Opinion
C/A No. 9:20-1734-BHH-MHC
04-22-2021
Theresa Ann Foster, Plaintiff, v. Andrew M. Saul, Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
Plaintiff Theresa Ann Foster filed the complaint in this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final decision of Defendant Commissioner of Social Security (the Commissioner) denying her claim for Disability Insurance Benefits (DIB) under Title II of the Social Security Act. This case was referred to the undersigned for a report and recommendation pursuant to 28 U.S.C. § 636(b) and Local Civil Rule 73.02(B)(2)(a) (D.S.C.). Having carefully considered the parties' submissions and the applicable law, the undersigned recommends that the Commissioner's decision be reversed and remanded for further findings for the reasons that follow.
I. BACKGROUND
A. Procedural History
Plaintiff applied for DIB on November 3, 2016, alleging disability beginning January 31, 2016. R.pp. 169-170. Plaintiff's claim was denied initially on March 6, 2017, and upon reconsideration on June 16, 2017. Plaintiff then requested a hearing before an Administrative Law Judge (ALJ). R.pp. 15, 78, 88, 95. A hearing, at which Plaintiff and a vocational expert (VE) testified, was held on April 19, 2019. R.p. 15. The ALJ thereafter denied Plaintiff's claims in a decision issued on April 29, 2019, finding that Plaintiff was not disabled from the date of her application through the date of the decision. R.pp. 15-27.
Plaintiff states in her brief that she also applied for benefits under Title XVI, ECF No. 17 at 1; however, her application is only for Title II benefits.
The Appeals Council denied Plaintiff's timely request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. R.pp. 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision.
B. ALJ's Decision
The ALJ found, in pertinent part:
1. The [Plaintiff] meets the insured status requirements of the Social Security Act through June 30, 2022.
2. The [Plaintiff] has not engaged in substantial gainful activity since January 31, 2016, the alleged onset date (20 CFR 404.1571 et seq.).
3. The [Plaintiff] has the following "severe" impairments: obesity; bilateral carpal tunnel syndrome; status-post left shoulder rotator cuff repair; left shoulder bursitis; major depression and adjustment disorder with anxiety (20 CFR 404.1520(c)).
4. The [Plaintiff] does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, and 404.1526).
5. After careful consideration of the entire record, I find that the [Plaintiff] has the residual functional capacity to perform medium work as defined in 20 CFR 404.1567(c) except: she is limited to lifting and carrying up to 20 pounds occasionally and 10 pounds frequently with the left arm only; however, she is able to lift and carry up to 50 pounds occasionally and 25 pounds frequently using the left arm as an assist to the right arm; there are no limitations on sitting, standing, and walking; she is limited to occasional overhead reaching with the left arm; she is limited to frequent use of the hands for fingering; she is limited to simple and detailed tasks (SVP 1 through 4) but is precluded from performing complex tasks (SVP 5 and above); and she requires no more than occasional changes in the work routine.
"Medium work involves lifting no more than 50 pounds at a time with frequent lifting or carrying of objects weighing up to 25 pounds." 20 C.F.R. §§ 404.1567(c), 416.967(c).
6. The [Plaintiff] is capable of performing past relevant work as a hand packager (DOT code 920.587-018, medium work activity with an SVP of 2). This work as generally performed does not require the performance of work-related activities precluded by the [Plaintiff]'s residual functional capacity (20 CFR 404.1565).
7. In the alternative, considering the [Plaintiff]'s age, education, work experience, and residual functional capacity, there are other jobs that exist in significant numbers in the national economy that the [Plaintiff] can also perform (20 CFR 404.1569 and 404.1569a).
8. The [Plaintiff] has not been under a disability, as defined in the Social Security Act, from January 31, 2016 through the date of this decision (20 CFR 404.1520(f)). R.pp. 15-27.
The ALJ made the following decision regarding Plaintiff's claim: "Based on the application for a period of disability and disability insurance benefits filed on November 3, 2016, the [Plaintiff] is not disabled under sections 216(i) and 223(d) of the Social Security Act." R.p. 27.
II. APPLICABLE LAW
A. Scope of Review
Jurisdiction of this Court is pursuant to 42 U.S.C. § 405(g). Under § 405(g), judicial review of a final decision regarding disability benefits is limited to determining (1) whether the factual findings are supported by substantial evidence, and (2) whether the correct legal standards were applied. 42 U.S.C. § 405(g); Walls v. Barnhart, 296 F.3d 287, 290 (4th Cir. 2002) (citing Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990)). Accordingly, a reviewing court must uphold the final decision when "an ALJ has applied correct legal standards and the ALJ's factual findings are supported by substantial evidence." Brown v. Comm'r Soc. Sec. Admin., 873 F.3d 251, 267 (4th Cir. 2017) (internal quotation marks omitted).
"Substantial evidence" is an evidentiary standard that is not high: it is "more than a mere scintilla" and means only "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019). A reviewing court does not reweigh conflicts in evidence, make credibility determinations, or substitute its judgment for that of the ALJ. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). "Where conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the responsibility for that decision falls on the [ALJ]." Id. (alteration in original) (internal quotation marks and citation omitted).
