Opinion
CIVIL 1:21-CV-00584
02-25-2022
CADE SHEARN Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security[1] Defendant.
(CARLSON, MAGISTRATE JUDGE)
REPORT AND RECOMMENDATION
MANNION, JUDGE
I. Introduction
The Supreme Court has underscored for us the limited scope of our substantive review when considering Social Security appeals, noting that:
The phrase “substantial evidence” is a “term of art” used throughout administrative law to describe how courts are to review agency factfinding. T-Mobile South, LLC v. Roswell, 574 U.S. __, __, 135 S.Ct. 808, 815, 190 L.Ed.2d 679 (2015). Under the substantial-evidence standard, a court looks to an existing administrative record and asks whether it contains “sufficien[t] evidence” to support the agency's factual determinations. Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) (emphasis deleted). And whatever the meaning of “substantial” in other contexts, the threshold for such evidentiary sufficiency is not high. Substantial evidence, this Court has said, is “more than a mere scintilla.” Ibid.;
see, e.g., Perales, 402 U.S. at 401, 91 S.Ct. 1420 (internal quotation marks omitted). It means-and means only-“such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Consolidated Edison, 305 U.S. at 229, 59 S.Ct. 206. See Dickinson v. Zurko, 527 U.S. 150, 153, 119 S.Ct. 1816, 144 L.Ed.2d 143 (1999) (comparing the substantial-evidence standard to the deferential clearly-erroneous standard).Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019).
Shearn applied for supplemental security income under Title II of the Social Security Act on March 7, 2019, alleging a mental disability which began at his birth on April 22, 1997. A hearing was held before an Administrative Law Judge (“ALJ”), and the ALJ found that Shearn was not disabled since March 7, 2019, the date his application was filed. Shearn now appeals this decision, arguing that the ALJ's decision is not supported by substantial evidence. However, after a review of the record, and mindful of the fact that substantial evidence “means only-‘such relevant evidence as a reasonable mind might accept as adequate to support a conclusion, '” Biestek, 139 S.Ct. at 1154, we find that substantial evidence supported the ALJ's findings in this case. Therefore, for the reasons set forth below, we will recommend that the court affirm the decision of the Commissioner.
II. Statement of Facts and of the Case
Cade Shearn is a young man described by his mother as “extremely intelligent” who taught himself Japanese and casually studied computer programming. Despite being bright, Shearn struggles with mental impairments which present as social anxiety and result in his near constant seclusion in his bedroom at his parents' home. He has never had a job, but his records indicate that he believed he could work if he found a job with the right pay and accommodations.
Shearn filed the instant Title II claim for disability benefits on March 7, 2019, alleging an onset date of his disability as his birth date, April 22, 1997. (Tr. 122). His claim was denied on April 18, 2019. (Tr. 60). Shearn requested a hearing on June 14, 2019, (Tr. 67), and on March 10, 2020, appeared before an ALJ. (Tr. 33). He alleged disability due to psychological disorders, including anxiety avoidant personality disorder, depression with anxiety, dysthymic disorder, post-traumatic stress disorder, schizoid personality disorder, and autism. (Tr. 128). He also alleged the physical disorder of obesity as a basis for his disability claim. (Id.) Shearn has a 12th grade education, (Tr. 35) and has never had a job. (Tr. 186). Though his primary language is English, his mother indicated he taught himself Japanese. (Tr. 45). The record also indicates that he studied computer programming and enjoyed computer programming as a hobby. (Tr. 232, 255, 281).
Shearn's disability claim is rooted in his social anxiety; Shearn testified that he only leaves his home that he shares with his parents once every three months to visit his therapist. (Tr. 40). His medical record reflects regular sessions every three months with his treating psychologist, Dr. Sheri Keogh, PsyD at WellSpan Behavior Health from September 2017 to March 2019. Shearn's initial psychiatric evaluation at WellSpan, in September 2017, noted he was referred by his mother, who believed he was unhappy. (Tr. 267). Prior to his September 2017 evaluation, he had no prior psychiatric inpatient treatment but had seen a therapist for two sessions and was prescribed Lexapro by his PCP for a short time. (Tr. 268). Records from Shearn's evaluation and initial therapy assessment note that in Summer 2017 he attempted suicide by carbon monoxide poisoning, which he attributed to being “bored of [his] situation” and said he was “not affected” by the carbon monoxide. (Tr. 254, 268). The initial psychiatric evaluation noted a well-groomed appearance, normal speech, goal directed thought processes with no suicidal ideation or delusion as well as focused attention span, appropriate insight and judgment and a constructive affect. (Tr. 268). Shearn was diagnosed with post-traumatic stress disorder and depression with anxiety, and after his first office visit with Dr. Keogh, schizoid personality disorder and dysthymic disorder were added to his diagnoses. (Tr. 256, 267).
The record includes various first names attributed to Dr. Keogh. She is referred to as “Shen” Keogh in the ALJ's opinion and the plaintiff's brief in support of his request for review. The plaintiff also referred to her as “Chang” Keogh in his brief. The medical records indicate the treating doctor's name is “Sheri” Keogh which is what she will be referred to throughout this Report and Recommendation.
Shearn's WellSpan intake forms indicated he was seeking therapy for “social/friendship” problems and because, as he indicated, “I do not leave the house, ” (Tr. 258-59), but at his first office visit with Dr. Keogh, he admitted he attended therapy at the urging of his parents, “not of his own volition.” (Tr. 254). And at most of his subsequent appointments with Dr. Keogh, Shearn reiterated that he did not want to be in therapy, had no goals for his therapy sessions and was only attending therapy to appease his mother. (Tr. 228, 323, 244, 254). Dr. Keogh's notes from his appointments every three months show that Shearn experienced social anxiety and depression, virtually never left his parents' home except to attend appointments, spent most of his time online or watching television, and exhibited very little motivation to change his circumstances. (Tr. 228, 232, 238, 244). At times he expressed an interest in developing “his online business” and indicated that he was studying computer programming and could use his improved computer skills to get a job if he could “find a company that treated [him] right.” (Tr. 232, 250). In January 2020, Dr. Keogh updated Shearn's diagnosis in light of information regarding Shearn's autism spectrum diagnosis provided by Shearn's mother. Schizoid personality disorder and avoidant personality disorder were removed from his current problem list and social anxiety disorder was added. (Tr. 340).
Shearn's medical records also note several physical examinations with Timothy Schrant, CRNP. Those records note ongoing health issues of anxiety, avoidant personality disorder, depression with anxiety, dysthymic disorder, obesity, post-traumatic stress disorder, and schizoid personality disorder. (Tr. 272). However, Schrant noted Shearn as attentive, answering questions appropriately albeit in very short phrases. (Tr. 278, 283). His annual physical examination mentioned concerns about his weight, but overall normal speech and behavior, normal thought content, good eye contact, calm and cooperative, attentive, alert, and oriented. (Tr. 278).
