Opinion
CIVIL 3:22-CV-1852
12-13-2023
LYNN A. MCARTHUR, Plaintiff v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant
(Chief Judge Brann)
REPORT AND RECOMMENDATION
DARYL F. BLOOM, UNITED STATES MAGISTRATE JUDGE
I. Introduction
On October 29, 2013, McArthur filed an application for disability and disability insurance benefits. (Tr. 198-209). A hearing was held before an Administrative Law Judge (“ALJ”), who found that McArthur was not disabled from her alleged onset date, September 5, 2013, to April 29, 2016, the date the ALJ issued his decision. (Tr. 21). McArthur appealed that decision, and the Court remanded the case for further consideration. McArthur v. Berryhill, No. 1:17-CV-2076, 2019 WL 1051200 (M.D. Pa. Jan. 30, 2019), report and recommendation adopted, No. 1:17-CV-2076, 2019 WL 1040673 (M.D. Pa. Mar. 5, 2019).
On September 21, 2020, a second hearing was held before a different ALJ, who again found that McArthur was not disabled from the alleged onset date to July 21, 2022, the date the decision was issued. (Tr. 385). McArthur now appeals this decision, arguing that the decision is not supported by substantial evidence. (Doc. 13). After a review of the record, and mindful of the fact that substantial evidence “means only- ‘such relevant evidence as a reasonable mind might accept as adequate to support a conclusion,'” Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019), we conclude that substantial evidence supports the ALJ's decision in this case. Therefore, we recommend that the district court affirm the decision of the Commissioner denying McArthur's claim.
II. Statement of Facts and of the Case
On October 29, 2013, Lynn McArthur applied for disability and supplemental security insurance benefits, citing an array of emotional impairments. (Tr. 198-209). At the time of the alleged onset of her disability, McArthur was 45 years old, had a high school education, and had previously worked as a tax accounting technician for the Commonwealth of Pennsylvania. (Tr. 382, 406).
On September 26, 2013, McArthur reported to her mental health provider that she had ended her employment with the Pennsylvania Department of Revenue because her supervisor had repeatedly sexually harassed her. (Tr. 371-72). On October 31, 2013, during an assessment for therapy, McArthur reported experiencing anxiety and depression related to the abuse she had suffered at work. (Tr. 882). After her initial assessment, McArthur attended regular therapy sessions with Marilyn Roads Mamone, LPC. (Tr. 826-82). Between November 7, 2013 and December 2, 2013, McArthur reported that she was having trouble sleeping and that she was feeling generally overwhelmed by life, but that her appetite and energy levels had improved. (Tr. 346, 879-81).
On December 4, 2013, Sandra Banks, Ph.D.-a State agency psychological consultant-rendered an opinion on McArthur's mental functioning. (Tr. 75). In forming her opinion, Dr. Banks reviewed McArthur's medical records from September 11, 2013 and September 25, 2013. (Tr. 65). Dr. Banks concluded that McArthur could understand, remember, and execute simple instructions, maintain concentration and attention during routine tasks, “work within a designated schedule[,]” and “maintain socially appropriate behavior.” (Id.). Therefore, according to Dr. Banks, McArthur would not require special supervision to “sustain a basic, repetitive work routine.” (Id.).
Between December of 2013 and January of 2014, McArthur reported that her attorney was going to file a civil suit against her former employer and that she felt “disgusted” at the thought of attending a court hearing and seeing the perpetrator. (Tr. 349, 877). On January 13, 2014, McArthur stated to her therapist that she had experienced a breakdown over the weekend in anticipation of the hearing, which was scheduled for the following day. (Tr. 876). However, on January 20, 2014, McArthur reported that she testified at the hearing in a “strong[,] assertive manner.” (Tr. 875).
McArthur attended three therapy sessions in February of 2014. (Tr. 871-74). During those sessions, McArthur reported that she does not like leaving her home because she is afraid of encountering former coworkers, whom she fears will ask her about the abuse she suffered at work. (Tr. 873). However, McArthur also shared that she was feeling better and would like to stop taking medication. (Tr. 871-73).
In March of 2014, McArthur's “affect was bright,” and she reported that she had been “getting out more” and planned to start swimming. (Tr. 870). However, McArthur also reiterated that she felt safest at home and shared that she was thinking of moving to Norfolk, Virginia. (Tr. 868). In April of 2014, McArthur stated that her mother been diagnosed with breast cancer and that she was increasingly nervous about her mother's upcoming lumpectomy. (Tr. 866-67).
Between May and of July 2014, McArthur's “spirits were bright” and she reported traveling and fulfilling multiple responsibilities. (Tr. 859-64). Specifically, McArthur stated that she had been caring for her brother, who had a stroke in 2012, and taking her mother to her radiation therapy appointments. (Tr. 862, 864). Though McArthur reported that she “ha[d] not left the house much,” she also stated that she travelled to see her family in Virginia Beach, visited her godmother, and spent two days in Washington, D.C., where she cooked for her son and his friend. (Tr. 856-60).
Between September 4, 2014 and December 4, 2014, McArthur was generally in good spirits and reported that she had been travelling again. (Tr. 846-54). The medical record shows that McArthur had a “bright” affect, displayed a good sense of humor, and was “elated that she [had] been taking out her god mother [sic] [and] enjoying her time with her.” (Tr. 851, 853). McArthur also reported that she had a great time campaigning for Tom Wolf with two of her friends by knocking on people's doors and making phone calls. (Tr. 852). However, McArthur later stated that she “gets triggered by the news,” that her brother “sponges off her[,]” that she felt depressed because the holidays were approaching, and that she was thinking everyday about the abuse she experienced. (Tr. 846-50).
