides that an ALJ decision “must contain specific reasons for the weight given to the individual's symptoms, be consistent with and supported by the evidence, and be clearly articulated so the individual and any subsequent reviewer can assess how the adjudicator evaluated the individual's symptoms.” SSR 16-3p, 2017 WL 5180304, at *10. Here, however, the ALJ does not explain which statements she found to inconsistent or provide any reasons why she found Plaintiff's statements regarding her symptoms to be inconsistent, and without clear articulation of how the ALJ evaluated Plaintiff's symptoms, meaningful review is frustrated.
The Commissioner argues that the ALJ “explained why the evidence supported an RFC that limited Plaintiff to performing sedentary work” with restrictions, and the Commissioner maintains that “[t]his same evidence establishes why Plaintiff's claims of being disabled were not entirely consistent with the evidence.” ECF No. 16 at 21. However, “an RFC assessment is a separate and distinct inquiry from a symptom evaluation, and [an] ALJ err[s] by treating them as one and the same.” Dowling v. Comm 'r of Soc. Sec. Admin., 986 F.3d 377, 387 (4th Cir. 2021).
Tellingly, the Commissioner does not point to anywhere in the decision where the ALJ explains her symptom evaluation or why she concluded that Plaintiff's symptoms are not entirely consistent with the record; rather, the Commissioner merely notes that the ALJ discussed Plaintiff's medical records and provides post-hac rationale for how these records could support the ALJ's conclusory statement that the reported intensity, persistence and limiting effects of Plaintiff's subjective symptoms are not entirely consistent with the medical evidence and other evidence in the record. See ECF No. 16 at 21-22. However, the court “cannot accept post-hoc rationalizations not contained within the ALJ's decision.” Hilton v. Astrue, No. CA 6:10-2012-CMC, 2011 WL 5869704, at *4 (D.S.C. Nov. 21, 2011); see also Bray v. Comm'r of Soc. Sec. Admin., 554 F.3d 1219, 1225 (9th Cir. 2009) (“Long-standing principles of administrative law require us to review the ALJ's decision based on the reasoning and factual findings offered by the ALJ-not post hoc rationalizations that attempt to intuit what the adjudicator may have been thinking.” (first emphasis added)).
Moreover, the medical evidence and opinion evidence summarized by the ALJ largely corroborates many of Plaintiff's complaints of fatigue, persistent pain, and muscle spasms, despite evidence of “[p]ersistent attempts to obtain relief of symptoms, such as increasing dosages and changing medications, trying a variety of treatments, [and] referrals to specialists.” See SSR 163p, 2017 WL 5180304, at *9 (explaining that such persistent attempts “may be an indication that an individual's symptoms are a source of distress and may show that they are intense and persistent”); see also R.pp. 771-85. Without explanation from the ALJ, as required by SSR 16-3p, the undersigned is left to guess at which of Plaintiff's statements regarding the limiting effects of her symptoms the ALJ found inconsistent and why. See SSR 16-3p, 2017 WL 5180304, at *10.
Plaintiff notes that when the ALJ found unpersuasive Dr. John Fulkerson's opinion that Plaintiff would not be able to return to her work without additional treatment, the ALJ stated that Plaintiff's post-surgery “improved neck range of motion, combined with her abilities to drive, shop, and performed household chores, support a finding that she has greater functional abilities.” ECF No. 12 at 28 (citing R.p. 782). However, the ALJ does not appear to consider the extent to which Plaintiff can perform those activities, and there is evidence that Plaintiff is more limited than the ALJ suggests.
Specifically, at her 2019 hearing, Plaintiff testified that she cannot dress herself or wash her own hair at times; does not cook or do laundry; can only clean with her left hand; she drives only occasionally and avoids driving because of her neck spasms and pain when she turns her neck; and shops only with her adult daughter, who picks everything off the shelf and puts them in the cart and car. R.pp. 40-56. Plaintiff also testified that she has difficulty sleeping through the night; naps two to four hours a day; experiences medication side effects including fatigue, diarrhea, nausea, migraines, difficulty concentrating and remembering, and sleeplessness; no longer can garden or play bingo because of pain; and that her pain generally ranges from six to ten. R.pp. 4056. Plaintiff similarly testified at her January 2021 hearing that she avoids driving because of her neck; her husband does the cooking and cleaning; a neighbor cleans their house every other week; her husband places online grocery orders that get delivered right to the door; she experiences medication side effects day and night, including feeling “always fatigued, foggy, nausea, [and] diarrhea”; and her pain is constant and ranges from a five to a ten. R.pp. 72, 77-84.
