Opinion
C/A No. 0:19-1819-RMG-PJG
07-10-2020
Nancy Long Suddeth, Plaintiff, v. Andrew Saul, Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
This social security matter is before the court for a Report and Recommendation pursuant to Local Civil Rule 83.VII.02 (D.S.C.). The plaintiff, Nancy Long Suddeth, brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) to obtain judicial review of a final decision of the defendant, Commissioner of Social Security ("Commissioner"), denying her claims for Disability Insurance Benefits ("DIB"). Having carefully considered the parties' submissions and the applicable law, the court concludes that the Commissioner's decision should be reversed and that the case should be remanded for further consideration as explained below.
SOCIAL SECURITY DISABILITY GENERALLY
Under 42 U.S.C. § 423(d)(1)(A) and (d)(5), as well as pursuant to the regulations formulated by the Commissioner, the plaintiff has the burden of proving disability, which is defined as an "inability to do 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." 20 C.F.R. § 404.1505(a); see also Blalock v. Richardson, 483 F.2d 773 (4th Cir. 1973). The regulations require the Administrative Law Judge ("ALJ") to consider, in sequence:
(1) whether the claimant is engaged in substantial gainful activity;20 C.F.R. § 404.1520(a)(4). If the ALJ can make a determination that a claimant is or is not disabled at any point in this process, review does not proceed to the next step. Id.
(2) whether the claimant has a "severe" impairment;
(3) whether the claimant has an impairment that meets or equals the requirements of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 ("the Listings"), and is thus presumptively disabled;
(4) whether the claimant can perform her past relevant work; and
(5) whether the claimant's impairments prevent her from doing any other kind of work.
The court observes that effective August 24, 2012, ALJs may engage in an expedited process which permits the ALJs to bypass the fourth step of the sequential process under certain circumstances. 20 C.F.R. § 404.1520(h).
Under this analysis, a claimant has the initial burden of showing that she is unable to return to her past relevant work because of her impairments. Once the claimant establishes a prima facie case of disability, the burden shifts to the Commissioner. To satisfy this burden, the Commissioner must establish that the claimant has the residual functional capacity, considering the claimant's age, education, work experience, and impairments, to perform alternative jobs that exist in the national economy. 42 U.S.C. § 423(d)(2)(A); see also McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983); Hall v. Harris, 658 F.2d 260, 264-65 (4th Cir. 1981); Wilson v. Califano, 617 F.2d 1050, 1053 (4th Cir. 1980). The Commissioner may carry this burden by obtaining testimony from a vocational expert. Grant v. Schweiker, 699 F.2d 189, 192 (4th Cir. 1983).
ADMINISTRATIVE PROCEEDINGS
In February 2016, Suddeth applied for DIB, alleging disability beginning October 17, 2013. Suddeth's application was denied initially and upon reconsideration, and she requested a hearing before an ALJ. A video hearing was held on May 16, 2018, at which Suddeth appeared and testified and was represented by Timothy A. Clardy, Esquire. After hearing testimony from Suddeth's husband as well as from a vocational expert, the ALJ issued a decision on September 19, 2018 finding that Suddeth was not disabled from October 17, 2013 through the date of the decision. (Tr. 15-32.)
Suddeth was born in 1979 and was thirty-four years old on her alleged disability onset date. She has a General Education Diploma ("GED") and a general business associates degree, and past relevant work experience as an account clerk at a metal company, a business specialist at a staffing agency, a data entry clerk at a graveyard, and a bank teller. (Tr. 197-98.) Suddeth alleged disability due to fibromyalgia, chronic fatigue, carpal tunnel syndrome, sleep apnea, arthritis in her hip and back, a bulging disc, depression, anxiety, and insomnia. (Tr. 196.)