On December 16, 2014, David DeMatteo, Ph.D. and Jaymes Fairfax-Columbo, B.A., psychologically examined McArthur at the request of her attorney in connection with her lawsuit against the Commonwealth of Pennsylvania. (Tr. 323-35). Though Dr. DeMatteo's report states that he reviewed McArthur's therapy records from Holy Spirit Hospital, he appears to have summarized McArthur's symptoms based on her statements during the examination and collateral interviews with McArthur's mother and brother. (Tr. 324-32). During the examination, McArthur described herself as a “‘homebody' who typically does not leave her house too much.” (Tr. 326). “When asked what she does for fun, [ ] McArthur stated, ‘Nothing because people know me and Harrisburg is not as big as Philly.'” (Id.). McArthur explained that she was afraid she would encounter former coworkers if she left her home and reported depression, intense worrying, difficulty sleeping, impaired concentration, and frequent nightmares. (Tr. 329-30). Consequently, McArthur said that she “‘stay[ed] in her bed for 2 to 3 days at a time'...at least twice per month.” (Tr. 330).
However, McArthur also stated that her mental health symptoms had improved over time and that she had reduced the frequency of her therapy sessions from once per week to once every two weeks. (Tr. 32931). During the assessment, McArthur appeared polite and cooperative, and her “capacity for attention and concentration appeared adequate.” (Tr. 330). In fact, McArthur “was able to focus well throughout the entire evaluation without becoming visibly distracted.” (Id.).
Dr. DeMatteo used two mechanisms to evaluate McArthur's mental capacity-the Brief Symptom Inventory (“BSI”) and the Minnesota Multiphasic Personality Inventory (“MMPI”). (Tr. 331-32). McArthur reported being “quite a bit” or “extremely” distressed by 31 of the 53 items on the BSI. (Tr. 331). Regarding the MMPI, Dr. DeMatteo noted that “[McArthur] endorsed an unusually large number and range of clinical symptoms, and her response style was somewhat inconsistent.” (Tr. 332). Thus, Dr. DeMatteo warned that although “[McArthur's] resulting MMPI-2 profile is valid, [ ] it may present a somewhat exaggerated picture of her current psychological functioning.” (Id.). Ultimately, Dr. DeMatteo concluded that “[McArthur's] anxiety symptoms, and the simultaneous constriction of her life activities, are not compatible with being employed in any meaningful way.” (Tr. 334). However, he also noted that “the continuation of talk therapy, in combination with her psychotropic medications, may eventually lead to meaningful symptom reduction.” (Tr. 335).
On December 18, 2014, McArthur reported that she had been shopping, “that her spirits ha[d] been good since she'[d] been out and about[,]” and that she planned to celebrate her birthday out of town. (Tr. 845). On January 5, 2015, McArthur's spirits appeared bright, and she explained that she was excited to take a trip with her mother and brother to celebrate her fiftieth birthday. (Tr. 844). McArthur also stated that she wanted to decrease the amount of psychotropic medication she was taking. (Id.).
In March of 2015, McArthur reported that she was grieving because her mother had passed away. (Tr. 353, 843). However, in April of 2015, she reported that she “[wa]s getting better[,]” was “getting out of the house[,]” and was planning a trip to Disney World with her brother. (Tr. 842). In May 2015, McArthur stated that she “ha[d] been sleeping a lot” and was “exhausted from being in court...” (Tr. 841). However, McArthur's therapy notes from May also indicate that she was “out and about in her life and meeting [ ] friends and family with a spirit of love and support.” (Tr. 840).
In June of 2015, McArthur reported that she was still grieving the loss of her mother. (Tr. 839). However, her affect was much brighter than it had been and she was “looking forward to a trip to Disney World in July..” (Tr. 837, 839). McArthur also reported that she “loves life and wants to help everybody she encounters..” (Tr. 837).
In July and August of 2015, McArthur reported that her cousin and her son's grandmother had both passed away and that she “‘[could not] take another funeral.'” (Tr. 835). However, McArthur's “[a]ffect was generally bright...” and she reported feeling refreshed after taking a trip to Disney World. (Tr. 834-35). McArthur also stated that she visited her mother's grave, “‘had a little birthday celebration[ ]'” with her son and brother and attended a church picnic. (Tr. 833).
Between September and November of 2015, McArthur's mood was generally positive, and she reported taking additional trips. (Tr. 337, 829-32). McArthur cancelled a therapy session on September 4, 2015 to take a trip and went to Norfolk, Virginia with her brother for three days in October of 2015. (Tr. 829, 832). McArthur also reported that she had been going to church regularly, attended a three-day church revival, and was “in the process of fixing up her kitchen..” (Tr. 830). McArthur's therapy and psychiatry notes state that “her spirits were bright and she laughed easily[,]” and that she was “doing well[,]” displayed good hygiene, and denied suicidal ideation. (Tr. 337).
Between March and June 2016, McArthur stated that she “still spen[t] most of her time at home[,]” but also reported that she had been going to church and “ha[d] forged relationships with older people[,]” whom she cooked for. (Tr. 827). McArthur also stated that she was relieved because her civil case, which had been stressful for her, had settled. (Tr. 339). On June 7, 2016, McArthur reported that she had lost her Klonopin prescription and felt anxious because she had not been taking that medication. (Tr. 950). However, on that same date, she also told her psychiatrist that her therapist had retired and that she no longer needed individual psychotherapy. (Id.).
On September 7, 2016, Silvestre Delacruz, M.D.-McArthur's psychiatrist-issued an opinion on McArthur's mental capacity. (Tr. 94849). In that opinion, Dr. Delacruz stated that McArthur “remains permanently mentally disabled to perform her Employment [sic] duties.” (Tr. 948). Dr. Delacruz explained that “[McArthur] said she is unable to work in any employment due to ‘[her] severe and [sic] anxiety.'” (Id.). Dr. Delacruz also told McArthur that he was retiring on January 1, 2017 and that she would be transferred to a new psychiatrist. (Id.). At the end of the session, McArthur reported that she had bought a house, where she intended to live with her brother and son. (Id.). Notes from that visit describe McArthur's mood and affect as “depressed,” but indicate that she denied suicidal ideation, her memory was intact, her thought processes were “within normal limits,” her appetite and energy levels were normal, and she was sleeping for seven to eight hours per day. (Id.).
