Opinion
No. 5:18-CV-00480-D
07-16-2019
Angelina Jean Wells, Plaintiff, v. Andrew Saul, Commissioner of Social Security, Defendant.
Memorandum & Recommendation
Plaintiff Angelina Wells instituted this action in October 2018 to challenge the denial of her application for social security income. Wells claims that Administrative Law Judge ("ALJ") Mason Hogan erred in (1) determining Wells's residual functional capacity ("RFC") and (2) evaluating her statements on functioning. Both Wells and Defendant Andrew Saul, Commissioner of Social Security, have filed motions seeking a judgment on the pleadings in their favor. D.E. 17, 20.
After reviewing the parties' arguments, the court has determined that ALJ Hogan reached the appropriate determination. Substantial evidence supports ALJ Hogan's finding that Wells can perform a reduced range of light work. And the undersigned finds no error in ALJ Hogan's determination that Wells's statements were not fully consistent with the record. The undersigned magistrate judge therefore recommends that the court deny Wells's motion, grant the Commissioner's motion, and affirm the Commissioner's decision.
The court has referred this matter to the undersigned for entry of a Memorandum and Recommendation. 28 U.S.C. § 636(b).
I. Background
In May 2016, Wells protectively applied for disability benefits and supplemental security income. In both applications, she alleged a disability that began in January 2010. After her claims were denied at the initial level and upon reconsideration, Wells appeared at a hearing before ALJ Hogan to determine whether she was entitled to benefits. ALJ Hogan determined that Wells was not entitled to benefits because she was not disabled. Tr. at 15-36.
Wells later amended her disability onset date to May 29, 2014. Tr. at 16.
ALJ Hogan found that Wells had several severe impairments: morbid obesity, spondylosis, mild degenerative joint disease of the left hip, sacroiliitis, osteopenia, and diabetes mellitus. Tr. at 18. ALJ Hogan found that Wells's impairments, alone or in combination, did not meet or equal a Listing impairment. Tr. at 22.
ALJ Hogan determined that Wells had the RFC to perform a reduced range of light work. Tr. at 23-24. Wells can occasionally climb ramps and stairs, but she can never climb ladders, ropes, or scaffolds. Id. She is limited to occasional stooping, kneeling, couching, and crawling. Id. Wells must avoid concentrated exposure to pulmonary irritants such as fumes, odors, dust, gases, and poor ventilation. Id. And Wells must also avoid concentrated exposure to hazards such as unprotected heights and dangerous machinery. Id.
ALJ Hogan concluded that Wells cannot perform her past relevant work as a housekeeper, fast food worker, or machine operator. Tr. at 33. But considering her age, education, work experience, and RFC, ALJ Hogan found that other jobs existed in significant numbers in the national economy that Wells could perform. Tr. at 34-35. These include laundry folder, cashier, and mail clerk. Tr. at 35. Thus, ALJ Hogan found that Wells was not disabled. Id.
After unsuccessfully seeking review by the Appeals Council, Wells began this action in June 2018. D.E. 1.
II. Analysis
A. Standard for Review of the Acting Commissioner's Final Decision
When a social security claimant appeals a final decision of the Commissioner, the district court's review is limited to the determination of whether, based on the entire administrative record, there is substantial evidence to support the Commissioner's findings. 42 U.S.C. § 405(g); Richardson v. Perales, 402 U.S. 389, 401 (1971). Substantial evidence is defined as "evidence which a reasoning mind would accept as sufficient to support a particular conclusion." Shively v. Heckler, 739 F.2d 987, 989 (4th Cir. 1984) (quoting Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966)). If the Commissioner's decision is supported by such evidence, it must be affirmed. Smith v. Chater, 99 F.3d 635, 638 (4th Cir. 1996).
