Opinion
C/A 9:23-cv-04378-RMG-MHC
07-26-2024
Lisa B.,[1] Plaintiff, v. Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
Molly H. Cherry United States-Magistrate Judge
Plaintiff Lisa B. (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 remanded for further administrative proceedings.
Citations to the record refer to the page numbers in the Social Security Administration Record. See ECF No. 7.
Plaintiff applied for DIB on October 28, 2020, alleging disability beginning on September 16, 2016. R.pp. 202-203. Plaintiff filed an amendment to the DIB application, changing her alleged onset date to September 29, 2016. R.pp. 204-205. The state agency denied her claims initially and on reconsideration. R.pp. 110-113, 116-119.
On September 19, 2022, a telephonic hearing was held before an ALJ. Plaintiff, who was represented by counsel, and an impartial vocational expert (VE) appeared and testified. R.pp. 5278. On July 7, 2022, the ALJ issued a decision finding that Plaintiff was not disabled under the Act. R.pp. 36-47. On June 27, 2023, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision final. R.pp. 22-28. This appeal followed.
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'rSoc. 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, 487 U.S. 97, 103 (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 during the relevant time period (the alleged onset date of September 29, 2016 through her date last insured of September 30, 2017). R.pp. 36-47. The ALJ found, in pertinent part:
1. The claimant last met the insured status requirements of the Social Security Act on September 30, 2017.
2. The claimant did not engage in substantial gainful activity during the period from her alleged onset date of September 29, 2016, through her date last insured of September 30, 2017 (20 CFR 404.1571 et seq.).
3. Through the date last insured, the claimant had the following severe impairments: congestive heart failure; coronary artery disease; stroke; and aphasia (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 light work as defined in 20 CFR 404.1567(b) except no climbing ladders, ropes, or scaffolds; only frequent climbing stairs or ramps, balancing, stooping, kneeling, crouching, or crawling; and no occupation requiring constant oral communication or talking.
6. Through the date last insured, the claimant was unable to perform any past relevant work (20 CFR 404.1565).
7. The claimant was . . . 51 years old, which is defined as an individual closely approaching advanced age, on the date last insured (20 CFR 404.1563).
8. The claimant has at least a high school education (20 CFR 404.1564).
9. Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that
the claimant is “not disabled,” whether or not the claimant has transferable job skills (See SSR 82-41 and 20 CFR Part 404. Subpart P, Appendix 2).
10. Through the date last insured, considering the claimant's age, education, work experience, and residual functional capacity, there were jobs that existed in significant numbers in the national economy that the claimant could have performed (20 CFR 404.1569 and 404.1569a).
11. The claimant was not under a disability, as defined in the Social Security Act, at any time from September 29, 2016, the alleged onset date, through September 30, 2017, the date last insured (20 CFR 404.1520(g)).R.pp. 38-46.
Based on Plaintiff's birthdate (see R.pp. 45, 58), Plaintiff was 52 years old on the date last insured of September 30, 2017, which is also defined as an individual closely approaching advanced age. See 20 CFR 404.1563.
IV. DISCUSSION
Plaintiff argues that the ALJ failed to explain his findings regarding her RFC, as required by SSR 96-8p, and failed to properly evaluate her subjective symptomology. ECF No. 12 at 12, 19. In particular, Plaintiff asserts that the ALJ failed to properly consider her non-severe impairments, including her upper extremity limitations, in formulating the RFC and discounting her subjective complaints. Id. at 14. The Commissioner contends that the ALJ's RFC discussion is sufficient to allow for meaningful judicial review and that his decision as to Plaintiff's RFC and subjective complaints is supported by substantial evidence. ECF No. 15 at 9-16.
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, SSR 96-8p, 1996 WL 374184, at *1 (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 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 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.
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.” Soc. Sec. Ruling 16-3p: 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), 416.929(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.”).
