Opinion
C. A. 20-2408-JMC-PJG
04-26-2021
Lisa Ann Holden-Adams, Plaintiff, v. Andrew Saul, Commissioner of the Social Security Administration, Defendant.
REPORT AND RECOMMENDATION ON PLAINTIFF'S APPEAL FROM THE SOCIAL SECURITY ADMINISTRATION'S DENIAL OF SOCIAL SECURITY BENEFITS [X] AFFIRM [ ] REVERSE AND REMAND
PAIGE J. GOSSETT UNITED STATES MAGISTRATE JUDGE
This social security matter is before the court for a Report and Recommendation pursuant to Local Civil Rule 83.VII.02 (D.S.C.). The plaintiff brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) to obtain judicial review of a final decision of the defendant, Commissioner of Social Security (“Commissioner”), denying the plaintiff's claims for social security benefits.
Part I-Plaintiff seeks:
[ ] Supplemental Security Income (“SSI”)
Application Date:___ Plaintiff's age at filing:___
[X] Disability Insurance Benefits (“DIB”)
Date last insured: December 31, 2023
[ ] Other:
Plaintiff's Year of Birth: 1960
Plaintiff's alleged onset Dated: January 16, 2018
Part II-Social Security Disability Generally
Under 42 U.S.C. § 423(d)(1)(A), (d)(5), and/or 42 U.S.C. § 1382c(a)(3)(H)(i), as well as pursuant to the regulations formulated by the Commissioner, the plaintiff has the burden of proving disability, which is defined as an “inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 20 C.F.R. § 404.1505(a) and/or § 416.905(a); see also Blalock v. Richardson, 483 F.2d 773 (4th Cir. 1973). The regulations generally require the Administrative Law Judge (“ALJ”) to consider five issues in sequence, as outlined below. 20 C.F.R. § 404.1502(a)(4) and/or § 416.920(a)(4). If the ALJ can make a determination that a claimant is or is not disabled at any point in this process, review does not proceed to the next step. Id.
A claimant has the initial burden of showing that he/she is unable to return to past relevant work because of his/her impairments. Once the claimant establishes a prima facie case of disability, the burden shifts to the Commissioner. To satisfy this burden, the Commissioner must establish that the claimant has the residual functional capacity, considering the claimant's age, education, work experience, and impairments, to perform alternative jobs that exist in the national economy. 42 U.S.C. § 423(d)(2)(A) and/or § 1382c(a)(3)(A)-(B); see also McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983); Hall v. Harris, 658 F.2d 260, 264-65 (4th Cir. 1981); Wilson v. Califano, 617 F.2d 1050, 1053 (4th Cir. 1980). The Commissioner may carry this burden by obtaining testimony from a vocational expert. Grant v. Schweiker, 699 F.2d 189, 192 (4th Cir. 1983).
Part III-Administrative Proceedings
Date of ALJ Decision: November 8, 2019
In applying the requisite five-step sequential process, the ALJ found:
Step 1: Plaintiff was engaged in substantial gainful activity during the relevant time period: [ ] Yes [X] No
Step 2: [X] Plaintiff has the following severe impairments: Seronegative inflammatory arthritis; degenerative disc disease (DDD); osteoarthritis of the fingers and toes.
[ ] Plaintiff does not have a severe impairment.
Step 3: [X] Plaintiff's impairment(s) does/do not meet or medically equal a Listing. 20 C.F.R. Part 404, Subpart P, Appendix 1.
Step 4: Plaintiff's Residual Functional Capacity is as follows:
[T]he claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b). In particular, the claimant can lift or carry up to 20 pounds occasionally and 10 pounds frequently. She can stand or walk for approximately 6 hours of an 8-hour workday and sit for approximately 6 hours of an 8-hour workday with normal breaks. The claimant can frequently climb ramps and stairs, occasionally climb ladders, ropes and scaffolds, stoop, kneel, crouch and crawl.
[X] Plaintiff could return to his/her past relevant work.
Step 5: [ ] Plaintiff could not return to his/her past relevant work, but using the Medical-Vocational Guidelines (“Grids”) as a framework supports a finding that Plaintiff is not disabled. 20 C.F.R. Pt. 404, Subpt. P, App'x 2.
[ ] Plaintiff could not return to his/her past relevant work, but there are jobs in the national economy that Plaintiff can perform, as follows:Date of Appeals Council decision: June 3, 2020
Part IV-Standard of Review
Pursuant to 42 U.S.C. § 405(g), the court may review the Commissioner's denial of benefits. However, this review is limited to considering whether the Commissioner's findings “are supported by substantial evidence and were reached through application of the correct legal standard.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996); see also 42 U.S.C. § 405(g); Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). Thus, the court may review only whether the Commissioner's decision is supported by substantial evidence and whether the correct law was applied. See Brown v. Comm'r Soc. Sec. Admin., 873 F.3d 251, 267 (4th Cir. 2017); Myers v. Califano, 611 F.2d 980, 982 (4th Cir. 1980). “Substantial evidence” means “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance.” Craig, 76 F.3d at 589; see also Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019); Pearson v. Colvin, 810 F.3d 204, 207 (4th Cir. 2015). “Under the substantial-evidence standard, a court looks to an existing administrative record and asks whether it contains ‘sufficien[t] evidence' to support the agency's factual determinations.” Biestek, 139 S.Ct. at 1154 (citation omitted). In reviewing the evidence, the court may not “undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner].” Craig, 76 F.3d at 589; see also Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Accordingly, even if the court disagrees with the Commissioner's decision, the court must uphold it if it is supported by substantial evidence. Blalock, 483 F.2d at 775.
Part V-Issues for Judicial Review
Plaintiff argues that the ALJ's decision is not supported by substantial evidence because the ALJ erred (1) in failing to properly evaluate her subjective complaints, (2) in failing to properly assess the medical opinions in her case, and (3) in failing to properly assess Plaintiff's residual functional capacity, both as to her physical and mental limitations.
