Opinion
C. A. 9:21-cv-03390-RMG-MHC
01-06-2023
Karren Spencer, Plaintiff, v. Kilolo Kijakazi,[1] Acting Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
MOLLY H. CHERRY, UNITED STATES MAGISTRATE JUDGE
Plaintiff Karren Spencer (Spencer) filed the complaint in this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the Administrative Law Judge's (ALJ's) final decision denying her claim for disability insurance benefits (DIB) and supplemental security income (SSI) under the Social Security Act (Act). This case was referred to the undersigned for a report and recommendation pursuant to Local Civil Rule 73.02(B)(2)(a) (D.S.C.). For the reasons that follow, the undersigned recommends that the ALJ's decision be remanded for further administrative action.
Citations to the record refer to the page numbers in the Social Security Administration Record. See ECF No. 4.
On October 9, 2018, Spencer applied for DIB and SSI alleging disability as of May 18, 2018. R.pp. 33, 301-17. The State agency responsible for disability determinations denied Spencer's claims initially on June 21, 2019, and upon reconsideration on February 18, 2020. R.pp. 242-49, 253-64.
On August 6, 2020, a telephonic hearing was held before an ALJ, at which Spencer, who was not represented by counsel, and an impartial vocational expert testified. R.pp. 90-147. On December 29, 2020, the ALJ issued a decision finding Spencer not disabled. R.pp. 30-47. On August 12, 2021, the Appeals Council denied Spencer's request for review, making the ALJ's decision final. R.pp. 1-7. This appeal followed.
Because this Court writes primarily for the parties who are familiar with the facts, the Court dispenses with a lengthy recitation of the medical history from the relevant period. To the extent specific records or information are relevant to or at issue in this case, they are addressed within the Discussion section below.
II. APPLICABLE LAW
A. Scope of Review
Jurisdiction of this Court is pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). Under § 405(g), judicial review of a final decision regarding disability benefits is limited to determining (1) whether the factual findings are supported by substantial evidence, and (2) whether the correct legal standards were applied. 42 U.S.C. § 405(g); Walls v. Barnhart, 296 F.3d 287, 290 (4th Cir. 2002) (citing Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990)). Accordingly, a reviewing court must uphold the final decision when “an ALJ has applied correct legal standards and the ALJ's factual findings are supported by substantial evidence.” Brown v. Comm r Soc. Sec. Admin., 873 F.3d 251, 267 (4th Cir. 2017) (internal quotation marks omitted).
“Substantial evidence” is an evidentiary standard that is not high: it is “more than a mere scintilla” and means only “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019). A reviewing court does not reweigh conflicts in evidence, make credibility determinations, or substitute its judgment for that of the ALJ. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). “Where conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the responsibility for that decision falls on the [ALJ].” Id. (alteration in original) (internal quotation marks and citation omitted). However, this limited review does not mean the findings of an ALJ are to be mechanically accepted, as the “statutorily granted review contemplates more than an uncritical rubber stamping of the administrative action.” Howard v. Saul, 408 F.Supp.3d 721, 725-26 (D.S.C. 2019) (quoting Flack v. Cohen, 413 F.2d 278, 279 (4th Cir. 1969)).
B. Social Security Disability Evaluation Process
To be considered “disabled” within the meaning of the Social Security Act, a claimant must show that he has an impairment or combination of impairments which prevent him from engaging in all substantial gainful activity for which he is qualified by his age, education, experience, and functional capacity, and which has lasted or could reasonably be expected to last for a continuous period of not less than twelve months. See 42 U.S.C. § 423. The Social Security Administration established a five-step sequential procedure in order to evaluate whether an individual is disabled for purposes of receiving benefits. See 20 C.F.R. §§ 404.1520, 416.920; see also Mascio v. Colvin, 780 F.3d 632, 634-35 (4th Cir. 2015) (outlining the questions asked in the five-step procedure). The burden rests with the claimant to make the necessary showings at each of the first four steps to prove disability. Mascio, 780 F.3d at 634-35. If the claimant fails to carry his burden, he is found not disabled. Lewis v. Berryhill, 858 F.3d 858, 861 (4th Cir. 2017). If the claimant is successful at each of the first four steps, the burden shifts to the Commissioner at step five. Id.
