Opinion
C. A. 0:20-cv-2671-DCC-PJG
08-26-2021
Nancy Erwin, Plaintiff, v. Andrew Saul, Commissioner of the Social Security Administration, Defendant.
REPORT AND RECOMMENDATION ON PLAINTIFF'S APPEAL FROM THE SOCIAL SECURITY ADMINISTRATION'S DENIAL OF SOCIAL SECURITY BENEFITS
PAIGE J. GOSSETT, UNITED STATES MAGISTRATE JUDGE
[] Affirm
[X] Reverse and Remand
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 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 the plaintiff's claims for social security benefits.
Part I-Plaintiff seeks:
[] Supplemental Security Income (“SSI”): Plaintiff's age at filing:
[X] Disability Insurance Benefits (“DIB”): Date last insured: December 31, 2018
[] Other:
Application Dated: February 28, 2018
Plaintiff's Year of Birth: 1960
Plaintiff's alleged onset Dated: July 1, 2017
Part II-Social Security Disability Generally
Under 42 U.S.C. § 423(d)(1)(A), (d)(5), and/or 42 U.S.C. § 1382c(a)(3)(H)(i), 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) and/or § 416.905(a); see also Blalock v. Richardson, 483 F.2d 773 (4th Cir. 1973). The regulations generally require the Administrative Law Judge (“ALJ”) to consider five issues in sequence, as outlined below. 20 C.F.R. § 404.1502(a)(4) and/or § 416.920(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.
A claimant has the initial burden of showing that he/she is unable to return to past relevant work because of his/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) and/or § 1382c(a)(3)(A)-(B); 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).
Part III-Administrative Proceedings
Date of ALJ Decision: September 18, 2019
In applying the requisite five-step sequential process, the ALJ found:
Step 1: Plaintiff was engaged in substantial gainful activity during the relevant time period:
[] Yes [X] No
Step 2: [X] Plaintiff has the following severe impairments:
Heart Failure, Coronary Artery Disease (CAD), Dilated Cardiomyopathy
[] Plaintiff does not have a severe impairment.
Step 3: [X] Plaintiff's impairment(s) does/do not meet or medically equal a Listing. 20 C.F.R. Part 404, Subpart P, Appendix 1.
Step 4: Plaintiff's Residual Functional Capacity is as follows:
After careful consideration of the entire record, the undersigned finds that, through the date last insured, the claimant had the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a) except she can never climb ladders, ropes, or scaffolds. She engages in occasional balancing, stooping, kneeling, crouching, crawling and climbing ramps or stairs. She must avoid concentrated exposure to workplace hazards such as unprotected heights and moving machinery and extreme cold or heat.
[X] Plaintiff could return to his/her past relevant work as a Payroll Clerk, Personnel Clerk, and Accounting Clerk.Date of Appeals Council decision: June 11, 2020
Part IV-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 Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019); Pearson v. Colvin, 810 F.3d 204, 207 (4th Cir. 2015). “Under the substantial-evidence standard, a court looks to an existing administrative record and asks whether it contains ‘sufficien[t] evidence' to support the agency's factual determinations.” Biestek, 139 S.Ct. at 1154 (citation omitted). 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.
Part V-Issues for Judicial Review
Plaintiff asserts that the ALJ improperly evaluated two medical opinions-one offered by a consultative examiner, Dr. Charles Tollison, and one offered by treating practitioners, Dr. Jason (“CCC”).
Oral Argument:
[] Held on__.
[X] Not necessary for recommendation.
Summary of Reasons
Effective March 27, 2017, the federal regulations were amended with regard to applications filed on or after that date, and the new regulations enumerated in 20 C.F.R. § 404.1520c are applicable here. The new regulations provide that the ALJ will no longer “give any specific evidentiary weight . . . to any medical opinion(s) . . . including those from [the claimant's] medical sources, ” but the ALJ is still directed to weigh them pursuant to the same factors previously provided for weighing opinion evidence. See 20 C.F.R. § 404.1520c. The ALJs are instructed to consider and evaluate the persuasiveness of the opinion evidence considering supportability, consistency, relationship with the claimant, specialization, and other factors that tend to support or contradict a medical opinion. Id. Supportability and consistency are the most important factors to consider, and an ALJ must explain how these factors are considered. As to supportability, the regulation states, “[t]he more relevant the objective medical evidence and supporting explanations presented by a medical source are to support his or her medical opinion(s) . . ., the more persuasive the medical opinions . . . will be.” Id. As to consistency, “[t]he more consistent a medical opinion(s) . . . is with the evidence from other medical sources and nonmedical sources in the claim, the more persuasive the medical opinion(s) . . . will be.” Id. The ALJ may, but is not required to, explain how the other factors are considered. Id.
