Opinion
C. A. 9:22-cv-03066-SAL-MHC
12-21-2023
Jennine C. M.,[1] Plaintiff, v. Kilolo Kijakazi, Acting Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
Molly H. Cherry, United States magistrate Judge.
Plaintiff Jennine C. M. (Plaintiff) filed the complaint in this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the Administrative Law Judge's (ALJ's) final decision denying her claim for Disability Insurance Benefits (DIB) under the Social Security Act (Act). This case was referred to the undersigned for a report and recommendation pursuant to Local Civil Rule 73.02(B)(2)(a) (D.S.C.). For the reasons that follow, the undersigned recommends that the ALJ's decision be affirmed.
Citations to the record refer to the page numbers in the Social Security Administration Record. See ECF No. 11.
Plaintiff protectively filed for DIB on September 26, 2019. R.pp. 11, 226. She alleged disability caused by Multiple Sclerosis, diabetes, and a spinal condition. R.p. 267. Her alleged onset date was initially March 18, 2019, but was later amended to April 29, 2020. R.pp. 11, 56, 232.
Plaintiff's claims were denied at the initial and reconsideration stages of administrative review. R.pp. 75, 85. Plaintiff requested a hearing before an ALJ, which was held on December 22, 2021. R.pp. 48-74. At the hearing, Plaintiff and a vocational expert testified. R.pp. 48-74.
On January 6, 2022, the ALJ issued an unfavorable decision denying Plaintiff's claims. R.pp. 11-19. The Appeals Council denied Plaintiff's request for review, rendering the ALJ's decision final. R.pp. 1-6. This appeal followed.
Because this Court writes primarily for the parties who are familiar with the facts, the Court dispenses with a lengthy recitation of the medical history from the relevant period. To the extent specific records or information are relevant to or at issue in this case, they are addressed within the Discussion section below.
II. APPLICABLE LAW
A. Scope of Review
Jurisdiction of this Court is pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). Under § 405(g), judicial review of a final decision regarding disability benefits is limited to determining (1) whether the factual findings are supported by substantial evidence, and (2) whether the correct legal standards were applied. 42 U.S.C. § 405(g); Walls v. Barnhart, 296 F.3d 287, 290 (4th Cir. 2002) (citing Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990)). Accordingly, a reviewing court must uphold the final decision when “an ALJ has applied correct legal standards and the ALJ's factual findings are supported by substantial evidence.” Brown v. Comm r Soc. Sec. Admin., 873 F.3d 251, 267 (4th Cir. 2017) (internal quotation marks omitted).
“Substantial evidence” is an evidentiary standard that is not high: it is “more than a mere scintilla” and means only “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019). A reviewing court does not reweigh conflicts in evidence, make credibility determinations, or substitute its judgment for that of the ALJ. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). “Where conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the responsibility for that decision falls on the [ALJ].” Id. (alteration in original) (internal quotation marks and citation omitted). However, this limited review does not mean the findings of an ALJ are to be mechanically accepted, as the “statutorily granted review contemplates more than an uncritical rubber stamping of the administrative action.” Howard v. Saul, 408 F.Supp.3d 721, 725-26 (D.S.C. 2019) (quoting Flack v. Cohen, 413 F.2d 278, 279 (4th Cir. 1969)).
B. Social Security Disability Evaluation Process
To be considered “disabled” within the meaning of the Social Security Act, a claimant must show that he has an impairment or combination of impairments which prevent him from engaging in all substantial gainful activity for which he is qualified by his age, education, experience, and functional capacity, and which has lasted or could reasonably be expected to last for a continuous period of not less than twelve months. See 42 U.S.C. § 423. The Social Security Administration established a five-step sequential procedure in order to evaluate whether an individual is disabled for purposes of receiving benefits. See 20 C.F.R. §§ 404.1520, 416.920; see also Mascio v. Colvin, 780 F.3d 632, 634-35 (4th Cir. 2015) (outlining the questions asked in the five-step procedure). The burden rests with the claimant to make the necessary showings at each of the first four steps to prove disability. Mascio, 780 F.3d at 634-35. If the claimant fails to carry his burden, he is found not disabled. Lewis v. Berryhill, 858 F.3d 858, 861 (4th Cir. 2017). If the claimant is successful at each of the first four steps, the burden shifts to the Commissioner at step five. Id.
At the first step, the ALJ must determine whether the claimant has engaged in substantial gainful activity since his alleged disability onset date. 20 C.F.R. §§ 404.1520(b), 416.920(b). At step two, the ALJ determines whether the claimant has an impairment or combination of impairments that meet the regulations' severity and duration requirements. Id. §§ 404.1520(c), 416.920(c). At step three, the ALJ considers whether the severe impairment meets the criteria of an impairment listed in Appendix 1 of 20 C.F.R. part 404, subpart P (the “Listings”) or is equal to a listed impairment. If so, the claimant is automatically eligible for benefits; if not, before moving on to step four, the ALJ assesses the claimant's residual functional capacity (RFC). Id. §§ 404.1520(d), (e), 416.920(d), (e); Lewis, 858 F.3d at 861.
