Opinion
EP-22-CV-00349-FM-MAT
02-21-2024
MONICA VASQUEZ, Plaintiff, v. MARTIN O'MALLEY, COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION[1] Defendant.
REPORT AND RECOMMENDATION
MIGUEL A. TORRES, UNITED STATES MAGISTRATE JUDGE
Plaintiff Monica Vasquez (“Plaintiff”) appeals from a decision of the Acting Commissioner of the Social Security Administration (“Commissioner”) denying her claim for supplemental security income (“SSI”) under Title XVI of the Social Security Act. On October 3, 2022, Senior United States District Judge Frank Montalvo referred this case to the undersigned for review and recommendation pursuant to 28 U.S.C. § 636 and Appendix C to the Local Rules of the United States District Court for the Western District of Texas. For the following reasons, the Court recommends that the Commissioner's decision be AFFIRMED.
I. BACKGROUND & PROCEDURAL HISTORY
Plaintiff is 42 years old and, in the past, worked as a retail greeter and pawn broker. Pl.'s Br. 4, ECF No. 19. On July 10, 2020, Plaintiff filed a Title XVI application for SSI. Tr. of Admin. R. at 18 [hereinafter, “Tr.”], ECF No. 14. In her application, Plaintiff alleged her disability commenced on May 6, 2020. Id. at 18. She claimed disability due to suffering from jackhammer esophagus, a rare disorder of esophageal functioning. Pl.'s Br. at 5-6. On October 29, 2020, Plaintiff's claims were denied, and again upon reconsideration on January 26, 2021. Tr. at 18. Administrative Law Judge (“ALJ”) Kathryn Preston held a hearing by telephone on October 14, 2021, and later issued a decision denying Plaintiff's claims on February 1, 2022. Tr. at 18-27. Plaintiff requested review of the ALJ's decision, which was denied by the SSA's Appeals Council on July 28, 2022. Tr. at 11. The ALJ's decision became the final decision of the Commissioner at that time. Plaintiff now seeks judicial review of the decision.
II. DISCUSSION
A. Standard of Review
Judicial review of the Commissioner's decision is limited to a determination of whether (1) the Commissioner's final decision is supported by substantial evidence on the record and (2) the Commissioner applied the proper legal standards. See 42 U.S.C. § 405(g); Copeland v. Colvin, 771 F.3d 920, 923 (5th Cir. 2014).
“Substantial evidence is more than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Sun v. Colvin, 793 F.3d 502, 508 (5th Cir. 2015). In applying the “substantial evidence” standard, “the court scrutinizes the record to determine whether such evidence is present,” id., but it may not “try the issues de novo” or “reweigh the evidence,” Salmond v. Berryhill, 892 F.3d 812, 817 (5th Cir. 2018). “[N]or, in the event of evidentiary conflict or uncertainty,” may the court substitute its judgment for the Commissioner's, “even if [it] believe[s] the evidence weighs against the Commissioner's decision.” Garcia v. Berryhill, 880 F.3d 700, 704 (5th Cir. 2018). “Conflicts of evidence are for the Commissioner, not the courts, to resolve.” Sun, 793 F.3d at 508. “A finding of no substantial evidence is appropriate only if no credible evidentiary choices or medical findings support the decision.” Whitehead v. Colvin, 820 F.3d 776, 779 (5th Cir. 2016).
Generally, “[w]here . . . the Secretary has relied on erroneous legal standards in assessing the evidence, he must reconsider that denial.” Leidler v. Sullivan, 885 F.2d 291, 294 (5th Cir. 1989). However, even if the ALJ commits legal error, “remand is warranted only if the . . . error was harmful.” Miller v. Kijakazi, No. 22-60541, 2023 WL 234773, at *3 (5th Cir. Jan. 18, 2023) (per curiam) (unpublished) (citing Shineski v. Sanders, 556 U.S. 396, 407-08 (2009)); see also Mays v. Bowen, 837 F.2d 1362, 1364 (5th Cir. 1988) (“Procedural perfection in administrative proceedings is not required. This court will not vacate a judgment unless the substantial rights of a party have been affected.”). “Harmless error exists when it is inconceivable that a different administrative conclusion would have been reached even if the ALJ did not err.” Keel v. Saul, 986 F.3d 551, 556 (5th Cir. 2021). It is the plaintiff's burden to show prejudice or harm from the error. Jones v. Astrue, 691 F.3d 730, 734-35 (5th Cir. 2012).