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 h[er] 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 her 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. The Parties' Arguments
As noted above, the ALJ assessed the following RFC for Plaintiff:
[T]he claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) except no climbing ladders, ropes, or scaffolds; only frequent climbing stairs or ramps, balancing, stooping, kneeling, crouching, or crawling; and no occupation requiring constant oral communication or talking.R.p. 40. At the hearing, the ALJ asked the VE to consider whether a person who was closely approaching advanced age; had a high school education; and was limited to light, unskilled work which involved no climbing ladders, ropes, or scaffolds; was limited to frequent climbing stairs or ramps, balancing, stooping, kneeling, crouching, or crawling; and could do no occupation requiring constant oral communication or talking could perform past relevant work as a hairdresser. The VE stated that such an individual could not perform the past relevant work as a hairdresser but could perform the light, unskilled jobs of routing clerk, office helper, and mail clerk. R.p. 75. In response to a second hypothetical question from the ALJ asking if a person with the above RFC and an additional limitation of only occasional use of the nondominant hand for fingering, handling, and feeling could perform the jobs identified, the VE stated that the identified jobs would all require at least frequent bilateral use of the upper extremities such that the additional restriction would eliminate the identified occupations. Additionally, the VE testified that previous work as a hair stylist would not provide any skills that would transfer to work at the sedentary level. R.p. 76.
The ALJ found that there were jobs that existed in significant numbers in the national economy that the claimant could have performed based on the VE's testimony that an individual with the restrictions in the first hypothetical question could perform the light, unskilled jobs of routing clerk, office helper, and mail clerk. R.pp. 45-46.
Plaintiff argues that if she is limited to sedentary work she would be disabled under the Medical-Vocational Guidelines. ECF No. 12 at 18. For a claimant closely approaching advanced age with a high school education or more that does not provide for direct entry into skilled work and with skilled or semiskilled-skills that are not transferable, the Medical-Vocational Guidelines direct a finding of disabled. See 20 C.F.R. Pt. 404, Subpt. P, App'x 2, § 201.14.
Plaintiff contends that the ALJ failed to perform a proper function-by-function analysis regarding her RFC as required by SSR 96-8. In particular, she argues that ALJ did not consider any of her non-severe impairments in the decision, failed to discuss medical evidence regarding her cervical spine condition and upper extremities limitations, and failed to explain how these conditions were accounted for in the RFC. She appears to assert that the medical evidence and her testimony support a finding that she has upper extremity restrictions such as manipulative restrictions and/or restrictions on reaching and she experienced impairments in her upper extremities and neck which, in combination, affected her ability to lift, reach, handle, and finger. Plaintiff contends that the ALJ failed to consider these impairments in combination. Additionally, she argues that the ALJ's failure to consider her upper extremity limitations related to stroke (also known as a cerebral vascular accident) and cervical spondylosis, including neck pain and numbness and tingling in her arms, is significant because the VE testified that a hypothetical individual limited to occasional use of the nondominant hand for fingering, handling, and feeling could not perform the identified occupations and there would be no transferable skills to sedentary work. ECF No. 12 at 12-19.
Plaintiff also argues that the ALJ did not properly evaluate her subjective symptomology as required under SSR 16-3p. In particular, she claims that the ALJ failed to explain how he determined that activities described by Plaintiff, with the fatigue she allegedly experienced, were consistent with activities necessary for obtaining and maintaining full-time competitive employment; failed to consider the extent she could perform her activities; failed to adequately explain how the objective evidence was inconsistent with Plaintiff's claims that her impairments prevented her from performing competitive, full-time light work; and failed to explain which of her statements “undercut her subjective evidence of pain intensity as limiting her functional capacity.” Id. at 19-25.
The Commissioner contends that the ALJ applied the correct law and relied on substantial evidence to properly find that Plaintiff was not disabled during the relevant time period of September 26, 2016 through September 30, 2017. See ECF No. 8 at 3, 8-9. As to Plaintiff's RFC, the Commissioner argues that the ALJ complied with SSR 96-8p by digesting the relevant probative evidence and explaining why the evidence supported or did not support his conclusions and built a sufficient logical bridge between the evidence and his conclusions. ECF No. 15 at 1011. The Commissioner contends that the ALJ properly evaluated Plaintiff's congestive heart failure, coronary artery disease, stroke, and aphasia impairments and asserts that the ALJ did not have to discuss Plaintiff's upper extremity impairments because the record did not support any upper extremity limitations Id. at 11. Additionally, the Commissioner argues that the ALJ properly evaluated Plaintiff's subjective complaints of pain and other symptoms and properly considered all of the record evidence. Id. at 12-13.
C. Analysis
Upon review, the undersigned agrees with Plaintiff that the ALJ's RFC assessment and evaluation of her subjective complaints do not permit meaningful appellate review.
