Opinion
2:20-CV-53-D
02-14-2022
JACKIE HOWARD PIERCE, Plaintiff/Claimant, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant.
MEMORANDUM AND RECOMMENDATION
Robert B. Jones, Jr. United States Magistrate Judge.
This matter is before the court on the parties' cross-motions for judgment on the pleadings [DE-18, -22] pursuant to Fed.R.Civ.P. 12(c). Claimant Jackie Howard Pierce (“Claimant”) filed this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the denial of her application for a period of disability and Disability Insurance Benefits (“DIB”). The time for filing responsive briefs has expired, and the pending motions are ripe for adjudication. Having carefully reviewed the administrative record and the motions and memoranda submitted by the parties, it is recommended that Claimant's Motion for Judgment on the Pleadings be denied, Defendant's Motion for Judgment on the Pleadings be allowed, and the final decision of the Commissioner be affirmed.
I. STATEMENT OF THE CASE
Claimant protectively filed an application for a period of disability and DIB on July 24, 2017, alleging disability beginning August 12, 2016. (R. 10, 180-86). Her claim was denied initially and upon reconsideration. (R. 10, 75-103). A hearing before the Administrative Law Judge (“ALJ”) was held on September 4, 2019, at which Claimant, represented by counsel, and a vocational expert (“VE”) appeared and testified. (R. 37-74). On September 18, 2019, the ALJ issued a decision denying Claimant's request for benefits. (R. 7-26). On June 15, 2020, the Appeals Council denied Claimant's request for review. (R. 1-6). Claimant then filed a complaint in this court seeking review of the now-final administrative decision.
II. STANDARD OF REVIEW
The scope of judicial review of a final agency decision regarding disability benefits under the Social Security Act (“Act”), 42 U.S.C. § 301 et seq., is limited to determining whether substantial evidence supports the Commissioner's factual findings and whether the decision was reached through the application of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). “The findings of the Commissioner ... as to any fact, if supported by substantial evidence, shall be conclusive . . . .” 42 U.S.C. § 405(g). Substantial evidence is “evidence which a reasoning mind would accept as sufficient to support a particular conclusion.” Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966). While substantial evidence is not a “large or considerable amount of evidence, ” Pierce v. Underwood, 487 U.S. 552, 565 (1988), it is “more than a mere scintilla ... and somewhat less than a preponderance.” Laws, 368 F.2d at 642. “In reviewing for substantial evidence, [the court should not] undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner].” Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996), superseded by regulation on other grounds, 20 C.F.R. § 416.927(d)(2)). Rather, in conducting the “substantial evidence” inquiry, the court's review is limited to whether the ALJ analyzed the relevant evidence and sufficiently explained his or her findings and rationale in crediting the evidence. Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).
III. DISABILITY EVALUATION PROCESS
The disability determination is based on a five-step sequential evaluation process as set forth in 20 C.F.R. § 404.1520 under which the ALJ is to evaluate a claim:
The claimant (1) must not be engaged in “substantial gainful activity, ” i.e., currently working; and (2) must have a “severe” impairment that (3) meets or exceeds [in severity] the “listings” of specified impairments, or is otherwise incapacitating to the extent that the claimant does not possess the residual functional capacity to (4) perform ... past work or (5) any other work.Albright v. Comm 'r of the SSA, 174 F.3d 473, 475 n.2 (4th Cir. 1999). “If an applicant's claim fails at any step of the process, the ALJ need not advance to the subsequent steps.” Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995) (citation omitted). The burden of proof and production during the first four steps of the inquiry rests on the claimant. Id. At the fifth step, the burden shifts to the ALJ to show that other work exists in the national economy which the claimant can perform. Id.
When assessing the severity of mental impairments, the ALJ must do so in accordance with the “special technique” described in 20 C.F.R. § 404.1520a(b)-(c). This regulatory scheme identifies four broad functional areas in which the ALJ rates the degree of functional limitation resulting from a claimant's mental impairment(s): understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing oneself. Id. § 404.1520a(c)(3). The ALJ is required to incorporate into his written decision pertinent findings and conclusions based on the “special technique.” Id. § 404.1520a(e)(3).