In applying the five-step sequential process, the ALJ found that Suddeth had not engaged in substantial gainful activity since her alleged onset date of October 17, 2013. The ALJ also determined that Suddeth's migraine headaches, obesity, fibromyalgia, chronic fatigue syndrome, obsessive compulsive disorder, and major depressive disorder were severe impairments. However, the ALJ found that Suddeth did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (the "Listings"). The ALJ further found that Suddeth retained the residual functional capacity to
perform sedentary work as defined in 20 CFR 404.1567(a) except the claimant can never climb ladders, ropes, and scaffolds; she can occasionally balance, stoop,
kneel, crouch, and crawl; she can occasionally climb ramps or stairs; she should avoid concentrated exposure to workplace hazards such as unprotected heights and moving machinery; in addition, she can perform simple, routine tasks for two-hour blocks of time with normal rest breaks during an eight-hour workday.(Tr. 22-23.) The ALJ found that Suddeth was unable to perform any past relevant work, but that considering Suddeth's age, education, work experience, and residual functional capacity, there were jobs that existed in significant numbers in the national economy that Suddeth could perform. Accordingly, the ALJ found that Suddeth was not disabled from October 17, 2013 through the date of the decision.
The Appeals Council denied Suddeth's request for review on June 12, 2019, thereby making the decision of the ALJ the final action of the Commissioner. (Tr. 1-5.) This action followed.
STANDARD OF REVIEW
Pursuant to 42 U.S.C. § 405(g), the court may review the Commissioner's denial of benefits. However, this review is limited to considering whether the Commissioner's findings "are supported by substantial evidence and were reached through application of the correct legal standard." Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996); see also 42 U.S.C. § 405(g); Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). Thus, the court may review only whether the Commissioner's decision is supported by substantial evidence and whether the correct law was applied. See Brown v. Comm'r Soc. Sec. Admin., 873 F.3d 251, 267 (4th Cir. 2017); Myers v. Califano, 611 F.2d 980, 982 (4th Cir. 1980). "Substantial evidence" means "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance." Craig, 76 F.3d at 589; see also Pearson v. Colvin, 810 F.3d 204, 207 (4th Cir. 2015). In reviewing the evidence, the court may not "undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]." Craig, 76 F.3d at 589; see also Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Accordingly, even if the court disagrees with the Commissioner's decision, the court must uphold it if it is supported by substantial evidence. Blalock, 483 F.2d at 775.
ISSUES
Suddeth raises the following issues for this judicial review:
A. Treating psychiatrist Dr. Jacobs. A treating doctor's opinion is ordinarily entitled to more weight than other evidence. The ALJ gave "little weight" to Dr. Jacobs's opinion, but the ALJ's reasons are contrary to the record and the law. Is reversal required where the ALJ does not show a good reason for rejecting the treating specialist's opinion?(Pl.'s Br., ECF No. 13.)
B. Treating primary care Dr. Hall. A treating doctor's opinion is ordinarily entitled to more weight than other evidence. The ALJ gave "little weight" to Dr. Hall's opinion, but the ALJ's reasons are contrary to the record and the law. Should an ALJ decision be reversed where the ALJ does not show a good reason for rejecting the treating doctor's opinion?
C. Credibility, RFC. An ALJ's credibility and RFC reasoning must include an accurate, logical explanation why the evidence supports his conclusions. The ALJ's conclusions lack supporting substantial evidence, and the ALJ disregarded important evidence supporting the testimony of Suddeth and her husband. Should an ALJ decision [] be reversed where the ALJ does not reasonably explain his conclusions in light of the evidence?
DISCUSSION
The court notes that numerous social security regulations and social security rulings (SSRs) have changed effective March 27, 2017. However, these changes specifically state that they are applicable to claims filed on or after March 27, 2017. See, e.g., 20 C.F.R. §§ 404.1513, 404.1527. Because the instant claim was filed before that time, all references in the instant Report and Recommendation are to the prior versions of the regulations and SSRs in effect at the time Suddeth's application for benefits was filed, unless otherwise specified.
Although Suddeth raises several issues on appeal, for the reasons that follow the court finds that remand is required to properly consider and assess the opinion evidence from Suddeth's treating sources, Dr. David Jacobs and Dr. Russell Hall. Specifically, upon careful review of the parties' arguments, the ALJ's decision as a whole, and the record, the court is simply unable to determine whether the ALJ's decision is supported by substantial evidence.