At the first step, the ALJ must determine whether the claimant has engaged in substantial gainful activity since his alleged disability onset date. 20 C.F.R. §§ 404.1520(b), 416.920(b). At step two, the ALJ determines whether the claimant has an impairment or combination of impairments that meet the regulations' severity and duration requirements. Id. §§ 404.1520(c), 416.920(c). At step three, the ALJ considers whether the severe impairment meets the criteria of an impairment listed in Appendix 1 of 20 C.F.R. part 404, subpart P (the “Listings”) or is equal to a listed impairment. If so, the claimant is automatically eligible for benefits; if not, before moving on to step four, the ALJ assesses the claimant's residual functional capacity (RFC). Id. §§ 404.1520(d), (e), 416.920(d), (e); Lewis, 858 F.3d at 861.
The RFC is “the most the claimant can still do despite physical and mental limitations that affect her ability to work.”Mascio, 780 F.3d at 635 (internal quotation marks and citations omitted).
At step four, the ALJ determines whether, despite the severe impairment, the claimant retains the RFC to perform his past relevant work. 20 C.F.R. §§ 404.1520(e), (f), 416.920(e), (f). If the ALJ finds the claimant capable of performing his past relevant work, he is not disabled. Id. §§ 404.1520(f), 416.920(f). If the exertion required to perform the claimant's past relevant work exceeds his RFC, then the ALJ goes on to the final step.
At step five, the burden of proof shifts to the Social Security Administration to show that the claimant can perform other jobs existing in significant numbers in the national economy, considering the claimant's age, education, work experience, and RFC. Id. §§ 404.1520(g), 416.920(g);Mascio, 780 F.3d at 634-35. Typically, the Commissioner offers this evidence through the testimony of a vocational expert answering hypotheticals that incorporate the claimant's limitations. Mascio, 780 F.3d at 635. “If the Commissioner meets her burden, the ALJ finds the claimant not disabled and denies the application for benefits.” Id.
III. ADMINISTRATIVE FINDINGS
The ALJ employed the statutorily-required five-step sequential evaluation process to determine whether Spencer was disabled from the alleged onset date of May 18, 2018. R.pp. 3342. The ALJ found, in pertinent part:
1. The claimant meets the insured status requirements of the Social Security Act through September 30, 2022.
2. The claimant has not engaged in substantial gainful activity since May 18, 2018, the alleged onset date (20 CFR 404.1571 et seq., and 416.971 et seq.).
3. The claimant has the following severe impairments: avascular necrosis, left hip, S/P remote total hip arthroplasty; and morbid obesity (20 CFR 404.1520(c) and 416.920(c)). The claimant also has the following nonsevere impairments: binocular cataracts; noninsulin-dependent diabetes mellitus with neuropathy and nonproliferative retinopathy; uterine fibroids; hypertension; intermittent palpitations; hypothyroidism; depression; and anxiety.
4. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926).
5. After careful consideration of the entire record, I find the claimant has the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a) and 416.967(a) in that she can lift and carry up to 10 lbs. occasionally and less than 10 lbs. frequently; can stand and walk an aggregate of up to 2 hours and can sit at least 6 hours of an 8-hour workday; can no more than occasionally stoop, balance and climb stairs or ramps, but cannot crawl, crouch, kneel, or climb ladders, ropes, or scaffolds. She should have no required exposure to unprotected heights, vibration, or dangerous machinery.
6. The claimant is capable of performing past relevant work as an Accounting Clerk, DOT 216.482-010, sedentary, SVP 5. This work does not require the performance of work-related activities precluded by the claimant's residual functional capacity (20 CFR 404.1565 and 416.965).
7. The claimant has not been under a disability, as defined in the Social Security Act, from May 18, 2018, through the date of this decision (20 CFR 404.1520(f) and 416.920(f)).R.pp. 35-41.
IV. DISCUSSION
Spencer argues three main points of error warrant remand. First, Spencer argues that the ALJ erred in finding Spencer could do her past relevant work. ECF No. 5 at 10-18. Second, Spencer argues that the ALJ erred in finding several of her medically determinable impairments non-severe. ECF No. 5 at 18-21. Third, Spencer maintains that the ALJ did not adequately explain his reasoning regarding Spencer's RFC. ECF No. 5 at 22-30.