It is not clear from the decision how the ALJ considered this testimony in determining that Plaintiff's subjective statements of the limiting effects of her symptoms are not entirely consistent with the record. However, it is well-settled that in evaluating a claimant's pain-related complaints, an “ALJ may not consider the type of activities a claimant can perform without also considering the extent to which she can perform them.” Woods v. Berryhill, 888 F.3d 686, 694 (4th Cir. 2018) (emphasis in original); see Arakas, 983 F.3d at 100 (finding reversible error and explaining that because the “ALJ selectively cited evidence concerning tasks which Arakas was capable of performing and improperly disregarded her qualifying statements[,] . . . he failed to build an accurate and logical bridge from the evidence to his conclusion” (internal quotation marks omitted) (citing Monroe, 826 F.3d at 189; Hines v. Barnhart, 453 F.3d 559, 565 (4th Cir. 2006))). The ALJ's reliance on evidence that Plaintiff can drive, shop, and do household chores to discount a medical opinion, without consideration of the very limited extent to which she can perform these activities, suggests that the ALJ may not have properly considered Plaintiff's daily activities in evaluating her subjective statements.
The ALJ's cursory statements that Plaintiff's allegations of disabling limitations are not fully consistent with the medical evidence and other evidence is insufficient to adequately explain why the ALJ reached this conclusion and which aspects of the Plaintiff's testimony was discounted. Without explanation by the ALJ regarding how she considered Plaintiff's subjective statements, she failed to “build an accurate and logical bridge” from the evidence to her conclusion. See Arakas, 983 F.3d at 100.
Remand is required here as the undersigned is unable to determine whether the ALJ's evaluation of Plaintiff's subjective complaints, which necessarily impacts other aspects of the decision, is supported by substantial evidence. See Mascio, 780 F.3d at 636. Accordingly, this matter should be remanded for further consideration and explanation of the ALJ's consideration of Plaintiff's subjective complaints and ultimately how she arrived at Plaintiff's RFC.
C. Remaining allegations of error
Plaintiff also argues the ALJ erred in finding some of her medically determinable impairments non-severe, in failing to consider the combined effects of her impairments, and in failing to properly assess the medical opinion evidence. ECF No. 12. Because the undersigned has determined that the errors in ALJ's symptom evaluation warrant remand, the undersigned declines to further address these remaining claims of error. However, upon remand, the ALJ should take such claims of error into consideration. With respect to any remaining claims of error, the ALJ will be able to reconsider and re-evaluate the evidence in toto as part of the reconsideration. See Hancock v. Barnhart, 206 F.Supp.2d 757, 763 n.3 (W.D. Va. 2002) (noting the ALJ's prior decision has no preclusive effect, as it is vacated, and the new hearing is conducted de novo).
V. CONCLUSION
It is RECOMMENDED that the decision of the Commissioner be REVERSED and REMANDED pursuant to sentence four of 42 U.S.C. § 405(g) for further administrative review.
The parties are directed to the next page for their rights to file objections to this recommendation.
Notice of Right to File Objections to Report and Recommendation
The parties are advised that they may file specific written objections to this Report and Recommendation with the District Judge. Objections must specifically identify the portions of the Report and Recommendation to which objections are made and the basis for such objections. “[I]n the absence of a timely filed objection, a district court need not conduct a de novo review, but instead must ‘only satisfy itself that there is no clear error on the face of the record in order to accept the recommendation.'” Diamond v. Colonial Life & Acc. Ins. Co., 416 F.3d 310 (4th Cir. 2005) (quoting Fed.R.Civ.P. 72 advisory committee's note).
Specific written objections must be filed within fourteen (14) days of the date of service of this Report and Recommendation. 28 U.S.C. § 636(b)(1); Fed.R.Civ.P. 72(b); see Fed.R.Civ.P. 6(a), (d). Filing by mail pursuant to Federal Rule of Civil Procedure 5 may be accomplished by mailing objections to:
Robin L. Blume, Clerk
United States District Court
Post Office Box 835
Charleston, South Carolina 29402
Failure to timely file specific written objections to this Report and Recommendation will result in waiver of the right to appeal from a judgment of the District Court based upon such Recommendation. 28 U.S.C. § 636(b)(1); Thomas v. Arn, 474 U.S. 140 (1985); Wright v. Collins, 766 F.2d 841 (4th Cir. 1985); United States v. Schronce, 727 F.2d 91 (4th Cir. 1984).