Opinion
5:21-CV-133-FL
09-28-2022
BELINDA MCCALL, Plaintiff/Claimant, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant.
MEMORANDUM AND RECOMMENDATION
Robert B. Jones, Jr., United States Magistrate Judge.
This matter is before the court on the parties' cross-motions for judgment on the pleadings [DE-15, -21] pursuant to Fed.R.Civ.P. 12(c). Claimant Belinda McCall (“Claimant”) filed this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the denial of her applications for a period of disability and Disability Insurance Benefits (“DIB”). The time for filing responsive briefs has expired, and the pending motions are ripe for adjudication. Having carefully reviewed the administrative record and the motions and memoranda submitted by the parties, it is recommended that Claimant's Motion for Judgment on the Pleadings be denied, Defendant's Motion for Judgment on the Pleadings be allowed, and the final decision of the Commissioner be affirmed.
I. STATEMENT OF THE CASE
Claimant protectively filed applications for a period of disability and DIB on December 2, 2019, alleging disability beginning June 30,2019. (R. 12,159-62). The claim was denied initially and upon reconsideration. (R. 12, 50-74). A telephonic hearing before an Administrative Law Judge (“ALJ”) was held on November 12, 2020, at which Claimant, represented by counsel, and a vocational expert (“VE”) appeared and testified. (R. 12, 24-49). On December 8, 2020, the ALJ issued a decision denying Claimant's request for benefits. (R. 9-23). On January 21, 2021, the Appeals Council denied Claimant's request for review. (R. 1-6). Claimant then filed a complaint in this court seeking review of the now-final administrative decision.
IL STANDARD OF REVIEW
The scope of judicial review of a final agency decision regarding disability benefits under the Social Security Act (“Act”), 42 U.S.C. § 301 et seq., is limited to determining whether substantial evidence supports the Commissioner's factual findings and whether the decision was reached through the application of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). “The findings of the Commissioner ... as to any fact, if supported by substantial evidence, shall be conclusive . . . .” 42 U.S.C. § 405(g). Substantial evidence is “evidence which a reasoning mind would accept as sufficient to support a particular conclusion.” Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966). While substantial evidence is not a “large or considerable amount of evidence,” Pierce v. Underwood, 487 U.S. 552, 565 (1988), it is “more than a mere scintilla . . . and somewhat less than a preponderance.” Laws, 368 F.2d at 642. “In reviewing for substantial evidence, [the court should not] undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner].” Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996), superseded by regulation on other grounds, 20 C.F.R. § 416.927(d)(2)). Rather, in conducting the “substantial evidence” inquiry, the court's review is limited to whether the ALJ analyzed the relevant evidence and sufficiently explained his or her findings and rationale in crediting the evidence. Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).
III. DISABILITY EVALUATION PROCESS
The disability determination is based on a five-step sequential evaluation process as set forth in 20 C.F.R. § 404.1520 under which the AL J is to evaluate a claim:
The claimant (1) must not be engaged in “substantial gainful activity,” i.e., currently working; and (2) must have a “severe” impairment that (3) meets or exceeds [in severity] the “listings” of specified impairments, or is otherwise incapacitating to the extent that the claimant does not possess the residual functional capacity to (4) perform ... past work or (5) any other work.Albright v. Comm'r of the SSA, 174 F.3d 473, 475 n.2 (4th Cir. 1999). “If an applicant's claim fails at any step of the process, the ALJ need not advance to the subsequent steps.” Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995) (citation omitted). The burden of proof and production during the first four steps of the inquiry rests on the claimant. Id. At the fifth step, the burden shifts to the ALJ to show that other work exists in the national economy which the claimant can perform. Id.
When assessing the severity of mental impairments, the ALJ must do so in accordance with the “special technique” described in 20 C.F.R. § 404.1520a(b)-(c). This regulatory scheme identifies four broad functional areas in which the ALJ rates the degree of functional limitation resulting from a claimant's mental impairment(s): understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing oneself. Id. § 404.1520a(c)(3). The ALJ is required to incorporate into his written decision pertinent findings and conclusions based on the “special technique.” Id. § 404.1520a(e)(3).
In this case, Claimant alleges the ALJ erred by (1) finding Claimant had the residual functional capacity (“RFC”) to perform light work, and (2) finding Claimant's statements were not consistent with the medical evidence. Pl.'s Mem. [DE-16] at 3-11.