B. Standard for Evaluating Disability
In making a disability determination, the ALJ engages in a five-step evaluation process. 20 C.F.R. § 404.1520; see Johnson v. Barnhart, 434 F.3d 650 (4th Cir. 2005). The analysis requires the ALJ to consider the following enumerated factors sequentially. At step one, if the claimant is currently engaged in substantial gainful activity, the claim is denied. At step two, the claim is denied if the claimant does not have a severe impairment or combination of impairments significantly limiting him or her from performing basic work activities. At step three, the claimant's impairment is compared to those in the Listing of Impairments. See 20 C.F.R. Part 404, Subpart P, App. 1. If the impairment is listed in the Listing of Impairments or if it is equivalent to a listed impairment, disability is conclusively presumed. However, if the claimant's impairment does not meet or equal a listed impairment, the ALJ assesses the claimant's RFC to determine, at step four, whether he can perform his past work despite his impairments. If the claimant cannot perform past relevant work, the analysis moves on to step five: establishing whether the claimant, based on his age, work experience, and RFC can perform other substantial gainful work. The burden of proof is on the claimant for the first four steps of this inquiry, but shifts to the Commissioner at the fifth step. Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995).
C. Medical Background
Wells established care with Eastern North Carolina Medical Group in May 2014 for chronic back pain that radiated into her hips and legs. Tr. at 450-55. Wells also reported a history of uncontrolled diabetes. Id. Charles Hunter, PA-C, prescribed medications to Wells. Id.
Four months later, Wells informed providers that she had been out of her medication because of financial difficulties. Tr. at 428-49. In December 2014, Wells stated that she had low blood sugars in the mornings, which caused jitteriness. Id. She also reported back pain with numbness and tingling into her lower extremities. Id. Providers continued Wells's medications.
The next month, Wells established care with Carolina Regional Orthopaedics for back pain with radiation into her lower left extremity. Tr. at 502-05. An examination showed tenderness in the paraspinal region with pain upon rotation ad flexation. Id. X-rays revealed sclerosis and loss of joint space in Wells's left hip and disc space narrowing with anterior spurring in her lumbar spine. Id. Dr. Glenn MacNichol prescribed medication and administered an injection in Wells's left hip. Id.
One month later, Wells reported continued numbness but rated her pain level as four out of ten. Tr. at 494-502. Providers increased her medications, and continued that dosage at a follow-up appointment the next month. Id.
Wells reported symptoms of depression and being isolated to Laura Medlin, PA. Tr. at 432-37. She reiterated depressive symptoms, as well as numbness and weakness, at a follow-up visit in April 2015. Tr. at 491-94. Medlin continued Wells's medication regimen. Id.
The next month, Dr. MacNichol performed an examination which found tenderness in the paraspinal muscles and left hip pain aggravated by abduction, flexation, and extension. Tr. at 473-91. Wells received another injection to her left hip later that month. Id. In June 2015, Dr. MacNichol adjusted Wells's mediations and administered a left SI joint injection. Id. He continued her medication two months later when Wells reported no change in her symptoms. Id.
Wells was hospitalized in February 2016 for autoimmune hepatitis. Tr. at 414-18. Later that month, she sought treatment at Boice Willis Clinic for elevated liver enzymes and positive AIH markers. Tr. at 540-51. Dr. Mitchell Mahmoud adjusted Wells's medications. Id. Dr. Mahmoud continued her medication protocol at a follow-up visit two months later. Id.
In June 2016, Wells returned to Hunter for complaints of chronic pain, for which he prescribed medications. Tr. at 566-73. Wells followed-up with Hunter three months later again reporting chronic pain, and he continued her medications. Tr. a 626-37.
In August 2016, Wells returned to Medlin reporting no change in her pain levels, and Medlin recommended physical therapy. Tr. at 709-18. Two months later, Wells again noted chronic pain, rated as eight out of ten. Id. Providers continued her medications. Id. In December 2016, Wells said she had more pain, and providers increased her medications. Id.
The next month, Wells saw Carly Amato, PA-C, at Carolina Regional Orthopaedics. Tr. at 695-709. Wells claimed to have nausea with the increased medication, as well as weakness, numbness, and symptoms of depression. Id. Providers continued Wells's medications. Id. Amato adjusted Well's medication one month later. Id. At a follow-up visit in March 2017, Wells claimed her pain symptoms had intensified, and her medication dosage was again increased. Id. She also received another injection to her left hip later that month, for which Wells reported some relief. Tr. at 692-95.
