Opinion
4:20-CV-92-FL
06-18-2021
SWAIN WILLIAMS, Plaintiff/Claimant, v. ANDREW SAUL, Commissioner of Social Security, Defendant.
MEMORANDUM AND RECOMMENDATION
Robert B. Jones, Jr., United States Magistrate Judge.
This matter is before the court on the parties' cross-motions for judgment on the pleadings [DE-18, -21] pursuant to Fed.R.Civ.P. 12(c). Claimant Swain Williams (“Claimant”) filed this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the denial of her application for a period of disability and Disability Insurance Benefits (“DIB”). Plaintiff filed a response in opposition to Defendant's motion, [DE-23], and the pending motions are ripe for adjudication. Having carefully reviewed the administrative record and the motions and memoranda submitted by the parties, it is recommended that Claimant's Motion for Judgment on the Pleadings be denied, Defendant's Motion for Judgment on the Pleadings be allowed, and the final decision of the Commissioner be affirmed.
I. STATEMENT OF THE CASE
Claimant filed an application for a period of disability and DIB on June 13, 2016, alleging disability beginning June 10, 2016. (R. 15, 181-84). Her claim was denied initially and upon reconsideration. (R. 15, 70-97). A hearing before the Administrative Law Judge (“ALJ”) was held on December 21, 2018, at which Claimant, represented by counsel, and a vocational expert (“VE”) appeared and testified. (R. 37-69). On April 2, 2019, the ALJ issued a decision denying Claimant's request for benefits. (R. 12-35). On April 13, 2020, the Appeals Council denied Claimant's request for review. (R. 1-6). Claimant then filed a complaint in this court seeking review of the now-final administrative decision.
II. STANDARD OF REVIEW
The scope of judicial review of a final agency decision regarding disability benefits under the Social Security Act (“Act”), 42 U.S.C. § 301 et seq., is limited to determining whether substantial evidence supports the Commissioner's factual findings and whether the decision was reached through the application of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). “The findings of the Commissioner ... as to any fact, if supported by substantial evidence, shall be conclusive . . . .” 42 U.S.C. § 405(g). Substantial evidence is “evidence which a reasoning mind would accept as sufficient to support a particular conclusion.” Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966). While substantial evidence is not a “large or considerable amount of evidence, ” Pierce v. Underwood, 487 U.S. 552, 565 (1988), it is “more than a mere scintilla . . . and somewhat less than a preponderance.” Laws, 368 F.2d at 642. “In reviewing for substantial evidence, [the court should not] undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner].” Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996), superseded by regulation on other grounds, 20 C.F.R. § 416.927(d)(2)). Rather, in conducting the “substantial evidence” inquiry, the court's review is limited to whether the ALJ analyzed the relevant evidence and sufficiently explained his or her findings and rationale in crediting the evidence. Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).
III. DISABILITY EVALUATION PROCESS
The disability determination is based on a five-step sequential evaluation process as set forth in 20 C.F.R. § 404.1520 under which the ALJ is to evaluate a claim:
The claimant (1) must not be engaged in “substantial gainful activity, ” i.e., currently working; and (2) must have a “severe” impairment that (3) meets or exceeds [in severity] the “listings” of specified impairments, or is otherwise incapacitating to the extent that the claimant does not possess the residual functional capacity to (4) perform ... past work or (5) any other work.Albright v. Comm 'r of the SSA, 174 F.3d 473, 475 n.2 (4th Cir. 1999). “If an applicant's claim fails at any step of the process, the ALJ need not advance to the subsequent steps.” Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995) (citation omitted). The burden of proof and production during the first four steps of the inquiry rests on the claimant. Id. At the fifth step, the burden shifts to the ALJ to show that other work exists in the national economy which the claimant can perform. Id.
When assessing the severity of mental impairments, the ALJ must do so in accordance with the “special technique” described in 20 C.F.R. § 404.1520a(b)-(c). This regulatory scheme identifies four broad functional areas in which the ALJ rates the degree of functional limitation resulting from a claimant's mental impairment(s): understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing oneself. Id. § 404.1520a(c)(3). The ALJ is required to incorporate into his written decision pertinent findings and conclusions based on the “special technique.” Id. § 404.1520a(e)(3).
In this case, Claimant alleges that the ALJ erred in failing to account for her moderate limitation in maintaining concentration, persistence, and pace in the RFC. Pl.'s Mem. [DE-19] at 3-16.