IV. ALJ'S FINDINGS
Applying the above-described sequential evaluation process, the ALJ found Claimant “not disabled” as defined in the Act. At step one, the ALJ found Claimant did not engage in substantial gainful activity from the alleged onset date of June 30, 2019 through the date last insured of June 30, 2020. (R. 14-15). Next, the ALJ determined Claimant had the severe impairments of degenerative disc disease, degenerative joint disease, osteoarthritis, and dysfunction of major joints and the non-severe impairments of hypertension and hyperlipidemia. (R. 15). At step three, the ALJ. concluded these impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. Id.
Prior to proceeding to step four, the ALJ assessed Claimant's RFC, finding Claimant had the ability to perform light work with the following additional limitations:
Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, you must have the ability to do substantially all of these activities. If an individual can perform light work, he or she can also perform sedentary work, unless there are additional limiting factors such as the loss of fine dexterity or the inability to sit for long periods of time. 20 C.F.R. § 404.1567(b).
she can occasionally lift, carry, push, and pull up to 20 pounds, frequently lift, carry, push, and pull up to 10 pounds as well as sit, stand, and walk about six hours in an eight-hour workday. She can frequently climb ramps/stairs; balance; stoop; kneel; crouch; and crawl, but never climb ladders, ropes, or scaffolds. The claimant can frequently reach overhead with her right upper extremity.(R. 15-18). In making this assessment, the ALJ found Claimant's statements about the intensity, persistence, and limiting effects of her symptoms were not entirely consistent with the medical and other evidence. (R. 18).
At step four, the ALJ concluded Claimant was capable of performing the requirements of her past relevant work as a security guard. (R. 18-19).
V. DISCUSSION
Claimant contends the ALJ erred in determining she had the RFC to perform light work and, in doing so, erred in finding her statements were not consistent with the medical evidence. Pl.'s Mem. [DE-16] at 3-11. Specifically, Claimant argues that the ALJ failed to perform a proper fiinction-by-fimction analysis of her ability to stand, walk, reach, and lift and that Claimant's testimony regarding her limitations is consistent with the medical evidence in the record. Id. at 811. Defendant contends the evidence does not support Claimant's assertion that she required a more restrictive RFC, and the ALJ's decision is supported by substantial evidence. Def.'s Mem. [DE-22] at 6-15.
An individual's RFC is the capacity an individual possesses despite the limitations caused by physical or mental impairments. 20 C.F.R. § 404.1545(a)(1); see also SSR 96-8p, 1996 WL 374184, at *1 (July 2, 1996). The RFC is based on all relevant medical and other evidence in the record and may include a claimant's own description of limitations arising from alleged symptoms. 20 C.F.R. § 404.1545(a)(3); see also SSR 96-8p, 1996 WL 374184, at *5. “[T]he residual functional capacity ‘assessment must first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions' listed in the regulations.” Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting SSR 96-8p). The ALJ must provide “a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations).” Id. (quoting SSR 96-8p); see also Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000) (observing that the ALJ “must build an accurate and logical bridge from the evidence to his conclusion”).
1. Function-by-Function Analysis
The ALJ did not perform an explicit function-by-function analysis. (R. 15-18); see Monroe v. Colvin, 826 F.3d 176,179 (4th Cir. 2016) (“Only after such a function-by-function analysis may an ALJ express RFC ‘in terms of the exertional levels of work.'”) (quoting Mascio, 780 F.3d at 636). However, the Fourth Circuit has rejected “a per se rule requiring remand when the ALJ does not perform an explicit function-by-function analysis.” Mascio, 780 F.3d at 636. Rather, the court explained that “[r]emand may be appropriate ... where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite contradictory evidence in the record, or where other inadequacies in the ALJ's analysis frustrate meaningful review.” Id. (citation omitted). Therefore, the court must look to the ALJ's RFC discussion to determine whether it otherwise provides a sufficient basis for meaningful review. See Dowling v. Comm'r of Soc. Sec. Admin., 986 F.3d 377, 388 (4th Cir. 2021) (holding that “the lack of a rule requiring remand does not mean that remand is never the appropriate outcome when an ALJ fails to engage in a function-by-function analysis” and finding that remand was appropriate when the claimant's ability to sit was a contested issue and the ALJ “barely mentioned [the claimant's] sitting problems in his decision”).