The RFC is “the most the claimant can still do despite physical and mental limitations that affect her ability to work.”Mascio, 780 F.3d at 635 (internal quotation marks and citations omitted).
At step four, the ALJ determines whether, despite the severe impairment, the claimant retains the RFC to perform his past relevant work. 20 C.F.R. §§ 404.1520(e), (f), 416.920(e), (f). If the ALJ finds the claimant capable of performing his past relevant work, he is not disabled. Id. §§ 404.1520(f), 416.920(f). If the requirements to perform the claimant's past relevant work exceed his RFC, then the ALJ goes on to the final step.
At step five, the burden of proof shifts to the Social Security Administration to show that the claimant can perform other jobs existing in significant numbers in the national economy, considering the claimant's age, education, work experience, and RFC. Id. §§ 404.1520(g), 416.920(g);Mascio, 780 F.3d at 634-35. Typically, the Commissioner offers this evidence through the testimony of a vocational expert answering hypotheticals that incorporate the claimant's limitations. Mascio, 780 F.3d at 635. “If the Commissioner meets her burden, the ALJ finds the claimant not disabled and denies the application for benefits.” Id.
III. ADMINISTRATIVE FINDINGS
The ALJ employed the statutorily-required five-step sequential evaluation process to determine whether Plaintiff was disabled from the alleged onset date of April 29, 2020. R.pp. 1119. The ALJ found, in pertinent part:
1. The claimant meets the insured status requirements of the Social Security Act through December 31, 2024.
2. The claimant has not engaged in substantial gainful activity since April 29, 2020, the alleged onset date (20 CFR 404.1571 et seq.).
3. The claimant has the following severe impairments: Multiple sclerosis, spinal disorder, and obesity (20 CFR 404.1520(c)).
4. The claimant 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 and 404.1526).
5. After careful consideration of the entire record, I find that the claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(a) except the claimant can never climb ladders, ropes and scaffolds. She can occasionally climb ramps and stairs, kneel, crouch, and crawl. She can occasionally stoop to lift within the exertional level from the floor to the waist. She can frequently stoop to lift within the exertional level from waist height and above. She can frequently balance. Bilateral reaching, handling and fingering can be performed frequently within the exertional level. She can occasionally be exposed to extreme heat, vibrations, loud noise, and hazards associated with unprotected dangerous machinery or unprotected heights.
6. The claimant is unable to perform any past relevant work (20 CFR 404.1565).
7. The claimant was . . . 41 years old, which is defined as a younger individual age 18-44, on the alleged disability onset date (20 CFR 404.1563).
8. The claimant has at least a high school education (20 CFR 404.1564).
9. Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant is “not disabled,” whether or not the claimant has transferable job skills (See SSR 82-41 and 20 CFR Part 404, Subpart P, Appendix 2).
10. Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform (20 CFR 404.1569 and 404.1569a).
11. The claimant has not been under a disability, as defined in the Social Security Act, from April 29, 2020, through the date of this decision (20 CFR 404.1520(g)).R. pp. 13-19.
IV. DISCUSSION
Plaintiff presents three arguments in support of remand. First, Plaintiff argues that the ALJ erred in finding some of her impairments non-severe. ECF No. 18 at 10-14. Second, Plaintiff argues the ALJ failed to properly evaluate her impairments when formulating the RFC. ECF No. 18 at 14-23. Third, Plaintiff argues the ALJ did not properly evaluate her subjective symptoms. ECF No. 18 at 23-26. For the reasons that follow, remand is not warranted.
A. Non-severe impairments at step two
Plaintiff argues the ALJ erred in finding some of her impairments non-severe. Specifically, Plaintiff argues the ALJ erred in finding her diabetes and optic neuritis as non-severe impairments at step two of the sequential evaluation process. ECF No. 18 at 10-14. Plaintiff has not shown reversible error.
Plaintiff also includes a paragraph arguing the ALJ “failed to even mention” the impact her headaches had on her RFC. ECF No. 18 at 12-13. However, because Plaintiff does not appear to contest this as an error at step two, but rather an issue with the RFC, the undersigned addresses Plaintiff's headaches below in part B.
At step two of the sequential evaluation process, an ALJ must determine whether a claimant has a medically determinable impairment or a combination of impairments that is severe. 20 C.F.R. §§ 404.1520(c), 416.920(c). A “severe” impairment is one that “significantly limits [a claimant's] physical or mental ability to do basic work activities.” Id. §§ 404.1520(c), 416.920(c). “Basic work activities” are “the abilities and aptitudes necessary to do most jobs,” examples of which include “physical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling.” Id. §§ 404.1522(b), 416.922(b). An ALJ must consider all of a claimant's medically determinable impairments, even those that are not severe, in the RFC assessment. Id. §§ 404.1545(a)(2), 416.945(a)(2). An inadequate analysis of impairments at step two may be rendered harmless if the ALJ later considers those impairments in subsequent steps. See Jenkins v. Colvin, No. 6:13-cv-02021-DCN, 2015 WL 1311694, at *4 (D.S.C. Mar. 24, 2015) (“Courts in this district have determined that an ALJ's failure to consider an impairment at step two is harmless when the ALJ considers the impairment in subsequent steps of its analysis.” (collecting cases)).