McArthur met with a new psychiatrist on March 8, 2017. (Tr. 943). During that session, McArthur reported feeling “anxious going out in crowds or social situations[]” and frustration with politics, but indicated that she was “doing well overall” and had even been babysitting for family members. (Id.). Though McArthur had been prescribed two 0.5 mg capsules of Klonopin per day, she reported that she had only been taking one capsule on most days. (Tr. 944). Additionally, McArthur stated that she did not want a referral to therapy. (Tr. 946).
Between June 2017 and January of 2018, McArthur reported intermittent depression but consistently denied experiencing significant anxiety. (Tr. 928-40). After McArthur's psychiatrist prescribed Remeron, McArthur reported that she was “doing very well emotionally and mentally[,]” that she did not feel depressed or anxious, and that her sleep, appetite, energy levels, and PTSD symptoms had improved. (Tr. 929). Though McArthur stopped taking Klonopin when she started taking Remeron, instead of gradually reducing her Klonopin usage, as discussed, her attention span, concentration, and memory remained intact, and her depression was in full remission. (Tr. 927-30). In fact, McArthur told her psychiatrist that she “[went] to [c]hurch every Sunday” and tried to spend time with her neighbors, whom she described as “really supportive and nice.” (Tr. 940).
Between April and December of 2018, McArthur's mood fluctuated but she consistently reported that her PTSD was under control. (Tr. 91325). In July of 2018, McArthur reported that she was doing well, that she was not experiencing depression or anxiety, and that her PTSD was under “fair control.” (Tr. 921-22). In October of 2018, McArthur shared that she was “feeling depressed, stressed, overwhelmed and anxious [ ]” because the “Me Too” movement was bringing back traumatic memories. (Tr. 918). However, in December of 2018, after her psychiatrist increased her Remeron dosage, McArthur reported that she was doing well, did not feel depressed, and had no “major concerns with anxiety.” (Tr. 914). McArthur also reported that she socialized with her neighbors, enjoyed gathering with friends, rescued a dog from her cousin, and “[went] to church every Sunday.” (Tr. 918, 921, 925). She also shared that her son, his girlfriend, and their 17-month-old daughter had moved in with her and expressed that she would be happy to take care of her granddaughter. (Tr. 921-22). McArthur's treatment notes indicate that her attention span, fund of knowledge, abstract reasoning skills, linguistic abilities, and memory were intact and that she denied suicidal ideation. (Tr. 913, 921). On December 3, 2018, McArthur's psychiatrist decreased McArthur's Remeron dosage at McArthur's request. (Tr. 914).
Between April of 2019 and June of 2019, McArthur reported that she was “doing well overall[,]” that she was not experiencing significant anxiety, that her PTSD was “under control[,]” and that she had not decompensated after reducing her Remeron dosage. (Tr. 909-10). McArthur reported that she had asked her son and his wife to leave her home and that she was afraid she might never see her granddaughter again. (Tr. 910). McArthur also shared that she “gets triggered by the political issues...” surrounding Donald Trump and avoids going out in public “because sometimes when she speaks her mind she gets into trouble..” (Tr. 905). However, McArthur's attention span, fund of knowledge, abstract reasoning skills, linguistic abilities, and memory were intact, and she denied having panic attacks or having serious concerns about generalized anxiety. (Tr. 904-05).
On August 30, 2019, McArthur “report[ed] doing well overall.” (Tr. 900). She explained that she “ha[d] good days and bad days[,]” but was “able to manage her bad days.” (Id.). McArthur told her psychiatrist that she had independently decreased her Prozac dosage the prior month but had not decompensated. (Id.). Though McArthur stated that she had “occasional concerns with generalized anxiety,” she “denie[d] panic attacks[]” and reported that her PTSD symptoms were “overall under control..” (Id.).
On January 29, 2020, McArthur treated with a new psychiatrist and reported feeling depressed and socially isolated. (Tr. 895). McArthur also stated that she was “frustrated and stressed about the current political situation.” and was following Donald Trump's impeachment proceedings. (Id.). However, McArthur's energy levels were normal, her thought processes were “goal directed and logical,” and she stated that she was advocating for minorities and the poor. (Id.). Though McArthur reported experiencing occasional concerns with anxiety, she denied experiencing panic attacks and indicated that her PTSD symptoms were under control. (Id.). At that appointment, McArthur was candid, cooperative, and polite, and her attention, concentration, and memory were intact. (Tr. 896-97). McArthur continues to meet with her psychiatric provider every three months. (Tr. 406).
Against the backdrop of this evidence, the ALJ conducted a hearing in McArthur's case on July 6, 2022. (Tr. 399-412). McArthur and a vocational expert both testified at the hearing. (Id.). Following the hearing, on July 21, 2022, the ALJ issued a decision denying McArthur's application for benefits. (Tr. 362-85). First, the ALJ concluded that McArthur did not engage in substantial gainful activity between September 5, 2013, her alleged onset date, and the date the decision was issued. (Tr. 365). At Step 2 of the sequential analysis that governs Social Security cases, the ALJ found that McArthur suffered from three severe impairments: major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder. (Id.). The ALJ also found that McArthur had been treated for hypertension and hyperlipidemia. (Tr. 365-66). However, the ALJ concluded that those conditions were non-severe because none of them caused more than mild limitations. (Id.).