Claimant contends the ALJ did not sufficiently consider the impact of her persistent bilateral foot pain on her ability to stand and walk, the impact of her persistent right shoulder pain on her ability to reach above shoulder level, and the impact of her low back pain on her ability to lift. Pl.'s Mem. [DE-16] at 8. Claimant further argues that the ALJ summarized the medical records without providing analysis of her functional limitations and that her limitations prevent her from performing her past relevant work. Id. at 8-9.
In formulating Claimant's RFC, the ALJ first discussed her testimony, including her stated limitations on her ability to stand for more than ten minutes, her need to alternate between sitting and standing every five to ten minutes, and her inability to reach overhead or to lift and carry more . than five pounds. (R. 16).
Next, the ALJ discussed Claimant's medical records related to each of her alleged impairments and functional limitations. The ALJ discussed records from October 2018 related to Claimant's shoulder pain and cervical pain, including x-rays demonstrating some degenerative disease. (R. 16,424-27). However, the ALJ observed that Claimant received a shoulder injection, she acknowledged that the pain had resolved, and her physical examination was within normal limits. Id. Treatment notes indicate Claimant reported engaging in 150 minutes of moderate exercise and two or more days of strength training weekly. (R. 17, 536, 554). The ALJ noted that Claimant presented to the emergency department in November 2019 with back pain radiating to her lower right leg, but she ambulated with a normal gait and demonstrated marked improvement with a Toradol injection. (R. 17, 416-19). The ALJ also noted that in August 2020, Claimant requested an ultrasound for blood clots that Claimant's doctor found to be medically unnecessary, and her doctor offered to send her to orthopedics if her leg pain was worsening but she declined. (R. 17, 530). In October 2020, Claimant sought medication for right shoulder pain, examination revealed only mild tenderness and limitations due to pain, and she was given an orthopedic referral. (R. 18, 551-56). A cervical spine x-ray from October 2020, demonstrated .no evidence of fractures or dislocations, cervical degenerative disc disease at ¶ 5-6 and C6-7, and lost cervical lordosis but no significant soft tissue swelling. (R. 18, 573).
The ALJ discussed Claimant's treatment for foot pain from October 2019 through September 2020. (R. 17). Plaintiff initially had pain in multiple areas of both feet, pain with range of motion, and an antalgic gait and was given a CAM walker and instructed on home treatments, such as applying ice and stretching. (R. 17, 520-24). Plaintiff's foot pain improved over the next few months, her activity increased with treatment, and she was given ankle foot orthosis for her right foot and counseled on appropriate footwear. (R. 17, 516-18). The ALJ acknowledged that in February and June 2020, Claimant reported her foot pain worsening, and she was counseled on appropriate footwear and given a night splint. (R. 17, 513-15, 540-43). Claimant was seen again for her foot pain in September 2020, and it was noted that strenuous activity made her pain worse, she could not perform all activities of daily living, her pain was worse on first standing but better after standing or walking, her gait was normal, and she was again educated on appropriate shoe choices due to her foot deformity. (R. 17, 544-46).
Finally, there were no opinions from Claimant's treatment providers for the ALJ to consider, but the opinions of the state agency consultants, who opined Claimant could perform light exertional work with restrictions, were discussed and found by the ALJ to be persuasive. (R. 18, 51-61, 63-74). The ALJ explained that while the overall record demonstrated Claimant has bilateral foot deformities with pain, except for an occasional finding of an antalgic gait, her gait was mostly normal. (R. 18). The ALJ also acknowledged that while Claimant had degenerative disc disease and osteoarthritis in the right shoulder, she received only conservative treatment, had mostly normal range of motion, and had a very mild limitation of rotation in the right shoulder due to pain. Id.