Here, at step two, the ALJ found Plaintiff had the following severe impairments: Multiple Sclerosis (MS), spinal disorder, and obesity. R.p. 13. Further, the ALJ found Plaintiff's diabetes and optic neuritis were non-severe impairments. R.p. 14. The ALJ reasoned:
As for the claimant's diabetes, she has no specific comp, however her [A1c] was 11.3 on March 5, 2020 (Exhibit 4F). She did have some problems with her blood sugars while she was on steroid treatment for her eye (Exhibit 2F, page 27). On May 11, 2011, the claimant had no diabetes complications. She denied blurry vision, foot numbness, foot ulcers, hypoglycemia, or mylagias an[d] joint pains. (Exhibit 7F). Her [A1c] that day was 8.8 (Exhibit 7F).
As for the claimant's optic neuritis, on May 22, 2019, she was noted to have very mild atrophy in the right eye due to optic neuritis. She had made a nice [recovery] following steroids (Exhibit 2F). Her visual field constriction of the right eye was near normal. She did have myopia in both eyes and eyeglass prescriptions were provided. On May 1, 2020, the claimant noted in her Function report that she did not drive anymore with her blurred vision (Exhibit 8E). She has not complained of any vision issues to her neurologist (Exhibit 8F).
As these impairments cause no more than minimal limitation on the claimant's ability to perform basic work activities, they are determined to be “non-severe.”R.p. 14.
The year for this date appears to be a typo (it should be 2021), given the treatment notes in Exhibit 7F. See R.p. 538.
Upon review, the undersigned finds no error. As an initial matter, the above represents an adequate analysis of Plaintiff's diabetes and optic neuritis at step two. The ALJ explained his reasoning, and the undersigned is not left to guess at why the ALJ determined these impairments were non-severe. See Mascio, 780 F.3d 636-37 (noting remand may be appropriate when courts are left to guess at how the ALJ arrived at their conclusions and meaningful review is frustrated); see also Robinson v. Colvin, No. 4:13-CV-00823-DCN, 2014 WL 4954709, at *14 (D.S.C. Sept. 29, 2014) (“In his opinion, the ALJ thoroughly addressed his reasons for finding Plaintiff's depression to be non-severe[.]”). The mere diagnosis of a disorder does not compel an ALJ to find the disorder severe, nor does it preordain a disability finding. See Sutton v. Saul, No. 2:20cv00008, 2021 WL 1921391, at *11 (W.D. Va. May 13, 2021) (noting the “fact that a claimant received treatment is not sufficient to show a ‘severe impairment,'” and “a mere diagnosis does not make an impairment ‘severe'” either); Rouse v. Colvin, No. CIV.A. 0:11-2636-MGL, 2013 WL 6050163, at *5 (D.S.C. Nov. 14, 2013) (noting “functional limitations-not diagnosis-are the focus in determining disability”); see also Gross v. Heckler, 785 F.2d 1163, 1166 (4th Cir. 1986) (“However, a psychological disorder is not necessarily disabling. There must be a showing of related functional loss.”).
This is especially true with regard to optic neuritis, as Plaintiff did not list either optic neuritis or blurred vision as a disabling medical condition when she applied for benefits. See R.p. 267.
In any event, even if the ALJ erred in finding Plaintiff's diabetes and optic neuritis non-severe at step two, such error was harmless because the ALJ considered these non-severe impairments when formulating the RFC in the subsequent steps of the evaluation process. See R.pp. 15-18; Collier v. Colvin, No. 9:13-cv-3323-DCN, 2015 WL 1519796, at *7 n.3 (D.S.C. Mar. 30, 2015) (“To the extent [claimant] argues that the ALJ erred in finding her [impairment] non- severe at step two, such an error is harmless because the ALJ considered the [impairment] in subsequent steps.”).
Indeed, the ALJ explicitly stated that he “also considered the combined effect of the claimant's non-severe impairments of diabetes and optic neuritis when assessing the residual functional capacity,” noting these non-severe impairments were fully accommodated by the limited exertional levels stated in the RFC. R.p. 17. Thus, Plaintiff has not shown remand is warranted. See Singleton v. Astrue, No. 9:08-1892-CMC-BM, 2009 WL 1942191, at *3 (D.S.C. July 2, 2009) (“Even were the court to agree that Plaintiff's depression should have been found ‘severe' at step two, any error would be harmless because if Plaintiff makes a threshold showing of any ‘severe' impairment, the ALJ continues with the sequential evaluation process and considers all impairments, both severe andnonsevere.” (emphasis in original)).