At follow-up visits over the next few months, Wells reported increased pain in her left leg and across her lumbar area. Tr. at 620-25, 674-77, 688-92. Providers continued or adjusted her medications after these visits. Id.
In September 2017, Wells saw Amato for increased pain. Tr. at 670-74. An examination showed tenderness in the SI joint region as well as hip pain aggravated by abduction, flexation, and extension. Id. She received another injection to her left hip the next month. Tr. at 664-70. Wells reported that the injection provided relief for only two weeks before her pain symptoms returned. Id. And she continued to have tenderness in her SI joint region. Id.
Dr. Robert Martin evaluated Wells in November 2017. Tr. at 660-64. Wells reported chronic back and left hip pain with swelling and stiffness. Id. An examination revealed tenderness and pain with internal rotation. Id. A left hip x-ray showed joint space narrowing, osteophyte formation, and subchondral sclerosis. Id. He instructed Wells to lose weight and continue her pain management. Id.
Wells reported increased pain at follow-up visits later that month and again in December 2017. Tr. at 653-60. Providers continued her medication protocol. Id.
Wells saw Amato in February 2018 for increased joint pain. Tr. at 646-50. Amato continued Wells's medication. Id. The next month, Wells received another injection to her left hip. Tr. at 640-46. At a follow-up visit one month later, Wells reported that the injection provided her some relief. Id. Providers again continued her medications. Id.
D. Residual Functional Capacity
Wells contends that ALJ Hogan erred in his RFC determination by failing to account for her back pain and left hip arthritis which, she argues, preclude her from performing the standing and walking requirements associated with light work. The Commissioner argues that although she received treatment for her these conditions, Wells has not shown that the record supports additional limitations not reflected in the RFC. The undersigned finds no error in ALJ Hogan's RFC determination.
The RFC is a determination, based on all the relevant medical and non-medical evidence, of what a claimant can still do despite her impairments; the assessment of a claimant's RFC is the responsibility of the ALJ. See 20 C.F.R. §§ 404.1520, 404.1545, 404.1546; SSR 96-8p, 1996 WL 374184, at *2. If more than one impairment is present, the ALJ must consider all medically determinable impairments, including medically determinable impairments that are not "severe," when determining the claimant's RFC. Id. §§ 404.1545(a), 416.945(a). The ALJ must also consider the combined effect of all impairments without regard to whether any such impairment, if considered separately, would be of sufficient severity. Id. § 404.1523; see Walker v. Bowen, 889 F.2d 47, 50 (4th Cir. 1989) ("[I]n evaluating the effect[] of various impairments upon a disability benefit claimant, the [Commissioner] must consider the combined effect of a claimant's impairments and not fragmentize them.").
The ALJ must provide "findings and determinations sufficiently articulated to permit meaningful judicial review." DeLoatche v. Heckler, 715 F.2d 148, 150 (4th Cir. 1983); see also Wyatt v. Bowen, 887 F.2d 1082, 1989 WL 117940, at *4 (4th Cir. 1989) (per curiam). The ALJ's RFC determination "must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g. laboratory findings) and nonmedical evidence (e.g. daily activities, observations)." Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting Social Security Ruling ("SSR") 96-8p). Furthermore, "[t]he record should include a discussion of which evidence the ALJ found credible and why, and specific application of the pertinent legal requirements to the record evidence." Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013). Fourth Circuit precedent "makes it clear that it is not [the court's] role to speculate as to how the ALJ applied the law to [her] findings or to hypothesize the ALJ's justifications that would perhaps find support in the record. Fox v. Colvin, 632 F. App'x 750, 755 (4th Cir. 2015).
