Opinion
Civil Action 1:22CV4
12-15-2022
TIMOTHY WAYNE WILLIAMS, Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant.
KLEEH JUDGE
REPORT AND RECOMMENDATION
JAMES P. MAZZONE UNITED STATES MAGISTRATE JUDGE
I. Introduction
This action arises out of the denial of Plaintiff's application for Social Security Disability Benefits (“DIB”) and Supplemental Security Income (“SSI”) under Title II and Title XVI of the Social Security Act. After Plaintiff's application proceeded through the administrative process, United States Administrative Law Judge, Brian Rippel (“ALJ”) concluded that Plaintiff was not disabled within the meaning of the Social Security Act. Plaintiff's request for review by Appeals Council was denied, making the ALJ's decision the final decision of the Defendant. Plaintiff seeks judicial review of the ALJ's decision.
Plaintiff acknowledges that, inasmuch as the ALJ's decision post-dates Plaintiff's date of last insured, there are two issues currently pending before the Court: (1) related to DIB, whether the ALJ's decision that Plaintiff was not disabled at any time before March 31, 2021 is free of legal error and supported by substantial evidence; and (2) related to SSI, is the ALJ's decision that Plaintiff was not disabled at any time between his application for benefits in December 2018 and the ALJ's decision on July 7, 2021, free of legal error and supported by substantial evidence? Plaintiff asserts that the assignments of error apply equally to both questions. This Report and Recommendation applies to both issues.
The facts and legal arguments have been adequately presented, and the decisional process would not be significantly aided by oral argument. Accordingly, after considering the parties' briefs, the Administrative Record, and the applicable law, the undersigned is unable to determine whether the ALJ's decision is supported by substantial evidence, and this matter should be remanded for further consideration as set forth below.
II. Factual/Procedural History
On December 27, 2019, Plaintiff filed a Title II application for a period of disability and disability insurance benefits and a Title XVI application for supplemental security income, alleging that he became disabled on December 6, 2018, at the age of 43. R. 19, 121, 136. Plaintiff's applications were denied initially and upon reconsideration. R. 19. Plaintiff requested and was afforded a hearing before an ALJ, which took place on May 24, 2021, by telephone (due to the COVID-19 pandemic). R. 19; 51-72. Plaintiff was represented by counsel during the hearing and provided testimony. A vocational expert appeared and testified. R. 51-72. Following the hearing, the ALJ determined that Plaintiff was not disabled within the meaning of the Social Security Act. R. 19-38. Plaintiff sought relief with the Appeals Council, which denied Plaintiff's request for rehearing, making the ALJ's decision the Final Decision of the Social Security Commissioner. R. 1-6.
Plaintiff filed the instant action on January 11, 2022. ECF No. 1. Defendant filed an Answer to Plaintiff's Complaint on March 30, 2022. ECF No. 7. On the same date, Defendant filed a copy of the Administrative Record. ECF No. 8. Plaintiff filed his Motion for Summary Judgment on June 2, 2022. ECF No. 12. Defendant filed her Motion for Summary Judgment on June 30, 2022. ECF No. 13. Plaintiff filed his Response in Opposition to Defendant's Motion for Summary Judgment on July 8, 2022. ECF No. 16.
III. ALJ Decision
A. The Five-Step Evaluation Process
To be disabled under the Social Security Act, a claimant must meet the following criteria:
An individual shall be determined to be under a disability only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work....'[W]ork which exists in the national economy' means work which exists in significant numbers either in the region where such individual lives or in several regions of the country.42 U.S.C. § 423(d)(2)(A), 1382c(a)(3)(B). The Social Security Administration uses the following five-step sequential evaluation process to determine if a claimant is disabled:
(i) At the first step, we consider your work activity, if any. If you are doing substantial gainful activity, we will find that you are not disabled.
(ii) At the second step, we consider the medical severity of your impairment(s). If you do not have a severe medically determinable physical or mental impairment that meets the duration requirement . . . or a combination of impairments that is severe and meets the duration requirement, we will find that you are not disabled.
(iii) At the third step, we also consider the medical severity of your impairments(s). If you have an impairment(s) that meets or equals one of our listings . . . and meets the duration requirement, we will find that you are disabled.
[Before the fourth step, the residual functioning capacity of the claimant is evaluated based "on all the relevant medical and other evidence in your case record . . ." 20 C.F.R. §§ 404.1520; 416.920.]
(iv) At the fourth step, we consider our assessment of your residual functional capacity and your past relevant work. If you can still do your past relevant work, we will find that you are not disabled.