In this case, Claimant alleges the ALJ committed the following errors: (1) failing to properly analyze the medical opinions, (2) failing to properly analyze Claimant's subjective symptoms, (3) finding Claimant was capable of performing a reduced range of light work, (4) failing to properly apply the Grid Rules, and (5) failing to include all of Claimant's limitations in the hypothetical to the VE. Pl.'s Mem. [DE-19] at 24-32.
IV. ALJ'S FINDINGS
Applying the above-described sequential evaluation process, the ALJ found Claimant “not disabled” as defined in the Act. At step one, the ALJ found Claimant had not engaged in substantial gainful employment since the alleged onset date of August 12, 2016. (R. 12). Next, the ALJ determined Claimant had the severe impairments of sacroiliac joint dysfunction and obesity, and the nonsevere impairments of hypertension, hyperlipidemia, osteopenia, insomnia, gastroesophageal reflux disease (GERD), depressive disorder, anxiety disorder, and sleep-wake disorder. Id. However, at step three, the ALJ concluded these impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listed impairments in 20 C.ER. Part 404, Subpart P, Appendix 1. (R. 14). Applying the technique prescribed by the regulations, the ALJ found that Claimant's mental impairments resulted in no limitations in understanding, remembering, or applying information and interacting with others, and mild limitations in concentrating, persisting, or maintaining pace and adapting or managing oneself. (R. 13).
Prior to proceeding to step four, the ALJ assessed Claimant's RFC, finding Claimant had the ability to perform light work with the following limitations:
Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, you must have the ability to do substantially all of these activities. If an individual can perform light work, he or she can also perform sedentary work, unless there are additional limiting factors such as the loss of fine dexterity or the inability to sit for long periods of time. 20 C.F.R. § 404.1567(b).
she must have the option to stand for 1-3 minutes after sitting for 30 minutes and sit for 1-3 minutes after standing and/or walking for 30 minutes. She can occasionally push/pull and operate foot controls with both lower extremities; occasionally climb ramps or stairs; never climb ladders, ropes or scaffolds;
occasionally balance, stoop, kneel, crouch, and crawl; have occasional exposure to vibration; and have occasional exposure to unprotected heights, hazardous machinery or hazardous moving mechanical parts. Claimant would be off task no more than 5% of the time in an 8-hour workday, in addition to normal breaks (with normal breaks defined as a 15 minute morning and afternoon break and a 30-60 minute lunch break).(R. 14-20). In making this assessment, the ALJ found Claimant's statements about her limitations not entirely consistent with the medical and other evidence. (R. 16). At step four, the ALJ concluded Claimant could perform the requirements of her past relevant work as a paralegal as it is generally performed. (R. 20-21). Alternatively, at step five, upon considering Claimant's age, education, work experience, and RFC, the ALJ determined Claimant is capable of adjusting to the demands of other employment opportunities that exist in significant numbers in the national economy. (R. 21-22).
V. DISCUSSION
A. The RFC Assessment
Claimant contends the ALJ erred in formulating her RFC by failing to properly analyze the medical opinions, failing to properly analyze Claimant's subjective symptoms, and finding Claimant was capable of performing a reduced range of light work. Pl.'s Mem. [DE-19] at 24-26, 28-30.
1. The Medical Opinions
Claimant contends the ALJ erred in failing to accord great weight to the medical source statements and opinions of Dr. Patel, Dr. Chafin, and Dr. Semaan El-Khoury. Pl.'s Mem. [DE-19] at 24-25.
As an initial matter, the regulation upon which Claimant relies, 20 C.F.R. § 404.1527(d)(2), is not applicable to her claim. Because Claimant protectively filed her application on July 24, 2017, 20 C.F.R. § 404.1520c, which applies to claims filed on or after March 27, 2017, governs how the ALJ considers the medical opinions in Claimant's case.