The record also includes two mental RFC determinations by medical experts: the medical opinion of a State agency psychological consultant, John Gavazzi, Psy.D. as well as the assessment by Shearn's treating provider, Dr. Keogh. The expert medical opinions departed in their assessment of whether Shearn would be capable of maintaining attendance and interacting, even minimally, with coworkers and supervisors.
Dr. Gavazzi completed an assessment of Shearn's medical record on April 18th, 2019. (Tr. 50). Based on the record, he determined that Shearn had one or more medically determinable impairments, including severe personality and impulse-control disorders, manifesting as detachment from social relationships, and severe depressive, bipolar, and related disorders. (Tr. 53). Dr. Gavazzi opined Shearn had a moderate limitation in his ability to interact with others and adapt or manage himself, but only a mild limitation in his ability to understand, remember, or apply information and concentrate, persist, or maintain pace. (Id.) He found that Shearn's statements regarding his symptoms were partially consistent with the medical record, in that his limitation in his social interaction and ability to adapt could be reasonably expected to produce the symptoms he described, but such limitations were not of a disabling severity based on the medical record. (Tr. 54-55). On this score, Dr. Gavazzi noted that while Shearn's reported symptoms included social withdrawal, mood disturbance, little interest in social relationships, and difficulty coping with changes, those symptoms were only partially consistent with his activities of daily life, clinical records, expectations with treatment, and functioning. (Tr. 56).
As to his Mental Residual Functional Capacity assessment, Dr. Gavazzi noted a moderate limitation in Shearn's ability to interact with the public and accept and respond appropriately to criticism from supervisors, but no significant limitation in his ability to ask simple questions, request assistance, get along with coworkers or peers, and maintain socially appropriate behavior. (Tr. 55-56). He acknowledged Shearn's struggles with social skills, but noted that he communicates clearly, relates appropriately to familiar others, and behaves predicably in most social situations. (Tr. 56). Dr. Gavazzi found a moderate limitation in Shearn's ability to respond appropriately to changes in the work setting, but no significant limitations in his ability to be aware of normal hazards and take appropriate precautions, and no significant limitations in his ability to travel in unfamiliar places or take public transportation or to set realistic goals or make plans independently of others. (Id.) Dr. Gavazzi opined that although Shearn's impairments limited him to unskilled work, he could perform simple, routine, repetitive tasks in a stable environment. (Tr. 56-57).
Dr. Keogh, Shearn's treating psychologist, also performed an RFC determination, with noted differences in her assessment of Shearn compared to Dr. Gavazzi. Similarly to Dr. Gavazzi, Dr. Keogh found no limitation in Shearn's ability to remember work-like procedures, maintain attention for two-hour segments, carry out short simple instructions, make simple work-related decisions, perform at a consistent pace, and be aware of normal hazards and take appropriate precautions, (Tr. 331), and only mild limitation in Shearn's understanding, remembering, or applying information, concentrating, persisting, or maintaining pace, and adapting or managing himself. (Tr. 332). Dr. Keogh also noted only a moderate limitation in Shearn's ability to ask simple questions or request assistance and respond appropriately to changes in a routine work setting. (Tr. 331).
However, Dr. Keogh noted marked limitations in Shearn's ability to maintain regular attendance and be punctual, complete a normal workday and workweek without interruptions from psychologically based symptoms, and opined that Shearn would likely be unable to complete an eight-hour workday four or more days per month. (Tr. 331-32). She also noted extreme difficulties in Shearn's ability to interact with others, (Tr. 332), and marked limitations in his ability to accept instructions and respond appropriately to criticism from supervisors, get along with co-workers or peers without unduly distracting them or exhibiting behavioral extremes, and deal with normal work stress. (Tr. 331). Dr. Keogh's assessment noted that Shearn would have difficulty working a regular job on a sustained basis because he has anxiety when he leaves his home. (Tr. 333). Her noted symptoms also primarily focus on Shearn's social limitations, including diminished interest in almost all activities, detachment from social relationship, distrust and suspiciousness of others. (Tr. 329).
It is against this medical backdrop that the ALJ held a hearing on Shearn's claim on March 10, 2020. (Tr. 33). At the hearing, Shearn, Shearn's mother, Lisa Shearn, and a Vocational Expert (“VE”) testified. (Tr. 31). Shearn testified that he was supported by his parents and that they completed the majority of the chores around the house, but that he was able to dress and bathe himself and take out the trash. (Tr. 35-36). He testified that he did not have a driver's license, and that he mostly just sat on the computer all day browsing the internet. (Tr. 36-37). When asked by the ALJ if he could do a small office cleaning job that involved light cleaning and little interaction with others, Shearn first asked if it would “be minimum wage, ” but then answered that he believed he could do such a job. (Tr. 37). He later clarified that although he would physically be able to do the work, he may not be able to keep up after a couple days because of his low energy level and anxiety. (Tr. 41).
Shearn testified that he believed he was disabled due to his autism and his inability to communicate with other people. (Tr. 38). He elaborated that he feels anxiety being around other people, especially in tense situations and at large public gatherings. (Tr. 39). He testified that his depression ranges from “middling” to “pretty bad” and on bad days it is difficult for him to get out of bed. (Tr. 40). He admitted to only leaving the house once every three months for his therapist. (Id.) Although medication and regular exercise had been suggested by his doctors to help with his depression and low energy levels, Shearn indicated that the medication he was prescribed made his symptoms and depression worse, (Tr. 38), and exercise made him feel more exhausted. (Tr. 42).
Shearn's mother, Lisa, also testified at the hearing. She testified that the doctor who saw Shearn for his autism “refused to see him anymore” because he tried to commit suicide and he didn't think anyone could ever fix his severe mood disorder. (Tr. 43). She reiterated that he never leaves his room and leaves the house only every three months for his therapy appointments and needs prompted to do basics like take a shower and brush his teeth. (Tr. 43, 45) She also mentioned that Shearn has struggled to keep his weight under control and “has a problem with food.” (Tr. 45). Nonetheless, Lisa described Shearn as “extremely intelligent” noting “there's nothing he can't do” and commenting that he taught himself Japanese. (Id.)
By a decision dated April 9, 2020, the ALJ denied Shearn's application for benefits. (Tr. 13-26). In that decision, the ALJ first concluded that Shearn had not engaged in any substantial gainful activity since March 7, 2019, the application date. (Tr. 18). At Step 2 of the sequential analysis that governs Social Security cases, the ALJ found that Shearn had the following severe impairments: social anxiety disorder, depression with anxiety, and dysthymic disorder. (Id.) The ALJ also noted that Shearn was diagnosed with other medical conditions, such as obesity, post-traumatic stress disorder (“PTSD”), and autism spectrum disorder, but that there was no evidence that the claimant had severe symptoms related to those conditions that persisted for twelve months or that they would affect Shearn's ability to perform basic work activities. (Id.) Specifically, he noted that Shearn's obesity did not cause functional limitation according to his medical records and his history of PTSD and autism were not documented during the period at issue. (Id.) At Step 3, the ALJ determined that Shearn did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments. (Tr. 19). The ALJ specifically considered Listings 12.04, 12.06, and 12.08. (Id.)