IV. ALJ'S FINDINGS
Applying the above-described sequential evaluation process, the ALJ found Claimant “not disabled” as defined in the Act. At step one, the ALJ found Claimant had not engaged in substantial gainful employment since June 10, 2016, her alleged onset date. (R. 17). Next, the ALJ determined Claimant had the following severe impairments: coronary artery disease, diabetes mellitus, hypertension, obesity, major depressive disorder with psychotic features, and borderline intellectual functioning. Id. The ALJ also found Claimant had nonsevere impairments of hyperlipidemia, sleep apnea, iron deficient anemia, and stable moderate lower thoracic spondylosis. (R. 17-18). However, at step three, the ALJ concluded these impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 18-20). Applying the technique prescribed by the regulations, the ALJ found that Claimant's mental impairments have resulted in a mild limitation in understanding, remembering, or applying information; interacting with others; and adapting or managing oneself and a moderate limitation in concentrating, persisting, or maintaining pace. (R. 20).
The ALJ noted Claimant's testimony at the hearing that she was working thirty-two hours a week, records indicated she was working forty hours a week earning $10/hour, and even at thirty-two hours a week the earnings would rise to the level of substantial gainful activity. (R. 17). However, the ALJ did not deny the claim at step one but proceeded through the five steps of the sequential evaluation process. (R. 17-30).
Prior to proceeding to step four, the ALJ assessed Claimant's RFC, finding Claimant had the ability to perform light work with the following limitations:
Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, you must have the ability to do substantially all of these activities. If an individual can perform light work, he or she can also perform sedentary work, unless there are additional limiting factors such as the loss of fine dexterity or the inability to sit for long periods of time. 20 C.F.R. § 404.1567(b).
she must avoid concentrated exposure to temperature extremes, wetness, humidity, and pulmonary irritants, such as fumes, odors, dusts, gases, poor ventilation, and the like. Also, avoid concentrated exposure to workplace hazards, such as dangerous moving machinery and unprotected heights. She is generally able to understand and perform simple, routine, repetitive tasks, and she is able to maintain concentration, persistence, and pace to stay on task for 2-hour periods over the course of a typical 8-hour workday with normal breaks. She has postural limitations to include frequent climbing ramps and stairs, occasional climbing ladders, ropes, or scaffolds, and frequent balancing, kneeling, stooping, crouching, and/or crawling.(R. 20-29). In making this assessment, the ALJ found Claimant's statements about her limitations “not persuasive of disability based upon the medical and other evidence in the record.” (R. 27). At step four, the ALJ concluded Claimant had the RFC to perform the requirements of her past relevant work as a housekeeper. (R. 29). Alternatively, at step five, upon considering Claimant's age, education, work experience, and RFC, the ALJ determined Claimant is capable of adjusting to the demands of other employment opportunities that exist in significant numbers in the national economy. (R. 29-30).
V. DISCUSSION
Claimant contends that the ALJ failed to incorporate into the RFC sufficient non-exertional limitations on her ability to stay on task where the ALJ determined Claimant was moderately impaired in the ability to maintain concertation, persistence, and pace. Pl.'s Mem. [DE-19] at 716. The Commissioner contends that the ALJ fully explained his reasons for assessing Plaintiff's RFC without the need for further limitations, and the decision is supported by substantial evidence in the record. Def.'s Mem. [DE-22] at 4-13.
Claimant also questions whether the ability to stay on task for two-hour periods over the course of an eight-hour workday with normal breaks is even a limitation on her ability to work, when a normal workday includes a morning break, a lunch period, and an afternoon break at approximately two-hour intervals. Pl.'s Mem. [DE-19] at 14-16. The court need not consider this question because consideration of the first argument assumes the ALJ did not limit Claimant beyond SRRTs.
An individual's RFC is the capacity she possesses despite the limitations caused by physical or mental impairments. 20 C.F.R. § 404.1545(a)(1); see also S.S.R. 96-8p, 1996 WL 374184, at *1 (July 2, 1996). The RFC is based on all relevant medical and other evidence in the record and may include a claimant's own description of limitations arising from alleged symptoms. 20 C.F.R. § 404.1545(a)(3); see also S.S.R. 96-8p, 1996 WL 374184, at *5. Where a claimant has numerous impairments, including non-severe impairments, the ALJ must consider their cumulative effect in making a disability determination. 42 U.S.C. § 423(d)(2)(B); see Hines v. Brown, 872 F.2d 56, 59 (4th Cir. 1989) (“[I]n determining whether an individual's impairments are of sufficient severity to prohibit basic work related activities, an ALJ must consider the combined effect of a claimant's impairments.”) (citations omitted).