(v) At the fifth and last step, we consider our assessment of your residual functional capacity and your age, education, and work experience to see if you can make an adjustment to other work. If you can make an adjustment to other work, we will find that you are not disabled. If you cannot make an adjustment to other work, we will find that you are disabled.20 C.F.R. §§ 404.1520; 416.920. If the claimant is determined to be disabled or not disabled at one of the five steps, the process does not proceed to the next step. Id.
B. ALJ Findings
The ALJ determined that Plaintiff met the insured status requirements of the Social Security Act through March 31, 2021, and that Plaintiff had not engaged in substantial gainful activity since December 6, 2018, the alleged onset date. R. 21. The ALJ further determined that Plaintiff has the following severe impairments: morbid obesity; spine disorder; bilateral shoulder disorder; rheumatoid arthritis; depression; somatic symptom disorder; posttraumatic stress disorder; borderline intellectual functioning; anxiety disorder; seizure disorder; allergic rhinitis; and osteoarthritis of the shoulders, elbows, and hips. R. 21-22. At step three of the analysis, the ALJ determined that Plaintiff does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926). At step four, the ALJ found that Plaintiff has the following residual functional capacity (“RFC”):
[t]o perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except [Plaintiff] is able to lift and/or carry up to 20 pounds occasionally and 10 pounds frequently; stand and/or walk up to 6 hours and sit up to 6 hours in an 8-hour workday. Additional limitations include only frequent balancing as defined in the SCO (the Selected Characteristics of Occupations Defined in the Dictionary of Occupational Titles); only occasional climbing ramps or stairs, stooping, kneeling, crouching, crawling; no climbing ladders, ropes, or scaffolds; only occasional overhead reaching with the bilateral upper extremities; only occasional exposure to cold or heat extremes, vibration, or respiratory irritants (such as fumes, odors, dust, gases, poorly ventilated areas in concentrations higher than found in a typical household). There must be no exposure to workplace hazards (including unprotected heights and dangerous machinery); and work is limited to simple, routine tasks in entry-level, unskilled work with instructions that are not involved.
R. 25. At step five, the ALJ determined that Plaintiff is unable to perform any past relevant work. Considering Plaintiff's age, education, work experience, and residual functional capacity, the ALJ determined that there are jobs that exist in significant numbers in the national economy that the Plaintiff could perform. R. 36. Therefore, the ALJ concluded that Plaintiff has not been under a disability as defined in the Social Security Act, from December 6, 2018, through the date of decision. R. 37.
IV. Motions for Summary Judgment
A. Arguments of the Parties
1. Plaintiff's Arguments
Plaintiff argues that the ALJ's RFC finding is contrary to law and not supported by substantial evidence because, in fashioning the RFC, the ALJ failed to properly consider Plaintiff's description of his limitations, ignored probative evidence, and failed to discuss factors required by the regulations. In making his arguments Plaintiff relies upon Arakas v. Commissioner, Social Security Administration, 983 F.3d 83 (4th Cir. 2020).
2. Defendant's Arguments
Defendant maintains that the ALJ's RFC is supported by substantial evidence notwithstanding Plaintiff's self-described limitations, and that the ALJ determined that Plaintiff could perform a range of simple, light work which took into account his significant limitations. Finally, Defendant distinguishes this matter from Arakas by arguing, among other things, that this matter does not involve a diagnosis of fibromyalgia, and this matter does not involve errors such as the ones discussed in Arakas. To the contrary, Defendant maintains that the ALJ was faithful to the record and properly and accurately characterized the evidence found in the same.
B. The Standards
1. Summary Judgment
“Summary Judgment is appropriate ‘if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.'” Lawson v. Union Cty. Clerk of Court, 828 F.3d 239, 247 (4th Cir. 2016) (quoting Fed.R.Civ.P. 56(a)).
2. Judicial Review
This Court's review of the ALJ's decision is limited to determining whether the decision is supported by “substantial evidence.” 42 U.S.C. §§ 405(g), 1383(c)(3). “Substantial evidence” is “more than a mere scintilla of evidence but may be somewhat less than a preponderance.” Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990). “Substantial evidence” is not 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, 564-65 (1988) (internal citations and quotations omitted). “If there is evidence to justify a refusal to direct a verdict were the case before a jury, then there is ‘substantial evidence'.” Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966), overruled by implication on other grounds by The Black and Decker Disability Plan v. Nord, 538 U.S. 822 (2003).
C. Discussion
As stated above, Plaintiff's primary assignment of error relates to the ALJ's RFC finding. More specifically, Plaintiff argues that, in fashioning the RFC, the ALJ failed to consider Plaintiff's description of his symptoms and limitations, ignored probative evidence, and failed to discuss the factors required by the regulations while improperly emphasizing a lack of objective evidence. ECF No. 12 at p. 8. Plaintiff argues that, as a result, the ALJ's decision fails to build an accurate and logical bridge between the evidence of record and the RFC finding. Id. After considering the record, the undersigned would agree with Plaintiff.