The ALJ's discussion of the evidence is sufficient for the court to conduct a meaningful review of the decision, despite the failure to perform a function-by-function analysis. The ALJ discussed Claimant's foot, back, and shoulder impairments, including her testimony, the treatment she received, and the opinion evidence. The ALJ explained that the limitations suggested by the state agency consultants were persuasive, citing Claimant's mostly normal gait, conservative treatment, and mild limitations. (R. 18). Claimant has cited no evidence the ALJ failed to consider, and it is not the court's role to re-weigh the evidence where, as here, the court can trace the ALJ's reasoning and it is supported by substantial evidence in the record. See Britt v. Saul, No. 7:18-CV-107-FL, 2019 WL 4855717, at *6 (E.D. N.C. Sept. 30,2019) (finding failure to perform a function-by-function analysis did not frustrate meaningful review where, in formulating the RFC, the ALJ discussed the relevant evidence, explained how he accounted for plaintiffs limitations from her impairments, and cited substantial evidence in support of the RFC determination), aff'd, 860 Fed.Appx. 256 (4th Cir. 2021); Whitted v. Berryhill, No. 7:17-CV-124-FL, 2018 WL 4664124, at *4 (E.D. N.C. Sept. 28, 2018) (finding remand not required for further function-by-function analysis where the ALJ sufficiently discussed “the full range of evidence bearing upon plaintiff's upper extremity weakness, and the ALJ's determination is supported by substantial evidence.”); Beisler v. Kijakazi, No. 7:20-CV-170-RJ, 2022 WL 673270, at *8 (E.D. N.C. Mar. 7, 2022) (finding meaningful review is not frustrated where the ALJ considered Claimant's testimony, his course of treatment, and the medical opinion evidence, and the court can trace the ALJ's reasoning, which is supported by the record). Accordingly, the ALJ's failure to conduct an explicit function-by-function analysis does not warrant remand.
Claimant also argues that the ALJ failed to perform a proper analysis of her ability to perform her past relevant work. Pl.'s Mem. [DE-16] at 9. However, this argument is derivative of the one above, in that it is premised on Claimant being unable to perform the reduced range of light work found by the ALJ. The ALJ received testimony from the VE classifying Claimant's past work as a security guard at the light exertional level. (R. 47). The VE also testified that a hypothetical individual, with the same RFC that the ALJ found Claimant to possess, could perform Claimant's past work as a security guard. (R. 47-48). Accordingly, the ALJ did not err in analyzing Claimant's ability to perform her past relevant work.
2. Claimant's Testimony
Claimant contends the medical evidence supports Claimant's statements that she cannot stand for more than ten minutes at a time; she has neck stiffness, foot pain, shoulder pain, and low back pain that radiates down her legs; she must change positions after sitting for ten minutes due to pain and stiffness; and she has swelling in her right shoulder that causes trouble reaching and limits her to lifting five pounds. Pl.'s Mem. [DE-16] at 11.
Federal regulation 20 C.F.R. § 404.1529(a) provides the authoritative standard for the evaluation of subjective complaints of pain and symptomology, whereby “the determination of' whether a person is disabled by pain or other symptoms is a two-step process.” Craig, 76 F.3d at 593-94. First, the ALJ must objectively determine whether the claimant has medically documented impairments that could cause his or her alleged symptoms. S.S.R. 16-3p, 2016 WL 1119029, at *3 (Mar. 16, 2016); Hines v. Barnhart, 453 F.3d 559, 564 (4th Cir. 2006). If the ALJ makes that determination, he must then evaluate “the intensity and persistence of the claimant's pain[,] and the extent to which it affects her ability to work,” Craig, 76 F.3d at 595, and whether the claimant's statements are supported by the objective medical record. S.S.R. 16-3p, 2016 WL 1119029, at *4; Hines, 453 F.3d at 564-65.
Objective medical evidence may not capture the full extent of a claimant's symptoms, so where the objective medical evidence and subjective complaints are at odds, the ALJ should consider all factors concerning the “intensity, persistence and limiting effects” of the claimant's symptoms. S.S.R. 16-3p, 2016 WL 1119029, at *7; 20 C.F.R. § 404.1529(c)(3) (showing a complete list of factors). The ALJ may not discredit a claimant solely because his or her subjective complaints are not supported by objective medical evidence, Craig, 76 F.3d at 595-96, but neither is the ALJ required to accept the claimant's statements at face value; rather, the ALJ must “evaluate whether the statements are consistent with objective medical evidence and the other evidence.” S.S.R. 16-3p, 2016 WL 1119029, at *6; see Taylor v. Astrue, No. 5:10-CV-263-FL, 2011 WL 1599679, at *4-8 (E.D. N.C. Mar. 23, 2011), adopted by 2011 WL 1599667 (E.D. N.C. Apr. 26, 2011).
The ALJ recounted Claimant's hearing testimony as follows:
At her hearing, the claimant testified that she was 5'7 and weighed 171 pounds. She reported that she was able to drive with some difficulty due to stiffness in. her back and neck. The claimant indicated that she was currently working as a call service/customer service representative from home. She stated that she started in August 2020 and worked 30-40 hours per week. The claimant reported that she had difficulty standing or sitting for prolonged periods of time due to her neck and shoulder pain. She indicated that she had arthritis in her right hand. The claimant .
stated that she could stand for about 10 minutes before needing to sit down. She reported that the arthritis in her back went down into her legs.