B. Evaluation Process
Under the Social Security Act, disability is defined as the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment ... 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 42 U.S.C. § 416(i). In evaluating a disability claim, the ALJ follows a five-step sequential process to determine whether: (1) the claimant is presently engaged in substantial gainful employment; (2) the claimant has a severe medically determinable physical or mental impairment; (3) the claimant's impairment meets or medically equals an impairment listed in the appendix to the regulations; (4) the impairment prevents the claimant from doing past relevant work; and (5) the impairment prevents the claimant from performing other substantial gainful activity. 20 C.F.R. § 404.1520(a)(4); Salmond, 892 F.3d at 817.
Between steps three and four, the ALJ determines the claimant's “residual functional capacity” (“RFC”). 20 C.F.R. § 404.1520(e). The RFC “is the most [the Plaintiff] can still do despite [their] limitations.” Id. § 404.1545(a)(1). The ALJ determines the RFC by examining “all of the relevant medical and other evidence.” 20 C.F.R. § 404.1545(a)(3). When using medical opinions as evidence, the ALJ must assess the persuasiveness of such evidence in her opinion. Id. § 404.1520c(a). Persuasiveness is based on a number of factors that the ALJ must consider, but the ALJ is only required to articulate “supportability” and “consistency” in her decision. Id. § 404.1520c(b)(2). “Supportability” means that a medical opinion is “more persuasive” when it is supported by relevant objective medical evidence and explanations provided by the source. Id. § 404.1520c(c)(1). “Consistency” means that medical opinions are “more persuasive” when it coincides “with the evidence from other medical sources and nonmedical sources in the claim.” Id. § 404.1520c(c)(2). In other words, “supportability looks internally to the bases presented by the medical opinion itself” while “consistency is an external inquiry that juxtaposes a medical opinion to other evidence in the record, including opinions of other medical professionals.” Probst v. Kijakazi, No. EP-22-CV-00286-RFC, 2023 WL 3237435, at *3 (W.D. Tex. May 3, 2023) (citing Sharon H. v. Kijakazi, No. 5:21-CV-167-H, 2022 WL 3951488, at *3 (N.D. Tex. Aug. 31, 2022)). The ALJ then uses the Plaintiff's RFC in making determinations at steps four and five. Id. § 404.1520(e).
“[A]n individual claiming disability insurance benefits under the Social Security Act has the burden of proving her disability.” Hames v. Heckler, 707 F.2d 162, 165 (5th Cir. 1983). Thus, the claimant carries the burden of proof through the first four steps. Anderson v. Sullivan, 887 F.2d 630, 632 (5th Cir. 1989). “However, if after proceeding through the first four ... steps, the claimant shows that he is unable to return to his past work, then the burden shifts to the Commissioner to meet the fifth and final step.” Guillen v. Astrue, 584 F.Supp.2d 930, 934 (W.D. Tex. 2008) (citing Anderson, 887 F.2d at 632).
C. The ALJ's Findings
In this case, at step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since July 10, 2020, her alleged disability application date. Tr. at 20. At step two, the ALJ found that Plaintiff had the following severe impairments: chronic gastritis with dysphagia and esophageal motility disorder. Id. The ALJ also found that Plaintiff's “medically determinable mental impairments of depression and anxiety ... do not cause more than minimal limitation in [her] ability to perform basic mental work activities and are therefore non-severe.” Tr. at 21. At step three, the ALJ concluded that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. Tr. at 22.
Next, the ALJ found that Plaintiff retained the RFC:
to perform a range of work at all exertional levels, but with non-exertional limitations. Specifically, she is unable to climb ladders, ropes, or scaffolds. She is unable to tolerate exposure to unprotected heights and use of dangerous moving machinery. Due to her combined symptoms, she is able to perform simple, routine, and repetitive tasks in a work environment free of fast-paced production requirements, involving only simple workplace decisions and routine workplace changes.Id. At the fourth step, the ALJ concluded that Plaintiff “is capable of performing past relevant work as a greeter” as actually or generally performed. Tr. at 25-26. At step five, considering the Plaintiff's relatively young age, high school education, work experience, and RFC, the ALJ concluded that “the claimant is capable of making successful adjustment to other work that exists in significant numbers in the national economy.” Tr. at 27. The ALJ also relied on the vocational expert testimony that given all of these factors, Plaintiff would be able to perform the requirements of representative occupations such as “cleaner, kitchen helper, and courtesy clerk.” Tr. at 26-27. Therefore, the ALJ determined, Plaintiff was not disabled under the Social Security Act from July 10, 2020 (her amended disability onset date), through February 1, 2022 (the date of the ALJ's decision). Tr. at 48.