At Step 3, the ALJ concluded that none of McArthur's severe impairments met or equaled the severity of an impairment listed in the Commissioner's regulations. (Tr. 366). In making that determination, the ALJ found that McArthur had moderate limitations in all four areas of functioning-understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing oneself. (Tr. 366-70). The ALJ found that McArthur had only moderate limitations in her ability to interact with others because her medical record showed that she frequently socialized. (Tr. 366-67). The ALJ spent more than a page recounting McArthur's social activity, which is summarized above. (Id.). The ALJ noted, among other things, that McArthur took her mother to her appointments and radiation therapy five days per week, took trips to Virginia Beach, Norfolk, Washington, D.C., and Disney World, regularly shopped and attended church, attended a three-day church revival, and campaigned for Tom Wolf with two friends by knocking on doors and making telephone calls. (Id.).
The ALJ also explained that McArthur is only moderately limited in her ability to concentrate, persist, or maintain pace because her medical record shows that was able to perform tasks that require concentration. (Tr. 368). For example, the ALJ noted that McArthur reminded her brother, who previously lived with her, to take his medication and administered his insulin. (Id.). Additionally, the ALJ noted that McArthur “ke[pt] up with the paperwork” related to her civil and criminal cases. (Id.). Moreover, as the ALJ explained, McArthur displayed average intelligence during her December 16, 2014 assessment and records from her therapy sessions from January 24, 2018 to January 29, 2020, showed that her concentration and attention were both intact. (Id.). Finally, the ALJ noted that McArthur reported following impeachment proceedings and advocating for minorities and poor people. (Id.).
Between Steps 3 and 4 the ALJ concluded that McArthur had the following residual functional capacity:
[T]he claimant has the residual functional capacity to perform a full range of work at all exertional levels but with the following nonexertional limitations: The claimant retains the mental capacity to perform simple and routine tasks involving only simple work related decisions with few, if any, workplace changes and to tolerate occasional interaction with supervisors, coworkers and the public, but never to perform production pace work.(Tr. 370).
In reaching this RFC determination, the ALJ considered the objective medical record detailed above, McArthur's reported symptoms, and the medical opinions rendered by Drs. Banks, Delacruz, and DeMatteo. (Tr. 366-82). Ultimately, the ALJ found that McArthur's statements concerning the intensity, persistence, and limiting effects of her impairments were not entirely consistent with the objective medical evidence. (Tr. 371). McArthur testified that she feels anxious when she goes outside or speaks to other people. (Tr. 405). According to McArthur, she only leaves her house “[m]aybe once a week, if that” and that it takes her several days to one week to prepare to go outside. (Tr. 403, 405). McArthur testified that her brother previously lived with her, and she used to administer insulin to him and remind him to take his medication. (Tr. 404). Now, according to McArthur, her brother helps her by going to the grocery store, getting medication for her, and doing yard work. (Id.). McArthur testified that she needs her brother's help because she has depression, which requires her to speak to a psychiatrist every three months and take medication that causes grogginess. (Tr. 405-06). McArthur also testified that although her dosages have continually increased, she does not feel any better. (Tr. 405).
The ALJ found McArthur's testimony to be inconsistent with the objective clinical findings. (Tr. 371). The ALJ first noted that McArthur did not undergo inpatient psychiatric hospitalization or emergency treatment for her mental health symptoms, which improved with medication and therapy. (Tr. 378). The ALJ also noted that McArthur reduced her therapy sessions from once per week to once every other week between the onset date and the fall of 2014 and stopped therapy by June of 2016. (Id.). Similarly, the ALJ reasoned that, contrary to her physician's advice, McArthur stopped taking Klonopin in January of 2018 and reduced her Prozac dosage in July of 2019 without decompensating. (Id.).
The ALJ also found that McArthur's activities of daily living suggest that she could work at the assigned RFC. (Tr. 379). Though McArthur testified that she only left the house once “[m]aybe once a week...” and that leaving the house and interacting with others made her anxious, the ALJ explained that McArthur frequently travelled and interacted with others according to her medical records. (Tr. 379-80). Among other things, the ALJ noted that McArthur took her mother to her appointments and radiation therapy five days per week, took trips to Virginia Beach, Norfolk, Washington, D.C., and Disney World, regularly attended church, attended a three-day church revival, and campaigned for Tom Wolf with two friends by knocking on doors and making telephone calls. (Tr. 379-80).
After evaluating the objective medical record, the ALJ considered the opinions of Drs. Banks, Delacruz, and DeMatteo. (Tr. 380-82). The ALJ gave Dr. Banks' opinion significant weight because it was more consistent with the record than the opinions of Drs. Delacruz and DeMatteo. (Tr. 380). Specifically, the ALJ reasoned that Dr. Banks' opinion was consistent with the fact that McArthur never received inpatient or emergency hospitalization, reduced her psychiatric medication without experiencing decompensation, stopped attending therapy in June of 2016, participated in social activities, such as campaigning and attending church, and left her house to take multiple vacations. (Id.).
By contrast, the ALJ found that Dr. Delacruz's opinion was inconsistent with the record. (Tr. 380-81). The ALJ first noted that although Dr. Delacruz was McArthur's psychiatric provider, he appeared to have premised his conclusion on McArthur's statement that she was unable to work due to extreme anxiety, rather than an “objective clinical evaluation.” (Id.). Moreover, the ALJ reasoned that Dr. Delacruz's opinion was inconsistent with McArthur's statement that she no longer needed to see a therapist. (Tr. 381). Additionally, the ALJ noted that Dr. Delacruz rendered his opinion after McArthur had decompensated from running out of Klonopin but before McArthur independently discontinued Klonopin and reduced her Prozac dosage without decompensating. (Id.). Finally, the ALJ reasoned that Dr. Delacruz's opinion was “not supported by the observations of McArthur's intact attention span, concentration and memory at appointments with her psychiatric provider or McArthur's abilities to vacation at multiple locations, to take her mother to appointments and radiation treatments, to be active with church events and to campaign for a candidate.” (Id.). Accordingly, the ALJ afforded this opinion little weight.