Between Steps 3 and 4, the ALJ fashioned a residual functional capacity (“RFC”), considering Shearn's limitations from his impairments:
After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform a full range of work at all exertional levels but with the following nonexertional limitations: work in a low stress job (defined has [sic] having only occasional changes in the work setting), no interaction with the public, occasional interaction with coworkers (but no tandem tasks), and occasional supervision.(Tr. 20).
Specifically, in making this RFC determination, the ALJ considered all Shearn's symptoms and the extent to which these symptoms could reasonably be accepted as consistent with the objective medical evidence and other evidence. (Id.) The ALJ also considered the medical opinions and prior administrative medical findings. (Tr. 21). In assessing Shearn's symptoms, the ALJ followed a two-step process, determining first whether there was an underlying medically determinable physical or mental impairment that could reasonably be expected to produce the claimant's pain or symptoms, and then evaluating the intensity, persistence, and limiting effects of such symptoms to determine the extent to which they limit claimant's functional limitations. (Id.) After applying this two-step process, the ALJ found that Shearn's medically determinable impairments could reasonably be expected to cause his alleged symptoms, but his statements concerning the intensity, persistence and limiting effects of those symptoms were not entirely consistent with the medical evidence and other evidence in the record. (Id.)
Specifically, the ALJ noted that, while Shearn alleged he was unable to work due to his autism making him unable to communicate and get along with others, complete tasks, concentrate, and follow instructions, the medical evidence indicated that his symptoms were managed with infrequent, conservative treatment involving therapy sessions every three months. (Tr. 21-22). The ALJ also noted significant evidence of Shearn's noncompliance with treatment, including being minimally engaged, attending therapy less often than recommended, and declining to take medication to treat his anxiety and depression. (Tr. 22). He found the fact that Shearn's symptoms were being managed without medication and without a higher level of psychiatric care, such as inpatient hospitalization, indicated that his symptoms may not have been as severe as he alleged. (Id.) Nonetheless, the ALJ acknowledged Shearn's treating provider's opinion that Shearn's poor motivation to work on his skills may be attributed to his anxiety and considered this in his recommendation that Shearn be restricted to low stress jobs. (Id.) Shearn's aversion to others was also considered by the ALJ in limiting him to only occasional interaction with coworkers and supervisors, no tandem tasks with coworkers, and no public interaction. (Id.) The ALJ further noted that, while Shearn continues to reside with his parents, and the record indicates that he spends most of his time in his room avoiding others, he was able to remain at home while his parents were away on a two-week vacation and his therapy records indicated that he did not believe he was disabled and that he was going to look into Job Corps information in January 2020. (Id.)
In making his determination, the ALJ considered the reports of the medical experts, noting that the ALJ would not defer to or give controlling weight to any prior medical findings or opinions. The ALJ found the findings of Dr. John Gavazzi, Psy.D., a State agency psychological consultant, to be persuasive, noting that the opinion that Shearn had limitation in his ability to interact appropriately with the general public, accept instructions and respond appropriately to criticism from supervisors, and respond appropriately to changes in the work setting was consistent with the therapy records and the claimant's statements of social avoidance and his mother's statements that he stays in his room most of the time. (Tr. 22-23). Further, the ALJ found Gavazzi's finding that Shearn had only a moderate limitation in these areas was supported by his ability to manage his symptoms with very conservative treatment and his cooperative behavior with others noted in his mental status examination. (Id.)
Conversely, the ALJ found the opinions of treating provider, Sheri Keogh, Psy.D., only partially persuasive. He found that Dr. Keogh's opinion that Shearn had a marked limitation in his ability to maintain regular attendance, be punctual within customary tolerances, work in coordination with or in proximity to others without being distracted by them, complete a normal workday and workweek without interruptions from psychologically based symptoms, accept instructions and respond appropriately to criticism from supervisors, get along with coworkers or peers without distracting them or exhibiting behavioral extremes, and deal normal work stress was not supported by the findings of intact cognition, memory and attention/concentration on mental status examination, the cooperative behavior noted with medical providers, his ability to make conversation with others in the clinical setting, and his ability to manage his symptoms with no medication and infrequent, conservative treatment. (Tr. 23). He further noted that Shearn's ability to attend college in Seattle and Penn State for some time suggested he was able to leave his room and was thus inconsistent with the finding that he had a marked limitation in his ability to maintain regular attendance. (Id.) He did find Dr. Koegh's opinion that Shearn had no limitation in his ability to remember work-like procedures, understand, remember, and carry out short and simple instructions, maintain attention for two-hour segments, sustain an ordinary routine without special supervision, or make simple work-related decisions to be supported by the medical record indicating intact attention/concentration, cognition, and memory as well as his mother's testimony that Shearn taught himself Japanese. (Id.)
The ALJ also acknowledged a “Statement of Dependent Eligibility Beyond Limiting Age Due to Mental or Physical Disability Form” completed by Timothy Schrank, CRNP, that was submitted by Shearn in support of his claim. (Tr. 287). This form appears to have been originally completed for insurance purposes. The ALJ declined to analyze the statement under Section 404.1520b as a statement on an issue reserved for the Commissioner. The ALJ's determination not to include the statement in his analysis is not determinative in our analysis of whether a scintilla of evidence existed to support his opinion, and thus need not be subject to further discussion.
Having arrived at this RFC assessment, the ALJ found at Step 4 that Shearn had not engaged in any work activity that met the durational and earnings requirements to constitute past relevant work. (Tr. 24). Between Step 4 and Step 5, the ALJ concluded that Shearn was 21 years old, which is defined as a younger individual age 18-49 on the date the application was filed. (Id.) He noted that Shearn has at least a high school education and is able to communicate in English. (Id.) The ALJ further determined that transferability of job skills was not an issue because Shearn did not have past relevant work. (Id.)
The ALJ then made a finding at Step 5 that Shearn could perform work available in the national economy as merchandise marker, mail clerk, or laundry worker. (Tr. 25). In doing so, the ALJ considered Shearn's residual functional capacity, age, education, and work experience in conjunction with the Medical Vocational Guidelines. The ALJ found that Shearn's ability to perform work at all exertional levels was compromised by nonexertional limitations. (Id.) Thus, the ALJ posed hypothetical questions to a vocational expert at the hearing to determine if jobs existed in the national economy for an individual such as Shearn, who could perform work at all exertional levels but with the nonexertional limitations of work in a low stress job, no interaction with the public, occasional interaction with coworkers but not tandem tasks, and occasional supervision. (Tr. 25). The VE testified that, given all of these factors, and considering Shearn's age, education, and work experience, there existed jobs in the national economy that Shearn could perform. (Id.) The ALJ concluded that Shearn was capable of making a successful adjustment to other work that exists in significant numbers in the national economy. (Id.) Accordingly, the ALJ concluded that Shearn did not meet the stringent standard for disability set by the Act and denied his claim. (Id.)