“An RFC assessment is a determination of an individual's ability to perform sustained work-related activities on a regular and continuing basis.” Price v. Kijakazi, 2022 WL 620830, at * 6 (D.S.C. Mar. 3, 2022). “In formulating the RFC, the ALJ is to consider all impairments, even those that are not severe, and review all relevant medical and other evidence.” Id. (internal citations and quotations omitted) (quoting Jackson v. Berryhill, 2017 WL 685603, at * 6 (E.D. N.C. Jan. 23, 2017)). An “ALJ must consider the entire record and may not disregard an individual's statements about intensity, persistence, and limiting effects of symptoms solely because the objective medical evidence does not substantiate them.” Arakas v. Commissioner, Social Security Administration, 983 F.3d 83, 95 (4th Cir. 2020) (internal quotations omitted).
“The RFC must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts such as laboratory findings and non-medical evidence like daily activities and observations. However, there is no particular language or format the narrative discussion must follow as long as it permits meaningful judicial review.” Price v. Kijakazi, 2002 WL 320830, at * 6 (D.S.C. Mar. 3, 2022) (internal citations omitted). The ALJ “must.. .explain how any material inconsistencies or ambiguities in the evidence in the case record were considered and resolved.” Id. Indeed, “[a]n ALJ has the obligation to consider all relevant medical evidence and cannot simply cherry pick facts that support a finding of nondisability while ignoring evidence that points to a disability finding.” Arakas v. Commissioner, Social Security Administration, 983 F.3d 83, 98 (4th Cir. 2020).
Here, the ALJ found that Plaintiff suffers from the following severe physical impairments: morbid obesity; spine disorder; bilateral shoulder disorder; rheumatoid arthritis; and osteoarthritis of the shoulders, elbows, and hips. R. 21. In formulating the RFC, the ALJ found that Plaintiff's medically determinable impairments could reasonably be expected to cause the symptoms alleged by Plaintiff (R. 26), but that his statements concerning the intensity, persistence, and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record. R. 26. In support of this conclusion, the ALJ provided a lengthy, albeit a somewhat inaccurate, summary of the medical evidence of record. The ALJ then concluded that,
A summary of Plaintiff's self-described limitations can be found at R. 26.
In his opinion, the ALJ incorrectly noted that Dr. Asuquo found chronic venous stasis changes “without” pigmentation. The ALJ also failed to acknowledge that Plaintiff could not walk on his toes due to pain. R. 27.
[b]ased on the foregoing, the undersigned finds the claimant has the above residual functional capacity assessment, which is supported by a totality of the evidence, including the opinions. The claimant suffers from severe physical impairments but the physical findings, observations, and objective studies have largely demonstrated adequate functioning with symptoms that have been accounted for with the light exertional limitations... .the overall medical record does not document functional restrictions that are incompatible with the ability to sustain work as described in the within functional capacity assessments. As such, the undersigned finds the claimant is capable of working within the functional parameters of this residual functional capacity assessment.R. 35-36. The substantive portion of the ALJ's finding only references the objective medical evidence (“physical findings, observations, and objective studies”; “overall medical record”). Further, there is no reference to or apparent consideration of Plaintiff's subjective complaints and/or self-described limitations. A review of the balance of the ALJ's decision as it relates to the RFC finding reveals only a brief summary of Plaintiff's self-described limitations, but no substantive consideration thereof in conjunction with the evidence in the record. See R. 25-36. In this case, such an omission prevents the meaningful consideration of the ALJ's RFC finding because contradictory evidence exists in the record as to whether and to what extent Plaintiff is able to function during a normal workday.
For example, in a note dated February 27, 2019, Dr. John Asuquo found that Plaintiff displayed chronic venous stasis changes in his lower extremities with pigmentation (R. 959-962), which is consistent with Plaintiff's complaints that his lower legs are swollen and discolored from blood leakage. Dr. Asuquo also noted that Plaintiff could walk on his heels but not his toes due to pain. R. 962. At the conclusion of the examination, Dr. Asuquo's impressions included that Plaintiff suffered from chronic back pain and chronic osteoarthritis involving the shoulders, elbows, and hips. Dr. Asuquo summarized his findings as follows:
[t]he claimant is a 43-year-old male claiming disability due to back pain, joint pain, and seizure disorder. There were positive physical findings related to those complaints as documented in the above physical exam section.