The ALJ also rejected Dr. DeMatteo's opinion, giving it little weight, on the grounds that it was prepared for McArthur's civil suit and was inconsistent with McArthur's medical record. (Id.). The ALJ first noted that McArthur's attorney paid Dr. DeMatteo $2,000 “to provide evidence in a civil lawsuit McArthur had filed against her former employer.” (Id.). The ALJ also explained that Dr. DeMatteo's opinion was not supported by the objective medical record, which showed that McArthur benefitted from medication and therapy, reported not needing therapy anymore in June of 2016, independently reduced her dosages of Klonopin and Prozac without experiencing decompensation, took her mother to her doctor's appointments and radiation therapy five days per week, took multiple vacations in different states, worked on a political campaign, and frequently prepared and brought food to friends and loved ones. (Id.). Finally, the ALJ reasoned that Dr. DeMatteo's opinion was inconsistent with his conclusions that the MMPI-2 may present an exaggerated picture of McArthur's mental health symptoms and that McArthur may benefit from additional therapy. (Id.).
Having made these findings, the ALJ found at Step 4 that McArthur could not perform her past work but found at Step 5 that she could perform other jobs in the national economy, such as production helper, weeder, and laundry laborer. (Tr. 382-83). Accordingly, the ALJ found that McArthur had not met the stringent standard prescribed for disability benefits and denied her claim. (Tr. 385).
This appeal followed. On appeal, McArthur challenges the ALJ's decision, citing five errors that fall into two broad categories. (Doc. 13 at 9). First, McArthur argues that ALJ erroneously rejected her testimony. (Id. at 11-15). Second, McArthur contends that the ALJ erred by crediting Dr. Banks' opinion over Dr. DeMatteo's opinion. (Id. at 1314). As discussed in greater detail below, having considered the arguments of counsel and carefully reviewed the record, we conclude that the ALJ's decision should be affirmed.
III. Discussion
A. Substantial Evidence Review - the Role of This Court
This Court's review of the Commissioner's decision to deny benefits is limited to the question of whether the findings of the final decisionmaker are supported by substantial evidence in the record. See 42 U.S.C. §405(g); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D. Pa. 2012). Substantial evidence means less than a preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). Substantial evidence “does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Pierce v. Underwood, 487 U.S. 552, 565 (1988).
A single piece of evidence is not substantial evidence if the ALJ “ignores, or fails to resolve, a conflict created by countervailing evidence.” Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993) (quoting Kent v. Schweiker, 710 F.2d 110, 114 (3d Cir. 1983)) (internal quotations omitted). However, where there has been an adequately developed factual record, substantial evidence may be “something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's decision] from being supported by substantial evidence.” Consolo v. Fed. Maritime Comm'n, 383 U.S. 607, 620 (1966). The court must “scrutinize the record as a whole” to determine if the decision is supported by substantial evidence. Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D. Pa. 2003).
The Supreme Court has explained the limited scope of our review, noting that “[substantial evidence] means-and means only-‘such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'” Biestek, 139 S.Ct. at 1154 (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)). Under this standard, we must look to the existing administrative record to determine if there is “‘sufficient evidence' to support the agency's factual determinations.” Id. Thus, the question before us is not whether McArthur is disabled, but rather whether the Commissioner's finding that he or she is not disabled is supported by substantial evidence and was based upon a correct application of the law. See Arnold v. Colvin, No. 3:12-CV-O2417, 2014 WL 940205, at *1 (M.D. Pa. Mar. 11, 2014) (“[I]t has been held that an ALJ's errors of law denote a lack of substantial evidence”) (alterations omitted); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D. Pa. 1981) (“The Secretary's determination as to the status of a claim requires the correct application of the law to the facts”); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990) (noting that the scope of review on legal matters is plenary); Ficca, 901 F.Supp.2d at 536 (“[T]he court has plenary review of all legal issues . . . .”).
When conducting this review, “we must not substitute our own judgment for that of the fact finder.” Zirnsak v. Colvin, 777 F.3d 607, 611 (3d Cir. 2014) (citing Rutherford v. Barnhart, 399 F.3d 546, 552 (3d Cir. 2005)). Thus, we cannot reweigh the evidence. Instead, we must determine whether there is substantial evidence to support the ALJ's findings. In doing so, we must also determine whether the ALJ's decision meets the burden of articulation necessary to enable judicial review; that is, the ALJ must articulate the reasons for his decision. Burnett v. Comm'r of Soc. Sec. Admin., 220 F.3d 112, 119 (3d Cir. 2000). This does not require the ALJ to use “magic” words, but rather the ALJ must discuss the evidence and explain the reasoning behind his or her decision with more than just conclusory statements. See Diaz v. Comm'r of Soc. Sec., 577 F.3d 500, 504 (3d Cir. 2009) (citations omitted). Ultimately, the ALJ's decision must be accompanied by “a clear and satisfactory explication of the basis on which it rests.” Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981).
B. Initial Burdens of Proof, Persuasion, and Articulation for the ALJ
To receive disability benefits under the Social Security Act, a claimant must show that he or she is unable to “engage in 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.” 42 U.S.C. §423(d)(1)(A); 42 U.S.C. §1382c(a)(3)(A); see also 20 C.F.R. §§404.1505(a), 416.905(a). This requires a claimant to show a severe physical or mental impairment that precludes her from engaging in previous work or “any other substantial gainful work which exists in the national economy.” 42 U.S.C. §423(d)(2)(A); 42 U.S.C. §1382c(a)(3)(B); 20 C.F.R. §§404.1505(a), 416.905(a). To receive benefits under Title II of the Social Security Act, a claimant must show that he or she is under retirement age, contributed to the insurance program, and became disabled prior to the date on which he or she was last insured. 42 U.S.C. §423(a); 20 C.F.R. §404.131(a).