Shearn filed a timely request for review of the ALJ's opinion with the Appeals Council, which was denied on January 21, 2021. (Tr. 1-7). This appeal followed. (Doc. 1). On appeal, Shearn argues that the ALJ erred in failing to properly weigh the opinion of treating physician Sheri Keogh and that the ALJ committed multiple errors with symptom evaluation which compel reversal of his decision. (Doc. 18, at 13-14). This case is fully briefed and is, therefore, ripe for resolution. For the reasons set forth below, we will recommend that the court affirm the decision of the Commissioner.
III. Discussion
A. Substantial Evidence Review - the Role of this Court
When reviewing the Commissioner's final decision denying a claimant's application for benefits, this Court's review is limited to the question of whether the findings of the final decision-maker are supported by substantial evidence in the record. See 42 U.S.C. §405(g); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D. Pa. 2012). Substantial evidence “does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence is less than a preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). But in an adequately developed factual record, substantial evidence may be “something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's decision] from being supported by substantial evidence.” Consolo v. Fed. Maritime Comm'n, 383 U.S. 607, 620 (1966). “In determining if the Commissioner's decision is supported by substantial evidence the court must scrutinize the record as a whole.” Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D. Pa. 2003).
The Supreme Court has recently underscored for us the limited scope of our review in this field, noting that:
The phrase “substantial evidence” is a “term of art” used throughout administrative law to describe how courts are to review agency
factfinding. T-Mobile South, LLC v. Roswell, 574 U.S. __, __, 135 S.Ct. 808, 815, 190 L.Ed.2d 679 (2015). Under the substantial-evidence standard, a court looks to an existing administrative record and asks whether it contains “sufficien[t] evidence” to support the agency's factual determinations. Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) (emphasis deleted). And whatever the meaning of “substantial” in other contexts, the threshold for such evidentiary sufficiency is not high. Substantial evidence, this Court has said, is “more than a mere scintilla.” Ibid.; see, e.g., Perales, 402 U.S. at 401, 91 S.Ct. 1420 (internal quotation marks omitted). It means-and means only-“such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Consolidated Edison, 305 U.S. at 229, 59 S.Ct. 206. See Dickinson v. Zurko, 527 U.S. 150, 153, 119 S.Ct. 1816, 144 L.Ed.2d 143 (1999) (comparing the substantial-evidence standard to the deferential clearly-erroneous standard).Biestek, 139 S.Ct. at 1154.
The question before this Court, therefore, is not whether the claimant is disabled, but rather whether the Commissioner's finding that he is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D. Pa. Mar. 11, 2014) (“[I]t has been held that an ALJ's errors of law denote a lack of substantial evidence”) (alterations omitted); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D. Pa. 1981) (“The Secretary's determination as to the status of a claim requires the correct application of the law to the facts.”); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990) (noting that the scope of review on legal matters is plenary); Ficca, 901 F.Supp.2d at 536 (“[T]he court has plenary review of all legal issues . . . .”).
Several fundamental legal propositions which flow from this deferential standard of review. First, when conducting this review “we are mindful that we must not substitute our own judgment for that of the fact finder.” Zirnsak v. Colvin, 777 F.3d 607, 611 (3d Cir. 2014) (citing Rutherford v. Barnhart, 399 F.3d 546, 552 (3d Cir. 2005)). Thus, we are enjoined to refrain from trying to re-weigh the evidence. Rather our task is to simply determine whether substantial evidence supported the ALJ's findings. However, we must also ascertain whether the ALJ's decision meets the burden of articulation demanded by the courts to enable informed judicial review. Simply put, “this Court requires the ALJ to set forth the reasons for his decision.” Burnett v. Comm'r of Soc. Sec. Admin., 220 F.3d 112, 119 (3d Cir. 2000).
As the Court of Appeals has noted on this score:
In Burnett, we held that an ALJ must clearly set forth the reasons for his decision. 220 F.3d at 119. Conclusory statements . . . are insufficient. The ALJ must provide a “discussion of the evidence” and an “explanation of reasoning” for his conclusion sufficient to enable meaningful judicial review. Id. at 120; see Jones v. Barnhart, 364 F.3d 501, 505 & n. 3 (3d Cir.2004). The ALJ, of course, need not employ particular “magic” words: “Burnett does not require the ALJ to use particular language or adhere to a particular format in conducting his analysis.” Jones, 364 F.3d at 505.Diaz v. Comm'r of Soc. Sec., 577 F.3d 500, 504 (3d Cir. 2009).
Thus, in practice ours is a twofold task. We must evaluate the substance of the ALJ's decision under a deferential standard of review, but we must also give that decision careful scrutiny to ensure that the rationale for the ALJ's actions is sufficiently articulated to permit meaningful judicial review.
This principle applies with particular force to legal challenges, like the claim made here, based upon alleged inadequacies in the articulation of a claimant's mental RFC. In Hess v. Comm'r Soc. Sec., 931 F.3d 198, 212 (3d Cir. 2019), the United States Court of Appeals recently addressed the standards of articulation that apply in this setting. In Hess, the court of appeals considered the question of whether an RFC, which limited a claimant to simple tasks, adequately addressed moderate limitations on concentration, persistence, and pace. In addressing the plaintiff's argument that the language used by the ALJ to describe the claimant's mental limitations was legally insufficient, the court of appeals rejected a per se rule which would require the ALJ to adhere to a particular format in conducting this analysis. Instead, framing this issue as a question of adequate articulation of the ALJ's rationale, the court held that, “as long as the ALJ offers a ‘valid explanation,' a ‘simple tasks' limitation is permitted after a finding that a claimant has ‘moderate' difficulties in ‘concentration, persistence, or pace.'” Hess v. Comm'r Soc. Sec., 931 F.3d 198, 211 (3d Cir. 2019). On this score, the appellate court indicated that an ALJ offers a valid explanation a mental RFC when the ALJ highlights factors such as “mental status examinations and reports that revealed that [the claimant] could function effectively; opinion evidence showing that [the claimant] could do simple work; and [the claimant]'s activities of daily living, . . . . ” Hess v. Comm'r Soc. Sec., 931 F.3d 198, 214 (3d Cir. 2019).
In our view, the teachings of the Hess decision are straightforward. In formulating a mental RFC, the ALJ does not need to rely upon any particular form of words. Further, the adequacy of the mental RFC is not gauged in the abstract. Instead, the evaluation of a claimant's ability to undertake the mental demands of the workplace will be viewed in the factual context of the case, and a mental RFC is sufficient if it is supported by a valid explanation grounded in the evidence.
B. Initial Burdens of Proof, Persuasion, and Articulation for the ALJ
To receive benefits under the Social Security Act by reason of disability, a claimant must demonstrate an inability to “engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. §423(d)(1)(A); see also 20 C.F.R. §404.1505(a). To satisfy this requirement, a claimant must have a severe physical or mental impairment that makes it impossible to do his or her previous work or any other substantial gainful activity that exists in the national economy. 42 U.S.C. §423(d)(2)(A); 20 C.F.R. §404.1505(a). To receive benefits under Title II of the Social Security Act, a claimant must show that he or she contributed to the insurance program, is under retirement age, and became disabled prior to the date on which he or she was last insured. 42 U.S.C. §423(a); 20 C.F.R. §404.131(a).