The law applicable to Suddeth's application provides that regardless of the source, the Commissioner will evaluate every medical opinion received. 20 C.F.R. § 404.1527(c). Typically, the Social Security Administration accords greater weight to the opinion of treating medical sources because treating physicians are best able to provide "a detailed, longitudinal picture" of a claimant's alleged disability. See id. However, "the rule does not require that the testimony be given controlling weight." Hunter v. Sullivan, 993 F.2d 31, 35 (4th Cir. 1992) (per curiam). Instead, a treating physician's opinion is evaluated and weighed "pursuant to the following non-exclusive list: (1) whether the physician has examined the applicant, (2) the treatment relationship between the physician and the applicant, (3) the supportability of the physician's opinion, (4) the consistency of the opinion with the record, and (5) whether the physician is a specialist." Johnson v. Barnhart, 434 F.3d 650, 654 (4th Cir. 2005) (citing 20 C.F.R. § 404.1527). Any other factors that may support or contradict the opinion should also be considered. 20 C.F.R. § 404.1527(c)(6). In the face of "persuasive contrary evidence," the ALJ has the discretion to accord less than controlling weight to such an opinion. Mastro v. Apfel, 270 F.3d 171, 178 (4th Cir. 2001). Further, "if a physician's opinion is not supported by clinical evidence or if it is inconsistent with other substantial evidence, it should be accorded significantly less weight." Id. (quoting Craig, 76 F.3d at 590).
At issue here are opinions from Dr. Jacobs, Suddeth's treating psychiatrist, and Dr. Hall, Suddeth's treating primary care doctor. The ALJ summarized these opinions in detail; however, the ALJ provided very little actual analysis in discounting these opinions. Specifically, the ALJ's evaluation of these opinions consists of the following:
David Jacobs, M.D., of SC Research Group, the claimant's treating psychiatrist, completed a mental status questionnaire on March 6, 2018 (Exhibit 12F). Dr. Jacobs noted the claimant could frequently follow work rules, use judgment, and function independently. She could occasionally relate to co-workers, deal with the public, interact with supervisors, deal with work stresses, and maintain attention and concentration. She could occasionally understand remember and carry out complex job instructions. She could frequently understand, remember, and carry out simple job instructions and detailed, but not complex, job instructions. She could occasionally relate predictably in social situations, and frequently maintain personal appearance, behave in an emotionally stable manner, and demonstrate reliability. The claimant would exceed the number of usual breaks in an eight-hour day; her mental impairment would interfere with the completion of an 8-hour day; and, she would be absent from work about two days per month (Exhibit 12F). I give little weight to this opinion, as it is internally inconsistent. Dr. Jacobs notes occasional limitations, but then notes that she would be absent two days each month. His medical records note that her medications had helped and she had even less fibromyalgia pain (Exhibit 13F). This statement is not consistent with the amount of limitations to which he opined.(Tr. 29-30.)
Russell Hall, M.D., of Internal Medicine of Piedmont, the claimant's treating physician, completed a physician's questionnaire on April 30, 2018 (Exhibit 15F). Dr. Hall stated that her diagnoses were fibromyalgia and depression (treated by her psychiatrist). She had constant pain from 3-8/10. He stated that medications for her fibromyalgia had been ineffective. The claimant's pain was constantly severe enough to interfere with her attention and concentration. She was capable of low stress jobs. She could walk 2 blocks; she could sit for one hour; she could stand for 45 minutes at a time; and she could stand or walk for less than two hours daily. The claimant needed to be able to shift at will. She would need to take unscheduled breaks. The claimant did not need to use an assistive device. She could frequently lift 10 pounds, but never 20 pounds; she could frequently look down, turn her head, look up, and hold her head in a static position; she could never climb ladders; she could occasionally twist, stoop, crouch, or climb stairs. In addition, she would be absent more than four days a month (Exhibit 15F). I give little weight to this opinion. Dr. Hall's records note that she is doing well (Exhibit 9F). That statement does not correlate to a finding of disability.