The applicable regulation provides the ALJ “will not defer or give any specific evidentiary weight, including controlling weight, to any medical opinion(s) or prior administrative medical finding(s), including those from [Claimant's] medical sources.” 20 C.F.R. § 404.1520c(a). Instead, the ALJ must consider the persuasiveness of medical opinions using five factors: (1) supportability, meaning that “[t]he more relevant the objective medical evidence and supporting explanations presented by a medical source are to support his or her medical opinion(s)... the more persuasive the medical opinions or prior administrative medical finding(s) will be”; (2) consistency, meaning that the more consistent an opinion is with other evidence in the record, the more persuasive the medical opinion will be; (3) the medical source's relationship with the claimant, which considers the length of the treating relationship, frequency of examinations, purpose of the treating relationship, extent of the treatment relationship, and whether the medical source examined the claimant; (4) specialization, meaning that “a medical source who has received advanced education and training to become a specialist may be more persuasive”; and (5) other factors that tend to support or contradict a medical opinion.” Id. § 404.1520c(c)(1)-(5). The most important factors are supportability and consistency. Id. § 404.1520c(a).
The regulation also requires the ALJ to “articulate in [her] determination or decision how persuasive [she] find[s] all of the medical opinions and all of the prior administrative medical findings in [the] case record.” Id. § 404.1520c(b). However, when a medical source provides multiple opinions, the ALJ may use a single analysis to evaluate all the opinions from a single source, and the ALJ is “not required to articulate how [she] considered each medical opinion or prior administrative medical finding from one medical source individually.” Id.
Because the ALJ was not required to give any specific evidentiary weight, including controlling weight, to any medical opinion, 20 C.F.R. § 404.1520c(a), Claimant's argument that the ALJ erred in failing to accord “great weight” to the medical source statements and opinions of Dr. Patel, Dr. Chafin, and Dr. Semaan El-Khoury lacks merit.
Claimant also argues that the ALJ's decision to disregard the medical source statements and opinions of Dr. Patel, Dr. Chafin, and Dr. Semaan El-Khoury regarding functional limitations is not supported by substantial evidence. Pl.'s Mem. [DE-19] at 25. In support, Claimant cites her diagnoses of chronic low back and hip pain and that the ALJ found her conditions were severe. Id. Mere diagnosis of a condition is not enough to prove disability without “a showing of related functional loss.” Gross v. Heckler, 785 F.2d 1163, 1166 (4th Cir. 1986). Likewise, the fact that an impairment is found to be “severe” at step two does not mean it is disabling. The “severity standard is a slight one.” Stemple v. Astrue, 475 F.Supp.2d 527, 536 (D. Md. 2007); see also McDaniel v. Bowen, 800 F.2d 1026, 1031 (11th Cir. 1986) (describing the burden of proving the severity of an impairment as “ mild” and stating “only claims based on the most trivial impairments” are rejected). Therefore, Claimant's diagnoses of chronic low back and hip pain and the ALJ's finding that these were severe impairments do not undermine the ALJ's evaluation of the medical opinion evidence, and Claimant's conclusory statement that the ALJ's decision regarding the medical opinions was not supported by substantial evidence fails to demonstrate with specificity any error on the part of the ALJ. Notwithstanding, the court has considered the ALJ's evaluation of the medical opinion evidence and finds it is consistent with the requirements of 20 C.F.R. § 404.1520c and supported by substantial evidence.
The ALJ considered several statements by Dr. Chafin regarding Claimant's limitations and ability to return to her previous job and found them to be somewhat persuasive. (R. 18, 331, 404, 497, 601, 622, 626, 630, 632, 637). The ALJ recognized that Dr. Chafin consistently treated Claimant, but found Dr. Chafin's statements regarding her limitations to be not fully supported by his treatment notes, which the ALJ found to generally contain Claimant's subjective reports of pain and limitations with limited examination findings. (R. 19, 515-608, 613-641). The ALJ also considered the lack of explanation supporting Dr. Chafin's opinions and the lack of support for Dr. Chafin's opinions in the overall record, which indicated Claimant generally had normal physical examinations, including full muscle strength and normal gait. (R. 19).