D. Analysis
The Plaintiff raises three points of error. Plaintiff alleges that the ALJ erred by (1) issuing an RFC that was not supported by substantial evidence because the ALJ relied on a lay interpretation of “raw medical data” to formulate the RFC; (2) issuing an RFC that “did not account for the limitations arising from Plaintiff's gastrointestinal impairments;” and (3) improperly evaluating Plaintiff's subjective symptoms under Social Security Ruling (SSR) 16-3p. Pl.'s Br. at 5, 7, 10, 13. Below, the Court addresses each in turn.
1. The ALJ Did Not Improperly Rely Upon Raw Medical Data in Formulating the RFC
Plaintiff argues that the RFC limitation including that “Plaintiff cannot climb ladders, ropes, or scaffolds, work at heights or around dangerous machinery, and that she can only perform simple tasks,” is not based on substantial evidence in the record. Id. at 10-11. She contends that the “RFC is a product of guesswork” where the ALJ “devised limitations based on her own interpretation of the medical evidence.” Id. Plaintiff claims that these limitations identified by the ALJ “seemingly have nothing to do with limitations that would reasonably be related to ‘chronic gastritis with dysphagia and esophageal motility disorder' which the ALJ found were severe impairments.” Id. at 11. Moreover, Plaintiff contends that the ALJ erred by failing to obtain “medical support for the limitations she assessed.” Id. at 10.
The Commissioner argues “the record in the instant case is clear and contains more than sufficient progress notes and examining medical provider findings, and physician interpretations of the raw medical data of record for the ALJ to properly assess Plaintiff's [RFC].” Br. in Supp. of Comm'r's Decision 3 [hereinafter, “Comm'r's Br.”], ECF No. 20. First, the Commissioner points out that the “ALJ considered and discussed fully the medical evidence of record.” Id. The ALJ identified that medical records stated Plaintiff's “condition was stable with continued dysphagia and normal examinations” even after Plaintiff complained of feeling poorly in 2021. Id. at 4-5. Second, the Commissioner contends that “regulatory provisions entrusting ALJs to base their determinations on the record as a whole would be obsolete, [] if an ALJ could not interpret anything other than medical opinions....” Id. at 5. The Commissioner also cites to 20 C.F.R. § 416.920c(a), to assert that controlling regulation bars deference to medical opinion evidence by the fact finder. Id. at 6. Finally, the Commissioner contends that the “ALJ was not required to obtain additional development in order to assess the allegedly ‘raw' medical record” because it is discretionary for an ALJ to ask for the opinion of a medical expert to appear at the hearing. Id.
The ALJ assesses a claimant's RFC “based on all of the relevant medical and other evidence.” 20 C.F.R. § 404.1545(a)(3). When evaluating physical limitations, the ALJ will “first assess the nature and extent of [the claimant's] physical limitations and then determine [the claimant's] residual functional capacity for work activity on a regular and continuing basis.” Id. § 404.1545(b). The ALJ “must build an accurate and logical bridge between the evidence and the final determination.” Price v. Astrue, 401 Fed.Appx. 985, 986 (5th Cir. 2010).
There is no requirement that the ALJ adopt a specific physician's assessment when determining a Plaintiff's RFC. Miller, 2023 WL 234773, at *4. “[T]he ALJ cannot completely disregard medical testimony in making an RFC determination, ... [but] the ALJ's decision need not mirror a medical opinion.” Jones v. Kijakazi, 625 F.Supp.3d 549, 553 (S.D.Miss. 2022). The ALJ has the “exclusive responsibility as the fact-finder to evaluate medical opinions ... and decide whether they are supported by and consistent with the rest of the record.” Myers v. Berryhill, 373 F.Supp.3d 528, 535 (M.D. Pa. 2019).