Pursuant to SSR 96-8p, an ALJ's RFC assessment must include an evaluation of the claimant's ability to perform the physical functions listed in 20 C.F.R. § 404.1545(b), which include “sitting, standing, walking, lifting, carrying, pushing, pulling, or other physical functions . . . [that] may reduce [a claimant's] ability to do past work and other work.” 20 C.F.R. § 404.1545(b); see SSR 96-8p, 1996 WL 374184, at *1; Dowling, 986 F.3d at 387. “‘Only after such a function-by-function analysis may an ALJ express RFC in terms of the exertional levels of work' of which [the ALJ] believes the claimant to be capable.” Dowling, 986 F.3d at 387 (quoting Monroe, 826 F.3d at 179). “Finally, every conclusion reached by an ALJ when evaluating a claimant's RFC must be accompanied by a narrative discussion describing the evidence that supports it.” Id. (internal quotation mark omitted); Thomas, 916 F.3d at 311. In this case, the ALJ's evaluation of Plaintiff's RFC fell short of these requirements.
In assessing the RFC, the ALJ summarized Plaintiff's testimony from the hearing as follows:
[T]he claimant testified that she had a stroke while getting ready for work in September 2016. She stated that she was hospitalized for 6-7 days and was diagnosed with a heart attack and stroke. The claimant testified that she had two stents placed in her heart approximately a month after her hospitalization. She was prescribed blood thinners. The claimant reported that she tried to go back to work as a hair stylist, but has had difficulty speaking and a lot of brain damage that caused her to lose customers. She stated she still has difficulty with finding words or using the wrong words. She takes Klonopin three times a day to help slow her speech down. The claimant stated that her stroke affected the left side of her body causing [nerve] damage in her left foot. She is unable to tolerate Lyrica or gabapentin for her nerve pain. She also stated that she has weakness in left hand. For example, she stated that she is left handed and often drops her comb when combing her hair.
Due to her impairments, she could lift 8-10 pounds, stand for an hour before needing to sit, and walk approximately 10 minutes. She tires quickly so she naps once a day for approximately two hours. After her stroke in 2016, the claimant was sleeping up to 13 hours a night. She was able to start driving approximately six months after her stroke. The claimant required help from her family to complete her activities of daily living. She was able to do some chores, such as washing laundry.R.p. 41.
Plaintiff testified that she was right-handed, not left-handed. R.p. 70; see also R.p. 249. She stated that she held a comb in her left hand (presumably while cutting hair with scissors in her right hand) and she kept dropping the comb. See R.p. 63.
The ALJ found that “the claimant's statements concerning the intensity, persistence and limiting effects of [her] symptoms are not entirely consistent with the medical evidence and other evidence in the record for the reasons explained in this decision.” R.p. 41. Thereafter, he wrote:
First, the claimant's allegations regarding the severity of her symptoms are inconsistent with her activities of daily living. Despite her impairments, the claimant has engaged in a somewhat normal level of daily activity and interaction. The claimant admitted activities of daily living including preparing simple meals, washing laundry, driving, grocery shopping, watching television, and weekly church attendance (Ex. 7E: Testimony). Some of the physical and mental abilities and social interactions required in order to perform these activities are the same as those necessary for obtaining and maintaining employment. I find the claimant's ability to participate in such activities diminishes the consistency of the claimant's allegations of functional limitations.R.p. 42.
The ALJ then summarized some of the medical evidence in the record, including records from Plaintiff's five-day hospitalization after her stroke in 2016 (during which she underwent a thrombectomy due to left distal M1 occlusion); her left heart catheterization with placement of two drug-eluting stents in December 2016; and follow up care with cardiologist Dr. Gyanendra Sharma (Dr. Sharma), a neurologist, and her primary care physician Dr. Rebecca A. Talley (Talley) from October 2016 to November 2017. R.pp. 42-44. As to Plaintiff's neck and upper extremity conditions, the ALJ recited records from the time of Plaintiff's stroke indicating that emergency medical services assessed Plaintiff as not moving on the right side and having mild left facial droop, hospital records indicating questionable mild right facial asymmetry and 4/5 strength in the right upper and lower extremities (R.p. 42), and reports by Plaintiff that she continued to have right hand dexterity problems and worsening right side numbness in January 2017 (R.p. 43).