The ALJ found Dr. Patel's opinion mostly persuasive because it was supported by a thorough examination and was consistent with the overall evidence that Claimant experienced back and hip pain but still demonstrated full strength and a generally normal gait. (R. 19, 47174). However, the ALJ noted that Dr. Patel's limitations were vaguely stated because he did not define what he meant by “moderately” limited. Id; see Vanderpool v. Berryhill, No. 5:18-CV-44-RJ, 2019 WL 118414, at *5 (E.D. N.C. Jan. 7, 2019) (holding that an ALJ did not err in giving a medical opinion partial weight because, among other reasons, the limitations in the opinion were vague).
Finally, the ALJ found Dr. El-Khoury's opinion unpersuasive because the limitations he indicated on a check-the-box form were not supported by explanation or with reference to the medical records, were not consistent with the overall medical record, and were not consistent with his examination of Claimant where she demonstrated normal ambulation, motor strength, movement of extremities, and gait. (R. 19, 507, 643-50); see Schaller v. Colvin, No. 5:13-CV-334-D, 2014 WL 4537184, at *16 (E.D. N.C. Sept. 11, 2014) (“[S]ince the opinion is in the form of a questionnaire, the ALJ was entitled to assign it less weight than a fully explanatory and narrative opinion because such form opinions do not offer adequate explanation of their findings.”) (citations omitted).
In sum, the ALJ considered several relevant factors, e.g., supportability, consistency, and treatment relationship, in evaluating the medical opinions, articulated how persuasive he found the opinions in conformity with the governing regulation, and cited substantial evidence in support of his determination. See Dunn v. Colvin, 607 Fed.Appx. 264, 267 (4th Cir. 2015) (“An ALJ's determination as to the weight to be assigned to a medical opinion generally will not be disturbed absent some indication that the ALJ has dredged up ‘specious inconsistencies,' or has failed to give a sufficient reason for the weight afforded a particular opinion.”) (quoting Scivally v. Sullivan, 966 F.2d 1070, 1077 (7th Cir. 1992)). Claimant failed to demonstrate with specificity any error in the ALJ's evaluation of the opinion evidence. Accordingly, the court finds that the ALJ did not err in evaluating the opinion evidence.
2. Claimant's Subjective Symptoms
Claimant contends the ALJ failed to properly assess her statements regarding the intensity, persistence, and limiting effects of her symptoms and their consistency with the medical evidence and other evidence of record. Pl.'s Mem. [DE-19] at 28-30.
Federal regulation 20 C.F.R. § 404.1529(a) provides the authoritative standard for the evaluation of subjective complaints of pain and symptomology, whereby “the determination of whether a person is disabled by pain or other symptoms is a two-step process.” Craig, 76 F.3d at 593-94. First, the ALJ must objectively determine whether the claimant has medically documented impairments that could cause his or her alleged symptoms. S.S.R. 16-3p, 2016 WL 1119029, at *3 (Mar. 16, 2016); Hines v. Barnhart, 453 F.3d 559, 564 (4th Cir. 2006). If the ALJ makes that determination, he must then evaluate “the intensity and persistence of the claimant's pain[, ] and the extent to which it affects her ability to work, ” Craig, 76 F.3d at 595, and whether the claimant's statements are supported by the objective medical record. S.S.R. 16-3p, 2016 WL 1119029, at *4; Hines, 453 F.3d at 564-65.
Objective medical evidence may not capture the full extent of a claimant's symptoms, so where the objective medical evidence and subjective complaints are at odds, the ALJ should consider all factors concerning the “intensity, persistence and limiting effects” of the claimant's symptoms. S.S.R. 16-3p, 2016 WL 1119029, at *7; 20 C.F.R. § 404.1529(c)(3) (showing a complete list of factors). The ALJ may not discredit a claimant solely because his or her subjective complaints are not supported by objective medical evidence, Craig, 76 F.3d at 595-96, but neither is the ALJ required to accept the claimant's statements at face value; rather, the ALJ must “evaluate whether the statements are consistent with objective medical evidence and the other evidence.” S.S.R. 16-3p, 2016 WL 1119029, at *6; see Taylor v. Astrue, No. 5:10-CV-263-FL, 2011 WL 1599679, at *4-8 (E.D. N.C. Mar. 23, 2011), adopted by 2011 WL 1599667 (E.D. N.C. Apr. 26, 2011).