To the extent Plaintiff suggests the evidence she cites in her brief supports a finding that her impairments are severe, this Court may not overturn a decision that is supported by substantial evidence just because the record may contain conflicting evidence. See Smith v. Chater, 99 F.3d 635, 638 (4th Cir. 1996) (“We must sustain the ALJ's decision, even if we disagree with it, provided the determination is supported by substantial evidence . . . [t]he duty to resolve conflicts in the evidence rests with the ALJ, not with a reviewing court.”). It is the job of the ALJ to weigh evidence and resolve any evidentiary conflicts, not this Court. See Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (“In reviewing for substantial evidence, we do not undertake to reweigh conflicting evidence, make credibility determinations, or substitute our judgment for that of the [ALJ].” (citation omitted)); Brown v. Colvin, No. CV 5:15-0321-KDW, 2016 WL 4425139, at *6 (D.S.C. Aug. 22, 2016) (“Furthermore, even if the allegedly contradictory evidence Plaintiff highlights could support a different result, the court's role is not to second-guess the ALJ's findings.”), aff'd, 675 Fed.Appx. 336 (4th Cir. 2017).
Accordingly, because the ALJ found in Plaintiff's favor at step two, proceeded through step five of the sequential evaluation process, and properly considered all of Plaintiff's impairments in evaluating her RFC, the undersigned finds no error. See Sawyer v. Colvin, 995 F.Supp.2d 496, 509 (D.S.C. 2014) (“The undersigned agrees with other courts that find no reversible error where the ALJ does not find an impairment severe at step two provided that she considers that impairment in subsequent steps.”); Washington v. Astrue, 698 F.Supp.2d 562, 580 (D.S.C. 2010) (“Because the ALJ thus accounted for limitations that may have been caused by Plaintiff's arthritis, he did not commit reversible error in failing to find it severe.”). Ultimately, Plaintiff merely disagrees with the ALJ's conclusions, which is not a basis for remand.
B. RFC Determination
Plaintiff argues the ALJ erred in assessing her RFC. A claimant's RFC, which represents “the most [she] can still do despite [her] limitations,” is determined by assessing all relevant evidence in the case record, including “all of the relevant medical and other evidence.” 20 C.F.R. § 404.1545(a)(1), (a)(3). As a result, an ALJ's “RFC assessment must include 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).” SSR 968p, 1996 WL 374184, at *7 (S.S.A. July 2, 1996). Moreover, the ALJ “must discuss the individual's ability to perform sustained work activities in an ordinary work setting on a regular and continuing basis (i.e., 8 hours a day, for 5 days a week, or an equivalent work schedule), and describe the maximum amount of each work-related activity the individual can perform based on the evidence available in the case record.” Id.
In evaluating an RFC, an ALJ must “consider all of the claimant's ‘physical and mental impairments, severe and otherwise, and determine, on a function-by-function basis, how they affect [her] ability to work.'” Thomas v. Berryhill, 916 F.3d 307, 311 (4th Cir. 2019) (quoting Monroe v. Colvin, 826 F.3d 176, 188 (4th Cir. 2016)). “[A]n ALJ's RFC assessment must include an evaluation of the claimant's ability to perform the physical functions listed in 20 C.F.R. §[§ 404.1545(b),] 416.945(b).” Dowling v. Comm'r of Soc. Sec. Admin., 986 F.3d 377, 387 (4th Cir. 2021) (citing SSR 96-8p, 1996 WL 374184, at *1). “‘Only after such a function-by-function analysis may an ALJ express RFC in terms of the exertional levels of work' of which he believes the claimant to be capable.” Id. (quoting Monroe, 826 F.3d at 179) (emphasis added). Moreover, every conclusion reached by an ALJ when evaluating a claimant's RFC must be accompanied by “a narrative discussion describing [] the evidence” that supports it. Id. (quoting Thomas, 916 F.3d at 311) (alteration in original).
These physical functions are “sitting, standing, walking, lifting, carrying, pushing, pulling, or other physical functions [that] may reduce [a claimant's] ability to do past work and other work.” 20 C.F.R. §§ 404.1545(b), 416.945(b).
Consequently, “a proper RFC analysis has three components: (1) evidence, (2) logical explanation, and (3) conclusion.” Thomas, 916 F.3d at 311. The ALJ's logical explanation is just as important as the ALJ's discussion of evidence and his conclusion. Id. Thus, in conducting an RFC analysis, an ALJ must identify both the evidence that backs his conclusion, and “build an accurate and logical bridge from [that] evidence to his conclusion.” Woods v. Berryhill, 888 F.3d 686, 694 (4th Cir. 2018) (alteration in original) (quoting Monroe, 826 F.3d at 189).
Plaintiff maintains that the RFC findings are inadequate in addressing (1) Plaintiff's vision problems and (2) Plaintiff's cervical spine disease and MS. ECF No. 18 at 14-23. She also generally argues that the ALJ did not adequately explain his findings, such that this Court cannot conduct a meaningful review. For the reasons that follow, the undersigned finds the RFC determination is subject to meaningful review and was supported by substantial evidence.