In making this determination at the administrative level, the ALJ follows a five-step sequential evaluation process. 20 C.F.R. §404.1520(a). Under this process, the ALJ must sequentially determine: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals a listed impairment; (4) whether the claimant is able to do his or her past relevant work; and (5) whether the claimant is able to do any other work, considering his or her age, education, work experience and residual functional capacity (“RFC”). 20 C.F.R. §404.1520(a)(4).
Between Steps 3 and 4, the ALJ must also assess a claimant's residual functional capacity (RFC). RFC is defined as “that which an individual is still able to do despite the limitations caused by his or her impairment(s).” Burnett v. Comm'r of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R. §§404.1520(e), 404.1545(a)(1). In making this assessment, the ALJ considers all of the claimant's medically determinable impairments, including any non-severe impairments identified by the ALJ at step two of his or her analysis. 20 C.F.R. §404.1545(a)(2).
There is an undeniable medical aspect to an RFC determination, since that determination entails an assessment of what work the claimant can do given the physical limitations that the claimant experiences. Yet, when considering the role and necessity of medical opinion evidence in making this determination, courts have followed several different paths. Some courts emphasize the importance of medical opinion support for an RFC determination and have suggested that “[r]arely can a decision be made regarding a claimant's residual functional capacity without an assessment from a physician regarding the functional abilities of the claimant.” Biller v. Acting Comm'r of Soc. Sec., 962 F.Supp.2d 761, 778-79 (W.D. Pa. 2013) (quoting Gormont v. Astrue, Civ. No. 11-2145, 2013 WL 791455 at *7 (M.D. Pa. Mar. 4, 2013)). In other instances, it has been held that, “[t]here is no legal requirement that a physician have made the particular findings that an ALJ adopts in the course of determining an RFC.” Titterington v. Barnhart, 174 Fed.Appx. 6, 11 (3d Cir. 2006). Further, courts have held in cases where there is no evidence of any credible medical opinion supporting a claimant's allegations of disability that, “the proposition that an ALJ must always base his RFC on a medical opinion from a physician is misguided.” Cummings v. Colvin, 129 F.Supp.3d 209, 214-15 (W.D. Pa. 2015).
These seemingly discordant legal propositions can be reconciled by evaluation of the factual context of these decisions. Those cases which emphasize the importance of medical opinion support for an RFC assessment typically arise in the factual setting where a well-supported medical source has identified limitations that would support a disability claim, but an ALJ has rejected the medical opinion which supported a disability determination based upon a lay assessment of other evidence. Biller, 962 F.Supp.2d at 778-79. In this setting, these cases simply restate the commonplace idea that medical opinions are entitled to careful consideration when making a disability determination, particularly when those opinions support a finding of disability. In contrast, when an ALJ is relying upon other evidence, such as contrasting clinical or opinion evidence or testimony regarding the claimant's activities of daily living, to fashion an RFC, courts have adopted a more pragmatic view and have sustained the ALJ's exercise of independent judgment based upon all the facts and evidence. See Titterington v. Barnhart, 174 Fed.Appx. 6, 11 (3d Cir. 2006); Cummings v. Colvin, 129 F.Supp.3d 209, 214-15 (W.D. Pa. 2015). In either event, once the ALJ has made this determination, our review of the ALJ's assessment of the plaintiff's RFC is deferential, and that RFC assessment will not be set aside if it is supported by substantial evidence. Burns v. Barnhart, 312 F.3d 113, 129 (3d Cir. 2002); see also Metzger v. Berryhill, No. 3:16-CV-1929, 2017 WL 1483328, at *5 (M.D. Pa. Mar. 29, 2017), report and recommendation adopted sub nom. Metzgar v. Colvin, No. 3:16-CV-1929, 2017 WL 1479426 (M.D. Pa. Apr. 21, 2017); Rathbun v. Berryhill, No. 3:17-CV-00301, 2018 WL 1514383, at *6 (M.D. Pa. Mar. 12, 2018), report and recommendation adopted, No. 3:17-CV-301, 2018 WL 1479366 (M.D. Pa. Mar. 27, 2018).
At Steps 1 through 4, the claimant bears the initial burden of demonstrating the existence of a medically determinable impairment that prevents him or her from engaging in any of his or her past relevant work. Mason, 994 F.2d at 1064. Once this burden has been met by the claimant, it shifts to the Commissioner at Step 5 to show that jobs exist in significant number in the national economy that the claimant could perform that are consistent with the claimant's age, education, work experience and RFC. 20 C.F.R. §404.1512(f); Mason, 994 F.2d at 1064.
The ALJ's disability determination must also meet certain basic substantive requisites. Most significant among these legal benchmarks is a requirement that the ALJ adequately explain the legal and factual basis for this disability determination. Thus, in order to facilitate review of the decision under the substantial evidence standard, the ALJ's decision must be accompanied by “a clear and satisfactory explication of the basis on which it rests.” Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981). Conflicts in the evidence must be resolved and the ALJ must indicate which evidence was accepted, which evidence was rejected, and the reasons for rejecting certain evidence. Id. at 706-07. In addition, “[t]he ALJ must indicate in his decision which evidence he has rejected and which he is relying on as the basis for his finding.” Schaudeck v. Comm'r of Soc. Sec., 181 F.3d 429, 433 (3d Cir. 1999).
C. Legal Benchmarks for the ALJ's Assessment of Medical Opinion Evidence
Shearn filed the instant disability application in March 2019, well after a paradigm shift in the manner in which medical opinions were evaluated when assessing Social Security claims. Prior to March 2017, ALJs were required to follow regulations which defined medical opinions narrowly and created a hierarchy of medical source opinions with treating sources at the apex of this hierarchy. However, in March of 2017, the Commissioner's regulations governing medical opinions changed in a number of fundamental ways. The range of opinions that ALJs were enjoined to consider were broadened substantially and the approach to evaluating opinions was changed from a hierarchical form of review to a more holistic analysis.
As one court as aptly observed:
The regulations regarding the evaluation of medical evidence have been amended for claims filed after March 27, 2017, and several of the prior Social Security Rulings, including SSR 96-2p, have been rescinded.
According to the new regulations, the Commissioner “will no longer give any specific evidentiary weight to medical opinions; this includes giving controlling weight to any medical opinion.” Revisions to Rules Regarding the Evaluation of Medical Evidence (“Revisions to Rules”), 2017 WL 168819, 82 Fed.Reg. 5844, at 5867-68 (Jan. 18, 2017), see 20 C.F.R. §§ 404.1520c(a), 416.920c(a). Instead, the Commissioner must consider all medical opinions and “evaluate their persuasiveness” based on the following five factors: supportability; consistency; relationship with the claimant; specialization; and “other factors.” 20 C.F.R. §§ 404.1520c(a)-(c), 416.920c(a)-(c).