The ALJ recounted Claimant's hearing testimony as follows. Claimant stopped working due to chronic pain in her lower back and hips, her spinal cord stimulator helped her pain some but lying flat on her back helped the most, and she takes pain medication as needed with no side effects and she also takes a muscle relaxer daily. Claimant stated that her pain causes anxiety and that her life has changed because she cannot do what she used to do, which has caused some minor depression. Claimant stated she could sit for fifteen minutes, stand for fifteen minutes, walk for fifteen minutes, and lift five pounds. She described problems when crouching, cooking, and bending to get clothes out of the dryer, all of which makes her pain worse. She testified she does very little housework, does some laundry, does not vacuum anymore, and puts dishes in the sink but her husband puts them in the dishwasher, and her husband does other chores and cooks. Claimant reported driving to her elderly parents' home to spend time with them and not doing grocery shopping, but being able to stop at a small store and pick up a few items. Claimant stated that she has one to two good days in a week but that she still has to lie down on those days. (R. 15).
The ALJ found Claimant's statements about her limitations were not entirely consistent with the medical and other evidence, including evidence demonstrating she generally had benign physical examinations, full motor strength, normal sensation, and normal gait, and that she was able to perform light work with restrictions including a sit/stand option. (R. 16, 20). Claimant argues the ALJ impermissibly discounted her testimony based on a lack of corroborating objective evidence and cites Arakas v. Comm'r, Soc. Sec. Admin., 983 F.3d 83, 97 (4th Cir. 2020), which held that “ALJs may not rely on objective medical evidence (or the lack thereof)-even as just one of multiple factors-to discount a claimant's subjective complaints regarding symptoms of fibromyalgia or some other disease that does not produce such evidence”). Here, Claimant does not have fibromyalgia or a disease that produces wholly subjective symptoms. Id. at 96 (“[P]hysical examinations [of patients with fibromyalgia] will usually yield normal results-a full range of motion, no joint swelling, as well as normal muscle strength and neurological reactions.”). Rather, Claimant's impairment is sacroiliac (“SI”) joint dysfunction, an orthopedic impairment for which one would not expect symptoms to be wholly subjective. See Donta J. v. Saul, No. 2:20-CV-131, 2021 WL 2711467, at *4 (E.D. Va. July 1, 2021) (distinguishing Arakas where “Plaintiff's injury-orthopedic damage to his knee-is not the type of injury whose symptoms are wholly subjective.”).
The ALJ noted in the RFC analysis that after Claimant's SI joint fusion on August 12, 2016, she reported on September 22 that her pain was resolved, (R. 303); however, on October 26 she indicated worsening pain for two weeks with tenderness to palpation over her bilateral SI joints and a positive Fortin's sign bilaterally but no evidence of hardware complications. (R. 16, 303, 306-09). The neurosurgeon noted the recurrence of her SI joint pain occurred in the context of new onset right knee pain, her hip x-rays were unremarkable, the cause appeared to be “inflammation, possibly exacerbated by altered biomechanics from her postop activity modification and knee injury, ” and it was recommended Claimant receive therapeutic/diagnostic SI joint injections. (R. 309). There are no records indicating Claimant returned to her neurosurgeon.
The Fortin finger test is a diagnostic measure used to identify sacroiliac joint disfunction and pain. See https://pubmed. ncbi. nlm. nih.gov/9247654/.