1. Vision impairments
Plaintiff first argues the ALJ failed to properly evaluate her vision problems. ECF No. 18 at 16-19. Specifically, she argues the ALJ failed to adequately explain why the RFC lacked restrictions related to her optic neuritis. Plaintiff suggests that the ALJ did not consider “the entirety of the record” when making the RFC findings. ECF No. 18 at 17-18. The undersigned finds that Plaintiff has not shown reversible error.
Contrary to Plaintiff's argument, the ALJ explained he also considered the effects of Plaintiff's non-severe impairments, including optic neuritis, when formulating Plaintiff's RFC. R.p. 17. As the ALJ had previously explained at step two, Plaintiff was diagnosed with optic neuritis after she experienced blurriness and loss of vision in the right eye in March 2019. See R.pp. 14, 384-89. Plaintiff made a nice recovery following a three-day steroid treatment and, by May 2019, she had only experienced mild atrophy and her visual field constriction was near normal. R.p. 14 (citing R.pp. 393, 411-12, 415, 418). While Plaintiff reported blurriness that interfered with her driving in May 2020, she reported no vision issues to her neurologist in April, May, or December 2020. R.p. 14 (citing R.pp. 319, 575, 583, 590). Although she reported visual disturbances during her headache episodes at a neurology appointment on August 10, 2021, she “Denie[d] Blurry vision” the very next day at her appointment with Dr. Burrell. R.pp. 538, 557. And, as already noted above, the ALJ explicitly stated that he “also considered the combined effect of the claimant's non-severe impairments of diabetes and optic neuritis when assessing the residual functional capacity,” noting these non-severe impairments were fully accommodated by the limited exertional levels stated in the RFC. R.p. 17. The ALJ thus duly considered Plaintiff's non-severe vision problems as part of his RFC assessment.
Plaintiff nevertheless maintains that the ALJ needed to further explain his decision. The Court is unpersuaded. As initial matter, as addressed above, the ALJ found that Plaintiff's optic neuritis was a non-severe impairment. If an impairment is non-severe, it, by definition, does not significantly limit a claimant's ability to do basic work activities. See 20 C.F.R. §§ 404.1522(a), 416.922(a). Thus, the need for a more thorough explanation as to why the ALJ omitted corresponding restrictions related to Plaintiff's non-severe impairment is significantly diminished. See Sprague v. Colvin, No. 8:13-CV-576-T-TGW, 2014 WL 2579629, at *6 (M.D. Fla. June 9, 2014) (noting, “in many, if not most cases, there will be no functional limitations from a non[-]severe impairment” (emphasis added)).
In other words, the ALJ's decision to omit limitations in the RFC makes logical sense, and the Court is not “left to guess” at why the ALJ did so here. See Perry v. Colvin, No. 2:15-CV-01145, 2016 WL 1183155, at *4 (S.D. W.Va. Mar. 28, 2016) (“The less functional limitation the ALJ determines a given mental impairment to impose on an individual's ability to work at step two, the less will be the need for the ALJ to consider such impairments in the ultimate RFC assessment.”). Although the ALJ could have, perhaps, been more explicit in his consideration, the undersigned is able to cross the logical bridge from the evidence to the ALJ's ultimate conclusion. See id. at *5 (“[A]lthough some consideration is required, there is no requirement that the RFC reflect a claimant's non-severe impairments to the extent the ALJ reasonably determines such impairments do not actually create functional limitations on a claimant's ability to work.”); Britt, 860 Fed.Appx. at 262 (“Meaningful review is frustrated-and remand necessary-only where we are unable to fathom the rationale in relation to evidence in the record.” (cleaned up) (emphasis added)).
To the extent Plaintiff points at evidence in the record and suggests that greater limitations were warranted, the undersigned notes the ALJ went further than the state agency experts by imposing greater limitations than what was proposed at the initial and reconsideration stages. See R.pp. 15-18. In any event, it is the job of the ALJ to weigh evidence and resolve any evidentiary conflicts, not this Court. See Smith, 99 F.3d at 638 (“We must sustain the ALJ's decision, even if we disagree with it, provided the determination is supported by substantial evidence . . . [t]he duty to resolve conflicts in the evidence rests with the ALJ, not with a reviewing court.”); Johnson, 434 F.3d at 653 (“In reviewing for substantial evidence, we do not undertake to reweigh conflicting evidence, make credibility determinations, or substitute our judgment for that of the [ALJ].” (citation omitted)).
As the ALJ noted, the additional evidence available at the hearing warranted greater limitations than those proposed by the agency medical consultants. R.p. 17. For this reason, the ALJ limited Plaintiff to a range of light work (not medium), and occasional kneeling, crouching, crawling, and climbing of ramps and stairs. R.p. 15; see also R.pp. 79-81, 92-95. The ALJ also imposed a limitation for frequent balancing, occasional stooping to lift items from floor to waist, and frequent stooping to lift from waist height and above. R.p. 15; see also R.pp. 79-81, 92-95. The ALJ departed from the agency consultants by imposing additional manipulative limitations for frequent reaching, handling, and fingering bilaterally. R.p. 15; see also R.pp. 79-81, 92-95. And the ALJ additionally limited Plaintiff to occasional exposure to heat, vibrations, loud noise, and hazards associated with unprotected dangerous machinery or unprotected heights. R.p. 15; see also R.pp. 79-81, 92-95.