The ALJ then stated the following:
I fully considered the claimant's allegations of coronary artery disease, congestive heart failure, stroke, and aphasia, but as noted above, the claimant's condition improved with generally conservative treatment. For example, she generally exhibited normal gait, normal coordination, normal sensation, no atrophy, no focal deficits, regular heart rate and rhythm, lungs clear to auscultation, non-labored respirations, and clear speech. Thus at most, the claimant is limited to light exertional work with frequent postural maneuvers except no climbing ladders, ropes, or scaffolds. She is further precluded from any occupation requiring constant oral communication or talking.R.p. 44.
Next, the ALJ considered the medical opinions of two physicians that reviewed the record of Plaintiff's physical impairments at the request of the agency. He noted that Drs. Susan Luberoff and Stephen Worsham found that there was insufficient evidence to evaluate Plaintiff's physical functioning from the period from the alleged onset date through the date last insured.The ALJ found that these findings were inconsistent with medical records documenting the existence of physical impairments since the alleged onset date including coronary artery disease, congestive heart failure, stroke, and aphasia. The ALJ found that these prior administrative medical findings were not persuasive. R.p. 44.
The ALJ also discussed the opinions of the two psychologists that reviewed the record at the request of the agency and opined that there was insufficient evidence to substantiate the presence of a mental disorder. See R.pp. 95-96, 99, 100, 103-104. The ALJ found that these opinions were persuasive (R.pp. 44-45) and Plaintiff has not challenged this finding.
The opinions of the agency physicians and psychologists are the only opinions of record. It is noted that these medical opinions are based on a date last insured of September 30, 2016, not the date last insured of September 30, 2017, as found by the ALJ. R.pp. 94, 99 (Dr. Luberoff) and 100, 102 (Dr. Worsham). Thus, it appears that these opinions did not cover the entire period at issue (from the alleged onset date of September 29, 2016 through the date last insured of September 30, 2017). These opinions contain no discussion of any evidence as to Plaintiff's upper extremity conditions. See R.pp. 94.
The ALJ then concluded his RFC analysis as follows:
In sum, I have considered the allegations set forth by the claimant in her initial application and testimony but do[] not find them to be persuasive. Instead, I rely on the claimant's activities of daily living, the objective medical evidence of record, and the opinion evidence in finding the claimant is capable of work within the confines of the residual functional capacity.R.p. 45.
Although the ALJ does not discuss Plaintiff's upper extremity and neck impairments, he appears to have concluded that Plaintiff was not restricted in her ability to use her upper extremities to perform unskilled, light work. “This conclusion should have been the result of an analysis that was separate from the ALJ's appraisal of [Plaintiff's] ability to perform other functions, and should have been accompanied by ‘a narrative discussion describing' the evidence supporting it.” Dowling, 986 F.3d at 388 (quoting Thomas, 916 F.3d at 311). However, the ALJ's evaluation of Plaintiff's ability to use her upper extremities was lacking in both respects.
Nowhere in the discussion does the ALJ evaluate Plaintiff's ability to use her upper extremities on a function-by-function basis. Instead, the ALJ's discussion related to the physical RFC assessment appears to consist only of the evaluation of Plaintiff's subjective complaints pursuant to SSR 16-13p and an evaluation of the opinion evidence. However, although “a claimant's symptoms, and the extent to which the alleged severity of those symptoms is supported by the record, is relevant to the RFC evaluation[,]...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, 986 F.3d at 387-88.
It is unclear how helpful these opinions are as they do not appear to cover the entire relevant time period and the ALJ found (R.p. 44) these opinions were “not persuasive.
At step two, the ALJ found that Plaintiff's congestive heart failure, coronary artery disease, stroke, and aphasia were severe impairments, but did not discuss any of Plaintiff's other medical impairments. R.p. 39. In his RFC analysis, the ALJ only discussed Plaintiff's severe impairments and did not discuss Plaintiff's neck/cervical spine condition and/or the ability to use her upper extremities to perform work functions. See R.p. 44. There is nothing in the decision, either before or after the statement of Plaintiff's RFC assessment, to demonstrate that the ALJ considered the limiting effect of all of Plaintiff's severe and non-severe impairments, including her upper extremity impairments, in determining her RFC. The ALJ must comply with the requirements of 20 C.F.R. § 416.945(b) and SSR 96-8p by considering the limiting effects of all of Plaintiff's impairments, both severe and non-severe, in determining her RFC.
