Opinion
C. A. 9:23-cv-02900-MGL-MHC
07-31-2024
Matthew R.,[1] Plaintiff, v. Martin O'Malley,[2] Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
Molly H. Cherry United States Magistrate Judge
Plaintiff Matthew R. (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 his claim for Supplemental Security Income (SSI) 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. 9.
On November 18, 2019, Plaintiff protectively filed an application for SSI, alleging disability as of December 1, 2015. R.p. 15, 256-64. The state agency responsible for making disability determinations denied his claim at the initial and reconsideration levels of administrative review. R.pp. 15, 103-34. At Plaintiff's request, an ALJ held an administrative hearing on September 20, 2022. R.pp. 31-59, 135-38. Plaintiff, who was represented by counsel, and a vocational expert testified.
On September 20, 2022, the ALJ concluded that Plaintiff was not disabled and issued a written decision denying Plaintiff's application for benefits. R.pp. 15-24. In April 2023, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. 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'rSoc. Sec. Admin., 873 F.3d 251, 267 (4th Cir. 2017) (internal quotation marks omitted).
“Substantial evidence” is an evidentiary standard that is not high: it is “more than a mere scintilla” and means only “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Biestek v. Berryhill, 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 application date of November 18, 2019. R.pp. 15-24. The ALJ found, in pertinent part:
The relevant period of review of Plaintiff's SSI claim begins with his application date. See 20 C.F.R. §§ 416.202 (claimant is not eligible for SSI until, among other factors, the date on which an SSI application was filed); 416.335 (SSI benefits cannot be paid until the month following the month the claimant applied); 416.501 (claimant may not be paid SSI for any time period that predates the first month he satisfies eligibility requirements, which cannot predate the application date).
1. The claimant has not engaged in substantial gainful activity since November 18, 2019, the application date (20 CFR 416.971 et seq.).
2. The claimant has the following severe impairment: Crohn's Disease (20 CFR 416.920(c)).
3. 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 416.920(d), 416.925 and 416.926).
4. After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform a range of light work as defined in 20 CFR 416.967(b). The person must avoid frequent exposure to nonweather-related hot temperatures. The person must also avoid frequent exposure to unprotected heights.
5. The claimant is capable of performing past relevant work as a deburrer and drill press operator. This work does not require the performance of work-related activities precluded by the claimant's residual functional capacity (20 CFR 416.965).
6. The claimant has not been under a disability, as defined in the Social Security Act, since November 18, 2019, the date the application was filed (20 CFR 416.920(f)).R.pp. 17-23.
IV. DISCUSSION
Plaintiff argues the ALJ erred for two primary reasons. First, he argues the RFC determination was not supported by substantial evidence. See ECF No. 15 at 9-19. Second, he argues the ALJ failed to properly evaluate medical opinion evidence. ECF No. 15 at 19-24. For the reasons that follow, Plaintiff has not shown remand is warranted.
A. RFC Determination
Plaintiff argues that the RFC determination is not supported by substantial evidence. 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 96-8p, 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).
Here, Plaintiff argues the RFC determination is not supported by substantial evidence because it (1) does not include limitations associated with his non-severe mental impairments, and because (2) it does not include limitations related to his Crohn's disease. The Court considers each argument in turn.
1. Mental impairments at step two
Plaintiff argues that the ALJ failed to properly account for his limitations in mental functioning when formulating the RFC. The Court disagrees.
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 follow a “special technique” to determine the severity of a claimant's mental impairments. 20 C.F.R. §§ 404.1520a(a), 416.920a(a). First, the ALJ evaluates the claimant's pertinent symptoms, signs, and laboratory findings to determine if he has a medically determinable mental impairment. Id. §§ 404.1520a(b)(1), 416.920a(b)(1). Second, assuming the claimant does have a medically determinable mental impairment, the ALJ rates the claimant's degree of functional limitation resulting from the impairment(s). Id. §§ 404.1520a(b)(2), 416.920a(b)(2).
To rate a claimant's degree of functional limitation, the ALJ determines the degree to which the impairment interferes with the claimant's overall “ability to function independently, appropriately, effectively, and on a sustained basis” in four broad areas of mental functioning: (1) understanding, remembering, or applying information; (2) interacting with others; (3) concentrating, persisting, or maintaining pace; and (4) adapting or managing oneself. Id. §§ 404.1520a(c)(3), 416.920a(c)(3). The functional areas are rated on a five-point scale: none, mild, moderate, marked, and extreme. Id. §§ 404.1520a(c)(4), 416.920a(c)(4).