Oral Argument:
[ ] Held on ___.
[X] Not necessary for recommendation.
Summary of Reasons
A. Subjective Complaints
With regard to subjective complaints, the United States Court of Appeals for the Fourth Circuit has stated that “the determination of whether a person is disabled by pain or other symptoms is a two-step process.” Craig v. Chater, 76 F.3d 585, 594 (4th Cir. 1996). The first step requires there to “be objective medical evidence showing the existence of a medical impairment(s) which results from anatomical, physiological, or psychological abnormalities and which could reasonably be expected to produce the pain or other symptoms alleged.” Id. (internal quotation omitted). During the second step, the ALJ must expressly consider “the intensity and persistence of the claimant's [symptom] and the extent to which it affects her ability to work.” Id. In making these determinations, the ALJ's 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. ALJs are further instructed to
limit their evaluation to the individual's statements about his or her symptoms and the evidence in the record that is relevant to the individual's impairments. In evaluating an individual's symptoms, our adjudicators will not assess an individual's overall character or truthfulness in the manner typically used during an adversarial court litigation. The focus of the evaluation of an individual's symptoms should not be to determine whether he or she is a truthful person. Rather, our adjudicators will focus on whether the evidence establishes a medically determinable impairment that could reasonably be expected to produce the individual's symptoms and given the adjudicator's evaluation of the individual's symptoms, whether the intensity and persistence of the symptoms limit the individual's ability to perform work-related activities . . . .Id. at *11.
Further, “claims of disabling pain may not be rejected ‘solely because the available objective evidence does not substantiate [the claimant's] statements' as to the severity and persistence of her pain.” Craig, 76 F.3d at 595 (citations omitted) (alteration in original); see also Arakas v. Comm'r, 983 F.3d 83, 95-96 (4th Cir. 2020) (finding that the ALJ disregarded “longstanding precedent and the agency's own policy by improperly discounting Arakas's subjective complaints of pain and fatigue, based largely on the lack of objective evidence substantiating her statements”). “This is not to say, however, that objective medical evidence and other objective evidence are not crucial to evaluating the intensity and persistence of a claimant's pain and the extent to which it impairs [her] ability to work.” Craig, 76 F.3d at 595. A claimant's subjective complaints “need not be accepted to the extent they are inconsistent with the available evidence, including objective evidence of the underlying impairment, and the extent to which that impairment can reasonably be expected to cause the [symptoms] the claimant alleges she suffers.” Id. The social security regulations inform claimants that in evaluating subjective complaints, the Commissioner will consider the following relevant factors:
(i) Your daily activities;
(ii) The location, duration, frequency, and intensity of your pain or other symptoms;
(iii) Precipitating and aggravating factors;
(iv) The type, dosage, effectiveness, and side effects of any medication you take or have taken to alleviate your pain or other symptoms;
(v) Treatment, other than medication, you receive or have received for relief of your pain or other symptoms;
(vi) Any measures you use or have used to relieve your pain or other symptoms (e.g., lying flat on your back, standing for 15 to 20 minutes every hour, sleeping on a board, etc.); and
(vii) Other factors concerning your functional limitations and restrictions due to pain or other symptoms.20 C.F.R. § 404.1529(c)(3).
In this case, the ALJ summarized Plaintiff's allegations as follows:
The claimant testified that she lived with her husband and had a driver's license but only drives about once a month. She has good days and bad days where she does not get out of bed. The claimant has rheumatoid arthritis and depression. She uses a knee brace and a back brace but she cannot be on her feet for long. She can sit for 15 minutes, stand about 15 minutes and lift 5 pounds. The claimant asserted that she had pain in her back, knees, hips, and shoulder. The claimant testified that she had a pelvic fracture in February 2019 but this had healed. She was roller skating on a good day and fell. She does not use a cane or a walker to ambulate. The claimant testified that she could only concentrate for 10 minutes and she had poor impulse control. Her husband helps her with her daily activities and with getting dressed. She does not do any household chores. She cannot do simple math and her husband handles the money.(Tr. 23.) The ALJ then summarized and discussed Plaintiff's medical records. (Tr. 23-25.) The ALJ found that Plaintiff's “statements concerning the intensity, persistence and limiting effects of [her alleged] symptoms are not entirely consistent with the medical evidence and other evidence in the record . . . .” (Tr. 25.) The ALJ also found numerous records, findings, and reports to be inconsistent with the severity of Plaintiff's symptoms, as alleged. Specifically, the ALJ found that the following were inconsistent with Plaintiff's complaints of incapacitating impairments:
• Plaintiff's December 2017 MRI of her right shoulder, which showed glenohumeral joint effusion but no other significant abnormalities;
• X-rays of Plaintiff's hands in April 2018, which showed no erosive arthropathy, preserved joint spaces, and no fracture or acute finding, as well as x-rays of Plaintiff's knees that showed some fullness in the suprapatellar bursas bilaterally consistent with small joint effusion but preserved joint spaces, and an x-ray of the pelvis, which showed preserved hip joint spaces and no abnormalities of the subsequent iliac joints;
• An MRI of Plaintiff's lumbar spine in October 2018, which showed multilevel spinal stenosis without spinal cord or active nerve root compression, multiple chronic fractures, presumably due to underlying osteoporosis, multilevel degenerative disc disease, most severe at ¶ 5-S1, but with minimal neural foraminal encroachment, and multilevel facet arthropathy;
• Objective examination, which showed as follows: Plaintiff was in no distress; she had normal heart and lung sounds; her neck was supple with good range of motion; Plaintiff had reduced range of motion in her lumbar spine with flexion and was positive for straight leg raising; Plaintiff had some decreased range of motion in her knees; she had some bony enlargement of the finger joints with tenderness and synovitis and bony enlargement of the ulnar-stylod process in both wrists with tenderness but no synovitis; Plaintiff had normal grip strength and normal fine and gross manipulation; Plaintiff otherwise had full range of motion in her upper and lower extremities; Plaintiff could perform gait maneuvers with some pain; Plaintiff's reflexes and sensation were normal; her cranial nerves were intact; and she could ambulate without assistance and without any problems.(See Tr. 25.) The ALJ concluded that the “objective and diagnostic test findings are not consistent with the alleged incapacitating impairments and indicate the claimant's impairments may not be as severe or debilitating as alleged.” (Tr. 25-26.)