In making this determination, the ALJ follows a five-step evaluation. 20 C.F.R. §§404.1520(a), 416.920(a). The ALJ must sequentially determine whether McArthur: (1) is engaged in substantial gainful activity; (2) has a severe impairment; (3) has a severe impairment that meets or equals a listed impairment; (4) is able to do his or her past relevant work; and (5) is able to do any other work, considering his or her age, education, work experience and residual functional capacity (“RFC”). 20 C.F.R. §§404.1520(a)(4), 416.920(a)(4).
Between Steps 3 and 4, the ALJ must also determine McArthur's residual functional capacity (RFC). RFC is defined as “that which an individual is still able to do despite the limitations caused by his or her impairment(s).” Burnett, 220 F.3d at 121 (citations omitted); see also 20 C.F.R. § 404.1545(a)(1). In making this assessment, the ALJ must consider all McArthur's medically determinable impairments, including any non-severe impairments identified by the ALJ at step two of his or her analysis. 20 C.F.R. §§404.1545(a)(2), 416.945(a)(2). Our review of the ALJ's determination of the plaintiff's RFC is deferential, and that determination will not be set aside if it is supported by substantial evidence. Burns v. Barnhart, 312 F.3d 113, 129 (3d Cir. 2002).
McArthur bears the burden at Steps 1 through 4 to show a medically determinable impairment that prevents her from engaging in any past relevant work. Mason, 994 F.2d at 1064. If met, the burden then shifts to the Commissioner to show at Step 5 that there are jobs in significant numbers in the national economy that McArthur can perform consistent with McArthur's RFC, age, education, and work experience. 20 C.F.R. §§404.1512(f), 416.912(f); Mason, 994 F.2d at 1064.
With respect to the RFC determination, courts have followed different paths when considering the impact of medical opinion evidence on this determination. While some courts emphasize the necessity of medical opinion evidence to craft a claimant's RFC, see Biller v. Acting Comm'r of Soc. Sec., 962 F.Supp.2d 761, 778-79 (W.D. Pa. 2013), other courts have held that “[t]here is no legal requirement that a physician have made the particular findings that an ALJ adopts in the course of determining an RFC.” Titterington v. Barnhart, 174 Fed.Appx. 6, 11 (3d Cir. 2006). Additionally, in cases that involve no credible medical opinion evidence, courts have held that “the proposition that an ALJ must always base his RFC on a medical opinion from a physician is misguided.” Cummings v. Colvin, 129 F.Supp.3d 209, 214-15 (W.D. Pa. 2015).
Given these differing approaches, we must evaluate the factual context underlying an ALJ's decision. Cases that emphasize the importance of medical opinion support for an RFC assessment typically arise where well-supported medical sources have found limitations to support a disability claim, but an ALJ has rejected those medical opinions based upon an assessment of other evidence. Biller, 962 F.Supp.2d at 778-79. These cases simply restate the notion an ALJ must carefully consider the claimant's medical records when making a disability determination. On the other hand, when no medical opinion supports a disability finding or when an ALJ relies on other evidence to fashion an RFC, courts routinely sustain the ALJ's exercise of independent judgment based upon all the facts and evidence. See Titterington, 174 Fed.Appx. 6; Cummings, 129 F.Supp.3d at 214-15. Ultimately, we must determine, considering the entire record, whether the RFC determination is supported by substantial evidence. Burns, 312 F.3d 113.
C. Legal Benchmarks for the ALJ's Assessment of a Claimant's Alleged Symptoms
When evaluating lay testimony regarding a claimant's reported degree of pain and disability, the ALJ must make credibility determinations. See Diaz v. Commr 577 F.3d 500, 506 (3d Cir.2009). Our review of those determinations is deferential. Id. However, it is incumbent upon the ALJ to “specifically identify and explain what evidence he found not credible and why he found it not credible.” Zirnsak v. Colvin, 777 F.3d 607, 612 (3d Cir. 2014) (citations omitted). An ALJ should give great weight to a claimant's testimony “only when it is supported by competent medical evidence.” McKean v. Colvin, 150 F.Supp.3d 406, 415-16 (M.D. Pa. 2015) (citations omitted). As the Third Circuit has noted, while “statements of the individual concerning his or her symptoms must be carefully considered, the ALJ is not required to credit them.” Chandler v. Comm'r of Soc. Sec., 667 F.3d 356, 363 (3d. Cir. 2011) (referencing 20 C.F.R. §404.1529(a) (“statements about your pain or other symptoms will not alone establish that you are disabled”).
The Social Security Rulings and Regulations provide a framework for evaluating the severity of a claimant's reported symptoms. 20 C.F.R. §§ 404.1529, 416.929; SSR 16-3p. Thus, the ALJ must follow a two-step process: first, the ALJ must determine whether a medically determinable impairment could cause the symptoms alleged; and second, the ALJ must evaluate the alleged symptoms in light of the entire administrative record. SSR 16-3p.
Symptoms such as pain or fatigue will be considered to affect a claimant's ability to perform work activities only if medical signs or laboratory findings establish the presence of a medically determinable impairment that could reasonably be expected to produce the alleged symptoms. 20 C.F.R. §§ 404.1529(b), 416.929(b); SSR 16-3p. During the second step of this assessment, the ALJ must determine whether the claimant's statements regarding the intensity, persistence, or limiting effects of his or her symptoms are substantiated when considered in light of the entire case record. 20 C.F.R. § 404.1529(c), 416.929(c); SSR 16-3p. This includes, but is not limited to, medical signs and laboratory findings; diagnoses; medical opinions provided by treating or examining sources and other medical sources; and information regarding the claimant's symptoms and how they affect his or her ability to work. 20 C.F.R. § 404.1529(c), 416.929(c); SSR 16-3p.