Additionally, although the ALJ is not required to discuss every piece of evidence, the medical record includes many entries concerning these conditions that the ALJ does not appear to have discussed or fully considered, including the evidence discussed below. During an emergency department visit on December 15, 2016, Plaintiff complained of left arm numbness and tingling in the entire length of her arm. It was also noted that Plaintiff had numbness/tinging in that arm since prior to her CVA. R. pp. 570, 574. At a neurology consolation on January 30, 2017, Plaintiff reported some issues with right hand dexterity and worsening of right-sided numbness when stressed or tired. R.p. 655. Plaintiff sought emergent care on May 22, 2017, complaining of two weeks of left arm numbness and neck pain after moving out of her house and lifting and moving boxes for two weeks. She reported right palmar numbness that was residual from her CVA and left arm numbness and neck pain exacerbated by neck movement. Physical examination indicated right palmar numbness, numbness of her entire right arm, and neck pain when she tilted her head to the left side. R.p. 717. On July 17, 2017, Plaintiff complained to Dr. Talley about left arm tingling that had gotten better but for which she still noted numbness and tingling in her left arm that “comes and goes” from day to day. Examination revealed that Plaintiff had tenderness in her left lateral neck muscles and complained of pain when turning her head to the left. R.pp. 10331035. The impression of cervical spinal x-rays on July 24, 2017, was moderate C6-C7 disc degenerative changes with spondylosis. R.p. 1027. The same day, Plaintiff reported occasional numbness and tingling down her left arm and neck pain (for which muscle relaxers had provided no relief of symptoms). R.p. 1030.
See Reid v. Comm'r of Soc. Sec., 769 F.3d 861, 865 (4th Cir. 2014) (“[T]there is no rigid requirement that the ALJ specifically refer to every piece of evidence in his decision.”).
On August 7, 2017, Plaintiff reported to Dr. Talley that she started to lose power in her hands and had some accidents as a hairdresser in that she was dropping combs and foils. R.p. 1023. The impression of an MRI of Plaintiff's cervical spine on August 14, 2017, was C6-C7 mild to moderate spinal canal stenosis and mild bilateral foraminal stenosis and C4-C5 moderate right facet arthropathy resulting in mild right neural foraminal stenosis. R.pp. 1019-1020. On September 19, 2017, Plaintiff reported to Dr. Sharma that she had occasional neck, shoulder, and arm pain. R.p. 796. On November 13, 2017, about a month after Plaintiff's date last insured, Plaintiff reported radicular symptoms with arm tingling. Dr. Talley wrote that she addressed Plaintiff's problem of cervical spondylolisthesis with weakness in her hands and “fine moto[,]” noted that Plaintiff hated Lyrica, and wrote that Plaintiff was not weak now [-] will watch.” R.p. 1013, 1015. Plaintiff sought emergency care for back pain along with left arm pain on March 19, 2018. R.p. 803.
The Commissioner contends that Plaintiff failed to show that the record supported additional limitations as to her upper extremities because she denied neck or back pain at the time she was admitted to the hospital in September 2016. The Commissioner also asserts that Plaintiff complained of left arm numbness and neck pain of two-week duration after moving out of her home and moving boxes for two weeks but that her left arm symptoms were better in July of 2017. Although the Commissioner notes that records from August 17, 2017, document acquired cervical spondylolisthesis with weakness in Plaintiff's hands and fine motor that were new and not present after the CVA the prior year, the Commissioner appears to argue that the ALJ's decision is supported by evidence that Plaintiff later had very strong grips of her right upper extremity and normal sensation and 5/5 strength bilaterally. R.p. 1025. The Commissioner also asserts that treatment notes from November 2017 show that Plaintiff no longer had weakness and that her acute neck pain diagnosis was noted as removed and resolved. R.pp. 1013 and 1013; see ECF No. 15 at 11.
However, as noted above, the ALJ did not include any discussion of Plaintiff's upper extremity impairments in his RFC analysis and does not include any mention of many of the records the Commissioner now discusses. The ALJ's decision does not contain the required RFC discussion as to Plaintiff's upper extremities and this this 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) 1225 (“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)). The Court is not at liberty to parse through the record and make findings never mentioned by the ALJ. See Fox v. Colvin, 632 Fed.Appx. 750, 755 (4th Cir. 2015) (holding that the court erred when it “engaged in an analysis that the ALJ should have done in the first instance.”). The Commissioner and the Court cannot substitute their reasoning for that of the ALJ in order to fill in obvious gaps left in the written decision.