The ALJ further noted that the treatment for Plaintiff's conditions had been conservative in that Plaintiff “ha[d] not required surgical intervention, . . . did not require inpatient admissions[, ] and . . . did not require more than minimal emergency care for stabilization of symptoms. (Tr. 26.) For example, Plaintiff's inflammatory arthritis had been successfully treated with steroids, and while Plaintiff had been advised to have back surgery for her degenerative disc disease, she had declined, and there were no other indications in the records that she had tried other conservative treatments, such as physical therapy or chiropractic care. (Id.)
In assessing Plaintiff's subjective complaints, the ALJ further considered Plaintiff's daily activities, including her statements made in function reports to the Administration dated March 6, 2018, and September 5, 2018. (Tr. 26, 190-97, 211-18.) Lastly, the ALJ considered the opinion evidence and found that
considering the criteria enumerated in the Regulations, Rulings and case law for evaluating the claimant's subjective complaints, the claimant's medical evidence was not persuasive to establish an inability to perform the range of work assessed herein. The location, duration, frequency, and intensity of the claimant's alleged symptoms, as well as, precipitating and aggravating factors and side effects of medications, are adequately addressed and accommodated in the above residual functional capacity. The claimant's clinical examinations and objective test results have not revealed the presence of any abnormalities that would be severe enough to prevent the claimant from performing light work activity, as set forth in the claimant's residual functional capacity. Based on the above evidence, I find the claimant's allegations that she is totally disabled from all work activity are not fully supported by the record.(Tr. 28.)
Plaintiff argues that the ALJ did not provide specific reasoning for rejecting her testimony regarding her symptoms and pain. She further argues that the ALJ ignored the evidence in the record that supported her hearing testimony, such as the references to her pain in the medical records, thereby cherry-picking from the record to support his conclusion. (Pl.'s Br. at 19, ECF No. 16 at 9.)
Also, in arguing that substantial evidence does not support the ALJ's findings as to Plaintiff's subjective complaints, Plaintiff asserts that the ALJ improperly considered the opinions of her treating and consulting doctors. The court considers this distinct issue in greater detail below.
After carefully considering Plaintiff's arguments and the record in this matter, the court concludes that Plaintiff has failed to demonstrate that the ALJ's evaluation of Plaintiff's subjective complaints is unsupported by substantial evidence or controlled by an error of law. See Craig, 76 F.3d at 589 (defining “substantial evidence” as “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance” and stating that the court may not “undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]”); Blalock, 483 F.2d at 775 (indicating that regardless of whether the court agrees or disagrees with the Commissioner's decision, the court must uphold it if it is supported by substantial evidence). Contrary to Plaintiff's arguments, the ALJ's decision reflects careful consideration of the medical evidence and the limitations stemming from Plaintiff's impairments. Further, the decision addressed the applicable factors in evaluating Plaintiff's subjective complaints. The ALJ's discussion reflects not just consideration of objective medical evidence but also Plaintiff's subjective reports to her medical sources as well as treatment methods and steps taken by Plaintiff as directed by her medical sources. Plaintiff has failed to demonstrate the ALJ's evaluation of her subjective complaints is unsupported by substantial evidence in light of all of the above factors and proper reasons offered by the ALJ to discount her allegations of disabling limitations. To reiterate, the court may not substitute its judgment for the Commissioner's and finds that the ALJ's conclusions are within the bounds of the substantial evidence standard. See Craig, 76 F.3d at 589-90 (“Although a claimant's allegations about her pain may not be discredited solely because they are not substantiated by objective evidence of the pain itself or its severity, they need not be accepted to the extent they are inconsistent with the available evidence, including objective evidence of the underlying impairment, and the extent to which that impairment can reasonably be expected to cause the pain the claimant alleges she suffers . . . .”); see also Hunter v. Sullivan, 993 F.2d 31, 35 (4th Cir. 1993) (per curiam) (finding that the ALJ may properly consider inconsistencies between a plaintiff's testimony and the other evidence of record in evaluating the credibility of the plaintiff's subjective complaints).
B. Medical Opinions
Within her arguments about the ALJ's treatment of her subjective complaints, Plaintiff asserts that the ALJ's consideration of two medical opinions was insufficient under the regulations and the Fourth Circuit's recent opinion in Dowling v. Comm'r Soc. Sec. Admin., 986 F.3d 377 (4th Cir. 2021). The Commissioner disagrees, arguing that Dowling is not applicable to Plaintiff's case and that there was substantial evidence to support the ALJ's decision.
The parties agree that effective March 27, 2017, the federal regulations were amended with regard to applications filed on or after March 27, 2017, and the new regulations enumerated in 20 C.F.R. § 404.1520c are applicable here. The new regulations provide that the ALJ will no longer “give any specific evidentiary weight . . . to any medical opinion(s) . . . including those from [the claimant's] medical sources, ” but the ALJ is still directed to weigh them pursuant to the same factors previously provided for weighing opinion evidence. See 20 C.F.R.§ 404.1520c. The ALJs are instructed to consider and evaluate the persuasiveness of the opinion evidence considering supportability, consistency, relationship with the claimant, specialization, and other factors that tend to support or contradict a medical opinion. Id. Supportability and consistency are the most important factors to consider, and an ALJ must explain how these factors are considered. The ALJ may, but is not required to, explain how the other factors are considered. Id.