The common thread that runs through all of Spencer's arguments is that the ALJ's decision lacks adequate explanation, which leaves this Court to guess at why the ALJ made the determinations he did. On this point, the Court is constrained to agree. Specifically, for the reasons that follow, the Court finds that the ALJ's determinations with regard to Spencer's vision are not subject to meaningful review such that remand is warranted.
Spencer's arguments on the various issues-and Defendant Commissioner's arguments in response-are largely repetitive, generally focusing on the same facts and points. The Court has reframed the arguments to avoid unnecessary repetition. What all these arguments touch on, and what ultimately warrants remand in this case, is the lack of adequate explanation by the ALJ, leaving the Court to guess at why the ALJ did what he did.
A. Spencer's vision
Spencer argues that the ALJ's assessment of Spencer's vision was flawed. The undersigned agrees. The ALJ's errors began at step two and were not cured in the subsequent steps of the evaluation process.
At step two of the sequential evaluation process, an ALJ must determine whether a claimant has a medically determinable impairment or a combination of impairments that is severe. 20 C.F.R. §§ 404.1520(c), 416.920(c). A “severe” impairment is one that “significantly limits [a claimant's] physical or mental ability to do basic work activities.” Id. §§ 404.1520(c), 416.920(c). “Basic work activities” are “the abilities and aptitudes necessary to do most jobs,” examples of which include “physical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling.” Id. §§ 404.1522(b), 416.922(b). An ALJ must consider all of a claimant's medically determinable impairments, even those that are not severe, in the RFC assessment. Id. §§ 404.1545(a)(2), 416.945(a)(2). An inadequate analysis of impairments at step two may be rendered harmless if the ALJ later considers those impairments in subsequent steps. See Jenkins v. Colvin, No. 6:13-cv-02021-DCN, 2015 WL 1311694, at *4 (D.S.C. Mar. 24, 2015) (“Courts in this district have determined that an ALJ's failure to consider an impairment at step two is harmless when the ALJ considers the impairment in subsequent steps of its analysis.” (collecting cases)).
At the administrative hearing, the ALJ asked Spencer her primary reason for being unable to work, aside from her history of hip replacement and subsequent problems related to her hip condition. R.p. 129. Spencer responded that her “number two” problem was her vision, and that she was “partially going blind in [her] left eye . . . or am blind” because she had developed cataracts. R.p. 129. The ALJ asked if the medical provider had considered surgery for the cataracts, and Spencer explained that surgery was needed but that it had been put off until she could get her diabetic condition under better control. R.p. 130.
At step two, the ALJ's discussion of Spencer's non-severe impairments was two sentences in length:
As for the physical non-severe impairments, binocular cataracts; non-insulindependent diabetes mellitus with neuropathy and non-proliferative retinopathy; uterine fibroids; hypertension; intermittent palpitations; and hypothyroidism, although they may have been medically diagnosed, there is no evidence that these impairments have caused more than a minimal impact on the claimant's ability to perform work-related functions. I considered all of the claimant's medically determinable impairments, including those that are not severe, when assessing the claimant's residual functional capacity.R.p. 36. Considering that Spencer specifically testified that her “number two” problem was that she was going blind, the ALJ's brief mention of her cataracts and retinopathy-sandwiched among all of her other non-severe impairments-is notable. See R.p. 129. Quite plainly, the two conclusory sentences at step two are not sufficient for this Court to review the ALJ's reasoning as to why he determined that Spencer's vision caused no more than a minimal impact on her ability to perform work-related functions. Cf. Robinson v. Colvin, No. 4:13-CV-00823-DCN, 2014 WL 4954709, at *14 (D.S.C. Sept. 29, 2014) (“In his opinion, the ALJ thoroughly addressed his reasons for finding Plaintiff's depression to be non-severe[.]” (emphasis added)). This was error.