On November 3, Claimant's pain management doctor, Dr. Chafin, administered a lumbar and a right knee injection, (R. 370), and on November 21, she reported continued pain affecting her ADLs and sleep, and Dr. Chafin recommended a spinal cord stimulator as an “option of last resort” to control her pain, which was implanted on December 29. (R. 16, 372-79). On January 5, 2017, Claimant reported being pain free with increased ADLs, better sleep, and reduced need for pain medication, and the spinal cord stimulator was permanently placed on February 15. (R. 17, 382-93). Claimant reported continued relief in March 2017, and on April 20, 2017, Claimant reported overall pain improvement but that she experienced back pain lifting greater than twenty pounds, she had difficulty with sitting and standing, and she required frequent position changes. (R. 17, 394-98). In March 2018, Claimant continued to report relief with use of the simulator but also that her pain affected her ADLs and sleep, a reevaluation of her lumbar spine revealed no gross abnormalities with bones or hardware, and adjustment of the stimulator was considered (R. 17, 604-07).
On June 12, 2018, Claimant reported pain in her right gluteal region that was exacerbated after staying in the hospital caring for her parents, and she received a right SI joint injection. (R. 17, 613-16). On July 30, 2018, she reported pain affecting her ADLs with the majority of pain in her left lower back and hip, and she received a steroid injection and Flexeril was prescribed. (R. 17, 617-20). On August 17, 2018, Claimant reported needing frequent position changes and an inability to lift and twist as required by her occupation, and she received a lumbar epidural steroid injection. (R. 17, 622-25). On January 3, 2019, Claimant stated her pain limited her ADLs and sleep, she could ride in a vehicle for thirty minutes before needing to get our and stretch, she was unable to stand less than one hour before needing to sit, she was unable to tolerate standing more than fifteen minutes without frequent position changes or sitting, and she could walk 150 feet before needing to rest. (R. 17, 626). Dr. Chafin refilled her medications with no changes, and opined she had reached maximum medical improvement, she was limited with activity, and her pain prevented her from returning to her work as a paralegal. (R. 17-19, 630). On a follow up visit in May 2019, Dr. Chafin added Celebrex and considered a rheumatoid panel if Claimant remained symptomatic, and in July 2019, he noted no changes, continued her on hydrocodone, and performed a disability evaluation, the results of which do not appear in the treatment note. (R. 19, 632-41).
The ALJ fully considered Claimant's testimony that she could only sit for fifteen minutes, stand for fifteen minutes, walk for fifteen minutes, and lift five pounds in light of her treatment for her SI joint dysfunction and associated pain and the opinion evidence. (R. 15-20). While Claimant contends that the ALJ presumed her “conservative treatment, ” “no hospitalizations, ” and lack of “emergency department visits” were inconsistent with her testimony regarding her limitations, Pl.'s Mem. [DE-19] at 30, this rationale does not appear in the ALJ's decision and appears to be from a different case.
Claimant states that her statements regarding her functional limitations are corroborated by objective medical and other evidence and that the ALJ cherry picked facts supporting a nondisability finding while ignoring evidence supporting disability, but Claimant provides no citation to the record of specific evidence that corroborates her statements or that the ALJ ignored, and essentially asks the court to reweigh the evidence. Id.; see Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012) (“In reviewing for substantial evidence, [the court does] not undertake to reweigh conflicting evidence, make credibility determinations, or substitute our judgment for that of the ALJ.”) (citation omitted). The ALJ explained that, despite Claimant having some limited lumbar range of motion and some tenderness on examination, he found her expressed limitations to be not fully consistent with evidence of normal imaging and benign physical examinations where she consistently exhibited normal strength, sensation, and gait, and he cited specific evidence in the record to support his conclusion. (R. 15-20); see Green v. Astrue, No. 3:10-CV-764, 2011 WL 5593148, at *4 (E.D. Va. Oct. 11, 2011) (“An individual does not have to be pain-free in order to be found ‘not disabled.'”) (citing Hays v. Sullivan, 907 F.2d 1453, 1457-58 (4th Cir.1990)), adoptedby 2011 WL 5599421 (E.D. Va. Nov. 17, 2011).