Although a treating physician's opinion is no longer entitled to controlling weight, the ALJ's reasons for finding the opinion of a medical source unpersuasive still must be supported by substantial evidence. The United States Court of Appeals for the Fourth Circuit has repeatedly stated that “[a]n ALJ has the obligation to consider all relevant medical evidence and cannot simply cherrypick facts that support a finding of nondisability while ignoring evidence that points to a disability finding.” Lewis v. Berryhill, 858 F.3d 858, 869 (4th Cir. 2017) (quoting Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010)); see also Arakas v. Comm'r, 983 F.3d 83, 98 (4th Cir. 2020). Moreover, an ALJ continues to have an obligation to “include a narrative discussion describing how the evidence supports each conclusion.” Monroe v. Colvin, 826 F.3d 176, 190 (4th Cir. 2016) (quoting Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015)); see also SSR 96-8p. Similarly, remand may be appropriate when the courts are left to guess at how the ALJ arrived at the conclusions and meaningful review is frustrated. Mascio, 780 F.3d at 636-37. The ALJ must “build an accurate and logical bridge from the evidence to his conclusions.” Monroe, 826 F.3d at 189.
Plaintiff asserts that the ALJ did not properly consider the medical opinions of her treating physician, Dr. Ronald Littlefield, and a consultative examiner, Dr. James Ruffing.
The ALJ considered Dr. Littlefield's September 2019 opinion as follows:
Dr. Littlefield opined the claimant had impairments that would distract the claimant in a job setting and limit her ability to work, she would require frequent rest periods, she could not perform sedentary work full-time, she would need unscheduled breaks, her symptoms were not likely to produce good and bad days, and she would never be absent from work (Exhibit 11F). I do not find this opinion persuasive as it is internally inconsistent. Dr. Littlefield opines that the claimant could not perform sedentary work full-time but further opines the claimant would never be absent from work. Additionally, this opinion is vague as to specific functional limitations and is not supported by any explanation as to the basis of the opinion. This opinion is not supported by his own treatment records showing essentially no abnormalities. Moreover, this is inconsistent with the claimant's rheumatology records showing that the claimant's symptoms significantly improved on medication, diagnostic tests showing overall moderate abnormalities and orthopedic records showing a healed pelvic fracture.(Tr. 27.)
Dr. Ruffing performed a mental status exam on April 25, 2018. (Tr. 307-10.) Dr. Ruffing indicated that Plaintiff had been referred for examination due to allegations of ADHD, depression, and anxiety. There were no medical or psychological records made available for his review; thus, his exam was based on his clinical interview with Plaintiff. Dr. Ruffing recounted Plaintiff's complaints, vocational history, other pertinent history, activities of daily living, and substance abuse. (Tr. 307-08.) He then outlined his observations of Plaintiff and her mental status function. (Tr. 308-09.) Plaintiff arrived at the interview with her husband but completed the intake questionnaire fully and accurately by herself. She was adequately groomed and fully dressed, including wearing makeup, jewelry, and a watch. Dr. Ruffing noted that Plaintiff was fairly calm and cooperative; she was pleasant and smiled. “At times, she was a bit pressured and intense but there was otherwise no acute emotional distress observed.” (Tr. 308.) Plaintiff reported feeling “calm.” (Id.) Dr. Ruffing indicated that Plaintiff had a generally appropriate affect and presented with a euthymic mood. Plaintiff stated that she had activities that she enjoyed but physically could not engage in those activities. Dr. Ruffing further described Plaintiff's presentation as follows: “Orientation full with an adequate stream of consciousness. Thought process is linear, logical, relevant, coherent. Thought content, I saw no evidence for psychosis or lack of reality contact.” (Id.) Plaintiff did not demonstrate distractibility from either internal or external stimuli. Her cognitive processing was normal to slightly accelerated. Dr. Ruffing's testing showed Plaintiff's mental status functioning was within normal limits. Dr. Ruffing's psychological impression was that Plaintiff had adjustment disorder with depressed mood, with mild symptoms the day of the exam. He also noted a provisional impression of adult ADHD. Dr. Ruffing concluded that Plaintiff “appear[ed] capable of understanding and responding to spoken word. She seems able to manage persistence and pace. She may struggle at times with concentration given her tendency to be distracted by her as suggested [sic] by her complaints. She does appear capable of managing her finances if awarded benefits.” (Tr. 309.)
The ALJ found Dr. Ruffing's opinion to be persuasive to support no more than mild limitations in concentration, persistence, and pace. However, the ALJ otherwise found Dr. Ruffing's opinions to be inconsistent with her other medical records. The ALJ further noted that his opinion was “not . . . supported by her mental status exams showing normal mood and affect, intact concentration and attention and normal behavior.” (Tr. 27.) The ALJ made a point of noting that in her physical consultative evaluation Plaintiff reported that she stopped working due to pain and fatigue, as opposed to having stopped work due to any mental symptoms. (Id.)