The ratings of these four broad areas of mental functioning affect whether the claimant's mental impairment will be considered severe or not severe. Id. §§ 404.1520a(d), 416.920a(d). The ALJ will generally find that a claimant's mental impairment is non-severe if the limitations are rated as “none” or “mild.” See id. §§ 404.1520a(d)(1), 416.920a(d)(1). If the ALJ determines the impairment is severe, he then determines “whether it qualifies as a listed impairment.” Patterson v. Comm'r of Soc. Sec. Admin., 846 F.3d 656, 659 (4th Cir. 2017); 20 C.F.R. §§ 404.1520a(d)(2), 416.920a(d)(2).
Finally, even when a mental impairment is found to be non-severe, the ALJ must nevertheless consider it in determining the claimant's RFC. 20 C.F.R. § 404.1545(e); see also SSR 96-8p, 1996 WL 374184, at *5 (“In assessing RFC, the adjudicator must consider limitations and restrictions imposed by all of an individual's impairments, even those that are not ‘severe.'”).
In considering Plaintiff's mental impairments at step two, the ALJ found:
The claimant's medically determinable mental impairments of depression and anxiety disorder do not cause more than minimal limitations in the claimant's ability to perform basic mental work activities and are therefore non-severe.
In making this finding, the undersigned has considered the broad functional areas of mental functioning set out in the disability regulations for evaluating mental disorders and in the Listing of Impairments (20 CFR, Part 404, Subpart P, Appendix 1). These four broad functional areas are known as the “paragraph B” criteria.
The first functional area is understanding, remembering or applying information. In this area, the claimant has mild limitation. Upon exam, the claimant's recent memory has been intact, but there has been mild impairment in his remote memory (Exhibit 3F, p. 10-11). However, his thought process has been logical and goal directed. Further, his memory was most recently intact (Exhibit 9F, p. 1-2).
The next functional area is interacting with others. In this area, the claimant has mild limitation. The claimant alleges that he has anger issues, but his attitude has been cooperative (Exhibit 3F, p. 10-11; Exhibit 7F, p. 1-2). While his mood has been depressed, it has also been described as euthymic (Exhibit 3F, p. 10; Exhibit 9F, p. 1-2).
The third functional area is concentrating, persisting or maintaining pace. In this area, the claimant has mild limitation. Upon exam, the claimant's attention has been intact, and his concentration has been only mildly impaired (Exhibit 3F, p. 10-11). Another examination showed intact concentration (Exhibit 7F, p. 1-2). The claimant has denied inattention (Exhibit 3F, p. 13-14).
The fourth functional area is adapting or managing oneself. In this area, the claimant has no limitation. The claimant has reported both minor episodes of anxiety, and a couple of interval panic attacks (Exhibit 3F, p. 13-14; Exhibit 7F, p. 1-2). In August of 2020, he reported doing fairly good (Exhibit 7F, p. 3-4). The claimant denied panic attacks and depression on October 21, 2020 (Exhibit 9F, p. 1-2). He has not been hospitalized.
Because the claimant's medically determinable mental impairments cause no more than “mild” limitation in any of the functional areas and the evidence does not otherwise indicate that there is more than a minimal limitation in the claimant's ability to do basic work activities, they are non-severe (20 CFR 416.920a(d)(1)).R.pp. 17-18.
Plaintiff appears to fault the ALJ's opinion in two ways. First, Plaintiff appears to argue that his depression and anxiety disorder should have been considered severe impairments at step two. See ECF No. 15 at 11, 15-16. Second, Plaintiff argues the ALJ erred by not incorporating limitations associated with his mental health impairments in the RFC. ECF No. 15 at 11-14. Neither reason warrants remand.