The ALJ did not require objective proof Claimant's pain, but rather “evaluate[d] whether the statements are consistent with objective medical evidence and the other evidence” as required by S.S.R. 16-3p, 2016 WL 1119029, at *6. See Johnson v. Saul, No. 8:18-CV-03223-TMC-JDA, 2019 WL 8375932, at *14 (D.S.C. Dec. 17, 2019) (rejecting argument that the AL J erred in failing to explain his evaluation of the plaintiff's subjective symptoms (that he was limited in the ability to sit from lumbar degenerative disc disease) where the ALJ “clearly considered Plaintiff's testimony regarding his limitations, but found that his claims were inconsistent with treatment notes that consistently found him to have normal range of motion, normal gait and station, normal reflexes and sensation, and normal tone and motor strength.”), report and recommendation adopted, 2020 WL 881033 (D.S.C. Feb. 24, 2020). The court can trace the ALJ's reasoning, and the ALJ did not err in evaluating Claimant's subjective statements regarding her limitations.
3. Claimant's Ability to Perform a Reduced Range of Light Work
Claimant contends she is unable to physically perform modified light work because she cannot sit, stand, or walk for six hours in an eight-hour workday, cannot lift and carry ten pounds on a frequent basis, and would have great difficulty bending, stooping, and crouching on an occasional basis. Pl.'s Mem. [DE-19] at 26-28.
The RFC is the capacity an individual possesses despite the limitations caused by physical or mental impairments. 20 C.F.R. § 404.1545(a)(1); see also S.S.R. 96-8p, 1996 WL 374184, at *1 (July 2, 1996). The RFC is based on all relevant medical and other evidence in the record and may include a claimant's own description of limitations arising from alleged symptoms. 20 C.F.R. § 404.1545(a)(3); see also S.S.R. 96-8p, 1996 WL 374184, at *5. “[T]he residual functional capacity ‘assessment must first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions' listed in the regulations.” Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting S.S.R. 968p). The ALJ must provide “a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations).” Id. (quoting S.S.R. 96-8p); see also Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000) (observing that the ALJ “must build an accurate and logical bridge from the evidence to his conclusion”).
Claimant, in support of her argument that she cannot perform a reduced range of light work as found by the ALJ, generally points to her testimony regarding her limitations, Dr. Chafin's course of treatment, Dr. Patel's exam and opinions, and Dr. El-Khoury's treatment and medical source statement. Pl.'s Mem. [DE-19] at 27. Again, Claimant fails to make any specific arguments regarding how this evidence supports her claim, id., and the ALJ fully considered this evidence in formulating the RFC.
As discussed above, the ALJ thoroughly considered Claimant's testimony, her course of treatment with Dr. Chafin and his opinions, the examination and opinions of Dr. Patel, and Dr. El-Khoury's treatment and medical source statement. The ALJ found Dr. Chafin's statements regarding Claimant's limitations to be not fully supported by his treatment notes and lacking in supporting explanation, she found Dr. Patel's opinion mostly persuasive but noted Dr. Patel did not define what he meant by “moderately” limited, and she found Dr. El-Khoury's opinion unpersuasive because the limitations he indicated were not supported by explanation or reference to the medical record and were inconsistent with examination findings. (R. 19).
Dr. Chafin opined that Claimant could not return to her work as a paralegal, which was at the medium exertion level as Claimant performed it but at the light exertion level as generally performed. (R. 60). The ALJ found that Claimant could perform her past work as generally, not actually, performed. (R. 20-21).
The ALJ, after carefully discussing all the evidence, determined that due to Claimant's SI joint dysfunction she was limited to light work with a sit/stand option to accommodate for needed changes in position and a limitation to only occasional climbing of ramps and stairs, balancing, stooping, kneeling, crouching, and crawling. (R. 14); see Ladda v. Berryhill, 749 Fed.Appx. 166, 172 (4th Cir. 2018) (finding no error in the ALJ's RFC determination where the ALJ used evidence from the record to explain his finding that the claimant was capable of light work, explained the weight assigned to statements made by the claimant and the opinion evidence, and provided a thorough discussion allowing the court to conclude the RFC was supported by substantial evidence). The ALJ explained that further limitations were inconsistent with unremarkable imaging, generally benign physical examinations, and normal strength, sensation, and gait. (R. 15-20); see Briley v. Berryhill, No. 5:18-CV-43-FL, 2019 WL 1330889, at *3 (E.D. N.C. Mar. 25, 2019) (finding no error in the AL J's RFC determination where the ALJ fully discussed substantial evidence in the record showing symptoms and examination findings supported a lesser functional limitation than the claimant suggested). The court can trace the AL J's reasoning in the RFC determination and finds it supported by substantial evidence.