Applying these legal principles, the Court reviews Plaintiff's first point of error in the following discussion of the merits.
a. Whether the ALJ Relied on Her Lay Reading of the Medical Evidence
Plaintiff maintains that the case “involves complex medical data and a rare medical condition [,] the consequences of which would not be reasonably apparent to a layperson ..” Pl.'s Br. at 11. Therefore, Plaintiff claims, the ALJ improperly relied on her own lay opinion to determine the effects of Plaintiff's impairments. In doing so, Plaintiff relies on her testimony that she was “experiencing severe issues secondary to being unable to eat solid foods due to her jackhammer esophagus... [and] issues with off-task time at work due to her special dietary needs,” arguing that the ALJ's decision does not account for these issues. Pl.'s Br. at 12.
The ALJ considered the examinations conducted by the state agency medical consultants, Amita Hegde, M.D., and Sheryl Smith, M.D. Tr. at 25. After reviewing Plaintiff's medical history, both Dr. Hegde and Dr. Smith stated in their disability determination explanations that no severe physical impairments were found. Id. Even so, the ALJ added that “while consistent with their discussion of the record, the consultants' findings are not supported by the entirety of the record, showing more than minimal limitations caused by the claimant's gastrointestinal condition.” Id.
The ALJ also considered and noted being “somewhat persuaded” by the medical findings by the state agency consultants, Howard G. Atkins, Ph.D., and Annette Brooks-Warren, M.D. Tr. at 25. The consultants reviewed the record of Plaintiff's psychiatric treatment and concluded “no severe limitations, with mild restrictions in claimant's ability to understand, recall, and apply information, and to concentrate, persist, and maintain pace.” Id.
Further, the ALJ considered the Plaintiff's medical records from early March 2021 when she reported worsening gastrointestinal distress and presented for emergency care with vomiting. Id. at 25. Plaintiff's medical records provide that “her condition improved with care and she was discharged in stable condition. At regular appointments in June and July, the [Plaintiff]'s condition was stable ...” Id. More importantly, the Plaintiff underwent an upper gastrointestinal endoscopy in September 2021. The ALJ noted:
The examined esophagus was normal without resistance to traversing the endoscope. The entire examined stomach was normal. The cardia and gastric fundus were normal on retroflexion. The examined duodenum was normal .. Repeat EGD showed minimal trauma to the mucosa. Imaging was consistent with the gastroesophageal outflow obstruction, and improved post-pneumatic dilation.Id. at 25. There are no findings in the medical evidence that Plaintiff has identified that establish that she needs more restrictive RFC limitations than the ones provided by the ALJ.
The addition of the RFC limitation related to exposure to workplace hazards such as climbing ladders and being free of “fast-paced production requirements” appears to stem from Plaintiff's digestive condition exacerbating mental conditions. “An ‘ALJ may appropriately reach a specific RFC incorporating' a limitation in a case in which ‘the record contains at least some evidence of a specific limitation, and [a] claimant's testimony is acceptable evidence to support the inclusion of a limitation in an RFC determination.'” Jose C. v. Kijakazi, No. EP-23-CV-00001-RFC, 2023 WL 8461640, at *4 (W.D. Tex. Dec. 5, 2023) (citing Barone v. Comm'r of Soc. Sec., No. 19-CV-00482 (JJM), 2020 WL 3989350, at *5 (W.D.N.Y. July 15, 2020)). Although “[t]he ALJ must consider the testimony of the claimant,” she “need not accept the claimant's contention as to the severity of his condition.” Price v. Astrue, 401 Fed.Appx. 985, 986 (5th Cir. 2010). Here, the ALJ noted that the “combination of physical and mental symptoms restricts the claimant to the performance of simple tasks in a relatively low stress environment.” Tr. at 25. The ALJ partially accepted Plaintiff's testimony about how Plaintiff's digestive condition causes distraction and lack of focus and added this limitation as a result. Thus, there is a "logical bridge” between the evidence and this RFC limitation. See Price, 401 Fed.Appx. at 986.
The Court concludes that the ALJ did not improperly draw medical opinions from raw data, but instead properly examined Plaintiff's extensive medical evidence, medical opinions of record, treatments and procedures, and Plaintiff's testimony regarding her need for extended time for meals. Remand is not warranted on this ground.
b. Development of the Record
Plaintiff also argues the RFC limitation is not supported by evidence because the ALJ failed to develop the record. Pl.'s Br. at 11. Plaintiff argues the ALJ “could have ordered a consultative examination ... [or] requested a medical expert with some experience in gastroenterology [to] testify at the hearing regarding Plaintiff's rare condition.” Id. The Commissioner responds by asserting that seeking the opinion of a medical expert is entirely within the discretion of the ALJ.