Although a treating physician's opinion is no longer entitled to controlling weight, the ALJ's reasons for finding the opinion of a medical source unpersuasive still must be supported by substantial evidence. The United States Court of Appeals for the Fourth Circuit has repeatedly stated that “[a]n 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.” Lewis v. Berryhill, 858 F.3d 858, 869 (4th Cir. 2017) (quoting Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010)); see also Arakas v. Comm'r, 983 F.3d 83, 98 (4th Cir. 2020). Moreover, an ALJ continues to have an obligation to “include a narrative discussion describing how the evidence supports each conclusion.” Monroe v. Colvin, 826 F.3d 176, 190 (4th Cir. 2016) (quoting Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015)); see also SSR 96-8p. Similarly, remand may be appropriate when the courts are left to guess at how the ALJ arrived at the conclusions and meaningful review is frustrated. Mascio, 780 F.3d at 636-37. The ALJ must “build an accurate and logical bridge from the evidence to his conclusions.” Monroe, 826 F.3d at 189.
Carolina Cardiology Consultants' Opinion
On May 29, 2018, Nurse Practitioner Sarah S. Matthews drafted a letter, in which Dr. Jason Leon Guichard joined, detailing the following course of treatment and reasons for disability:
This letter will be referred to as the CCC letter or the CCC opinion, here.
Ms. Erwin was initially seen in our clinic by Dr. Shah back in July of 2017 for progressive shortness of breath. Based off her symptoms and EKG, Dr. Shah ordered an echocardiogram. Echo showed severely depressed ejection fraction of 25 to 30%. Dr. Shah started her on a beta blocker and Entresto in addition to Lasix. She subsequently underwent two left heart catheterization in August 2017 and November 2017 that resulted in two drug-eluting stents to the RCA and OMI. After being on goal directed medical therapy for three months from PCI, cardiac MRE showed EF had improved slightly to 41%. Thus, ICD therapy was not indicated.
Ms. Erwin has continued to be followed since PCI by our heart failure specialist, Dr. Guichard, and myself. She has been compliant with medications. She has also been participating in cardiac rehab with Heartlife. Her heart failure regimen has been optimized. Despite all treatment and interventions, Ms. Erwin has continued
to struggle with heart failure symptoms to a disabling degree. She still has dyspnea on exertion and fatigue throughout the day.
Based on her AHA Stage C heart failure diagnosis with NYHA class III symptoms, it is our recommendation that Ms. Erwin be considered for permanent disability status.(Tr. 589.)
In analyzing Plaintiff's claim for disability, the ALJ briefly recited Plaintiff's medical history and her complaints. He then considered the medical opinions offered in Plaintiff's case, ultimately finding that none of them were persuasive. (Tr. 15-16.) As to the CCC letter, the ALJ rejected the opinions by Dr. Guichard and Nurse Practitioner Matthews based on the following reasoning:
I . . . find that the opinion in Exhibit 4F is not persuasive. It suggests that the claimant be “considered for permanent disability status, ” but I cannot reconcile this with the fact that the claimant stabilized from a cardiology standpoint and the record shows that she functions much better on a proper medication regimen, as shown above. I specifically note that the cardiology notes in Exhibit 11F, which span the time period October 15, 2018 to April 24, 2019, show “She has been doing OK, no major complaints today” (10/15/18, page 6); “She has done well with GDMT. She has participated in cardiac rehab as well. Today, she is here mostly with questions” (11/27/18, page 18); “Ms. Erwin continues to do well, minimal restrictions in activity. Remains active. BP and HR are stable” (2/19/19, page 30). These notations suggest the ability to perform within the sedentary level of exertion, as above.(Tr. 16.)
Plaintiff argues that although the ALJ acknowledged Plaintiff's New York Heart Association (“NYHA”) Class III classification earlier in his decision, he failed to consider the limitations of that classification in conjunction with the opinions expressed in the CCC letter. (Pl.'s Br. at 28, ECF No. 14 at 30.) Plaintiff further asserts that “it was improper for the ALJ to rely on notations of doing well or stability in light of the continued problems and treatment that Erwin required.” (Pl.'s Br. at 29, ECF No. 14 at 31.) The Commissioner counters that the ALJ considered the CCC opinion pursuant to the new regulatory framework, and to the extent the CCC letter opines that Plaintiff should be “considered for permanent disability status[, ]” that is not a medical opinion under the regulations. (Def.'s Br. at 13, ECF No. 15 at 13.) Additionally, the Commissioner argues that the NYHA classification in the CCC opinion does not mandate a disability finding and highlights other instances in the record where Plaintiff was diagnosed with Class II symptoms. (Def.'s Br. at 14, ECF No. 15 at 14.)