Plaintiff argues that Dowling requires that her case be remanded. In Dowling, the Fourth Circuit held:
The ALJ's failure to consider each of the Section 404.1527(c) factors was error. While an ALJ is not required to set forth a detailed factor-by-factor analysis in order to discount a medical opinion from a treating physician, it must nonetheless be apparent from the ALJ's decision that he meaningfully considered each of the factors before deciding how much weight to give the opinion.986 F.3d 377 (4th Cir. 2021). Although Plaintiff acknowledges that 20 C.F.R. § 404.1520c, and not 20 C.F.R. 404.1527(c), is applicable to her case, she argues that “Dowling does not limit its holding to the prior medical evidence regulations, and its reasoning should apply to the new medical regulations as well, since they were promulgated to serve the same regulatory purpose (transparency of the ALJ's analysis) as the prior regulations, and are nearly identical.” (Pl.'s Reply at 3, ECF No. 22 at 3.) Plaintiff's argument is flawed. As outlined above, the factors to be considered in evaluating medical opinions are the same in the regulations, but § 404.1520c expressly states, “[w]e may, but are not required to, explain how we considered the factors in paragraphs (c)(3) through (c)(5) of this section, as appropriate, when we articulate how we consider medical opinions and prior administrative medical findings in your case record.” 20 C.F.R. § 404.1520c(b)(2) (emphasis added). The former regulation contained no such caveat. The Fourth Circuit did not indicate that its findings in Dowling as to how ALJs must consider medical opinions under 20 C.F.R. § 404.1527(c) were similarly applicable to 20 C.F.R. § 404.1520c, and this court declines to extend Dowling in view of the distinguishable language in the new regulation. See Shipbuilders Council of Am. v. U.S. Coast Guard, 578 F.3d 234, 244 (4th Cir. 2009) (“In interpreting statutes and regulations, [courts] have a duty, where possible, ‘to give effect' to all operative portions of the enacted language, including its ‘every clause and word.' ”) (quoting Duncan v. Walker, 533 U.S. 167, 174 (2001)).
Of course, the ALJ's assessment of Dr. Littlefield's opinion must still be supported by substantial evidence and in compliance with the applicable regulation. As required by 20 C.F.R. § 404.1520c, the ALJs analysis of Dr. Littlefield's opinion addresses both supportability and consistency. In particular, the ALJ found Dr. Littlefield's opinion to be internally inconsistent, vague as to Plaintiff's specific functional limitations, and not supported by any explanation as to the basis of the opinion. (Tr. 27.) Indeed, the majority of Dr. Littlefield's opinion consists of questions that he answered by checking either “yes” or “no” with no additional explanation as to the reasons for his answers. (Tr. 397-98.) The ALJ also compared the opinion to Dr. Littlefield's own treatment notes, some of which the ALJ had previously summarized in the decision. (See Tr. 24-25, 27.) Additionally, the ALJ identified records from Plaintiff's other medical providers that were inconsistent with Dr. Littlefield's opinions. (Tr. 27.) As such, the ALJ considered both the supportability and consistency of Dr. Littlefield's opinion in accordance with 20 C.F.R. § 404.1520c.
Section 404.1520c(c)(1) explains supportability as follows: “The more relevant the objective medical evidence and supporting explanations presented by a medical source are to support his or her medical opinion(s) or prior administrative medical finding(s), the more persuasive the medical opinions or prior administrative medical findings will be.”
Section 404.1520c(c)(2) explains consistency as follows: “The more consistent a medical opinion(s) or prior administrative medical finding(s) is with the evidence from other medical sources and nonmedical sources in the claim, the more persuasive the medical opinion(s) or prior administrative medical finding(s) will be.”
As with Dr. Littlefield's opinion, the ALJ also specifically considered the supportability and consistency of Dr. Ruffing's opinion. Although Plaintiff's medical records were largely focused on her physical issues, the ALJ also noted what mental status information was in those medical records and compared that to Dr. Ruffing's examination results. (Tr. 27.) The ALJ also considered the lack of mental health diagnosis or treatment in the records in analyzing Dr. Ruffing's opinion, which the ALJ deemed vague and generally inconsistent with Plaintiff's medical and work history. (Tr. 27.)
To the extent the ALJ's decision does not expressly discuss the other factors set forth in 20 C.F.R. § 404.1520c(c) as to either doctor, as already explained above, the applicable regulation expressly does not require the ALJ to discuss them. Based on the foregoing, the court finds that Plaintiff has failed to demonstrate that the ALJ's evaluations of Dr. Littlefield's and Dr. Ruffing's opinions are unsupported by substantial evidence or based on an incorrect application of the law. See also Mastro v. Apfel, 270 F.3d 171, 178 (4th Cir. 2001) (stating that “if a physician's opinion is not supported by clinical evidence or if it is inconsistent with other substantial evidence, it should be accorded significantly less weight”) (internal quotation marks & citation omitted); Dunn v. Colvin, 607 Fed.Appx. 264, 267 (4th Cir. 2015) (“An ALJ's determination as to the weight to be assigned to a medical opinion generally will not be disturbed absent some indication that the ALJ has dredged up ‘specious inconsistencies,' . . . or has failed to give a sufficient reason for the weight afforded a particular opinion[.]”) (internal citations omitted).
C. Residual Functional Capacity
1. Physical Residual Functional Capacity
A claimant's residual functional capacity (“RFC”) is “the most [a claimant] can still do despite [her] limitations” and is determined by assessing all of the relevant evidence in the case record. 20 C.F.R. § 404.1545(a)(1). In assessing residual functional capacity, an ALJ should scrutinize “all of the relevant medical and other evidence.” 20 C.F.R. § 404.1545(a)(3). Social Security Ruling 96-8p further requires an ALJ to reference the evidence supporting his conclusions with respect to a claimant's residual functional capacity. “Thus, a proper RFC analysis has three components: (1) evidence, (2) logical explanation, and (3) conclusion.” Thomas v. Berryhill, 916 F.3d 307 (4th Cir. 2019). Additionally, “[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 v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting Cichocki v. Astrue, 729 F.3d 172, 177 (2d Cir. 2013)) (alterations in original); see also Monroe v. Colvin, 826 F.3d 176, 188 (4th Cir. 2016). Plaintiff raises a number of arguments concerning the ALJ's purported over-assessment of her physical RFC, including: (1) the ALJ failed to consider the combined effect of her impairments; (2) the ALJ erred in assessing her complaints of pain, which affected the RFC; and (3) the ALJ relied on an incorrect framework in assessing her RFC and did not fully explain the function-by-function analysis. (Pl.'s Br. at 27-31, ECF No. 16 at 27-31.) Plaintiff contends that she should have been limited to sedentary work.