An “ALJ has a duty to develop the facts fully and fairly relating to an applicant's claim for disability benefits.” Ripley v. Chater, 67 F.3d 552, 557 (5th Cir. 1995). An ALJ's failure to fulfill this duty is not reversible error unless the claimant is prejudiced. Id. “A consultative examination is required to develop a full and fair record only if the record establishes that such an examination is necessary to enable the ALJ to make the disability decision.” Webster v. Kijakazi, 19 F.4th 715, 720 (5th Cir. 2021) (quotation marks and citations omitted). Indeed, even where the record lacks any medical opinions “describing the types of work that the applicant is still capable of performing,” “[t]he absence of such a statement ... does not, in itself, make the record incomplete.” Ripley, 67 F.3d at 557. Instead, these types of medical opinions are just one of several categories of evidence the ALJ considers in making RFC determinations. See 20 C.F.R. § 404.1513. In fact, “where no medical statement has been provided, our inquiry focuses upon whether the decision of the ALJ is supported by substantial evidence in the existing record.” Ripley, 67 F.3d at 557.
Here, the record contained medical documents that from 2019, 2020, and 2021-sufficient to allow the ALJ to determine disability. Tr. at 24-25; See Hardman v. Colvin, 820 F.3d 142, 148 (5th Cir. 2016) (holding the ALJ had sufficient facts before him to determine disability where the record was “replete with medical documents that spanned years”). The ALJ reviewed Plaintiff's medical records, and the consultants' evaluations. Tr. at 24-25. Further, the ALJ heard testimony from Plaintiff regarding her ability to conduct daily tasks and from a vocational expert regarding jobs available for someone with the RFC being considered. Id. This represents a significant body of evidence from which the ALJ could make an informed, thorough decision. Although a consultative examination is an option within the ALJ's discretion, the record does not support that additional information was necessary in order for the ALJ to make the decision about disability. See Webster, 19 F.4th at 720. Therefore, the Court is satisfied that the record was sufficiently developed by the ALJ.
In sum, the record convinces the Court that the RFC determination is supported by substantial evidence because the ALJ did not improperly draw medical opinions from raw data and this Court did not find error in the development of the record.
2. The ALJ properly considered Plaintiff's severe impairments when determining her RFC
Next, Plaintiff argues that “none of the impairments [included in the RFC] account for the limitations arising from her digestive impairment, which center on [Plaintiff's] need for additional time off task due to the specific dietary restrictions and issues with food consumption arising from her impairment.” Pl.'s Br. at 14. Plaintiff asserts the ALJ should have obtained medical information as to what limitations might arise from her condition because it is a rare digestive disorder. Id.
The Commissioner responds that the ALJ “properly found that ‘there is no evidence in the record to support Plaintiff's subjective testimony that she would need additional time off task.” Comm'r's Decision at 7-8. The Commissioner also adds that even if Plaintiff required additional time to prepare meals and eat, “Plaintiff had the opportunity to cross-examine the [vocational expert] on the issue of additional time need[ed] for meals but chose not to do so.” Id.
In relation to the Plaintiff's claim regarding whether severe impairments were considered by the ALJ, the Plaintiff again complains the record was insufficiently developed by the ALJ. The record does not support that more information was necessary for the ALJ to make a determination.