Contrary to Plaintiff's arguments, the ALJ considered this non-severe impairment and the relevant evidence-both as part of the step two severity determination (already discussed in part A. above) and again at the RFC stage. See Smith v. Colvin, No. 6:15-CV-1750-PMD-KFM, 2016 WL 2619474, at *3 (D.S.C. May 9, 2016) (“[T]he ALJ's decision shows he carefully considered all the evidence in the record and, where appropriate, even made findings that favored [the claimant].”). The ALJ's consideration here in the RFC determination, although brief, is sufficient, especially when considering the ALJ's assessment of Plaintiff's optic neuritis at step two. See Perry, No. 2:15-CV-01145, 2016 WL 1183155, at *7 (“It is true that the ALJ did not again detail the mental health treatment records or medical opinions in the RFC portion of the analysis. But the ALJ's extensive discussion of that record evidence at step two, combined with her further conclusion at the RFC stage that Plaintiff's subjective assessment of the symptoms resulting from her mental impairments was inconsistent with that medical evidence and the Plaintiff's own selfreports of daily living, is more than sufficient to demonstrate that the ALJ considered Plaintiff's non-severe impairments when assessing RFC.”); see also Hewitt v. Colvin, No. CV 9:14-03790-MGL, 2015 WL 9216653, at *2 (D.S.C. Dec. 17, 2015) (“[T]there have been instances in which this Court has affirmed an appeal in which the ALJ could have done a better job explaining his decision because, when the opinion was read as a whole, the Court was able to take the ALJ at her or his word that she or he had properly analyzed the [combined effects of the impairments].”). Although Plaintiff disagrees with the ALJ's ultimate conclusion, that alone is not a valid reason for remand.
2. MS and spine disorder
Plaintiff argues the ALJ did not properly evaluate Plaintiff's MS and cervical spine disease. ECF No. 18 at 19-23. She highlights evidence in the record which she maintains supports her allegations. ECF No. 18 at 19-22. However, Plaintiff has not shown remand is warranted.
As an initial matter, a review of the ALJ's decision reveals that the ALJ summarized and reasonably considered the record evidence Plaintiff highlights. Specifically, regarding Plaintiff's MS, the ALJ considered all three MRI studies, which showed: periventricular white matter lesions consistent with demyelinating disease; numerous lesions in the supratentorial and infratentorial brain in a distribution that met the 2017 McDonald criteria for dissemination and space, with no evidence of active demyelination; and scattered foci of signal abnormality on the bilateral white matter, lesions on the right parietal and occipital white matter, with no evidence of active demyelination. R.p. 16 (citing R.pp. 389, 595-96, 601-03). The ALJ also noted Plaintiff's physical examination showing signs of cerebellar dysfunction and brisk reflexes, as contrasted against her otherwise normal use of her arms and legs and intact gait. R.p. 16 (citing R.pp. 403-11). As the ALJ observed, Plaintiff was prescribed Tysabri infusions, but there is no evidence Plaintiff underwent them. R.p. 16 (citing R.pp. 405-11). He also observed that in December 2020 Plaintiff had been prescribed Aubagio for her MS symptoms, but she had not started taking it. R.p. 16 (citing R.p. 573). He also noted Plaintiff reported tension headaches.
The ALJ noted that eight months later-at an August 10, 2021, appointment-Plaintiff reported fatigue, imbalance, and headaches. R.p. 16 (citing R.pp. 557-60). The ALJ noted, however, that the examination showed normal attention, orientation, concentration, and speech; she had 5/5 strength in her arms and legs, -5/5 bilateral iliopsoas muscles, and normal bulk and tone; her sensation was normal light touch, including pinprick cerebral testing showing no evidence of ataxia on finger to nose testing, tandem ataxia, and normal deep tendon reflexes except the ankle jerk on the right. R.p. 16 (citing R.pp. 557-60). Plaintiff was prescribed Propranolol and Aubagio to help with her headaches and elevated blood pressure; she still had not started the Aubagio. R.p. 16 (citing R.pp. 557-60). Overall, the ALJ explained that Plaintiff only treated with a neurologist occasionally and had not always been compliant with treatment recommendations. R.p. 16.
As for Plaintiff's spinal disorder, the ALJ considered Plaintiff's complaints of pain in her hands and shoulders that comes and goes but noted there was no treatment. R.p. 16. He also noted the results of both the June 2019 and April 2020 MRI studies, which showed multilevel spinal stenosis from C5-6 to C7-T1, congenitally short pedicles, spondylosis, and ossification of the posterior longitudinal ligament. R.p. 16 (citing R.pp. 401-04, 597-600). Despite these diagnostic abnormalities, Plaintiff has been essentially asymptomatic, and she was not recommended for any surgery. R.p. 16 (citing R.pp. 401-04).