The claimant indicated that she was in constant pain. She took pain medications and muscle relaxers. The claimant stated that she had to alternate between sitting and standing every five to ten minutes. She reported that the severe arthritis in her hands was due to carpal tunnel syndrome and she was unable to use a keyboard. The claimant received shots in her right shoulder for pain and was unable to lift or reach overhead. She indicated that she could lift and carry five pounds.
The claimant stated that she had high blood pressure and occasional headaches. Her pain medication caused her blood pressure to be elevated. She had deterioration of the bones in her right foot. The claimant was able to do the laundry and go outside during the day. She was able to care for her personal needs and dress herself as well as drive to the grocery store.(R. 16).
As explained above, the ALJ considered Claimant's testimony along with her medical records and treatment history with respect to her impairments, and the ALJ ultimately found that Claimant's statements were not entirely consistent with the medical evidence. (R. 18). The ALJ accurately recounted Claimant's testimony and acknowledged Claimant's bilateral foot deformities with pain but noted her gait was mostly normal. Id. The ALJ also discussed Claimant's degenerative disc disease and osteoarthritis in the right shoulder but noted there was only a very mild limited range of motion in her shoulder, and she received only conservative treatment for all her impairments. Id.; see Dunn v. Colvin, 607 Fed.Appx. 264, 275 (4th Cir. 2015) (“[I]f all that the claimant needs is conservative treatment, it is reasonable for an ALJ to find that the alleged disability is not as bad as the claimant says that it is.”); Richardson v. Colvin, No. 4:14-CV-125-FL, 2015 WL 5725546, at *6 (E.D. N.C. Aug. 11, 2015) (concluding that conservative treatment lends little support to claims of debilitating symptoms), adopted by 2015 WL 5737613 (E.D. N.C. Sept. 30, 2015). The ALJ also cited treatment notes indicating that injections were successful in relieving Claimant's shoulder and radiating back pain, and she declined an orthopedic referral. (R. 16-17); see Ladda, v. Berryhill, 749 Fed.Appx. 166, 171 (4th Cir. 2018) (finding no error in the ALJ's credibility determination where the ALJ sufficiently explained how the evidence supported his conclusions, including evidence that existing treatments managed the claimant's pain). Finally, the treatment records do not reflect complaints as severe as those to which Claimant testified, and no treatment provider imposed limitations as a result of Claimant's impairments. Accordingly, the ALJ's finding that Claimant's testimony regarding the severity of her impairments was not fully consistent with the medical evidence of record is supported by substantial evidence.
VI. CONCLUSION
For the reasons stated above, it is RECOMMENDED that Claimant's Motion for Judgment on the Pleadings [DE-15] be DENIED, Defendant's Motion for Judgment on the Pleadings [DE-21] be ALLOWED, and the final decision of the Commissioner be AFFIRMED.
IT IS DIRECTED that a copy of this Memorandum and Recommendation be served on each of the parties or, if represented, their counsel. Each party shall have until August 3, 2022 to file written objections to the Memorandum and Recommendation. The presiding district judge must conduct his or her own review (that is, make a de novo determination) of those portions of the Memorandum and Recommendation to which objection is properly made and may accept, reject, or modify the determinations in the Memorandum and Recommendation; receive further evidence; or return the matter to the magistrate judge with instructions. See, e.g, 28 U.S.C. § 636(b)(1); Fed.R.Civ.P. 72(b)(3); Local Civ. R. 1.1 (permitting modification of deadlines specified in local rules), 72.4(b), E.D. N.C. Any response to objections shall be filed by within 14 days of the filing of the objections.
If a party does not file written objections to the Memorandum and Recommendation by the foregoing deadline, the party will be giving up the right to review of the Memorandum and Recommendation by the presiding district judge as described above, and the presiding district judge may enter an order or judgment based on the Memorandum and Recommendation without such review. In addition, the party's failure to file written objections by the foregoing deadline will bar the party from appealing to the Court of Appeals from an order or judgment of the presiding district judge based on the Memorandum and Recommendation. See Wright v. Collins, 766 F.2d 841, 846-47 (4th Cir. 1985).