To the extent Plaintiff argues the ALJ erred by finding his depression and anxiety disorder non-severe at step two, the undersigned finds no error. The ALJ properly applied the special technique in determining that Plaintiff's mental impairments were non-severe. R.pp. 17-18. The ALJ explained that Plaintiff's “medically determinable mental impairments of depression and anxiety disorder do not cause more than minimal limitations in the claimant's ability to perform basic mental work activities and are therefore non-severe.” R.p. 17. The ALJ determined that Plaintiff had only mild limitations in three areas of mental functioning (understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace) and no limitation in adapting or managing oneself. R.p. 18. In reaching these findings, the ALJ cited to the record and sufficiently explained why Plaintiff's mental impairments of depression and anxiety disorder were non-severe and would not affect his RFC. Contrary to what Plaintiff suggests, 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[.]”).
Although Plaintiff points to his diagnosis of major depressive disorder and generalized anxiety disorder (ECF No. 15 at 12), 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.”). Indeed, to the extent Plaintiff suggests the evidence he cites in his brief supports a finding that his 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).
To the extent Plaintiff argues the ALJ erred in omitting mental limitations in the RFC, such arguments are unpersuasive for two reasons.
First, the functional areas are rated on a five-point scale: none, mild, moderate, marked, and extreme. 20 C.F.R. §§§ 404.1520a(c)(4), 416.920a(c)(4). The ALJ determined that Plaintiff had only mild limitations in three areas of mental functioning (understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace) and no limitation in adapting or managing oneself. R.p. 18. Under the regulations, mild difficulties have little to no effect on a claimant's ability to function independently, appropriately, effectively, and on a sustained basis in the four areas of mental functioning-which corresponds to a finding that the difficulties do not significantly limit the claimant's mental ability to do basic work activities. See 20 C.F.R. §§ 404.1520a(d)(1), 416.920a(d)(1); see also Sanford v. Saul, No. 5:18-CV-2886-KDW, 2020 WL 633743, at *20 (D.S.C. Feb. 11, 2020) (“Under the regulations, mild difficulties are materially different from moderate difficulties, in that mild difficulties have little to no effect on a claimant's concentration, persistence, or pace and correspond to a finding that the difficulties do not significantly limit the claimant's mental abilities to do basic work activities.” (cleaned up) (emphasis added) (citation omitted)). Consequently, as these mild difficulties have little to no effect on Plaintiff's ability to do basic work activities, the Court finds the ALJ did not err by not specifically accounting for them in the RFC determination. See Morgan v. Saul, No. 1:19-CV-00003-FDW, 2020 WL 290870, at *4 (W.D. N.C. Jan. 21, 2020) (“[A] mild incapacity is not required to become an RFC requirement. It is only required that the ALJ discuss the incapacity and determine whether it is severe enough to affect the functioning of the claimant. Here the ALJ did exactly that.”).
Plaintiff points to APRN Janice Reynolds's medical source opinion as evidence supporting the severe nature of his mental impairments. ECF No. 15 at 12-13. The ALJ considered this evidence and did not find APRN Reynolds's opinion particularly persuasive, which is discussed in more detail below.
Second, related to this idea, Plaintiff's argument that the ALJ needed to further explain his decision is unpersuasive. 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 impairments 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”). That is, 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, the undersigned is able to cross the logical bridge from the evidence to the ALJ's conclusion. See Britt v. Saul, 860 Fed.Appx. 256, 262 (4th Cir. 2021) (“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)). Thus, the undersigned finds the ALJ's RFC assessment is subject to meaningful review and free from legal error. See id.; Brown, 873 F.3d at 267 (noting, to warrant remand, a claimant must either show the ALJ has incorrectly applied a legal standard or show the ALJ's factual findings are not supported by substantial evidence).
In sum, the undersigned finds the ALJ properly applied the special technique in assessing Plaintiff's mental impairments. The ALJ summarized and thoroughly considered the record evidence relating to Plaintiff's mental impairments, which included treatment records, state agency medical opinions, and mental exams. See R.pp. 17-18, 21. The ALJ discussed the relevant evidence in sufficient detail and explained the reasoning which supported his determination that Plaintiff's mental impairments were non-severe.