Nevertheless, the ALJ's inadequate analysis of Spencer's vision impairments at step two may be rendered harmless if the ALJ adequately discussed it elsewhere in his decision. See Jenkins, No. 6:13-cv-02021-DCN, 2015 WL 1311694, at *4. Indeed, Defendant Commissioner argues this point, maintaining (1) that the ALJ subsequently considered Spencer's “statements that her cataracts greatly affected her vision and she was planning on surgery in the future,” (2) the ALJ also subsequently considered “the conflicting opinions of two of [Spencer's] treating providers, Joshua Robinson, M.D., and Shawn Iverson, D.O,” and finally that (3) the ALJ's decision is nevertheless supported by substantial evidence. See ECF No. 6 at 14, 13-20. The undersigned disagrees and addresses each point in turn.
1. The ALJ's later discussion of Spencer's hearing testimony was not sufficient to cure the error at step two.
Defendant Commissioner's first point is unpersuasive. Although the ALJ later acknowledged Spencer's statements about her cataracts and possible surgery when summarizing the hearing testimony, this brief mention lacks any real discussion or analysis of Spencer's vision problems. See R.p. 38. Merely noting hearing testimony later during the RFC determination with no analysis does not save the ALJ's inadequate discussion of this impairment earlier at step two. See Kinsey v. Berryhill, No. 8:16-CV-03682-BHH-JDA, 2018 WL 3133426, at *10 (D.S.C. Jan. 29, 2018) (“An inadequate step two analysis can be harmless and constitute non-reversible error when an impairment is discussed and analyzed elsewhere in a decision.” (second emphasis added)), report and recommendation adopted, No. CV 8:16-3682-BHH, 2018 WL 1443952 (D.S.C. Mar. 22, 2018). Indeed, the ALJ ultimately found that Spencer's vision did not significantly limit Spencer's abilities to perform work related functions, and thus did not account for these non-severe impairments in Spencer's RFC. Rehashing Spencer's testimony-where she stated her cataracts “greatly affected” her vision-does not give this Court any insight as to why the ALJ decided to not account for this non-severe limitation at all in the RFC. See R.p. 38. As noted above, it is the lack of discussion here that leaves the Court guessing. SeeMascio, 780 F.3d 636-37 (noting remand may be appropriate when courts are left to guess at how the ALJ arrived at their conclusions and meaningful review is frustrated).
2. The ALJ's evaluation of medical opinion evidence did not cure the error at step two.
Defendant Commissioner's second position suggests that the ALJ's discussion of Spencer's visual impairments-which occurred while evaluating medical opinion evidence-is substantial evidence sufficient to show that the ALJ adequately considered these impairments and properly determined that Spencer's vision did not cause any functional limitations. See ECF No. 6 at 14-17, 18-19; see also Jenkins, No. 6:13-cv-02021-DCN, 2015 WL 1311694, at *4 (“Courts in this district have determined that an ALJ's failure to consider an impairment at step two is harmless when the ALJ considers the impairment in subsequent steps of its analysis.” (collecting cases)). In this context, the ALJ's discussion of the medical opinion evidence involving Spencer's visual impairments must be such that “a reasonable mind might accept as adequate to support a conclusion.” See Biestek, 139 S.Ct. at 1154. The ALJ's conclusion here being that Spencer's visual impairments did not significantly limit her abilities to perform work related functions and did not need to be accounted for in Spencer's RFC. However, a closer look at Doctors Robinson's and Iverson's opinions, and the ALJ's evaluation of them, does not render the ALJ's error at step two harmless.
Neither party explicitly argues that the ALJ's persuasiveness evaluations of the medical opinions was done in error under the new regulations. See generally 20 C.F.R. §§ 404.1520c, 416.920c; Revisions to Rules Regarding the Evaluation of Medical Evidence, 82 FR 5844-01, 2017 WL 168819 (Jan. 18, 2017), corrected by 82 Fed.Reg. 15132-01, 2017 WL 1105368 (Mar. 27, 2017). Thus, the undersigned passes no judgment on whether the ALJ conducted a proper persuasiveness evaluation of the medical opinions under the revised regulations. The Court's focus is whether the ALJ's discussion of Spencer's visual impairments-done while evaluating medical opinion evidence-was sufficient to render the ALJ's error at step two harmless.