The court first addresses Plaintiff's arguments that the ALJ relied upon an incorrect regulatory framework and did not properly explain how the RFC was rooted in a function-by-function analysis. These arguments stem from another holding by the Fourth Circuit in Dowling, 986 F.3d at 386-89. In Dowling, the Fourth Circuit remanded a social security case where “[t]he ALJ's reliance on an incorrect regulatory framework led to an erroneous RFC assessment . . . .” Id. at 388. The Fourth Circuit initially found that the ALJ had not relied on the correct regulatory framework where the ALJ's RFC analysis referenced SSRs 96-7p and 16-3p, which relate to the process by which ALJs evaluate symptoms, but the ALJ never cited 20 C.F.R. § 416.945 or SSR 96-8p and never “indicate[d] that his RFC assessment was rooted in a function-by-function analysis of how Appellant's impairments impacted her ability to work.” Id. at 387. The Fourth Circuit stated that “[o]f course” a claimant's symptoms are relevant to the RFC, “[b]ut an RFC assessment is a separate and distinct inquiry from a symptom evaluation, and the ALJ erred by treating them as one and the same.” Id. The Fourth Circuit then discussed three aspects of the ALJ's RFC analysis that the court found “particularly troubling.” Id. at 388. First, the court held that the ALJ had erred in determining the RFC prior to engaging in a function-by-function analysis. Id. Second, the court held that the ALJ had erred in failing to adequately discuss sitting, a particular function that was critically relevant to Dowling's disability status. Id. at 388-89. In that discussion, the Fourth Circuit reaffirmed that there is no per se rule requiring remand when an ALJ fails to perform a function-by-function analysis, but the court noted Dowling's ability to sit was a “contested” function. Id. Third, the Fourth Circuit identified another aspect of Dowling's RFC that the ALJ failed to consider, which was whether she needed to work near a restroom and take frequent bathroom breaks. Id. at 389.
In the instant case, Plaintiff argues that the ALJ failed to cite to 20 C.F.R. § 416.945. That is true, but since Plaintiff filed for DIB, the applicable regulation is 20 C.F.R. § 404.1545. That corollary section is also entitled “Your residual functional capacity.” The ALJ cited to the proper regulation, as discussed in greater detail below.
The instant matter is distinguishable from Dowling. Unlike in Dowling, the ALJ in Plaintiff's case properly recognized that his RFC analysis was guided by 20 C.F.R. § 404.1545 and SSR 96-8p. (Tr. 18.) He also noted that he had considered “[t]he effects of [Plaintiff's] pain, fatigue and medications . . . in accordance with SSR 16-3p and SSR 96-in [sic] assessing the claimant's residual functional capacity . . . .” (Tr. 26.) Thus, the ALJ seems to have proceeded under the proper regulatory framework.
Like the ALJ in Dowling, the ALJ in Plaintiff's case did not expressly provide a function-by-function assessment within the RFC analysis. However, the ALJ fully discussed Plaintiff's subjective complaints, her medical history and treatment, her daily activities, and various medical opinions as to her disabilities. In particular, the ALJ found the opinions of the state agency consultants, who had done function-by-function assessments of Plaintiff's abilities, to be “generally persuasive.” (Tr. 27.) The function-by-function analyses by the state agency consultants, Dr. M. Fountain and Dr. Stephen Burge, closely track the RFC outlined by the ALJ. (Tr. 68-69, 81-83.) Although the doctors' opinions contained some minor differences, both doctors found Plaintiff could occasionally lift and/or carry twenty pounds and could frequently lift and/or carry ten pounds. (Tr. 68, 81-82.) Both opined that Plaintiff could stand and/or walk for about six hours and could sit for a total of six hours in an eight-hour workday. (Tr. 68, 82.) The doctors also both limited Plaintiff to only occasionally climbing ladders, ropes, and scaffolds and only occasionally stooping, kneeling, and crouching. (Tr. 68-69, 82.)
Other courts, both in this district and in this circuit, have found that an ALJ adequately builds a logical bridge from the evidence to his or her conclusion when such robust discussion is accompanied by the endorsement of a state agency consultant's opinion that includes a function-by-function analysis despite the ALJ's failure to provide such an analysis in his or her own discussion. See Sineath v. Colvin, 1:16CV28, 2016 WL 4224051, at *5 (M.D. N.C. Aug. 9, 2016) (“[A] proper function by function analysis conducted by a state agency consultant can satisfy an ALJ's requirement to conduct a function by function assessment.”); Linares v. Colvin, No. 5:15-CV-00120, 2015 WL 4389533, at *3 (W.D. N.C. July 17, 2015) (“Because the ALJ based his RFC finding, in part, on the function-by-function analysis of the State agency consultant, the ALJ's function-by-function analysis complied with SSR 96-8p.”); see also Wilbanks v. Comm'r Soc. Sec. Admin., Civil Action No. 1:17-cv-01069-JMC, 2018 WL 4476118, at * (D.S.C. Sept. 19, 2018) (“[E]ven after Mascio was handed down, . . . [the court] can still conduct a meaningful review when the ALJ does not conduct an explicit function-by-function analysis[, ] and . . . remanding the action is not necessarily warranted when such an analysis is absent.”); Savage v. Berryhill, C/A No. 5:16-1138-KDW, 2017 WL 3124177, at *10 (D.S.C. July 24, 2017) (finding an ALJ's discussion sufficient to enable meaningful review despite the lack of an explicit function-by-function analysis where part of that discussion included the ALJ giving great weight to a state agency consultant opinion); Johnson v. Colvin, Civil Action No. 6:15-4419-RBH-KFM, 2017 WL 238454, at *9-10 (D.S.C. Jan. 3, 2017) (finding “the ALJ built a logical bridge in his analysis of the plaintiff's RFC and referenced not only the treatment records, but also the consultative and state agency assessment, which supported the range of light work . . . [, ]” and further noting that the ALJ's reference to a state agency consultant's RFC assessment “contribute[d] to [the ALJ's] analysis of the plaintiff's limitations), adopted by 2017 WL 228004. The court finds that here, too, the ALJ successfully built a logical bridge from the evidence to his conclusions where he fully discussed Plaintiff's testimony, medical records, treatment, and daily activities, in conjunction with a discussion of state agency consultants' opinions, which included function-by-function analyses, and which the ALJ found to be persuasive. Notably, the ALJ's decision at issue in Dowling did not indicate that the ALJ found the opinions by state agency consultants to be persuasive or entitled to weight. Dowling v. Comm'r Soc. Sec. Admin., C/A No. 5:18-cv-387-MGL, ECF No. 10-2 at 38 (declining to give state agency consultants' opinions full weight due to the substantial amount of evidence received at the hearing level that was not available to the consultants).