Although the new regulations eliminate the perceived hierarchy of medical sources, deference to specific medical opinions, and assigning “weight” to a medical opinion, the ALJ must still “articulate how [he or she] considered the medical opinions” and “how persuasive [he or she] find[s] all of the medical opinions.” Id. at §§ 404.1520c(a) and (b)(1), 416.920c(a) and (b)(1). The two “most important factors for determining the persuasiveness of medical opinions are consistency and supportability, ” which are the “same factors” that formed the foundation of the treating source rule. Revisions to Rules, 82 Fed.Reg. 5844-01 at 5853.
An ALJ is specifically required to “explain how [he or she] considered the supportability and consistency factors” for a medical opinion. 20 C.F.R. §§ 404.1520c (b)(2), 416.920c(b)(2). With respect to “supportability, ” the new regulations provide that “[t]he more relevant the objective medical evidence and supporting explanations presented by a medical source are to support his or her medical opinion(s) or prior administrative medical finding(s), the more persuasive the medical opinions or prior administrative medical finding(s) will be.” Id. at §§ 404.1520c(c)(1), 416.920c(c)(1). The regulations provide that with respect to “consistency, ” “[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.” Id. at §§ 404.1520c(c)(2), 416.920c(c)(2).
Under the new regulations an ALJ must consider, but need not explicitly discuss, the three remaining factors in determining the persuasiveness of a medical source's opinion. Id. at §§ 404.1520c(b)(2), 416.920c(b)(2). However, where the ALJ has found two or more medical opinions to be equally well supported and consistent with the record, but not exactly the same, the ALJ must articulate how he or she considered those factors contained in paragraphs (c)(3) through (c)(5). Id. at §§ 404.1520c(b)(3), 416.920c(b)(3).Andrew G. v. Comm'r of Soc. Sec., No. 3:19-CV-0942 (ML), 2020 WL 5848776, at *5 (N.D.N.Y. Oct. 1, 2020).
Often, as in this case, an ALJ must evaluate various medical opinions. Judicial review of this aspect of ALJ decision-making is still guided by several settled legal tenets. First, when presented with a disputed factual record, it is well-established that “[t]he ALJ - not treating or examining physicians or State agency consultants - must make the ultimate disability and RFC determinations.” Chandler v. Comm'r of Soc. Sec., 667 F.3d 356, 361 (3d Cir. 2011). Thus, when evaluating medical opinions, “the ALJ may choose whom to credit but ‘cannot reject evidence for no reason or for the wrong reason.'” Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000) (quoting Mason, 994 F.2d at 1066). Therefore, provided that the decision is accompanied by an adequate, articulated rationale, it is the province and the duty of the ALJ to choose which medical opinions and evidence deserve greater weight.
Further, in making this assessment of medical evidence:
An ALJ is [also] entitled generally to credit parts of an opinion without crediting the entire opinion. See Thackara v. Colvin, No. 1:14-CV- 00158-GBC, 2015 WL 1295956, at *5 (M.D. Pa. Mar. 23, 2015); Turner v. Colvin, 964 F.Supp.2d 21, 29 (D.D.C. 2013) (agreeing that “SSR 96-2p does not prohibit the ALJ from crediting some parts of a treating source's opinion and rejecting other portions”); Connors v. Astrue, No. 10-CV-197-PB, 2011 WL 2359055, at *9 (D.N.H. June 10, 2011). It follows that an ALJ can give partial credit to all medical opinions and can formulate an RFC based on different parts from the different medical opinions. See e.g., Thackara v. Colvin, No. 1:14-CV- 00158-GBC, 2015 WL 1295956, at *5 (M.D. Pa. Mar. 23, 2015).Durden v. Colvin, 191 F.Supp.3d 429, 455 (M.D. Pa. 2016). Finally, where there is no evidence of any credible medical opinion supporting a claimant's allegations of disability “the proposition that an ALJ must always base his RFC on a medical opinion from a physician is misguided.” Cummings, 129 F.Supp.3d at 214-15.
D. Legal Benchmarks for the ALJ's Assessment of a Claimant's Alleged Symptoms
The interplay between the deferential substantive standard of review that governs Social Security appeals, and the requirement that courts carefully assess whether an ALJ has met the standards of articulation required by law, is also illustrated by those cases which consider analysis of a claimant's reported symptoms. When evaluating lay testimony regarding a claimant's reported degree of pain and disability, we are reminded that:
[T]he ALJ must necessarily make certain credibility determinations, and this Court defers to the ALJ's assessment of credibility. See Diaz v. Comm'r, 577 F.3d 500, 506 (3d Cir.2009) (“In determining whether
there is substantial evidence to support an administrative law judge's decision, we owe deference to his evaluation of the evidence [and] assessment of the credibility of witnesses....”). However, the ALJ must specifically identify and explain what evidence he found not credible and why he found it not credible. Adorno v. Shalala, 40 F.3d 43, 48 (3d Cir.1994) (citing Stewart v. Sec'y of Health, Education and Welfare, 714 F.2d 287, 290 (3d Cir.1983)); see also Stout v. Comm'r, 454 F.3d 1050, 1054 (9th Cir.2006) (stating that an ALJ is required to provide “specific reasons for rejecting lay testimony”). An ALJ cannot reject evidence for an incorrect or unsupported reason. Ray v. Astrue, 649 F.Supp.2d 391, 402 (E.D.Pa.2009) (quoting Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir.1993)).Zirnsak v. Colvin, 777 F.3d 607, 612-13 (3d Cir. 2014).
Yet, it is also clear that:
Great weight is given to a claimant's subjective testimony only when it is supported by competent medical evidence. Dobrowolsky v. Califano, 606 F.2d 403, 409 (3d Cir. 1979); accord Snedeker v. Comm'r of Soc. Sec., 244 Fed.Appx. 470, 474 (3d Cir. 2007). An ALJ may reject a claimant's subjective testimony that is not found credible so long as there is an explanation for the rejection of the testimony. Social Security Ruling (“SSR”) 96-7p; Schaudeck v. Comm'r of Social Security, 181 F.3d 429, 433 (3d Cir. 1999). Where an ALJ finds that there is an underlying medically determinable physical or mental impairment that could reasonably be expected to produce the individual's pain or other symptoms, however, the severity of which is not substantiated by objective medical evidence, the ALJ must make a finding on the credibility of the individual's statements based on a consideration of the entire case record.McKean v. Colvin, 150 F.Supp.3d 406, 415-16 (M.D. Pa. 2015) (footnotes omitted). Thus, we are instructed to review an ALJ's evaluation of a claimant's subjective reports of symptoms under a standard of review which is deferential with respect to the ALJ's well-articulated findings, but imposes a duty of clear articulation upon the ALJ so that we may conduct meaningful review of the ALJ's conclusions.