Additionally, there is no indication that the ALJ evaluated the combined effects of all of Plaintiff's impairments in formulating Plaintiff's RFC. The statutory and regulatory process for making disability determinations, as interpreted by the Fourth Circuit, requires an ALJ to consider and adequately explain his evaluation of the combined effects of a claimant's impairments in determining disability status. See Reid v. Comm'r of Soc. Sec., 769 F.3d at 866; Walker v. Bowen, 889 F.2d 47, 49-50 (4th Cir. 1989); Rabon v. Astrue, No. 4:08-CV-03442-GRA, 2010 WL 923857, at *13-19 (D.S.C. Mar. 9, 2010) (requiring remand when ALJ did not consider severe and non-severe impairments in combination). An ALJ's duty to consider the combined effects of a claimant's impairments permeates through each step of the sequential evaluation process. See 20 C.F.R. § 404.1523; Fleming v. Barnhart, 284 F.Supp.2d 256, 270 (D. Md. 2003) (“The ALJ is required to assess the combined effect of a claimant's impairments throughout the five-step analytical process.” (citing 20 C.F.R. § 404.1523 and Walker, 889 F.2d at 49-50)). Because there is no discussion of any of Plaintiff's non-severe impairments, including those of her upper extremities, it is unclear from the decision as a whole that the Commissioner considered the combined effects of all of her impairments.
It is also unclear from the decision that the ALJ properly evaluated Plaintiff's subjective complaints as required by SSR 16-3p. There is no explanation as to how the activities described by Plaintiff were consistent with the activities necessary for obtaining and maintaining full-time competitive employment. The ALJ stated that “[s]ome of the physical and mental abilities and social interactions required in order to perform [Plaintiff's admitted activities] are the same as those necessary for obtaining and maintaining employment.” R.p. 42. However, in her function report, Plaintiff indicated she prepares food consisting of crockpot meals and sandwiches weekly (not daily) for 10 minutes at a time, shopped two to three times a month, and was unable to drive and go places on her own. R.pp. 246-248. She testified that she could do some house cleaning, house care, dishes, laundry, and cooking during the period from after her stroke and for about a year after, but her daughter-in-law moved in with her and helped and did most of these activities. She said she did not cook and could do some laundry. R.p. 73. “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).
The ALJ, citing to Plaintiff's Function Report (R.pp. 244-251) and Plaintiff's testimony at the hearing, listed Plaintiff's admitted activities as “preparing simple meals, washing laundry, driving, grocery shopping, watching television, and weekly church attendance.” R.p. 42.
Although the ALJ was not required to accept Plaintiff's allegations or impose specific restrictions to address them, he was required to resolve the conflicting evidence and explain his reasons for finding that Plaintiff had no restrictions in the use of her upper extremities to perform light, unskilled work during a forty-hour workweek. Without more, the ALJ failed to “build an accurate and logical bridge” from the evidence related to the daily activities of living to her what appears to be his conclusion that Plaintiff could at least frequently use her nondominant hand for fingering, handling, and feeling and had the bilateral use of her upper extremities to perform the unskilled, light jobs identified by the VE. See Monroe, 826 F.3d at 189.
The ALJ's decision lacks the required logical bridge between the evidence and his conclusion, and 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 Monroe, 826 F.3d at 189; see also Thomas, 916 F.3d at 311. Moreover, the lack of explanation concerning what appears to be a finding of no upper extremity limitations frustrates meaningful appellate review, such that the undersigned cannot find that substantial evidence supports the ALJ's RFC assessment. See Mascio, 780 F.3d at 636.
The Fourth Circuit has not adopted “a per se rule requiring remand when the ALJ does not perform an explicit function-by-function analysis,” Mascio, 780 F.3d at 636, but it has explained that remand is appropriate in cases where the ALJ fails to analyze a claimant's ability to perform a particular function that is both contested and relevant to determining disability status. See Dowling, 986 F.3d at 388-89 (explaining that assessing the claimant's ability to sit was critically relevant to determining her disability status, such that the function was contested, and noting the reasoning set forth in Mascio bolsters the conclusion that remand was required); see also Mascio, 780 F.3d at 636 (explaining that remand 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” (emphasis added) (internal quotation marks omitted)). Such is the case here, as the impact of Plaintiff's impairments on her ability to use her upper extremities to perform light work is important to the disability determination. Accordingly, this matter should be remanded for further consideration and explanation of the ALJ's consideration of Plaintiff's subjective complaints and ultimately how he arrived at Plaintiff's RFC.
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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.