Consequently, upon reading the ALJ's opinion as a whole, the ALJ's decision to omit limitations in the RFC related to Plaintiff's mental impairments makes logical sense and does not require remand for further explanation. See Carol H. v. Kijakazi, No. 5:20-CV-00035, 2021 WL 3561241, at *13 (W.D. Va. Aug. 12, 2021) (“Read as a whole, ALJ Knight's analysis shows that she acknowledged [the claimant] had some ‘mild' mental limitations, but concluded, based on the evidence in the record, that they did not more than minimally impact her ability to perform basic work activities.”), report and recommendation adopted, No. 5:20-CV-00035, 2021 WL 4027199 (W.D. Va. Sept. 3, 2021); Morgan v. Saul, No. 1:19-CV-00003-FDW, 2020 WL 290870, at *4 (W.D. N.C. Jan. 21, 2020) (finding the ALJ did not err by not including mental RFC limitations corresponding with the claimant's credited “mild” mental limitations where the ALJ “clearly examined all the available evidence and found [the claimant] had not successfully shown” that RFC limitations were warranted); Pavlic v. Saul, No. 1:19CV146, 2020 WL 1326217, at *2-3 (M.D. N.C. Jan. 14, 2020) (finding no error where ALJ identified “mild” mental limitations in each of the four functional areas, but included no corresponding limitations in the RFC because ALJ sufficiently explained that “the record as a whole,” including claimant's treatment, examination findings, and medical opinions, did not support any mental functional limitations), report and recommendation adopted, No. 1:19CV146, 2020 WL 1322854 (M.D. N.C. Mar. 20, 2020).
2. Accounting for Crohn's disease
Plaintiff next argues the ALJ's RFC assessment is deficient because it failed to account for limitations stemming from Plaintiff's Crohn's disease. ECF No. 15 at 16-19. Specifically, Plaintiff argues there are no restrictions related to his alleged gastrointestinal issues and there is not a sufficient explanation as to why the RFC lacks restrictions in that regard. ECF No. 15 at 1617. The Court disagrees.
After summarizing Plaintiff's testimony from the hearing (R.p. 20), the ALJ assessed Plaintiff's Crohn's disease as follows:
The evidence demonstrates that the claimant has Crohn's Disease, for which he receives infusions of a medication called Remicade (Exhibit 2F, p. 36). While the claimant testified that he had joint trouble, his treatment notes were repeatedly negative for reports of weakness and numbness (Exhibit 2F, p. 39; Exhibit 5F, p. 17, 23; Exhibit 8F, p. 24, 30). The claimant even denied abdominal pain (Exhibit 1F, p. 4-5). On October 6, 2020, treatment notes suggested that the claimant had been on Remicade for two years and that he was doing quite well (Exhibit 11F, p. 2-3). While the claimant's body mass index suggested that the claimant was too thin, he ambulated normally. Further, he was healthy appearing. Moreover, he had normal movement of all extremities. The claimant's diagnosis was Crohn's Disease without complications.
In early 2021, the claimant reported weakness in his legs and knees (Exhibit 15F, p. 4). However, the claimant was not using an assistive device for ambulation. Moreover, treatment notes from late 2021 showed that the claimant reported good control on Remicade (Exhibit 14F, p. 6). The claimant testified during his hearing that he had chronic diarrhea. Yet, he told a provider on March 19, 2022, that he only experienced diarrhea “at times.” (Exhibit 14F, p. 4). Further, he reported leg pain only “at times.” There were no positive exam findings. For example, tenderness was not even documented. However, on April 19, 2022, an examination showed mild soft tissue swelling and tenderness in the right knee (Exhibit 14F, p. 3). The claimant was medicated. Yet, by May 28, 2022, exam findings were
negative, and the claimant's Crohn's Disease remained under good control (Exhibit 14F, p. 2). On June 9, 2022, the claimant was healthy appearing (Exhibit 13F, p. 5). There was no documentation of an assistive device.
Ultimately, the evidence does not support the need for an assistive device or significant limitations. The claimant's physical examinations are repeatedly negative. The claimant testified that he experiences symptoms every other day, but his treatment notes document symptoms only at times. The claimant has reported good results from his medication. The claimant is capable of the residual functional capacity above.R.pp. 20-21 (emphasis added).
Upon review, the undersigned can follow the ALJ's reasoning and substantial evidence supports his conclusions. See Woods, 888 F.3d at 694 (noting 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” (alteration in original) (quoting Monroe, 826 F.3d at 189)). The ALJ began his RFC analysis by summarizing Plaintiff's complaints from the hearing, including that he experienced back pain, swollen knees, and sore joints as a result of his Crohn's disease and medications, namely the Remicade infusion he received every two months. R.p. 20. The ALJ also noted Plaintiff brought a short cane to the hearing, and testified that he could sit and stand for thirty minutes. R.p. 20. He further testified he experienced cramping and diarrhea every other day. R.p. 20.