On March 21, 2019, Dr. Robinson conducted an eye examination of Spencer and concluded that there was evidence of moderate non-proliferative diabetic retinopathy. R.p. 799. Dr. Robinson explained to Spencer that this could be a major cause of vision loss and stressed the importance of good blood glucose and blood pressure measurements. R.p. 799. He also found age-related nuclear cataracts bilaterally, but stated that they did not appear to be “affecting the patient's quality of life to a significant degree.” R.p. 799. He recommended observation and informed Spencer that surgery may be needed if the cataracts began to affect her vision to a significant degree. R.pp. 799-800.
On June 2, 2020, Dr. Iverson provided a statement, which noted that Spencer had an eye examination in April 2020. R.p. 929. Dr. Iverson noted that Spencer had severe cataracts in both eyes. R.p. 929. He stated that Spencer has “low vision in both eyes due to cataracts and is functionally blind in various lightening [sic] situations due to glare from lights” caused by her cataracts. R.p. 929. Dr. Iverson found Spencer to have 20/100 vision overall and 20/400 in the right eye. R.p. 929. Dr. Iverson stated that Spencer's cataracts caused her functional limitations, but he did not elaborate on the extent of her functional limitations. R.p. 929. He recommended cataract surgery as the “only way to improve vision at this point.” R.p. 929.
In evaluating the opinions of Doctors Robinson and Iverson, the ALJ found:
The opinion of Joshua Robinson, M.D. is persuasive because of the nature and extent of his specialized treatment of the claimant and the consistency of his opinion
with the medical record as a whole. In March 2019, Dr. Robinson conducted an eye examination of the claimant and determined that although the claimant had an age-related nuclear cataract in the bilateral eyes, they did not appear to be affecting the claimant's quality of life to a significant degree (4F). Further, despite the impairment, no surgical procedures, but rather simple observation, was recommended at that point. Such a conclusion is compatible with the claimant's recent work history at Publix and the census work to which she testified, as well as her ability to drive a motor vehicle.
The opinion of Shawn Iverson, DO is not persuasive because although he has a treating relationship with the claimant, his opinion is inconsistent with the medical record as a whole. Dr. Iverson determined the claimant's vision was 20/200 and she was functionally blind in various lighting situations due to glare (12F). Dr. Iverson found that the claimant had severe binocular cataracts and needed surgery to harvest them (10F); however, this opinion regarding her cataracts limited her vision is materially inconsistent with the exam and findings of Dr. Joshua Robinson of the Palmetto Retina Center in March 2019, when he concluded they were not causing any significant limitations and should just be watched (4F). Similarly, that opinion is inconsistent with the claimant's ability to work part-time at Publix and to drive a motor vehicle.R.p. 40.
At first blush, the ALJ's evaluation of these two opinions appears to be reasonable. As Defendant Commissioner suggests, this could serve as substantial evidence to (1) support the ALJ's ultimate conclusion that Spencer's cataracts did not cause any functional limitations and (2) simultaneously cure the ALJ's lack of discussion of Spencer's visual impairments at step two. However, as Spencer persuasively points out, the ALJ's reliance on Dr. Robinson's March 2019 opinion as a basis to discount Dr. Iverson's June 2020 opinion (and ultimately conclude no functional limitations were warranted) makes little sense when considering the progressive nature of Spencer's condition. See ECF No. 5 at 14-15. As Spencer argues, and Defendant Commissioner does not dispute, someone with severe cataracts in both eyes can see a significant decrease in their visual functioning over the course of a year or more, and this is particularly true for someone with diabetes (like Spencer), which can accelerate the progression of vision loss caused by cataracts. ECF No. 5 at 14. Thus, the ALJ's reliance on Dr. Robinson's earlier-in-time examination raises questions that require further explanation. See Moore v. Colvin, No. 1:14CV992, 2016 WL 1060261, at *4 (M.D. N.C. Mar. 15, 2016) (“Where, as here, evidence indicates that Plaintiff's impairment worsened during the relevant timeframe, there is a question whether substantial evidence supports the ALJ's decision to discredit Dr. Jonas' 2013 opinion in favor of evidence or opinions from 2009 through early 2011.”), report and recommendation adopted, No. 1:14CV992, 2016 WL 11573007 (M.D. N.C. Apr. 26, 2016).