Consequently, the undersigned finds that the ALJ reviewed the relevant evidence in detail, including evidence Plaintiff appears to assert was ignored. As already noted above, the ALJ went further than the state agency experts by imposing greater limitations than those proposed at the initial and reconsideration stages. R.pp. 15-18. Thus, the ALJ properly performed the duty reserved to the ALJ as the finder of fact by weighing the relevant evidence in reaching his determination. See 20 C.F.R. §§ 404.1545(a), 416.945(a). Consequently, the undersigned finds the ALJ's decision was supported by substantial evidence. See Smith, No. 6:15-CV-1750-PMD-KFM, 2016 WL 2619474, at *3 (“[T]he ALJ's decision shows he carefully considered all the evidence in the record and, where appropriate, even made findings that favored [the claimant].”).
Nevertheless, Plaintiff points to her testimony regarding her problems balancing, presumably suggesting greater limitations were warranted. ECF No. 18 at 22. But the ALJ considered Plaintiff's impairments, including her reports of imbalance, see R.p. 16, and imposed limitations for frequent balancing and occasional exposure to hazards such as moving mechanical parts and unprotected heights. R.pp. 15-18. The Court agrees with the Commissioner that these limitations were sufficient to accommodate Plaintiff's issue with balancing, especially where Plaintiff was repeatedly found to have full strength in her upper and lower extremities, reported no falls based on imbalance, and generally had a normal gait. See R.pp. 402-03, 418, 434, 519-20, 539, 557, 560, 576, 590. Plaintiff similarly emphasizes her testimony regarding her inability to complete chores, lift things, and wash her hair because of weakness in her arms but, again, the ALJ considered the physical examinations showing Plaintiff had full strength in the upper and lower extremities. R.p. 16; see R.pp. 402-03, 519-20, 560, 576. Plaintiff asks the Court to give greater significance to the evidence she highlights, accept her characterization of the evidence over the ALJ's, and read the evidence differently. That is not the role of this Court. See Johnson, 434 F.3d at 653 (“In reviewing for substantial evidence, we do not undertake to reweigh conflicting evidence, make credibility determinations, or substitute our judgment for that of the [ALJ].” (citation omitted)).
To the extent the ALJ omitted discussion of some record evidence, the undersigned finds no reason for remand, as “there is no rigid requirement that the ALJ specifically refer to every piece of evidence in his decision.” See Reid v. Comm 'r of Soc. Sec., 769 F.3d 861, 865 (4th Cir. 2014) (citation omitted) (noting an ALJ need not refer to every piece of evidence in his decision and finding the ALJ's decision was based on the entire record and supported by substantial evidence); Jackson v. Astrue, No. C/A 8:08-2855-JFA-BHH, 2010 WL 500449, at *10 (D.S.C. Feb. 5, 2010) (“[A]n ALJ is not required to provide a written evaluation of every piece of evidence, but need only ‘minimally articulate' his reasoning so as to ‘make a bridge' between the evidence and his conclusions.” (citations omitted))
Accordingly, for the foregoing reasons, remand is not warranted. See Kellough v. Heckler, 785 F.2d 1147, 1149 (4th Cir. 1986) (“If the Secretary's dispositive factual findings are supported by substantial evidence, they must be affirmed, even in cases where contrary findings of an ALJ might also be so supported.”); Biestek, 139 S.Ct. at 1154 (noting substantial evidence is an evidentiary standard that is not high: it is “more than a mere scintilla” and means only “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion”).
C. Subjective complaints
Finally, Plaintiff argues that the ALJ improperly discounted her complaints of disabling symptoms. ECF No. 18 at 23-26. The Court disagrees.
SSR 16-3p provides a two-step process for evaluating an individual's symptoms. First, the ALJ must determine whether the individual has a medically determinable impairment “that could reasonably be expected to produce the individual's alleged symptoms.” SSR 16-3p, 2017 WL 5180304, at *3 (S.S.A. Oct. 25, 2017). In the second step the ALJ must “evaluate the intensity and persistence of an individual's symptoms such as pain and determine the extent to which an individual's symptoms limit his or her ability to perform work-related activities[.]” Id. at *4.
Here, the ALJ found that Plaintiff's medically determinable impairments could reasonably be expected to cause the alleged symptoms, but that Plaintiff's statements concerning the intensity, persistence, and limiting effects of these symptoms were not entirely consistent with the medical evidence and other evidence in the record. R.p. 17. In support of this finding, the ALJ considered all the available evidence, 20 C.F.R. § 404.1529(a)-(c), and set forth examples of why Plaintiff's complaints of disabling symptoms were not substantiated by the rest of the record. R.pp. 15-18.
Nevertheless, Plaintiff points to two specific items in support of her argument. First, she argues the ALJ was inaccurate in stating Plaintiff did not report vision problems to her neurologist, because she reported visual disturbances at an August 10, 2021, appointment. ECF No. 18 at 24. Second, she argues the ALJ failed to acknowledge the impact migraines/severe headaches had on her RFC. ECF No. 18 at 24-25.