In the same fashion that medical opinion evidence is evaluated, the Social Security Rulings and Regulations provide a framework under which the severity of a claimant's reported symptoms are to be considered. 20 C.F.R. §§ 404.1529, 416.929; SSR 16-3p. It is important to note that though the “statements of the individual concerning his or her symptoms must be carefully considered, the ALJ is not required to credit them.” Chandler v. Comm'r of Soc. Sec., 667 F.3d 356, 363 (3d. Cir. 2011) (referencing 20 C.F.R. §404.1529(a) (“statements about your pain or other symptoms will not alone establish that you are disabled.”). It is well-settled in the Third Circuit that “[a]llegations of pain and other subjective symptoms must be supported by objective medical evidence.” Hantraft v. Apfel, 181 F.3d 358, 362 (3d Cir. 1999) (referring to 20 C.F.R. §404.1529). When evaluating a claimant's symptoms, the ALJ must follow a two-step process in which the ALJ resolves whether a medically determinable impairment could be the cause of the symptoms alleged by the claimant, and subsequently must evaluate the alleged symptoms in consideration of the record as a whole. SSR 16-3p.
First, symptoms, such as pain or fatigue, will only be considered to affect a claimant's ability to perform work activities if such symptoms result from an underlying physical or mental impairment that has been demonstrated to exist by medical signs or laboratory findings. 20 C.F.R. §§ 404.1529(b), 416.929(b); SSR 16-3p. During the second step of this credibility assessment, the ALJ must determine whether the claimant's statements about the intensity, persistence or functionally limiting effects of his or her symptoms are substantiated based on the ALJ's evaluation of the entire case record. 20 C.F.R. § 404.1529(c), 416.929(c); SSR 16- 3p. This includes but is not limited to: medical signs and laboratory findings, diagnosis and other medical opinions provided by treating or examining sources, and other medical sources, as well as information concerning the claimant's symptoms and how they affect his or her ability to work. Id. The Social Security Administration has recognized that individuals may experience their symptoms differently and may be limited by their symptoms to a greater or lesser extent than other individuals with the same medical impairments, signs, and laboratory findings. SSR 16-3p.
Thus, to assist in the evaluation of a claimant's subjective symptoms, the Social Security Regulations identify seven factors which may be relevant to the assessment of the severity or limiting effects of a claimant's impairment based on a claimant's symptoms. 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3). These factors include: activities of daily living; the location, duration, frequency, and intensity of the claimant's symptoms; precipitating and aggravating factors; the type, dosage, effectiveness, and side effects of any medication the claimant takes or has taken to alleviate his or her symptoms; treatment, other than medication that a claimant has received for relief; any measures the claimant has used to relieve his or her symptoms; and, any other factors concerning the claimant's functional limitations and restrictions. Id.; see also George v. Colvin, No. 4:13-CV-2803, 2014 WL 5449706, at *4 (M.D. Pa. Oct. 24, 2014); Koppenaver v. Berryhill, No. 3:18-CV-1525, 2019 WL 1995999, at *9 (M.D. Pa. Apr. 8, 2019), report and recommendation adopted sub nom. Koppenhaver v. Berryhill, No. 3:18-CV-1525, 2019 WL 1992130 (M.D. Pa. May 6, 2019); Martinez v. Colvin, No. 3:14-CV-1090, 2015 WL 5781202, at *8-9 (M.D. Pa. Sept. 30, 2015).
It is against these legal benchmarks that we assess the instant appeal.
E. The ALJ's Decision was Supported by Substantial Evidence.
In this setting, we are mindful that we are not free to substitute our independent assessment of the evidence for the ALJ's determinations. Rather, we must simply ascertain whether the ALJ's decision is supported by substantial evidence, a quantum of proof which is less than a preponderance of the evidence but more than a mere scintilla, Richardson, 402 U.S. at 401, and “does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Pierce, 487 U.S. at 565. Judged against these deferential standards of review, we find that substantial evidence supported the decision by the ALJ that Shearn was not disabled.
Shearn argues that the ALJ failed to properly weigh the opinion of treating physician Dr. Keogh, conceding that the ALJ did not entirely dismiss Dr. Keogh's opinion but arguing that the fact the ALJ did not find Dr. Keogh's opinion to be more persuasive was not supported by substantial evidence. We find the ALJ's analysis of the persuasiveness of Dr. Keogh's medical opinion draws adequate support from the administrative record.
At the outset, we note that the question of disability is a legal determination and is not wholly dictated by medical opinions. Indeed, it is well settled that “[t]he ALJ-not treating or examining physicians or State agency consultants-must make the ultimate disability and RFC determinations.” Chandler, 667 F.3d at 361. Further, in making this assessment of medical opinion evidence, “[a]n ALJ is [also] entitled generally to credit parts of an opinion without crediting the entire opinion.” Durden, 191 F.Supp.3d at 455. Additionally, under the new regulations, so long as the ALJ's opinion is well-reasoned and articulated based on the factors of supportability, consistency, relationship with claimant, specialization, and other factors, an ALJ is entitled to determine which medical opinions are most persuasive, regardless of whether the physician examined the patient or based his findings off the medical record. 20 C.F.R. § 404.1520c.
Shearn argues the ALJ's reliance on his ability to interact appropriately in a clinical setting was inadequate to find unpersuasive Dr. Keogh's opinion that he had a marked limitation in his ability to work in coordination with or in proximity to others without being distracted by them, complete a normal workday and workweek without interruptions from psychologically based symptoms, accept instructions and respond appropriately to criticism from supervisors, get along with coworkers or peers without distracting them or exhibiting behavioral extremes. Shearn avers, “the ability to behave appropriately during a brief doctor's appointment says little about Mr. Shearn's ability to perform the same act over the course of a workday or workweek, ” and alleges that “the ALJ cited no evidence that permitted him to extrapolate how well Mr. Shearn would have interacted with the coworkers and supervisors based on brief doctors' visits.” (Doc. 16, at 7).
First, the ALJ's opinion reflects his consideration of a variety of factors in partially rejecting Dr. Keogh's opinion regarding Shearn's marked limitation in maintaining attendance and interacting with coworkers; and he articulated his reasoning quite clearly. In fact, the ALJ found that the medical findings of intact cognition, memory, and attention/concentration on mental status examination, combined with the cooperative behavior noted with medical providers and his ability to make conversation in a clinical setting were inconsistent with Dr. Keogh's finding of these marked limitations in social interactions. (Tr. 23). He also noted that Dr. Keogh's finding that Shearn would have marked limitation in his ability to maintain regular attendance was not consistent with his ability to attend college in Seattle and Penn State for some time, as well as Shearn's own statements that he was able to leave his room. (Tr. 23). Finally, he considered the opinion of Dr. Gavazzi, who noted only a moderate limitation in Shearn's ability to interact appropriately with the general public but restricted his work to a low stress job with only occasional interaction with coworkers. (Id.) Indeed, nothing in the administrative record seems to show Shearn to be unable to make appointments or interact appropriately when he is required to do so. And Dr. Keogh's own treatment records indicated in January 2020 that she recommended he look into Job Corps. (Tr. 344).