The parties agree that Exhibit 9F consist of treatment records from Dr. Bret Warner, Suddeth's neurologist.
Upon review of the record and the parties' briefs, the court is unable to determine whether the ALJ's evaluation of this evidence is supported by substantial evidence. Although the ALJ appears to have considered the requisite factors in evaluating this evidence, it is unclear whether the ALJ's application of some of these factors is supported by substantial evidence. The ALJ properly observed the doctors' treatment relationships and specialties; however, the ALJ's summary determinations that the opinions are inconsistent with or unsupported by the record renders the court, in this particular case, unable to determine whether the ALJ's decision is supported by substantial evidence. See Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (noting that "remand is necessary" because the court is "left to guess [at] how the ALJ arrived at his conclusions"). For example, it is unclear how Dr. Jacobs's opinion of occasional limitations in certain areas is internally inconsistent with his opinion that Suddeth would be absent two days each month. The ALJ points to records indicating that Suddeth's "medications had helped and she had even less fibromyalgia pain" and notes that Suddeth "is doing well." (Tr. 29, 30.) In response to Suddeth's arguments, the Commissioner points to evidence in the record that may support discounting aspects of these opinions; however, Suddeth is able to point to contrary evidence in the record that may support crediting the opinion evidence and indicating that Suddeth's conditions wax and wane. (See Pl.'s Br. at 13-15, 18-19, ECF No. 13 at 16-18, 21-22; see also Pl.'s Index to Med. Rec., ECF No. 13-1); see also Lewis v. Berryhill, 858 F.3d 858, 869 (4th Cir. 2017) ("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)). The ALJ's cursory analysis of these factors when ample contradictory evidence exists without an explanation as to why that evidence was not credited renders the court unable to determine whether the ALJ's evaluation of the opinion evidence is supported by substantial evidence, and meaningful review is frustrated. See 20 C.F.R. § 404.1527(c); Mascio, 780 F.3d at 636-37 (holding remand may be appropriate when the courts are left to guess at how the ALJ arrived at the conclusions and meaningful review is frustrated); see also Monroe, 826 F.3d at 189 (remanding where the ALJ failed to "build an accurate and logical bridge from the evidence to his conclusion") (citation omitted); cf. Mastro, 270 F.3d at 178 (stating that "if a physician's opinion is not supported by clinical evidence or if it is inconsistent with other substantial evidence, it should be accorded significantly less weight") (internal quotation marks and citation omitted).
Thus, the court is simply unable to conduct a meaningful judicial review of the ALJ's decision. Therefore, upon review of the parties' arguments, the record in the matter, and in accordance with the above discussed law, the court is constrained to recommend that this matter be remanded for further consideration and discussion of the opinion evidence.
The court expresses no opinion as to whether further consideration of the opinion evidence by the ALJ should necessarily lead to a finding that the opinions at issue are entitled to additional weight or that Suddeth is ultimately entitled to benefits. Further analysis and discussion may well not change the ALJ's conclusion on these points.
In light of the court's recommendation that this matter be remanded for further consideration, the court need not address Suddeth's remaining argument, as it may be rendered moot on remand. See Boone v. Barnhart, 353 F.3d 203, 211 n.19 (3d Cir. 2003) (remanding on other grounds and declining to address claimant's additional arguments). Moreover, if necessary, Suddeth may present his remaining argument concerning the ALJ's alleged errors on remand.
RECOMMENDATION
Based on the foregoing, the court recommends that the Commissioner's decision be reversed pursuant to sentence four of 42 U.S.C. § 405(g) and that the case be remanded to the Commissioner for further consideration as discussed above. July 10, 2020
Columbia, South Carolina
/s/_________
Paige J. Gossett
UNITED STATES MAGISTRATE JUDGE
The parties' attention is directed to the important notice on the next page.
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
901 Richland Street
Columbia, South Carolina 29201
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).