The purpose of assessing a claimant's RFC is to determine the work that can be done despite present limitations. See Myers v. Apfel, 238 F.3d 617, 620 (5th Cir. 2001) (per curiam); 20 C.F.R. § 404.1545(a). Courts have found that when impairments are identified as severe at step two, but an RFC does not include any limitations for those impairments, the RFC in effect contradicts the step two finding. See Walker v. Colvin, No. 3:14-CV-1498-L, 2015 WL 5836263, at *15 (N.D. Tex. Sept. 30, 2015); Spears v. Barnhart, 284 F.Supp.2d 477, 483 (S.D. Tex. 2002) (noting that by failing to include any limitations, the ALJ “basically contradict[ed] the fact that he found [the claimant's] impairments to be severe”); Norman v. Astrue, No. SA-10-CA-849-XR, 2011 WL 2884894, at *6 (W.D. Tex. July 18, 2011) (“Similar to Spears, here the ALJ did not include any limitations resulting from the [impairment], contradicting his own finding that the [impairment] was ‘severe.' ”); cf. Rangel v. Astrue, No. H-08-2246, 2009 WL 2971129, at *15 & n.11 (S.D. Tex. Sept. 14, 2009) (contrasting the facts with Spears, the district court noted that the ALJ found the claimant's depression to be severe and assessed the appropriate mental limitations in his RFC determination for any residual effects of his depression). These types of inconsistencies generally warrant remand. See, e.g., Spears, 284 F.Supp.2d at 483-84 (finding the ALJ's failure to address the claimant's limitations related to her severe impairment was error that warranted remand); Norman, 2011 WL 2884894, at *6 (finding remand was warranted where the ALJ found the claimant's limitation was severe at step two, but failed to include any limitation resulting from the impairment in his RFC analysis).
In Martinez v. Astrue, an ALJ failed to include limitations resulting from a plaintiff's hand surgery in the RFC despite finding that the hand surgery was a severe impairment. Martinez, 2011 WL 4128837, at *5-6. After noting that the ALJ may have made a mistake at step two or made a credibility determination regarding the claimant's limitations in deciding the RFC, the court explained that “on appellate review, [a court] cannot speculate as to what the ALJ may have considered.” Id. at *7. It remanded the case because it was unable to determine whether the ALJ intended the hand surgery to be a severe impairment, and if so, whether the RFC should have included certain limitations relating to it. Id. at *7 (noting “this Court cannot find that the ALJ's inclusion of the ... severe impairment was merely meaningless verbiage”).
Nevertheless, “having a severe impairment is not a sufficient condition for receiving benefits under the Secretary's regulations” and “means only that [the] claimant has passed the second step of the inquiry mandated by the regulations.” Shipley v. Sec. of Health & Human Servs., 812 F.2d 934, 935 (5th Cir. 1987) (per curiam). In other words, the consideration of whether a claimant's impairments are severe at step two is a different inquiry than an ALJ's assessment of the claimant's RFC. See Gutierrez v. Barnhart, No. 04-11025, 2005 WL 1994289, at *9 (5th Cir. Aug. 19, 2005) (per curiam) (“A claimant is not entitled to social security disability benefits merely upon a showing that she has a severe disability. Rather, the disability must make it so the claimant cannot work to entitle the claimant to disability benefits.”); see also Boyd v. Apfel, 239 F.3d 698, 706 (5th Cir. 2001) (“The ALJ's finding that [the claimant] had a ‘combination of impairments that [were] severe' did not foreclose a finding that [the claimant] had a residual functional capacity to perform a range of light work, and is not necessarily inconsistent with that finding.”); Quigley v. Astrue, No. 4:09-CV-402-A, 2010 WL 5557500, at *8 (N.D. Tex. Sept. 8, 2010) (noting that step two and the RFC determination are different inquiries), adopted by 2011 WL 61630 (N.D. Tex. Jan 5, 2011).
In some instances, courts have found that an ALJ did not err in finding severe impairments at step two and not attributing any limitation to those impairments in the RFC assessment. In these instances, the ALJs considered the limitations that were encompassed by the severe impairments or accounted for the limitations in some respect before making a disability finding. See, e.g., Gonzalez v. Colvin, No. 4:12-CV-641-A, 2014 WL 61171, at *6-7 (N.D. Tex. Jan. 6, 2014) (finding the ALJ's decision was not subject to reversal where he did not set forth specific limitations in his RFC determination relating only to the claimant's severe impairment but found other limitations that took into account the claimant's severe impairment); Carnley v. Colvin, No. 3:12-CV-3535-N, 2013 WL 5300674, at *9 (N.D. Tex. Sept. 20, 2013) (finding that although the ALJ erred by finding claimant's seizure disorder to be a severe impairment and failing to incorporate limitations from the disorder into the RFC, it was clear he intended to include seizure limitations because the hypothetical questions posed to the VE at the hearing included such limitations, thereby negating need to remand the case); Scott v. Colvin, No. 4:12-CV-01569, 2013 WL 6047555, at *11 (S.D. Tex. Nov. 14, 2013) (finding that the ALJ “fully addressed the impact of [the claimant's severe impairment] on her ability to do sustained work activities”). The ALJ must clearly consider the severe impairments in determining the claimant's RFC, not necessarily assess limitations for each severe impairment. See, e.g., Campbell v. Berryhill, No. 3:15-CV-3913-N, 2017 WL 1102797, at *12 (Feb. 24, 2017) (finding error where “the ALJ expressly found that Plaintiff's deep vein thrombosis was one of twelve severe impairments at step two, but [] did not expressly address what impact, if any, it had in determining Plaintiff's RFC”) (emphasis added), adopted by 2017 WL 1091651 (N.D. Tex. Mar. 23, 2017).