Contrary to Plaintiff's argument, the ALJ accounted for those limitations supported by the record. Although Plaintiff testified that he experienced cramping and diarrhea, the ALJ noted that Plaintiff only reported experiencing diarrhea “at times.” R.p. 20. The ALJ also observed that treatment records consistently revealed Plaintiff was doing well on his Remicade infusions. R.p. 20. Indeed, treatment notes made in conjunction with Plaintiff's infusions show that he had no complications, his medication was “working well,” and he was experiencing “no flares” of his Crohn's disease. See, e.g., R.pp. 526, 529, 533, 535, 540, 542, 549, 612, 614, 620, 627, 631, 635, 642, 646, 653, 657, 660, 663, 666, 669, 681, 684, 686. Thus, as the ALJ repeatedly noted that Plaintiff's medications were working well to control his Crohn's disease, the undersigned is not left to guess at why the ALJ did not further limit Petitioner in the RFC. See Gross v. Heckler, 785 F.2d 1163, 1166 (4th Cir. 1986) (“If a symptom can be reasonably controlled with medication or treatment, it is not disabling.”); see also 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)).
Thus, contrary to Plaintiff's argument, the ALJ did not merely recite some facts and ignore others in making his RFC assessment. See ECF No. 15 at 18. Rather, the ALJ evaluated the evidence, which showed Plaintiff did not consistently experience gastrointestinal symptoms associated with Crohn's disease, and included those limitations in the RFC assessment that were supported by the record.
For example, while the record did not support limitations as severe as those alleged by Plaintiff (e.g., the need for an assistive device), the ALJ noted that April 2022 examination findings documented mild swelling and tenderness in Plaintiff's right knee. R.p. 20 (referring to R.p. 675). As a result, the ALJ limited Plaintiff to light exertional work. See R.p. 19.
The undersigned finds that the ALJ explained what he did, why he did it, and supported his conclusions with evidence. To the extent Plaintiff argues other evidence in the record supports his position, this Court may not overturn a decision that is supported by substantial evidence just because the record may contain conflicting evidence. 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.”). It is the job of the ALJ to weigh evidence and resolve any evidentiary conflicts, not 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)). Plaintiff merely presents a disagreement with the ALJ's findings and fails to show reversible error.
B. Medical opinion evidence
Plaintiff argues that the ALJ did not properly evaluate the medical opinion of APRN Janice Reynolds. ECF No. 15 at 19-24. The Court disagrees. Effective March 27, 2017, numerous social security regulations and social security rulings (SSRs) were amended or superseded, making the new regulations applicable to claims filed on or after March 27, 2017. See Revisions to Rules Regarding the Evaluation of Medical Evidence, 82 FR 5844-01, 2017 WL 168819 (Jan. 18, 2017), corrected by 82 Fed.Reg. 15132-01, 2017 WL 1105368 (Mar. 27, 2017). Because Plaintiff's claim for benefits was filed after March 27, 2017, the ALJ was required to evaluate the application under 20 C.F.R. §§ 404.1520c and 416.920c.
Social Security Rulings, or “SSRs,” are “interpretations by the Social Security Administration of the Social Security Act.” Pass v. Chater, 65 F.3d 1200, 1204 n.3 (4th Cir. 1995). They do not carry the force of law but are “binding on all components of the Social Security Administration,” 20 C.F.R. § 402.35(b)(1), as well as on ALJs when they are adjudicating Social Security cases. See Bray v. Comm'r of Soc. Sec. Admin., 554 F.3d 1219, 1224 (9th Cir. 2009).
Under the new regulations, the ALJ is not to defer to or give any specific weight to medical opinions based on their source. 20 C.F.R. §§ 404.1520c(a), 416.920c(a). Rather, ALJs are instructed to consider and evaluate the persuasiveness of the opinion evidence by considering the following factors: (1) supportability, (2) consistency, (3) relationship with the claimant, (4) specialization, and (5) other factors that tend to support or contradict the opinion. 20 C.F.R. §§ 404.1520c(b), (c), 416.920c(b), (c). Supportability and consistency are the most important factors to consider, and an ALJ must explain how these factors are considered in the determination or decision. See 20 C.F.R. §§ 404.1520c(a), (b)(2), 416.920c(a), (b)(2). The ALJ may, but is not required to, explain how the other factors are considered. 20 C.F.R. §§ 404.1520c(b)(2), (c), 416.920c(b)(2), (c).