The Fourth Circuit held in Mascio v. Colvin that “an ALJ does not account ‘for a claimant's limitation in concentration, persistence, and pace by restricting the hypothetical question to simple, routine tasks or unskilled work.'” 780 F.3d 632, 638 (4th Cir. 2015) (quoting Winschel v. Comm 'r of Soc. Sec., 631 F.3d 1176, 1180 (11th Cir. 2011) (joining the Third, Seventh, and Eighth Circuits)). The court explained that “the ability to perform simple tasks differs from the ability to stay on task” and that “[o]nly the latter limitation would account for a claimant's limitation in concentration, persistence, or pace.” Id. The court acknowledged there could be instances where a moderate limitation in concentration, persistence, or pace at step three does not require a limitation in the RFC; however, the failure to explain such a result is error requiring remand. Id. (“Perhaps the ALJ can explain why Mascio's moderate limitation in concentration, persistence, or pace at step three does not translate into a limitation in Mascio's residual functional capacity. . . . But because the ALJ here gave no explanation, a remand is in order.”); see also Shinaberry v. Saul, 952 F.3d 113, 122 (4th Cir. 2020) (holding that ALJ decision comported with Mascio where the ALJ explained why evidence supported mental limitation to simple, routine, repetitive tasks and included limitations in hypothetical to VE); Iva K. v. Soc. Sec. Admin., No. 1: 19-CV-02954-JMC, 2020 WL 3060752, at *4 (D. Md. June 9, 2020) (“[P]ursuant to Mascio, once the ALJ made a step three finding that a claimant suffers from moderate difficulties in concentration, persistence, or pace, the ALJ must either include a corresponding limitation in the RFC assessment, or explain why no such limitation is necessary.”).
The ALJ first determined that Claimant was moderately impaired in the maintenance of concentration, persistence, and pace. (R. 20). In support of this determination the ALJ explained that
the claimant reported difficulty with concentration and indicated she could only pay attention for 15 to 20 minutes. She was found to be easily distracted (Exhibit 10F/9-12). However, further examinations noted she was focused (Exhibit 12F and 16F). Additionally, she reported she was able to drive, shop in stores, handle money, and watch television (Exhibit 7E and Hearing Testimony).(R. 20). Next, in determining Claimant's RFC, the ALJ discussed Claimant's testimony at the administrative hearing, the mental health diagnostic and treatment notes, and the opinion evidence. (R. 21, 23, 25-29). The ALJ concluded that Claimant is “generally able to understand and perform simple, routine, repetitive tasks [“SRRTs”], and she is able to maintain concentration, persistence, and pace to stay on task for 2-hour periods over the course of a typical 8-hour workday with normal breaks.” (R. 20-21).
The ALJ's determination that Claimant's moderate limitation in concentration, persistence, or pace did not require a limitation, beyond one to SRRTs, in the RFC is supported by substantial evidence, and the ALJ's decision allows for meaningful review. The ALJ discounted Claimant's mental health treatment, beginning in November 2016 after a heart attack, where she reported depression and visual hallucinations. (R. 23). Claimant's attention and concentration were “focused” on November 17, but she was noted to be “easily distracted” on November 23. (R. 23, 485, 488). The ALJ noted that at an August 2017 appointment for medication refills Claimant reported that she felt fine, had mild occasional depression, did not require adjustment to medications, and had focused attention and concentration. (R. 25, 500, 503). The ALJ discussed a January 2018 treatment note stating that Claimant had missed an appointment, run out of medication, started seeing shadows, and wanted to restart her medications. (R. 25, 962). However, it was also noted that Claimant reported her mood had been good and she was focused. (R. 25, 962, 965). The ALJ also discussed a July 2018 follow up appointment where Claimant reported doing “good” with no depression, and her mental examination was normal. (R. 26, 982, 985-86).
The ALJ also discussed and weighed the January 5, 2017 opinion of the state agency psychological consultant, Dr. Fulmer, who determined Claimant was capable of sustaining attention to perform SRRTs, interacting with others, and adapting to changes. (R. 27, 89). Dr. Fulmer found that with respect to “the ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods, ” Claimant was “not significantly limited” and that she was “capable of sustaining attention to perform SRRT.” (R. 93). The ALJ found this opinion to be overall consistent with and supported by the record, citing to the mental health treatment records discussed above, and gave it partial weight. (R. 27). Finally, the ALJ discussed and weighed the January 2012 opinion of a consultative examiner, Dr. Albert, who determined Claimant was functioning in the lower part of the borderline range of intellectual ability, was basically a “slow learner, ” was able to understand, retain, and follow simple directions, and could sustain attention to perform routine repetitive tasks on the simple jobs. (R. 28, 298-301). The ALJ concluded that “[p]rior to starting medication, [Claimant] was noted to have some issues with memory and concentration (Exhibit 10F/9-12). However, after starting medications, her examinations were consistently within normal limits, showing she was focused, her memory was intact, and her fund of knowledge was good as was selection of words for communication (Exhibit 12F and 16F).” (R. 28-29).