Social Security Ruling 96-8p explains how adjudicators should assess residual functional capacity. The Ruling instructs that the residual functional capacity "assessment must first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions" listed in the regulations. "Only after that may [residual functional capacity] be expressed in terms of the exertional levels of work, sedentary, light, medium, heavy, and very heavy." SSR 96-8p. The Ruling further explains that the residual functional capacity "assessment must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations)." Id.
There is no "per se rule requiring remand when the ALJ does not perform an explicit function-by-function analysis[.]" Mascio, 780 F.3d at 636. But "[r]emand may be appropriate . . . where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite contradictory evidence in the record, or where other inadequacies in the ALJ's analysis frustrate meaningful review." Id. (quoting Cichocki v. Astrue, 729 F.3d 172, 177 (2d Cir. 2013)). The function-by-function requirement can be satisfied by reference to a properly conducted analysis by a state agency consultant. See, e.g., Linares v. Colvin, No. 5:14-CV-00129, 2015 WL 4389533, at *3 (W.D.N.C. July 17, 2015) ("Because the ALJ based his RFC finding, in part, on the function-by-function analysis of the State agency consultant, the ALJ's function-by-function analysis complied with [Soc. Sec. Ruling] 96-8p." (citing Lemken v. Astrue, No. 5:07-cv-33-RLV-DCK, 2010 WL 5057130, at *8 (W.D.N.C. 26 July 2010))).
Testing has shown that Wells has sclerosis and loss of joint space in her left hip. Wells also has degenerative disc disease and anterior spurring in her back. She maintains that injections have provided her only temporary relief of her pain symptoms. So Wells asserts she cannot stand and walk for six hours a day, as required for light work.
The undersigned finds that substantial evidence supports ALJ Hogan's RFC determination. ALJ Hogan considered all the evidence, including objective testing, such as x-rays, and the treatment modalities Wells pursued, like injections and medications. While the record documents Wells's reports of back and hip pain, the treatment records reveal that she often took less than her prescribed dose of medication. And Wells reported positive results and reduced pain levels following injections. Although examinations found tenderness, Wells demonstrated intact strength and a normal gait. So the evidence fails to support Wells's position that her back and hip pain conditions preclude her from performing light work.
Wells has not identified evidence that ALJ Hogan failed to consider but merely disagrees with his evaluation of the evidence. Instead, she has shown only disagreement with ALJ Hogan's consideration of these conditions and their effect on her functioning. This is an insufficient basis to warrant remand. See Johnson, 434 F.3d at 653 (reviewing court should not seek to reweigh conflicting evidence, make credibility determinations, or substitute its judgment for that of the ALJ). Finding no error in ALJ Hogan's RFC determination, the court should reject Wells's claim on this issue.
E. Subjective Statements of Functioning
Wells next contends that ALJ Hogan failing to credit fully her statements about her symptoms and their limiting effects. The Commissioner asserts that the records supports ALJ Hogan's reasons for finding that Wells's statements were less than fully credible The undersigned concludes that ALJ Hogan did not err in evaluating Wells's subjective statements.
The Social Security Administration addressed credibility and revised considering a claimant's statement through SSR 16-3p, effective March 2016. In superceding SSR 96-7p, the new Ruling eliminated the term "credibility," noting that "subjective symptom evaluation is not an examination of an individual's character[]" and directed that the determination "contain specific reasons for the weight given to the individual's symptoms[.]" SSR 16-3p. But the methodology required by both SSR 16-3p and SSR 96-7p are similar. Both require the ALJ to consider a claimant's report of her own symptoms against the backdrop of the entire case record; in SSR 96-7p, this created a "credibility" analysis, in SSR 16-3, this allows the adjudicator to evaluate "consistency." See Harwley v. Berryhill, Case No. 6:16-cv-32, 2017 WL 4276833, at *8 n.14 (W.D. Va. Sept. 26, 2017).