B. The Grid Rules, and the Hypothetical to the VE
Claimant contends the ALJ erred in failing to apply the Grid Rule 201.14 and in failing to include all of Claimant's limitations in the hypothetical to the VE. Pl.'s Mem. [DE-19] at 25, 3031. Both arguments are foreclosed by the court's finding that the ALJ's RFC determination was without error.
Grid Rule 201.14 applies when an individual is, among other things, limited to sedentary work. 20 CFR pt. 404, subpt. P, app. 2, § 201.14; thus, it is inapplicable here where the ALJ determined Claimant could perform a limited range of light work.
With respect to the hypothetical posed to the VE, the additional limitations Claimant suggests the VE should have considered were not included in the RFC by the ALJ. The ALJ may utilize a VE at steps four and five “to assist the ALJ in determining whether there is work available in the national economy which this particular claimant can perform.” Walker v. Bowen, 889 F.2d 47, 50 (4th Cir. 1989). For a VE's opinion to be'“relevant or helpful, ” it must be given in response to a proper hypothetical question. Id. A proper hypothetical question “fairly set[s] out all of claimant's impairments” that are supported by the record. Id.; Russell v. Barnhart, 58 Fed.Appx. 25, 30 (4th Cir. 2003) (per curiam) (holding the ALJ's hypothetical question “adequately contemplated all of [claimant's] impairments and resulting limitations” as evidenced by the record). Claimant's argument here is derivative of the RFC arguments addressed above and is rejected for the same reasons. The hypothetical to the VE included the limitations the ALJ found supported by the record that were imposed in the RFC. See King v. Berryhill, No. 2:17-CV-58-D, 2018 WL 6817036, at *8 (E.D. N.C. Dec. 6, 2018), adopted by ZW WL 6815651 (E.D. N.C. Dec. 27, 2018). Accordingly, the ALJ's hypothetical to the VE was without error.
VI. CONCLUSION
For the reasons stated above, it is RECOMMENDED that Claimant's Motion for Judgment on the Pleadings [DE-18] be DENIED, Defendant's Motion for Judgment on the Pleadings [DE-22] be ALLOWED, and the final decision of the Commissioner be AFFIRMED.
IT IS DIRECTED that a copy of this Memorandum and Recommendation be served on each of the parties or, if represented, their counsel. Each party shall have until January 28, 2022 to file written objections to the Memorandum and Recommendation. The presiding district judge must conduct his or her own review (that is, make a de novo determination) of those portions of the Memorandum and Recommendation to which objection is properly made and may accept, reject, or modify the determinations in the Memorandum and Recommendation; receive further evidence; or return the matter to the magistrate judge with instructions. See, e.g, 28 U.S.C. § 636(b)(1); Fed.R.Civ.P. 72(b)(3); Local Civ. R. 1.1 (permitting modification of deadlines specified in local rules), 72.4(b), E.D. N.C. Any response to objections shall be filed by within 14 days of the filing of the objections.
If a party does not file written objections to the Memorandum and Recommendation by the foregoing deadline, the party will be giving up the right to review of the Memorandum and Recommendation by the presiding district judge as described above, and the presiding district judge may enter an order or judgment based on the Memorandum and Recommendation without such review. In addition, the party's failure to file written objections by the foregoing deadline will bar the party from appealing to the Court of Appeals from an order or judgment of the presiding district judge based on the Memorandum and Recommendation. See Wright v. Collins, 766 F.2d 841, 846-47 (4th Cir. 1985).