These questions are not answered by the ALJ's decision, requiring remand. Indeed, what is particularly perplexing is that the ALJ did not even rely on the most recent opinion of Dr. Robinson. As noted above, the ALJ's reasons for discounting Spencer's allegations of vision loss were based upon Dr. Robinson's notation that (1) Spencer's cataracts did not appear to be affecting her quality of life to a significant degree and (2) no surgical procedure, but rather “simple observation,” was recommended at that point in time. R.p. 40. These are also the two main reasons the ALJ gave for finding Dr. Iverson's opinion unpersuasive. R.p. 40. However, Dr. Robinson conducted a subsequent examination of Spencer in September 2019, wherein his opinion on these two points completely flipped:
There is evidence of moderate non-proliferative diabetic retinopathy on today's examination. I have reviewed the pathogenesis of this condition and that it can be a major cause of vision loss....The patient had a visually significant cataract that is affecting the patient's quality of life. I recommend referral for cataract surgery evaluation.R.p. 927 (emphasis added). Thus, the ALJ's reliance on Dr. Robinson's March 2019 examination as a basis to discount Spencer's allegations of vision loss and Dr. Iverson's opinion makes little sense, especially when the record contains a more recent opinion from Dr. Robison in September of 2019 that supports-rather than contradicts-both Spencer's allegations and Dr. Iverson's opinion. This omission strikes the undersigned as impermissible cherry-picking. See Lewis, 858 F.3d at 869 (“An ALJ has the obligation to consider all relevant medical evidence and cannot simply cherrypick facts that support a finding of nondisability while ignoring evidence that points to a disability finding.” (quoting Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010))). Upon review, the undersigned is left to guess at why the ALJ made the determinations he did. See Mascio, 780 F.3d 636-37 (noting remand may be appropriate when courts are left to guess at how the ALJ arrived at their conclusions and meaningful review is frustrated).
The ALJ also cited Spencer's ability to work part-time as a cashier and drive a car as reasons to discount Spencer's allegations of vision loss and Dr. Iverson's opinion. However, Spencer testified she drove only occasionally, and her mother typically drove. R.p. 114. Further, as argued by Spencer, neither of these activities would require the fine visual acuity required of work as an accounting clerk (reading documents with regular and small print, looking at computer monitors much of the day). Thus, these cited reasons, standing alone without further explanation, do not serve as substantial evidence capable of saving the ALJ's opinion where the Court is still is left to guess at why the ALJ made the determinations he did. See Mascio, 780 F.3d 636-37; see also generally Brown v. Comm'r Soc. Sec. Admin., 873 F.3d 251, 269-70 (4th Cir. 2017) (noting that merely listing a claimant's activities does not automatically equate to substantial evidence if those activities were “minimal daily activities” qualified by the claimant in ways that do not contradict claims of disability).
3. Substantial evidence does not support the ALJ's determination.
Finally, Defendant Commissioner generally argues that the ALJ's decision is nevertheless supported by substantial evidence. See ECF No. 6 at 13-20. Defendant Commissioner argues that when Spencer completed a Function Report in September 2019, she did not cite to vision problems as a condition limiting her work. ECF No. 6 at 16. Defendant Commissioner further highlights Spencer's administrative hearing testimony and maintains that Spencer's argument that her cataracts would prevent her from past relevant work in accounting is in direct conflict with her own hearing testimony that she could perform accounting jobs and was looking for such jobs. ECF No. 16 at 6. Defendant Commissioner also argues Dr. Iverson's opinion was inconsistent with Spencer's ability to read on a daily basis and Spencer's concessions at the administrative hearing that she could perform her past relevant work in accounting if she could find such a job. ECF No. 6 at 17.
The undersigned is unpersuaded. It may very well be that the ALJ's decision to discount Spencer's allegations of vision loss and Dr. Iverson's opinion were in part based on this evidence highlighted by Defendant Commissioner. But, the ALJ's decision contains no such discussion, and this Court “cannot accept post-hoc rationalizations not contained within the ALJ's decision.” Hilton v. Astrue, No. CA 6:10-2012-CMC, 2011 WL 5869704, at *4 (D.S.C. Nov. 21, 2011); see also Bray v. Comm'r of Soc. Sec. Admin., 554 F.3d 1219, 1225 (9th Cir. 2009) (“Long-standing principles of administrative law require us to review the ALJ's decision based on the reasoning and factual findings offered by the ALJ-not post hoc rationalizations that attempt to intuit what the adjudicator may have been thinking.” (first emphasis added)). Remand is, therefore, warranted.