This effectively does away with the so called “Treating Physician Rule” under the provisions of 20 C.F.R. §§ 404.1527(c)(2) and 416.927(c)(2), whereby an ALJ was directed to give controlling weight to the opinion of a treating physician if it was well supported by medically-acceptable clinical and laboratory diagnostic techniques and was not inconsistent with the other substantial evidence of record. In addition, 20 C.F.R. §§ 404.1527(c)(5) and 416.927(c)(5) provided that ALJ's should “generally give more weight to the opinion of a specialist about medical issues related to his or her area of specialty than to the opinion of a medical source who is not a specialist.”
This represents another significant departure from the requirements of 20 C.F.R. §§ 404.1527(c) and 416.927(c), whereby, if the ALJ declined to accord controlling weight to the treating physician's opinion, he was to weigh the medical opinions of record based on all of the following factors: (1) examining relationship; (2) treating relationship; (3) supportability; (4) consistency; (5) specialization; and (6) other factors that tended to support or contradict the opinion.
The supportability factor looks inward-directing an ALJ to examine: (1) the extent to which the objective medical evidence presented by the medical source supports that medical source's opinion; and (2) whether the medical source supports the opinion with explanation.Conversely, the consistency factor looks outward-directing an ALJ to evaluate a medical source's opinion in comparison to other evidence in the record. Put differently, the ALJ's analysis considers whether the medical source's opinion: (1) is supported by the source's own records and explanations; and (2) is consistent with the other evidence in the record. See 20 C.F.R. §§ 404.1520c(c)(1)-(2), 416.920c(c)(1)-(2).
In evaluating the supportability factor, “[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) or prior administrative medical finding(s), the more persuasive the medical opinions or prior administrative medical finding(s) will be.” 20 C.F.R. §§ 404.1520c(c)(1); 416.920c(c)(1). “Supportability” denotes “[t]he extent to which a medical source's opinion is supported by relevant objective medical evidence and the source's supporting explanation.” Revisions to Rules Regarding the Evaluation of Medical Evidence, 82 Fed.Reg. 5844-01, 5853, 2017 WL 168819 (Jan. 18, 2017); see also 20 C.F.R. §§ 404.1520c(c)(1); 416.920c(c)(1).
As for the consistency factor, “[t]he more consistent a medical opinion(s) or prior administrative medical finding(s) is with the evidence from other medical sources and nonmedical sources in the claim, the more persuasive the medical opinion(s) or prior administrative medical finding(s) will be.” 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2). In other words, “consistency” denotes “the extent to which the opinion is consistent with the evidence from other medical sources and nonmedical sources in the claim.” Revisions to Rules, 82 Fed.Reg. at 5853; see also 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(1).
Although these amended regulations do away with the idea of assigning “weight” to medical opinions, the ALJ's reasons for finding the opinion of a medical source unpersuasive still must be supported by substantial evidence. The United States Court of Appeals for the Fourth Circuit has repeatedly stated that “[a]n ALJ has the obligation to consider all relevant medical evidence and cannot simply cherrypick facts that support a finding of nondisability while ignoring evidence that points to a disability finding.” Lewis, 858 F.3d at 869 (quoting Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010)); see also Arakas v. Comm'r, Soc. Sec. Admin., 983 F.3d 83, 98 (4th Cir. 2020). Moreover, an ALJ continues to have an obligation to “include a narrative discussion describing how the evidence supports each conclusion.” Monroe v. Colvin, 826 F.3d 176, 190 (4th Cir. 2016) (quoting Mascio, 780 F.3d at 636); see also SSR 96-8p, 1996 WL 374184 at *7 (S.S.A. July 2, 1996) (“The 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).”). Similarly, remand may be appropriate when the courts are left to guess at how the ALJ arrived at the conclusions and meaningful review is frustrated. Mascio, 780 F.3d 636-37. The ALJ must “build an accurate and logical bridge from the evidence to [her] conclusion.” Monroe, 826 F.3d at 189 (citation omitted).