Further, the ALJ did not completely discount Dr. Keogh's findings which suggested Shearn's lack of motivation to leave his room could be attributed to his anxiety. The ALJ credited Dr. Keogh's assessment that Shearn had a moderate limitation in his ability to respond appropriately to changes in the work setting due to this limitation and, accordingly, fashioned an RFC which with certain interaction limitations.
Shearn also makes two arguments regarding the ALJ's further inquiry into certain aspects of the administrative record. He argues that the ALJ failed to adequately question Shearn about his conservative and infrequent treatment prior to relying on it to his detriment and that the ALJ should have contacted Dr. Keogh or the plaintiff's attorney to obtain clarification on any inconsistencies between her RFC assessment and her unremarkable mental status findings. As to any requirement that the ALJ obtain more information before reaching a decision, we note simply that these matters lie soundly in the discretion of the ALJ. Our standard or review requires only that we determine whether substantial evidence supported the ALJ's findings, and that the ALJ “provide a ‘discussion of the evidence' and an ‘explanation of reasoning' for his conclusion sufficient to enable meaningful judicial review.” Diaz, 577 F.3d at 504 (citing Burnett at 119). We find this standard has been met in this case. As we previously articulated, the inconsistencies between Dr. Keogh's opinion and the medical record as well as Shearn's noncompliance with treatment were two factors among several considered by the ALJ in making his final RFC assessment. Accordingly, we find that the ALJ has provided a valid explanation for his decision, which is all that is required under the law. Therefore, there are no grounds to set aside this decision based upon his assessment of the medical opinion evidence.
Shearn also argues that the ALJ made multiple errors regarding his evaluation of Shearn's alleged symptoms. In this case, the ALJ assessed the severity of Shearn's symptoms in accordance with the regulations and found that Shearn's statements regarding the intensity and persistence of his symptoms were not entirely consistent with the objective medical evidence. We first reiterate that, in evaluating a claimant's subjective systems, the ALJ should consider his activities of daily living; the location, duration, frequency, and intensity of the claimant's symptoms; precipitating and aggravating factors; the type, dosage, effectiveness, and side effects of any medication the claimant takes or has taken to alleviate his or her symptoms; treatment, other than medication that a claimant has received for relief; any measures the claimant has used to relieve his or her symptoms; and, any other factors concerning the claimant's functional limitations and restrictions. 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3). Here, in accordance with the regulations, the ALJ considered Shearn's minimal engagement in treatment and declination to take medication to treat his anxiety in his determination. As Shearn points out, non-compliance with treatment is common with individuals with mental health impairments, however contrary to the plaintiff's argument, the ALJ explicitly considered this, noting “his treating provider noted that his anxiety may contribute to his poor motivation to work on his skills. This has been considered in limiting him to low stress jobs.” (Tr. 22). He also noted that Shearn never required a higher level of treatment despite managing his symptoms without medication, and that while he indicated he declined the take the medication he was prescribed due to the side effects, including suicidal ideation, there is no evidence on the record that he tried other medications after experiencing these side effects. While the plaintiff argues these factors alone should not support the ALJ's determination, it is well established that the ALJ was required to evaluate these factors under the regulations. Further, the ALJ did not consider these factors in isolation, but among other factors including his assessment of Shearn's activities of daily living, finding that while he continues to reside with his parents, he was capable of remaining at home while his parents were away on vacation for two weeks, as well as the symptoms noted in his mental status examinations. Thus, there was no legal error in the ALJ's reliance upon these considerations when addressing the severity of Shearn's symptoms.
Most strikingly, Shearn's own representations regarding his ability to work support the ALJ's determination. As the ALJ pointed out, Shearn's therapy records indicate that he did not think he was disabled. And Shearn was open to his therapist's suggestion that he look into Job Corps, noting that he appeared hopeful that this could provide him a way out of his house. (Tr. 344). When asked directly by the ALJ if he could perform a small office cleaning job, he first asked, “Would it be minimum wage?” and then answered “Yes . . . Mostly, yes.” (Tr. 37).
On the facts as outlined above, the ALJ was forced to confront the difficult issue of whether, despite Shearn's unwillingness to leave his room and interact socially, the medical evidence and testimony presented showed that he was unable to do so. Accordingly, the ALJ found that, because it appeared Shearn could perform a full range of work with certain social limitations, he had not met the stringent standard for disability set by law. It is the right and responsibility of the ALJ to make such assessments, and we find that substantial evidence supported the ALJ's decision in the instant case. Thus, at bottom, it appears that Shearn is requesting that this Court re-weigh the evidence. This we may not do. See, e.g., Rutherford, 399 F.3d at 552 (quoting Williams v. Sullivan, 970 F.2d 1178, 1182 (3d Cir. 1992) (“In the process of reviewing the record for substantial evidence, we may not ‘weigh the evidence or substitute our own conclusions for those of the fact-finder”')). Because we cannot re-weigh the evidence, and because we find that the ALJ properly articulated that substantial evidence did not support this disability claim, we recommend that the court affirm the ALJ's decision in this case.
In closing, the ALJ's assessment of the evidence in this case complied with the dictates of the law and was supported by substantial evidence. This is all that the law requires, and all that a claimant can demand in a disability proceeding. Thus, notwithstanding the argument that this evidence might have been viewed in a way which would have also supported a different finding, we are obliged to affirm this ruling once we find that it is “supported by substantial evidence, ‘even [where] this court acting de novo might have reached a different conclusion.' ” Monsour Med. Ctr. v. Heckler, 806 F.2d 1185, 1190-91 (3d Cir. 1986) (quoting Hunter Douglas, Inc. v. NLRB, 804 F.2d 808, 812 (3d Cir. 1986)). Accordingly, under the deferential standard of review that applies to appeals of Social Security disability determinations, we find that substantial evidence supported the ALJ's evaluation of this case.
IV. Recommendation
Accordingly, for the foregoing reasons, IT IS RECOMMENDED THAT the decision of the Commissioner be AFFIRMED.
The parties are further placed on notice that pursuant to Local Rule 72.3:
Any party may object to a magistrate judge's proposed findings, recommendations or report addressing a motion or matter described in 28 U.S.C. § 636 (b)(1)(B) or making a recommendation for the disposition of a prisoner case or a habeas corpus petition within fourteen (14) days after being served with a copy thereof. Such party shall file with the clerk of court, and serve on the magistrate judge and
all parties, written objections which shall specifically identify the portions of the proposed findings, recommendations or report to which objection is made and the basis for such objections. The briefing requirements set forth in Local Rule 72.2 shall apply. A judge shall make a de novo determination of those portions of the report or specified proposed findings or recommendations to which objection is made and may accept, reject, or modify, in whole or in part, the findings or recommendations made by the magistrate judge. The judge, however, need conduct a new hearing only in his or her discretion or where required by law, and may consider the record developed before the magistrate judge, making his or her own determination on the basis of that record. The judge may also receive further evidence, recall witnesses or recommit the matter to the magistrate judge with instructions.