In the instant case, the ALJ found that Plaintiff's severe impairments included chronic gastritis with dysphagia and esophageal motility disorder. Tr. at 20. Despite these impairments, at step three, she found that Plaintiff had no impairment or combination of impairments that met or equaled the severity of one of the impairments listed in the social security regulations. Tr. at 22. Next, the ALJ determined that Plaintiff had the RFC to perform a range of work at all exertional levels, but with non-exertional limitations. Id. The ALJ concluded that the Plaintiff is unable to climb ladders, ropes, or scaffold, and unable to tolerate exposure to unprotected heights or use dangerous moving machinery. The ALJ determined Plaintiff can perform “simple, routine, and repetitive tasks involving only simple workplace decisions and routine workplace changes.” Id.
In making this finding, the ALJ explicitly considered Plaintiff's testimony including: (1) suffering from severe anxiety and depression because of her physical condition; (2) Plaintiff's self-described daily routine such as “seeing to her personal needs, cooking, doing household chores, and caring for her son;” (3) Plaintiff's explanation that “she cannot eat alone because she is worried about choking;” (4) needing “30 minutes to prepare meals, and one to one and half hours to eat;” (5) drinking “ensure for snacks and lunches;” and (6) suffering from insomnia due to her medications. Tr. at 23. After considering the evidence of record, and Plaintiff's allegations, the ALJ found her “medically determinable impairments could reasonably be expected to cause the alleged symptoms,” but found her statements “concerning the intensity, persistence, and limiting effects of these symptoms not entirely consistent with the medical evidence and other evidence in the record ...” Tr. at 24. This finding informs the ALJ's ultimate RFC assessment. cf. Martinez, 2011 WL 4128837, at *5-6 (“Without some explanation in the record as to how plaintiff can suffer from a severe impairment, which by definition must have more than a minimal effect on plaintiff's ability to work and why such severe impairment would not have had any limitation on plaintiff's ability to ... [fullfill the necessary functions of] the jobs identified by the vocational expert, the decision cannot stand.”).
Accordingly, the ALJ considered the medical impairments from step two when she made the RFC determination and assessed Plaintiff's limitations based on their impact on her actual ability to do work. Therefore, there is no inconsistency between the ALJ's step two findings and her RFC determination.
3. The ALJ properly considered Plaintiff's subjective symptoms under SSR 16-3p
Finally, Plaintiff alleges that the ALJ's subjective symptoms evaluation is not supported by substantial evidence. Pl.'s Br. at 15-16. Plaintiff contends that the ALJ failed to develop the record and as a result did not produce valid reasons for rejecting Plaintiff's subjective complaints as required by Social Security Ruling 16-3p. Id.
In response, the Commissioner asserts the ALJ did a proper subjective symptom analysis pursuant to regulations. Comm'r's Br. at 10. The Commissioner further contends that “the ALJ found that Plaintiff's medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record.” Id.
Social Security Ruling 16-3p explains that “an individual's statements of symptoms alone are not enough to establish the existence of a physical or mental impairment or disability.” S.S.R. 16-3p, 2017 WL 5180304, at *1-2 (Oct. 25, 2017). The ALJ, however, cannot ignore statements of symptoms but, rather, must evaluate them according to the two-step process set forth in this regulation. The ALJ must (1) consider “whether there is an underlying medically determinable physical or mental impairment(s) that could reasonably be expected to produce an individual's symptoms, such as pain;” and (2) evaluate of the intensity and persistence of the symptoms to determine the extent to which the symptoms limit an individual's ability to perform work-related activities. Id. at *2-4. The ALJ must evaluate the symptoms experienced by the claimant by looking to the objective medical evidence, the claimant's statements, medical sources, and several other factors, including daily activities, aggravating symptoms, pain characteristics, treatment, medication, etc. Id. at *3-6. In performing this evaluation, the ALJ is not, however, required to articulate expressly every regulatory factor or reason in making this determination. See Undheim v. Barnhart, 214 Fed.Appx. 448, 451 (5th Cir. 2007). Furthermore, the court must give “judicial deference” to the ALJ's evaluation of the plaintiff's subjective complaints “if [it] is supported by substantial evidence.” Villa v. Sullivan, 895 F.2d 1019, 1024 (5th Cir. 1990).