Under the regulations implementing the Social Security Act, an ALJ follows a two-step analysis when considering a claimant's subjective statements about impairments and symptoms. SSR 16-3p Titles II & XVI: Evaluation of Symptoms in Disability Claims, SSR 16-3p, 2017 WL 5180304 (Oct. 25, 2017); 20 C.F.R. §§ 404.1529(b)-(c), 416.929(b)-(c). First, the ALJ looks for objective medical evidence showing a condition that could reasonably produce the alleged symptoms, such as pain. Id. at *3, §§ 404.1529(b), 416.929(b). Second, the ALJ must evaluate the intensity, persistence, and limiting effects of the claimant's symptoms to determine how much they limit the claimant's ability to work. Id. §§ 404.1529(c), 416.929(c). In making that determination, the ALJ must "examine the entire case record, including the objective medical evidence; an individual's statements about the intensity, persistence, and limiting effects of symptoms; statements and other information provided by medical sources and other persons; and any other relevant evidence in the individual's case record." Id.
The ALJ has full discretion to weigh the subjective statements with the objective medical evidence and other matters of record. Craig v. Chater, 76 F.3d 585, 595 (4th Cir. 1996) (holding that claimant's allegations of pain need not be accepted to extent that they are inconsistent with the record). The ALJ may not discredit a claimant just because his subjective complaints are not confirmed by objective medical evidence. Id. at 595-96. But neither is the ALJ obligated to accept the claimant's statements at face value. Hawley v. Colvin, No. 5:12-CV-260-FL, 2013 WL 6184954, at *15 (E.D.N.C. Nov. 14, 2013). In a district court's review, the ALJ's findings are entitled to great weight because of the ALJ's ability to observe and evaluate testimony firsthand. Shively, 739 F.2d at 989-90.
In support of her argument, Wells asserts that she cannot sit for extended periods and her medications make her drowsy. Providers referred her to pain management for her back and leg pain. Examinations revealed tenderness and muscle spasms. And injections provided her only temporary relief. Wells estimated that she could lift no more than five pounds, stand for 20 minutes, and sit for 30 minutes before needing to change positions. Wells also contends that she must lie down throughout the day because of drowsiness from medications.
ALJ Hogan concluded that Wells's statements about the intensity, persistence, and limiting effects of her symptoms was not entirely consistent with the record. Tr. at 25. The undersigned cannot conclude that ALJ Hogan erred in considering Wells's statements of her limitations.
Despite her claims, treatment notes show several inconsistencies with Wells's statements. For instance, examinations found that Wells had normal gait, strength, and range of motion. She reported an improvement in her pain symptoms with medication and injections, with Wells describing improved functioning and quality of life. While she claimed to have experienced drowsiness from her medications, the record contains no account of this side effect. And the evidence also shows that Wells often took less medication than providers prescribed, which may suggest her pain was well-controlled. Wells claimed that providers advised her to get a cane and restricted her lifting capacity, but the record reflects no such directives.
In sum, ALJ Hogan properly evaluated all the evidence, including Wells's activities of daily living, symptoms, treatment modalities, and aggravating or alleviating factors, as required by the Regulations. ALJ Hogan's consideration of Wells's statements is well-reasoned and supported by the evidence. So Wells's argument on this issue lacks merit and should be denied.
III. Conclusion
For the forgoing reasons, the undersigned recommends that the court deny Wells's Motion for Judgment on the Pleadings (D.E. 17), grant Saul's Motion for Judgment on the Pleadings (D.E. 20), and affirm the Commissioner's determination.
The Clerk of Court must serve a copy of this Memorandum and Recommendation ("M&R") on each party who has appeared in this action. Any party may file a written objection to the M&R within 14 days from the date the Clerk serves it on them. The objection must specifically note the portion of the M&R that the party objects to and the reasons for their objection. Any other party may respond to the objection within 14 days from the date the objecting party serves it on them. The district judge will review the objection and make their own determination about the matter that is the subject of the objection. If a party does not file a timely written objection, the party will have forfeited their ability to have the M&R (or a later decision based on the M&R) reviewed by the Court of Appeals. Dated: July 16, 2019.
/s/_________
ROBERT T. NUMBERS, II
UNITED STATES MAGISTRATE JUDGE