Despite these positive findings and this assessment of Plaintiff's physical condition, the ALJ did not explain how Dr. Asuquo's impressions were considered and accounted for in the RFC finding. The Commissioner argues that the ALJ did not ignore this and other evidence in the record of “abnormal findings.” ECF No. 13 at p. 11. The Commissioner's point is well-taken - the ALJ did summarize at various points “abnormal findings,” but the ALJ did not specifically address these findings in his analysis, or explain how these findings, such as those of Dr. Asuquo set forth above, were accounted for with the RFC finding. This lack of explanation precludes meaningful review of the ALJ's RFC finding.
Similarly, the ALJ summarized Plaintiff's rheumatoid arthritis treatment (See R. 27-33), but the ALJ's RFC analysis failed to explicitly address Plaintiff's subjective complaints related to this condition or how Plaintiff's limitations were accounted for in the RFC. In May 2019, Plaintiff reported having RA flares every one to two months which lasted for several days. R. 29; 1442. By September 2019, Plaintiff reported that his RA flares were becoming more frequent with progressively worsening symptoms, including that Plaintiff had difficulty holding objects and turning a doorknob, and his rheumatoid arthritis appears to have been substantiated with photographic evidence. R. 30; 1264-1268 (“he does bring[] photos concerning for RA flare to hands”). During the administrative hearing, Plaintiff testified consistent with the medical records that he has frequent flare-ups and that the symptoms associated with a flare-up are so bad that he cannot grip a doorknob. See e.g., R. 57-61. And yet, the ALJ did not offer any explicit analysis of Plaintiff's testimony, the evidence regarding this condition, or how the RFC accounted for the limitations resulting from the same. The ALJ's failure to more explicitly address this impairment is particularly troublesome because the RFC says that Plaintiff can lift up to 20 pounds.
Plaintiff testified that he gets an RA flare a couple of times a week. R. 63.
Defendant argues that Plaintiff improperly relies upon Arakas to support his position because this matter does not involve a diagnosis of fibromyalgia, as was the case in Arakas. The undersigned is not persuaded by this argument. There is nothing in Arakas which limits that decision to cases involving fibromyalgia. Indeed, “[c]ourts in the Fourth Circuit.. .have rejected narrowing the scope of Arakas as only applying to fibromyalgia analysis.” Joseph J. v. Kijakazi, 2022 WL 2069283, at *3, n. 2 (D. Md. June 8, 2022). The Commissioner further argues that the ALJ's opinion does not contain the serious and significant flaws the Court identified in Arakas. The undersigned would agree. Nevertheless, the errors and omissions in the ALJ's decision still preclude meaningful review.
Finally, Defendant argues that any errors and omissions contained in the ALJ's evidentiary summary are harmless and the result of an extensive Administrative Record. The undersigned would agree that the Administrative Record is extensive, and the ALJ should not be expected to recite each piece of evidence in his opinion. See Reid v. Commissioner of Social Security, 769 F.3d 861, 865 (4th Cir. 2014) (“there is no rigid requirement that the ALJ specifically refer to every piece of evidence in his decision”). However, the errors and omissions in the ALJ's opinion concern information that appears to be inconsistent with the RFC finding. At a minimum, more explanation is needed as to how the ALJ resolved these inconsistencies (or how they are not inconsistencies at all) so that meaningful review can be undertaken.
V. Recommendation
Accordingly, and for all of the foregoing reasons, the undersigned would RECOMMEND that Plaintiff's Motion [12] for Summary Judgment be GRANTED and Defendant's Motion [13] for Summary Judgment be DENIED. The undersigned would further RECOMMEND that this matter be REMANDED for further consideration.
Any party who appears pro se and any counsel of record, as applicable, may, within fourteen (14) days after being served with a copy of this Report and Recommendation, file with the Clerk of the Court written objections identifying the portions of the Report and Recommendation to which objection is made, and the basis for such objection.
A copy of such objections should be submitted to the District Judge of Record. Failure to timely file objections to the Report and Recommendation set forth above will result in waiver of the right to appeal from a judgment of this Court based upon such Report and Recommendation. See 28 U.S.C. § 636(b)(1); Wright v. Collins, 766 F.2d 841, 845-48 (4th Cir. 1985); United States v. Schronce, 727 F.2d 91, 94 (4th Cir. 1984), cert. denied, 467 U.S. 1208 (1984); see also Thomas v. Arn, 474 U.S. 140, 155 (1985).
The Court DIRECTS the Clerk of the Court to provide a copy of this Report and Recommendation to all counsel of record, as provided in the Administrative Procedures for Electronic Case Filing in the United States District Court for the Northern District of West Virginia. The Court further DIRECTS the Clerk to mail a copy of this Report and Recommendation to any pro se party by certified mail, return receipt requested, to their last known address as reflected on the docket sheet.