As to Plaintiff's visual disturbances, although Plaintiff did report visual disturbances at this one appointment, she also reported no eye or vision-related issues at the other appointments she had with her neurologist in April, May, and December 2020. R.pp. 575, 583, 590. Perhaps more notably, the very next day after reporting visual disturbances to her neurologist, she treated with Dr. Burrell on August 11, 2021; Dr. Burrell's treatment note states Plaintiff “[d]enies Blurry vision.” R.p. 538. She also reported no vision-related issues to Dr. Burrell at her other appointments in April 2021, May 2021, as well as when Dr. McGee performed a colonoscopy in June 2021. See R.pp. 488, 491, 542-43. Finally, her application for benefits did not list optic neuritis or any other vision-related issue as a disabling medical condition. R.p. 267. In sum, a single report of visual disturbances does not invalidate all the other evidence in the record that fails to substantiate Plaintiff's alleged symptoms.
As to Plaintiff's suggestion that the ALJ did not consider Plaintiff's complaints of headaches in the RFC assessment, this is incorrect. The ALJ explicitly reviewed and considered Plaintiff's complaints of headaches made to her neurologist, as well as the medication prescribed for treating the headaches, Propranolol and Aubagio R.p. 16 (citing R.pp. 557, 560, 573). Additionally, during the ALJ hearing, Plaintiff testified the medication “eases” the migraines and helped give her “a little comfort,” but could make her drowsy. R.p. 57. As the ALJ noted, with regard to her MS-related treatment, including treatment for the headaches, she saw neurology “only occasionally” and Plaintiff was not fully compliant with regard to treatment recommendations (e.g., the Tysabri infusions and Aubagio prescription). R.p. 16. The ALJ thus considered Plaintiff's headache complaints, in the context of all the evidence, and accounted for them during the RFC assessment.
Accordingly, based on the record and evidence, the ALJ conducted a proper subjective complaint analysis in reaching his conclusions, and properly considered the record and evidence in this case. See 20 C.F.R. §§ 404.1529(a)-(c), 416.929(a)-(c); Carlson v. Shalala, 999 F.2d 180, 181 (7th Cir. 1993) (“What we require is that the ALJ sufficiently articulate his assessment of the evidence to ‘assure us that the ALJ considered the important evidence . . . [and to enable] us to trace the path of the ALJ's reasoning.'” (emphasis added) (citation omitted)). Although the ALJ did not articulate his consideration of certain evidence to Plaintiff's liking, this is not a basis for remand. See Jackson, No. C/A 8:08-2855-JFA-BHH, 2010 WL 500449, at *10 (“[A]n ALJ is not required to provide a written evaluation of every piece of evidence, but need only ‘minimally articulate' his reasoning so as to ‘make a bridge' between the evidence and his conclusions.” (citations omitted)); Russell v. Chater, 60 F.3d 824, 1995 WL 417576 at *3 (4th Cir. 1995) (unpublished) (rejecting an argument that the ALJ's analysis was insufficiently specific and noting Fourth Circuit precedent “does not establish an inflexible rule requiring an exhaustive point-by-point discussion in all cases”); see also Craig v. Apfel, 212 F.3d 433, 436 (8th Cir. 2000) (“[A]n ALJ is not required to discuss all the evidence submitted, and an ALJ's failure to cite specific evidence does not indicate that it was not considered.” (citation omitted)).
Consequently, for the foregoing reasons, remand is not warranted. See Biestek, 139 S.Ct. at 1154 (noting substantial evidence is an evidentiary standard that is not high: it is “more than a mere scintilla” and means only “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion”).
V. CONCLUSION
It is RECOMMENDED that the decision of the Commissioner be AFFIRMED.
The parties are directed to the next page for their rights to file objections to this recommendation.
Notice of Right to File Objections to Report and Recommendation
The parties are advised that they may file specific written objections to this Report and Recommendation with the District Judge. Objections must specifically identify the portions of the Report and Recommendation to which objections are made and the basis for such objections. “[I]n the absence of a timely filed objection, a district court need not conduct a de novo review, but instead must ‘only satisfy itself that there is no clear error on the face of the record in order to accept the recommendation.'” Diamond v. Colonial Life & Acc. Ins. Co., 416 F.3d 310 (4th Cir. 2005) (quoting Fed.R.Civ.P. 72 advisory committee's note).
Specific written objections must be filed within fourteen (14) days of the date of service of this Report and Recommendation. 28 U.S.C. § 636(b)(1); Fed.R.Civ.P. 72(b); see Fed.R.Civ.P. 6(a), (d). Filing by mail pursuant to Federal Rule of Civil Procedure 5 may be accomplished by mailing objections to:
Robin L. Blume, Clerk
United States District Court
Post Office Box 835
Charleston, South Carolina 29402
Failure to timely file specific written objections to this Report and Recommendation will result in waiver of the right to appeal from a judgment of the District Court based upon such Recommendation. 28 U.S.C. § 636(b)(1); Thomas v. Arn, 474 U.S. 140 (1985); Wright v. Collins, 766 F.2d 841 (4th Cir. 1985); United States v. Schronce, 727 F.2d 91 (4th Cir. 1984).