The Social Security Administration recognizes that individuals may be limited by their symptoms to a greater or lesser extent than other individuals with the same medical impairments, signs, and laboratory findings. SSR 16-3p. Thus, to assist in the evaluation of a claimant's subjective symptoms, the Social Security Regulations set forth seven factors that may be relevant to the assessment of the claimant's alleged symptoms. 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3). These factors include: the claimant's daily activities; the “location, duration, frequency, and intensity” of the claimant's pain or symptoms; the type, dosage, and effectiveness of medications; treatment other than medications; and other factors regarding the claimant's functional limitations. 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3).
D. Legal Benchmarks for the ALJ's Assessment of Medical Opinions
The Commissioner's regulations also set standards for the evaluation of medical evidence and define medical opinions as “statements from physicians and psychologists or other acceptable medical sources that reflect judgments about the nature and severity of [a claimant's] impairment(s), including [a claimant's] symptoms, diagnosis and prognosis, what [a claimant] can still do despite impairments(s), and [a claimant's] physical or mental restrictions.” 20 C.F.R. §404.1527(a)(2). The ALJ is required to evaluate every medical opinion received, regardless of the source. 20 C.F.R. §404.1527(c).
For applications filed prior to March of 2017, an ALJ is guided by factors outlined in 20 C.F.R. §404.1527(c) in deciding what weight to afford medical opinions and evidence. As ties between the source and the claimant become weaker, “[t]he regulations provide progressively more rigorous tests for weighing opinions.” SSR 96-6p, 1996 WL 374180 at *2. Treating sources have the closest ties to the claimant, thereby generally entitling their opinions to more weight. See 20 C.F.R. §404.1527(c)(2); 20 C.F.R. §404.1502. Under some circumstances, where the opinion is supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other medical evidence, the medical opinion of a treating source may even be entitled to controlling weight. 20 C.F.R. §§04.1527(c)(2); see also SSR 96-2p, 1996 WL 374188.
If no medical opinion is given controlling weight, the regulations direct the ALJ to consider several factors in deciding what weight to afford medical opinions, including: the nature and extent of the treatment relationship; the length of the treatment relationship and frequency of examination; whether the opinion is supported by and consistent with the relevant medical evidence in the record; whether the source is a specialist; and any other factors brought to the ALJ's attention. 20 C.F.R. §404.1527(c). These factors also call for careful consideration of treating source opinions.
An ALJ may not reject a treating source's opinion and substitute the judge's own lay assessment of the record for that medical opinion. Instead, the ALJ typically may only discount a treating opinion when it conflicts with other objective tests or examination results. Johnson v. Comm'r of Soc Sec., 529 F.3d 198, 202-03 (3d Cir. 2008). Likewise, an ALJ may afford little weight to a treating opinion based on inconsistencies between the physician's opinion and his or her own treatment notes. Torres v. Barnhart, 139 Fed.Appx. 411, 415 (3d Cir. 2005). Finally, even where an opinion is well-supported by objective findings, it may not be entitled to controlling weight if it is nonetheless inconsistent with the claimant's activities. Tilton v. Colvin, 184 F.Supp.3d 135, 145 (M.D. Pa. 2016). However, the ALJ must provide “a clear and satisfactory explication of the basis on which [his or her decision] rests[,]” including an explanation of the weight afforded to medical opinions. Cotter, 642 F.2d at 704. Therefore, remand may be appropriate if an ALJ does not fully articulate his or her reason for rejecting a treating source opinion.
E. The ALTs Decision is Supported by Substantial Evidence.
Our review of the ALJ's decision denying an application for benefits is significantly deferential. Our task is simply to determine whether the ALJ's decision is supported by substantial evidence in the record; that is “only [ ] ‘such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'” Biestek, 139 S.Ct. at 1154. Judged against this deferential standard of review, we conclude that substantial evidence supported the ALJ's decision in this case.
McArthur makes four arguments that turn, either primarily or exclusively, on the same premise-that the ALJ should have credited her hearing testimony and the statements she made to her medical providers. (Doc. 13 at 11-15). McArthur stated that she is so scared of working with supervisors, coworkers, and the public that she is “essentially confined to the house[,]” “require[s] several days to work up to leaving the home[,]” remains in her pajamas most days, and suffers daily panic attacks. (Id. at 11-12; 15). According to McArthur, the ALJ should have credited those statements and found that she was severely limited under paragraphs “b” and “c” of Listings 12.04 and 12.06, could not maintain regular attendance or even occasionally interact with others, and was completely unable to work. (Doc. 13 at 11-15).
Though McArthur argues that the ALJ erred by finding that she did not satisfy the paragraph “c” criteria of Listings 12.04 and 12.06, (Doc. 13 at 8), her arguments only address the criteria in paragraph “b.”
We disagree. In our view, the ALJ adequately articulated why he found McArthur's statements to be inconsistent with the record. As explained above, the ALJ spent multiple pages recounting McArthur's social activities, which included taking her mother to radiation therapy five days per week, taking vacations to Virginia Beach, Norfolk, Washington, D.C., and Disney World, regularly shopping and attending church, attending a three-day church revival, and campaigning for Tom Wolf with two friends by knocking on doors and making telephone calls. (Tr. 368-69, 378-80). These activities, along with the myriad others cited in the ALJ's opinion, demonstrate that McArthur was not “essentially confined to the house[,]” as she contends. (Doc. 13 at 12). Therefore, substantial evidence supports the ALJ's finding that McArthur suffered only moderate limitations under paragraphs “b” and “c,” could maintain regular attendance, could occasionally interact with coworkers, supervisors, and the public, and was generally capable of working.