The ALJ assessed the persuasiveness of APRN Reynolds's opinion as follows:
The undersigned finds the opinion from a provider within Kershaw County Mental Health Center unpersuasive (Exhibit 16F). This opinion is likely from Janice Reynolds. However, the extreme opinion and limitations suggested are not supported by the claimant's mental health records. For example, presumably Ms. Reynolds found that the claimant could not meet competitive standards in several areas including interacting appropriately with the public, maintaining regular attendance, and maintaining attention. Yet, the mental health records from this facility noted that the claimant was cooperative and calm upon exam, and his
concentration was intact (Exhibit 9F, p. 2). The evidence is not consistent with extreme limitations or any mental health related limitations. For example, the claimant alleges that he has anger issues, but his attitude has been cooperative (Exhibit 3F, p. 10-11; Exhibit 7F, p. 1-2). While his mood has been depressed, it has also been described as euthymic (Exhibit 3F, p. 10; Exhibit 9F, p. 1-2).R.p. 21.
Upon review of the ALJ's persuasiveness evaluation, the undersigned finds no error. A plain reading of the above reveals that the ALJ considered the supportability and consistency factors, as required by the new regulations. See 20 C.F.R. §§ 404.1520c(a), (b)(2), 416.920c(a), (b)(2).
The ALJ addressed the supportability factor by explaining that APRN Reynolds's opinion was not supported by her records from her facility, Kershaw County Mental Health Center. R.p. 21. The ALJ specifically noted that APRN Reynolds's mental health treatment records described Plaintiff as cooperative and calm, with intact concentration. R.p. 21 (referring to R.pp. 555-56); see also 20 C.F.R. § 416.920c(c)(1). The ALJ addressed the consistency factor by explaining that the overall mental health treatment records were inconsistent with extreme limitations, or any mental health limitations. R.p. 21 (referring to Dr. Xavier Belcher's treatment notes). Again, the ALJ noted that the overall records revealed unremarkable mental status examination findings, which were inconsistent with APRN Reynolds's opinion. R.p. 21; see also 20 C.F.R. § 416.920c(c)(2). Thus, the ALJ complied with the revised regulations by considering APRN Reynolds's opinion and explaining why it was “unpersuasive” under the pertinent regulatory factors. See R.p. 21.
Plaintiff's arguments to the contrary are unpersuasive. Plaintiff again argues the ALJ erred by not finding his mental impairments severe, but this argument has no merit, as explained above. Plaintiff also argues that the ALJ failed to consider that Plaintiff was referred to Kershaw Mental Health Clinic for anger management issues, as well as anxiety and depression. ECF No. 15 at 23. However, the issue, as the ALJ discussed, is that the record, which consistently revealed normal mental status examination findings, does not support a severe mental impairment and is inconsistent with APRN Reynolds's opinion. Indeed, although Dr. Belcher once noted Plaintiff exhibited mildly impaired concentration, he recorded otherwise normal findings, diagnosed depression, and prescribed medication. R.p. 471. At his next appointment, Plaintiff reported his symptoms improved with medication and he was “feeling really good.” R.p. 473. Dr. Belcher recorded normal examination findings, including intact concentration. R.p. 474. Although Plaintiff reported the medication was less effective in May 2020, Dr. Belcher recorded normal mental status examination findings. R.pp. 510-11. Three months later, Plaintiff again reported improvement, and Dr. Belcher again recorded normal mental status examination findings. R.pp. 512-13.
Thus, to the extent the ALJ did not fully recount the evidence as Plaintiff may have preferred or did not mention evidence, the mere omission of some evidence does not require remand. See Reid v. Comm 'r of Soc. Sec., 769 F.3d 861, 865 (4th Cir. 2014) (“[T]here is no rigid requirement that the ALJ specifically refer to every piece of evidence in his decision.” (quotation marks and citation 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 AL J is not required to discuss all the evidence submitted, and an AL J's failure to cite specific evidence does not indicate that it was not considered.” (citation omitted)).
Ultimately, Plaintiff disagrees with the ALJ's conclusions, which is not a basis for remand. See Brown, 873 F.3d at 267 (noting, to warrant remand, a claimant must either show the ALJ has incorrectly applied a legal standard or show the ALJ's factual findings are not supported by substantial evidence); 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”). For the above reasons, remand is not warranted.
V. CONCLUSION
It is recommended that the decision of the Commissioner be AFFIRMED.