Moreover, unlike in Dowling, Plaintiff has not identified any contested functions that are not covered by the state agency consultants' opinions. Plaintiff cites her own testimony to support her contention that she should have been limited to sedentary work (Pl.'s Br. at 29, ECF No. 16 at 29), but it is not clear that Plaintiff falls within the parameters of sedentary work based on her own testimony. See 20 C.F.R. § 404.1567(a). As previously discussed, Plaintiff's treating physician opined that she could not even do sedentary work due to her disability. As the ALJ noted in his analysis of Dr. Littlefield's opinion, the opinion itself was “vague as to specific functional limitations . . . .” (Tr. 27.) Plaintiff bears the burden of producing evidence demonstrating how her impairments affected her functioning during the relevant time period. See 20 C.F.R. § 404.1512(c); Stormo v. Barnhart, 377 F.3d 801, 806 (8th Cir. 2004) (“The burden of persuasion to prove disability and to demonstrate RFC remains on the claimant, even when the burden of production shifts to the Commissioner at step five.”); Creegan v. Colvin, No. 1:13CV5, 2014 WL 3579659 (W.D. N.C. July 21, 2014) (“It is the claimant's burden, however, to establish her RFC by demonstrating how her impairment impacts her functioning.”).
Based on the foregoing, the court concludes that Dowling does not require remand of this case despite the ALJ's failure to expressly go through a function-by-function analysis in his RFC discussion. As to Plaintiff's argument that the ALJ erred in assessing her subjective complaints, which, in turn, caused errors in his RFC analysis, the court rejects that argument for the same reasons outlined previously. Finally, Plaintiff's argument that the ALJ did not consider the combined effect of her impairments is both summary and conclusory and, accordingly, does not warrant in-depth discussion by the court. Suffice it to say, upon review of the record as a whole, the court finds that Plaintiff has not demonstrated that the ALJ's residual functional capacity analysis and findings are unsupported by substantial evidence or controlled by an error of law. In compliance with applicable law, the ALJ provided an extensive narrative discussion, which included a full discussion of the medical and nonmedical evidence as well as the opinion evidence. The ALJ's discussion explained his resolution of inconsistencies or ambiguities of the evidence in the case record, such as his evaluation of the medical evidence, Plaintiff's subjective complaints, and the opinion evidence. Further, Plaintiff has failed to direct the court to any evidence that would support additional physical limitations.
Accordingly, upon careful review of the decision, the court finds that Plaintiff's arguments are insufficient to show that the ALJ's residual capacity assessment is unsupported by substantial evidence or is controlled by an error of law.
2. Mental Residual Functional Capacity
Finally, Plaintiff argues that the ALJ failed to properly assess her mental residual functional capacity. Specifically, Plaintiff recounts her testimony from the hearing about her mental impairments. She then goes through the ALJ's Step Two analysis of Plaintiff's mental impairments and identifies purported errors in the ALJ's reasoning and evidentiary support:
• Understanding, remembering, or applying information. Although the ALJ found Plaintiff had no limitation (Tr. 20), Plaintiff asserts that her hearing testimony demonstrated that she had difficulty understanding the questions asked. (Pl.'s Br. at 33, ECF No. 16 at 33.)
• Interacting with others. The ALJ found Plaintiff did not allege any problems related to this domain and concluded she had no limitations. He further cited evidence in the record in support of her ability to get along with others. (Tr. 20.) Plaintiff argues that the ALJ's
analysis was “too general to qualify as meaningful analysis.” (Pl.'s Br. at 33, ECF No. 16 at 33.)
• Concentrating, persisting, or maintaining pace. The ALJ found Plaintiff had “no more than mild limitation in this domain” based on Plaintiff's testimony and the absence of evidence in the record as to any distractibility or an inability to complete testing that assesses concentration and attention. (Tr. 21.) Plaintiff asserts that the ALJ failed to give adequate weight to the report by Dr. Ruffin. (Pl.'s Br. at 33, ECF No. 16 at 33.)
• Adapting or managing oneself. The ALJ found Plaintiff had no limitation in this area based on: (1) no allegations of symptoms or limitations in this area; (2) Plaintiff's statements that she was able to manage her self-care and personal hygiene; (3) objective evidence in the records as to Plaintiff's appropriate grooming, hygiene, ability to get along with others, normal mood and affect, and temper control. (Tr. 21.) Plaintiff notes that the ALJ acknowledged that she was on Wellbutrin, a drug commonly used to treat depression. She further relies upon her testimony at the hearing, and she states that her decision to roller skate demonstrated “poor decision-making.”(See Pl.'s Br. at 33, ECF No. 16 at 33.) Plaintiff then indicates her belief that the ALJ did not properly explain his RFC findings as to her mental limitations, ultimately contending that her “mental and physical impairments cumulatively limit her ability to perform basic work activities when considering the record as a whole and Plaintiff's hearing testimony.” (Pl.'s Br. at 35, ECF No. 16 at 35.)