The parties agree that the recommendation in the CCC letter that Plaintiff “be considered for permanent disability status” is not a medical opinion under the applicable regulations. (Def.'s Br. at 13, ECF No. 15 at 13; Pl.'s Reply at 5, ECF No. 16 at 5.) Indeed, statements on issues reserved to the Commissioner-for example, whether a plaintiff is disabled-are “inherently neither valuable nor persuasive” under the new regulations. 20 C.F.R. § 404.1520b. Nevertheless, where such an opinion also includes functional limitations rising to the level of a medical opinion pursuant to 20 C.F.R. § 404.1513(a)(2), it must be considered. See 20 C.F.R. § 404.1520c. Of the opinions expressed in the CCC letter, the ALJ addressed only the statement that Plaintiff be “ ‘considered for permanent disability status[.]' ” (Tr. 16) (quoting Tr. 589). The ALJ did not address the opined functional limitations of “dyspnea on exertion and fatigue throughout the day.” (Tr. 589.) Nor did the ALJ discuss Plaintiff's “AHA Stage C heart failure diagnosis with NYHA class III symptoms, ” (Tr. 589), which corresponds to “[m]arked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea [(shortness of breath)].” Classes of Heart Failure, American Heart Association (May 31, 2017), https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/classes-of-heart-failure (last visited Aug. 18, 2021). It is unclear whether the ALJ considered these limitations and whether they would preclude Plaintiff from performing a range of sedentary work without any additional mental limitations. As a result of the ALJ's focus on a statement in the CCC letter that was not a medical opinion under the regulations, his reasoning for finding the opinion not persuasive was similarly misplaced. In particular, the evidence that the ALJ identified as irreconcilable with the letter's general recommendation that Plaintiff be considered for permanent disability did not address the functional limitations opined by Nurse Practitioner Matthews and Dr. Guichard. It is unclear to what extent, if at all, the ALJ considered the relevant medical opinion expressed in the CCC letter.
As explained above, upon review of the ALJ's decision and the record, the court is unable to determine whether the ALJ's decision as to the persuasiveness of the CCC opinion is supported by substantial evidence. See 20 C.F.R. § 404.1520c. Because it is unclear whether the ALJ properly considered all of the evidence in discounting the medical opinions and in finding Plaintiff capable of returning to her past relevant work, the court is constrained to agree with Plaintiff that the ALJ's consideration of the evidence frustrates meaningful review. See, e.g., Mascio, 780 F.3d at 636-37 (holding remand may be appropriate when courts are let to guess at how the ALJ arrived at the conclusion 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). The Commissioner has offered record-based reasons that the ALJ could have rejected the opinion expressed in the CCC letter, but such reasoning was not offered by the ALJ. See Bray v. Comm'r of Soc. Sec. Admin., 554 F.3d 1219, 1225 (9th Cir. 2005) (“Long-standing principles of administrative law require us to review the ALJ's decision based on the reasoning and factual findings offered by the ALJ-not post hoc rationalizations that attempt to intuit what the adjudicator may have been thinking.”). It is the purview of the ALJ, and not the court, to first consider and weigh the evidence. See Craig, 76 F.3d at 589 (stating that the court may not “undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]”); Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990) (holding that it is the ALJ's responsibility, not the court's, to determine the weight of evidence and resolve conflicts of evidence). Therefore, the court is constrained to recommend that this matter be remanded for further consideration of this opinion evidence.
In light of the court's recommendation that this matter be remanded for further consideration, the court need not address Plaintiffs remaining arguments, as they 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, Plaintiff may present her remaining arguments concerning the ALJ's alleged errors on remand.
RECOMMENDATION
It is recommended that this matter be
[] Affirmed. Plaintiff has failed to show that the Commissioner's decision was unsupported by substantial evidence or controlled by an error of law.
[X] Reversed and remanded pursuant to M Sentence Four □ Sentence Six of 42 U.S.C. § 405(g) for further consideration consistent with this Order.
[] Reversed and remanded for an award of benefits.
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).