However, this limited review does not mean the findings of an ALJ are to be mechanically accepted, as the "statutorily granted review contemplates more than an uncritical rubber stamping of the administrative action." Howard v. Saul, 408 F. Supp. 3d 721, 725-26 (D.S.C. 2019) (quoting Flack v. Cohen, 413 F.2d 278, 279 (4th Cir. 1969)); see also Lewis v. Berryhill, 858 F.3d 858, 870 (4th Cir. 2017). To pass muster, ALJs must "build an accurate and logical bridge" from the evidence to their conclusions. Arakas v. Comm'r, Soc. Sec. Admin., 983 F.3d 83, 95 (4th Cir. 2020)(citing Monroe v. Colvin, 826 F.3d 176, 189 (4th Cir. 2016)(quoting Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000)).
B. Social Security Disability Evaluation Process
To be considered "disabled" within the meaning of the Social Security Act, a claimant must show that she has an impairment or combination of impairments which prevent her from engaging in all substantial gainful activity for which she is qualified by her age, education, experience, and functional capacity, and which has lasted or could reasonably be expected to last for a continuous period of not less than twelve months. See 42 U.S.C. § 423. The Social Security Administration established a five-step sequential procedure in order to evaluate whether an individual is disabled for purposes of receiving DIB. See 20 C.F.R. § 404.1520; see also Mascio v. Colvin, 780 F.3d 632, 634-35 (4th Cir. 2015) (outlining the questions asked in the five-step procedure). The burden rests with the claimant to make the necessary showings at each of the first four steps to prove disability. Mascio, 780 F.3d at 634-35. If the claimant fails to carry her burden, she is found not disabled. Lewis, 858 F.3d at 861. If the claimant is successful at each of the first four steps, the burden shifts to the Commissioner at step five. Id.
At the first step, the ALJ must determine whether the claimant has engaged in substantial gainful activity since her alleged disability onset date. 20 C.F.R. § 404.1520(b). At step two, the ALJ determines whether the claimant has an impairment or combination of impairments that meet the regulations' severity and duration requirements. Id. § 404.1520(c). At step three, the ALJ considers whether the severe impairment meets the criteria of an impairment listed in Appendix 1 of 20 C.F.R. part 404, subpart P (the "Listings") or is equal to a listed impairment. If so, the claimant is automatically eligible for benefits; if not, before moving on to step four, the ALJ assesses the claimant's residual functional capacity (RFC). Id. § 404.1520(d), (e); Lewis, 858 F.3d at 861. At step four, the ALJ determines whether, despite the severe impairment, the claimant retains the RFC to perform her past relevant work. 20 C.F.R. § 404.1520(e), (f). If the ALJ finds the claimant capable of performing her past relevant work, she is not disabled. Id. § 404.1520(f). If the requirements of the claimant's past relevant work exceed her RFC, then the ALJ goes on to the final step.
The RFC is "the most the claimant can still do despite physical and mental limitations that affect her ability to work." Mascio, 780 F.3d at 635 (internal quotation marks and citations omitted).
At step five, the burden of proof shifts to the Social Security Administration to show that the claimant can perform other jobs existing in significant numbers in the national economy, considering the claimant's age, education, work experience, and RFC. Id. § 404.1520(g); Mascio, 780 F.3d at 634-35. Typically, the Commissioner offers this evidence through the testimony of a VE answering hypotheticals that incorporate the claimant's limitations. Mascio, 780 F.3d at 635. "If the Commissioner meets her burden, the ALJ finds the claimant not disabled and denies the application for benefits." Id.
III. DISCUSSION
Plaintiff asserts there is not substantial evidence to support the ALJ's decision that she is not disabled or to deny her claim for benefits. Specifically, she argues that the ALJ improperly evaluated her statements regarding her symptoms and erred in his assessment of her physical and mental RFC. The Commissioner contends that substantial evidence supports the ALJ's analysis of Plaintiff's subjective testimony, as well as her physical and mental RFC, such that the decision should be affirmed.
1. Subjective Statements
A claimant's statements are among the evidence the ALJ must consider and reconcile with his RFC assessment. "[A]n ALJ follows a two-step analysis when considering a claimant's subjective statements about impairments and symptoms." Lewis, 858 F.3d at 865-66 (citing 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." Id. at 866 (citing 20 C.F.R. §§ 404.1529(b), 416.929(b)). The ALJ proceeds to the second step only if the claimant's impairments could reasonably produce the symptoms she alleges. See 20 C.F.R. §§ 404.1529(c)(1), 416.929(c)(1).