Plaintiff couches her argument as one that the ALJ erred in failing to include additional limitations in her mental RFC. However, the crux of her argument lies in the ALJ's Step Two analysis. Step Two of the sequential evaluation requires the ALJ to “consider the medical severity of [a claimant's] impairment(s).” 20 C.F.R. § 404.1520(a)(4)(ii). The claimant bears the burden at this step to show that he has a severe impairment. See Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987). A severe impairment is one that “significantly limits [a claimant's] physical or mental ability to do basic work activities.” 20 C.F.R. § 404.1520(c). “Basic work activities” means “the abilities and aptitudes necessary to do most jobs.” Examples of these include:
(1) Physical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling;
(2) Capacities for seeing, hearing, and speaking;
(3) Understanding, carrying out, and remembering simple instructions;
(4) Use of judgments;
(5) Responding appropriately to supervision, co-workers and usual work situations; and
(6) Dealing with changes in a routine work setting.20 C.F.R. § 404.1522(b). “[A]n impairment can be considered as not severe only if it is a slight abnormality which has such a minimal effect on the individual that it would not be expected to interfere with the individual's ability to work, irrespective of age, education, or work experience.” Evans v. Heckler, 734 F.2d 1012, 1014 (4th Cir. 1984) (internal quotations marks omitted).
As set forth above, in Step Two, the ALJ found mild to no limitations in each of the functional areas that he considered. The ALJ thus concluded that Plaintiff's medically determinable mental impairments were nonsevere at Step Two. (Tr. 21.) Further, in determining Plaintiff's mental RFC, the ALJ included details regarding Plaintiff's mental functioning within his recitation of the medical records. (Tr. 23-25.) The ALJ also evaluated the medical opinions related to Plaintiff's mental functioning. As to Dr. Ruffing's opinion, the ALJ found it to be persuasive to support no more than mild limitations in concentration, persistence, and pace, but otherwise inconsistent with Plaintiff's medical records. On the other hand, the ALJ found the opinions by state agency consultants that Plaintiff had no severe mental impairments to be persuasive, as those opinions were “consistent with the claimant's lack of any significant mental health treatment, her essentially benign mental status exams with normal mood, affect and attention, and her reports that she stopped working due to physical problems, rather than mental impairments.” (Tr. 27.) Ultimately, the ALJ did not find any mental function limitations were warranted within the RFC. (Tr. 22-28.)
Whether Plaintiff is now challenging the ALJ's findings in the Step Two analysis or whether she is now challenging the ALJ's assessment of her mental RFC, she appears to rely almost exclusively on her testimony and subjective complaints. First, the record demonstrates that the ALJ did include Plaintiff's testimony and subjective complaints as part of his analysis at Step Two and in the RFC determination, but the ALJ compared Plaintiff's testimony and complaints to evidence in the record and found she had mild to no limitations. Second, as discussed previously, Plaintiff has failed to demonstrate that the ALJ's discounting of her subjective complaints was not supported by substantial evidence. The above analysis is similarly applicable here. In challenging the ALJ's conclusion as to her mental RFC, Plaintiff essentially asks the court to analyze the facts and reweigh the evidence presented, and such action is contrary to the substantial evidence standard of review that this court is bound to apply at this stage of the proceedings. See Blalock, 483 F.2d at 775 (indicating that even if the court disagrees with the Commissioner's decision, the court must uphold it if it is supported by substantial evidence). The court finds that the ALJ sufficiently explained his reasons to permit review and built a sufficient “accurate and logical bridge from the evidence to his conclusion.” Cf. Monroe v. Colvin, 826 F.3d 176, 189 (4th Cir. 2016) (remanding where the ALJ failed to “build an accurate and logical bridge from the evidence to his conclusion”) (citation omitted); Mascio, 780 F.3d at 636-37 (holding remand may be appropriate when the courts are left to guess at how the ALJ arrived at the conclusions and meaningful review is frustrated). Significantly, as argued by the Commissioner, the ALJ's finding that Plaintiff had no severe mental impairments at Step Two, in conjunction with his discussion about what mental health information was in her medical records and his findings about the medical opinions related to Plaintiff's mental abilities, translated into no functional limitations in the mental RFC. (See Def.'s Br. at 31, ECF No. 21 at 31) (citing Presnell v. Colvin, No. 1:12-CV-299-FDW, 2013 WL 4079214, at *4 (W.D. N.C. Aug. 13, 2013) (“[A]lthough some consideration is required, there is no requirement that the RFC reflect a claimant's non-severe impairments to the extent the ALJ reasonably determines such impairments do not actually create functional limitations . . . .”)). Accordingly, upon thorough review of the ALJ's decision and the record, the court finds that the ALJ's findings and conclusions are within the bounds of substantial evidence.
Contrast Anderson v. Saul Civil Action No. 4:19-cv-00846-MGL-TER, 2020 WL 3579745, at *5 (D.S.C June 25, 2020) (“It cannot be said here that the ALJ gave reasons and explanation, in accordance with SSR 96-8p, supported by substantial evidence for the RFC determination, where mental impairments, regardless of severity, were not discussed in formulating the RFC and mental limitation opinions by a treating physician were not assigned weight or mentioned by the ALJ.”).
RECOMMENDATION
It is recommended that this matter be
[X] Affirmed. Plaintiff has failed to show that the Commissioner's decision was unsupported by substantial evidence or controlled by an error of law.
[ ] Reversed and remanded pursuant to [ ] Sentence Four [ ] Sentence Six of 42 U.S.C. § 405(g) for further consideration consistent with this Order.
[ ] Reversed and remanded for an award of benefits.
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
901 Richland Street
Columbia, South Carolina 29201
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).