McArthur also argues that she is markedly limited in her ability to concentrate, persist, or maintain pace because her RFC precludes her from performing “production pace work.” (Doc. 13 at 12). We note that it is impossible to assess this argument because the term “production pace work” does not appear in the Social Security Regulations and the ALJ did not define it. (See generally Tr. 359-85). However, in our view, any error the ALJ may have committed is harmless.
Social Security appeals are subject to harmless error analysis. See Holloman v. Comm'r Soc. Sec., 639 Fed.Appx. 810, 814 (3d Cir. 2016). Under the harmless error analysis, a remand is warranted only if the error “prejudices a party's ‘substantial rights'”; that is, if the error “likely affects the outcome of the proceeding, . . .” Hyer v. Colvin, 72 F.Supp.3d 479, 494 (D. Del. 2014). Here, the outcome of the proceeding would not have changed even if McArthur was markedly, rather than moderately, limited in her ability to concentrate, persist, or maintain pace because a finding of only one marked limitation in one of the functional areas is insufficient to prevail at Step 3. 20 C.F.R. § 416.926a(a).
McArthur also argues that the ALJ erred by crediting Dr. Banks' opinion over Dr. DeMatteo's opinion. (Doc. 13 at 13-14). McArthur first argues that, unlike Dr. Banks, Dr. DeMatteo personally examined her. (Id. at 13). However, “‘[i]n appropriate circumstances, opinions from State agency medical and psychological consultant and other program physicians and psychologists may be entitled to greater weight than the opinion of treating or examining sources.'” Morris v. Colvin, No. 3:141902, 2015 WL 7252524, at *5 (M.D. Pa. Nov. 17, 2015). Thus, as this Court previously explained, “McArthur is mistaken in her claim that Dr. Banks opinion must be afforded lesser weight than Dr. DeMatteo's opinion purely because Dr. Banks' opinion is a non-examining opinion.” McArthur, 2019 WL 1051200, at *7 (report and recommendation adopted, No. 1:17-CV-2076, 2019 WL 1040673 (M.D. Pa. Mar. 5, 2019) (citing Morris, 2015 WL 7252524, at *5; Jackson v. Colvin, No. 3:13-00886, 2014 WL 4955231, at *9 (M.D. Pa. Sept. 30, 2014)).
Next, McArthur contends that the ALJ should have rejected Dr. Banks' opinion because it was more than nine years old at the time of the hearing. (Doc. 13 at 13). As an initial matter, the age of Dr. Banks' opinion is relatively inconsequential in context. At the time of the hearing, Dr. Banks' opinion was approximately eight and a half years old and Dr. DeMatteo's was approximately seven and a half years old. (Tr. 65; 323). Therefore, neither expert had the opportunity to review most of the medical records at issue on appeal. More importantly, as Judge Mehalchick previously explained, “‘[t]he Social Security regulations impose no limit on how much time may pass between a report and the ALJ's decision in reliance on it.'” McArthur, 2019 WL 1051200, at *7 (report and recommendation adopted, No. 1:17-CV-2076, 2019 WL 1040673 (M.D. Pa. Mar. 5, 2019) (quoting Chandler, 667 F.3d 356, 361). Thus, the ALJ did not err merely by crediting a relatively old opinion.
The relevant question is whether the ALJ adequately articulated why he afforded more weight to Dr. Banks' opinion than to Dr. DeMatteo's opinion. We conclude that the ALJ adequately explained his reasoning. As the ALJ noted, Dr. DeMatteo's findings were inconsistent with the objective medical record, which showed, among other things, that McArthur took her mother to radiation treatment five times per week, did not need therapy after June of 2016, reduced her medications without decompensating, took vacations to multiple destinations, and even worked on a political campaign. (Tr. 381-82). The ALJ also explained that he ascribed less weight to Dr. DeMatteo's opinion because Dr. DeMatteo was hired to provide evidence in McArthur's civil case and admitted that the MMPI-2 “present[ed] a somewhat exaggerated picture of [McArthur's] current psychological functioning.” (Tr. 381). Therefore, we conclude that substantial evidence supported the ALJ's explanation for rejecting Dr. DeMatteo's findings and crediting Dr. Banks' findings.
McArthur also argues that the ALJ erroneously reasoned that Dr. Banks' opinion was consistent with medical records that postdated the opinion. (Doc. 13 at 14). However, when evaluating a medical opinion, an ALJ should consider whether intervening records contradict the expert's reasoning. See Chandler, 667 F.3d at 363. This is especially true where, as here, the opinion is relatively dated. See id. Therefore, in our view, the ALJ did not err by considering medical records created after Dr. Banks issued her opinion.
Accordingly, under the deferential standard of review that applies to appeals of Social Security disability determinations, we conclude that substantial evidence supported the ALJ's evaluation of this case and recommend that this decision be affirmed.
IV. Recommendation
For the foregoing reasons, IT IS RECOMMENDED that the decision of the Commissioner in this case be affirmed, and the plaintiff's appeal denied.
The parties are further placed on notice that pursuant to Local Rule 72.3:
Any party may object to a magistrate judge's proposed findings, recommendations or report addressing a motion or matter described in 28 U.S.C. § 636 (b)(1)(B) or making a recommendation for the disposition of a prisoner case or a habeas corpus petition within fourteen (14) days after being served with a copy thereof. Such party shall file with the clerk of court, and serve on the magistrate judge and all parties, written objections which shall specifically identify the portions of the proposed findings, recommendations or report to which objection is made and the basis for such objections. The briefing requirements set forth in Local Rule 72.2 shall apply. A judge shall make a de novo determination of those portions of the report or specified proposed findings or recommendations to which objection is made and may accept, reject, or modify, in whole or in part, the findings or recommendations made by the magistrate judge. The judge, however, need conduct a new hearing only in his or her discretion or where required by law, and may consider the record developed before the magistrate judge, making his or her own determination on the basis of that record. The judge may also receive further evidence, recall witnesses or recommit the matter to the magistrate judge with instructions.