The ALJ's RFC is consistent with opinions he discussed and favorably weighed from the state agency reviewer and consultative examiner, which concluded Claimant's mental impairments of borderline intellectual functioning and depression would not impact her ability to sustain the attention necessary to perform SRRTs, and the treatment notes lend further support for this conclusion. See Shinaberry, 952 F.3d at 121 (“[W]hen medical evidence demonstrates that a claimant can engage in simple, routine tasks or unskilled work despite limitations in concentration, persistence, and pace, courts have concluded that limiting the hypothetical to include only unskilled work sufficiently accounts for such limitations.” (quoting Winschel v. Comm 'r of Soc. Sec., 631 F.3d 1176, 1180 (11th Cir. 2011)); Conti Sutherland v. Saul, No. 5:19-CV-551-FL, 2021 WL 1026947, at *4 (E.D. N.C. Mar. 17, 2021) (“Where . . . the ALJ explicitly relied on a medical source's evaluation of plaintiff's ability to stay on task, where substantial evidence supports that evaluation, and where the ALJ connected that evaluation to the RFC, the ALJ's failure to expressly quantify the number of hours or days that plaintiff can work does not require remand.” (citing Sizemore v. Berryhill, 878 F.3d 72, 80-81 (4th Cir. 2017)).
The ALJ could have done a better job connecting the evidence to the RFC determination. In Thomas v. Berryhill the Fourth Circuit explained that a proper RFC analysis contains a “logical explanation” connecting the evidence to the conclusion. 916 F.3d 307, 311 (4th Cir. 2019) (concluding the ALJ erred by failing to provide a logical explanation of how she weighed the record evidence and arrived at her RFC findings) (citing Woods v. Berryhill, 888 F.3d 686 (4th Cir. 2018); Monroe v. Colvin, 826 F.3d 176 (4th Cir. 2016); and Mascio, 780 F.3d at 632)). However, the ALJ's decision in Thomas contained errors that frustrated meaningful review not present in this case, such as failing to weigh or even discuss significant evidence related to the claimant's mental health treatment and including an undefined limitation to no “production rate or demand pace” work in the RFC. Id. at 312. In this case, the ALJ discussed the relevant mental health treatment notes and weighed favorably two medical opinions concluding that Claimant could sustain the attention necessary to perform SRRTs. (R. 23, 25-29). It is apparent from the ALJ's decision why no limitation in the RFC, beyond a limitation to SRRTs, was necessary despite Claimant's moderate limitation in concentration, persistence, or pace, and the ALJ's decision allows for meaningful review. See Dunn v. Colvin, 607 Fed.Appx. 264, 276 (4th Cir. June 1, 2015) (“[T]he fact that the ALJ could have offered a more thorough explanation for his decision does not change our conclusion that substantial evidence in the record supports that decision.”). Accordingly, it is recommended that the decision of the Commissioner be affirmed.
VI. CONCLUSION
For the reasons stated above, it is RECOMMENDED that Claimant's Motion for Judgment on the Pleadings [DE-18] be DENIED, Defendant's Motion for Judgment on the Pleadings [DE-21] be ALLOWED, and the final decision of the Commissioner be AFFIRMED.
IT IS DIRECTED that a copy of this Memorandum and Recommendation be served on each of the parties or, if represented, their counsel. Each party shall have until June 30, 2021 to file written objections to the Memorandum and Recommendation. The presiding district judge must conduct his or her own review (that is, make a de novo determination) of those portions of the Memorandum and Recommendation to which objection is properly made and may accept, reject, or modify the determinations in the Memorandum and Recommendation; receive further evidence; or return the matter to the magistrate judge with instructions. See, e.g, 28 U.S.C. § 636(b)(1); Fed.R.Civ.P. 72(b)(3); Local Civ. R. 1.1 (permitting modification of deadlines specified in local rules), 72.4(b), E.D. N.C. Any response to objections shall be filed by within 14 days of the filing of the objections.
If a party does not file written objections to the Memorandum and Recommendation by the foregoing deadline, the party will be giving up the right to review of the Memorandum and Recommendation by the presiding district judge as described above, and the presiding district judge may enter an order or judgment based on the Memorandum and Recommendation without such review. In addition, the party's failure to file written objections by the foregoing deadline will bar the party from appealing to the Court of Appeals from an order or judgment of the presiding district judge based on the Memorandum and Recommendation. See Wright v. Collins, 766 F.2d 841, 846-47 (4th Cir. 1985).