The ALJ stated in her decision that she considered the evidence in accordance with Social Security Regulation 16-3p. She found that Plaintiff's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the evidence of record and do not support a finding of disability. Tr. at 22-24. In reaching this conclusion, the ALJ specifically discussed Plaintiff's testimony that her gastrointestinal problems make eating difficult, and that she needs extended time for meals, which would prohibit her from working an eight-hour shift with normal breaks. Tr. 23-24. The ALJ also noted that Plaintiff stated that she “drinks Ensure for snacks and lunches,” prepares her son's meals, does household chores, and cares for her son. Tr. at 23. The Commissioner further notes that Plaintiff “specifically testified that she could drink liquids ... with no problems.” Comm'r's Br. at 11. In the portion of her testimony where she details her consumption of liquids, Plaintiff testified “it doesn't take [her] more than ten minutes.” Tr. at 90. Additionally, the ALJ cited to Plaintiff's treatment records showing normal exam results and a “repeat EGD exam show[ing] minimal trauma to the mucosa.” Tr. at 25.
The state agency medical examining doctors, Dr. Hegde and Dr. Smith, concluded Plaintiff had no severe physical impairments. Tr. at 25. The ALJ found these opinions less persuasive because they did not adequately consider the entirety of the record including Plaintiff's testimony which demonstrated more than minimal limitations caused by the Plaintiff's gastrointestinal condition. Id. The state agency medical consultants, Dr. Atkins and Dr. Brooks-Warren, reviewed Plaintiff's psychiatric treatment and found “no severe limitations, with mild restrictions in the claimant's ability to understand, recall, and apply information, and to concentrate, persist, and maintain pace.” Id. The ALJ found these opinions “somewhat” persuasive, more consistent with the record, and supported by Plaintiff's testimony regarding her “ability to adapt or manage herself well.” Id.
Consequently, considering the totality of the evidence, the ALJ concluded Plaintiff's condition exacerbates her mental condition, causing distraction and lack of focus, which restricts the Plaintiff to the performance of simple tasks in relatively low stress environments. However, the ALJ also concluded that there is no evidence in the record supporting Plaintiff's allegations that needing extended time for meals would prohibit her from working an eight-hour shift with normal breaks. The totality of Plaintiff's record, including Plaintiff's testimony and objective medical evidence, demonstrates that the ALJ's analysis of Plaintiff's subjective symptoms are supported by substantial evidence. Therefore, because substantial evidence supports the ALJ's decision, the Court gives it deference and finds the ALJ did not err on evaluating Plaintiff's subjective testimony.
In sum, the ALJ's conclusion that Plaintiff was not disabled was supported by substantial evidence because the ALJ (1) did not rely on a lay interpretation of raw medical data to formulate the RFC, (2) considered Plaintiff's medical impairments when she made the RFC determination and assessed Plaintiff's limitations based on their impact on her actual ability to work, and (3) properly considered all of Plaintiff's subjective complaints and objective evidence in the record to determine her RFC.
III. CONCLUSION
For these reasons, the Court RECOMMENDS that the decision of the Commissioner be AFFIRMED pursuant to 42 U.S.C. § 405(g).
SIGNED and ENTERED.
NOTICE
FAILURE TO FILE WRITTEN OBJECTIONS TO THE PROPOSED FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS CONTAINED IN THE FOREGOING REPORT, WITHIN FOURTEEN DAYS OF SERVICE OF SAME, MAY BAR DE NOVO DETERMINATION BY THE DISTRICT JUDGE OF AN ISSUE COVERED HEREIN AND SHALL BAR APPELLATE REVIEW, EXCEPT UPON GROUNDS OF PLAIN ERROR, OF ANY UNOBJECTED-TO PROPOSED FACTUAL FINDINGS AND LEGAL CONCLUSIONS AS MAY BE ACCEPTED OR ADOPTED BY THE DISTRICT COURT.