B. Remaining allegations of error
Spencer also argues errors regarding her past relevant work and the ALJ's explanations regarding her RFC. See ECF No. 5 at 10-18, 22-30. With respect to the RFC, she argues that (1) the ALJ did not properly evaluate her vision problems when formulating the RFC and that (2) the ALJ committed the same error highlighted in Dowling v. Comm'r of Soc. Sec. Admin., 986 F.3d 377, 387 (4th Cir. 2021) by not properly performing a function-by-function analysis of her hip and lower extremity pain.
Because the Court has determined that the error in the ALJ's assessment of Spencer's visual impairments warrants remand, the Court declines to further address these remaining claims of error. Upon remand however, the ALJ should take such claims of error into consideration. With respect to any remaining claims of error, the ALJ will be able to reconsider and re-evaluate the evidence in toto as part of the reconsideration. See Hancock v. Barnhart, 206 F.Supp.2d 757, 763 n.3 (W.D. Va. 2002) (noting the ALJ's prior decision has no preclusive effect, as it is vacated, and the new hearing is conducted de novo).
With regard to the RFC determination, it bears repeating that although the ALJ summarized Spencer's hearing testimony and the treatment notes of Doctors Robinson and Iverson, there is no meaningful discussion connecting this evidence to the ALJ's ultimate decision to omit any restrictions in the RFC. See Thomas v. Berryhill, 916 F.3d 307, 311 (4th Cir. 2019) (“[O]ur precedent makes clear that meaningful review is frustrated when an ALJ goes straight from listing evidence to stating a conclusion.”); Woods v. Berryhill, 888 F.3d 686, 694 (4th Cir. 2018) (noting an ALJ must “build an accurate and logical bridge” from the cited evidence to the ALJ's ultimate conclusion (quotingMonroe v. Colvin, 826 F.3d 176, 189 (4th Cir. 2016))). Additionally, the Court notes that although analysis of a claimant's symptoms under SSR 16-3p “is relevant to the RFC evaluation,” it cannot be used as a substitute for the RFC assessment. See Dowling v. Comm'r of Soc. Sec. Admin., 986 F.3d 377, 387 (4th Cir. 2021) (finding error where the ALJ failed to cite to SSR 96-8p and did not indicate the RFC assessment was rooted in a function-by-function analysis, and noting “an RFC assessment is a separate and distinct inquiry from a symptom evaluation, and the ALJ erred by treating them as one and the same”). All of these points and accompanying case law should be taken into consideration on remand.
V. CONCLUSION
It is recommended that the decision of the Commissioner be REVERSED and REMANDED pursuant to sentence four of 42 U.S.C. § 405(g) for further administrative review.
Notice of Right to File Objections to Report and Recommendation
The parties are advised that they may file specific written objections to this Report and Recommendation with the District Judge. Objections must specifically identify the portions of the Report and Recommendation to which objections are made and the basis for such objections. “[I]n the absence of a timely filed objection, a district court need not conduct a de novo review, but instead must ‘only satisfy itself that there is no clear error on the face of the record in order to accept the recommendation.'” Diamond v. Colonial Life & Acc. Ins. Co., 416 F.3d 310 (4th Cir. 2005) (quoting Fed.R.Civ.P. 72 advisory committee's note).
Specific written objections must be filed within fourteen (14) days of the date of service of this Report and Recommendation. 28 U.S.C. § 636(b)(1); Fed.R.Civ.P. 72(b); see Fed.R.Civ.P. 6(a), (d). Filing by mail pursuant to Federal Rule of Civil Procedure 5 may be accomplished by mailing objections to:
Robin L. Blume, Clerk
United States District Court
Post Office Box 835
Charleston, South Carolina 29402
Failure to timely file specific written objections to this Report and Recommendation will result in waiver of the right to appeal from a judgment of the District Court based upon such Recommendation. 28 U.S.C. § 636(b)(1); Thomas v. Arn, 474 U.S. 140 (1985); Wright v. Collins, 766 F.2d 841 (4th Cir. 1985); United States v. Schronce, 727 F.2d 91 (4th Cir. 1984).