At the second step, the ALJ is required to "evaluate the intensity, persistence, and limiting effects of the claimant's symptoms to determine the extent to which they limit the claimant's ability to perform basic work activities." Lewis, 858 F.3d at 866 (citing 20 C.F.R. §§ 404.1529(c), 416.929(c)). The ALJ must "evaluate whether the [claimant's] statements are consistent with objective medical evidence and the other evidence." Soc. Sec. Ruling 16-3p: Titles II & XVI: Evaluation of Symptoms in Disability Claims, SSR 16-3P, 2017 WL 5180304, at *6 (S.S.A. Oct. 25, 2017). Pursuant to SSR 16-3p, the ALJ must explain which of the claimant's symptoms the ALJ found "consistent or inconsistent with the evidence in [the] record and how [the ALJ's] evaluation of the individual's symptoms led to [the ALJ's] conclusions." 2017 WL 5180304, at *8. The ALJ must evaluate the "individual's symptoms considering all the evidence in [the] record." Id.
Here, after formulating Plaintiff's RFC, the ALJ summarized Plaintiff's hearing testimony as follows:
The claimant testified that she has ongoing left shoulder pain with any sort of movement and she has limitation in her ability to lift. The claimant further stated that she has difficulty remembering things and has to make a list when she goes grocery shopping. She further states that she has limitation with the use of her hands, she can no longer do her own hair and she needs help to perform activities during the day.R.p. 21.
Plaintiff's testimony at the hearing regarding her shoulder, memory and hands can be found at R.pp. 18-25.
With regard to the first step in the two-step process for considering Plaintiff's symptoms, the ALJ found that Plaintiff's medically determinable impairments could reasonably be expected to cause "only a portion of the alleged symptoms; consequently, [her] 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." R.pp. 24-25. This statement suggests that there were some symptoms stated by Plaintiff that could not reasonably be expected to be produced by her medically determinable impairments. However, the ALJ did not identify what those symptoms were.
The "severe" impairments identified by the ALJ were obesity; bilateral carpal tunnel syndrome; status-post left shoulder rotator cuff repair; left shoulder bursitis; major depression and adjustment disorder with anxiety. R.p. 17.
The ALJ's observation here appears directed more toward addressing the "intensity, persistence and limiting effects" of Plaintiff's symptoms, rather than whether any medically determinable impairment actually produced those symptoms. However, without further explanation from the ALJ, it is difficult to discern if, in fact, that is the case.
Instead, in the second step of the analysis process, the ALJ provided some explanation as to how he determined the extent to which at least two of the three symptoms he identified in the summary of Plaintiff's testimony limited her ability to perform basic work activities. See Lewis, 858 F.3d at 866; SSR 16-3p,2017 WL 5180304, at *8. Specifically, the ALJ addressed Plaintiff's testimony regarding her left shoulder pain and memory issues, identifying evidence in the record with which the testimony was inconsistent. R.p.25.
For example, the ALJ noted that although physical examinations showed Plaintiff had some ongoing limitation of her left shoulder following her rotator cuff surgery, they did not support her allegations of complete inability to perform work at any exertional level. R.p. 25. In contrast to her complaints, Plaintiff's physicians reported that she had 5/5 strength in her upper extremities. Id. The ALJ referred to evidence that showed that although Plaintiff still had some pain and mild weakness in her left arm, her left shoulder was stable and neurovascularly intact with good range of motion, and an MRI showed no significant rotator cuff issue apart from a small area that possibly had not healed. R.p. 22. The ALJ further noted that, although Plaintiff alleged significant problems with her memory and concentration from depression, her mental status examinations were consistently normal. R.pp. 23-25.
However, the ALJ provided no evaluation of Plaintiff's statements regarding the limited use of her hands from carpal tunnel syndrome. Plaintiff testified that, at times, she "can't even open a bottle of water" because of her carpal tunnel syndrome. R.pp.18-19. She explained that she cannot use zippers or buttons because her "hands are numb a lot" and that she "can't do anything with her hands." R.p.19. By way of example, she provided that she cannot wash her own hair and needs help getting dressed or taking a bath; and she cannot tie her shoes, open a pill bottle or fold most of her laundry. R.pp. 19, 21. Pursuant to SSR 16-3p, the ALJ must explain which of the claimant's symptoms the ALJ found "consistent or inconsistent with the evidence in [the] record and how [the ALJ's] evaluation of the individual's symptoms led to [the ALJ's] conclusions." 2017 WL 5180304, at *8. The ALJ must evaluate the "individual's symptoms considering all the evidence in [the] record." Id. Here, the ALJ did not evaluate Plaintiff's statements or otherwise explain his conclusion regarding Plaintiff's use of her hands.
The ALJ found that Plaintiff suffered from the severe impairment of carpal tunnel syndrome. R.p. 17. In his summary of the medical records, the ALJ notes Plaintiff complained of numbness and tingling in her hands. R.p. 21. He indicates the physical exam at that time showed Plaintiff had normal reflexes and coordination, with an assessment of carpal tunnel syndrome and a trial of wrist splints. Id. There is no other discussion of Plaintiff's medical records regarding her carpal tunnel syndrome.
An impairment is "severe" if it significantly limits a claimant's physical or mental ability to do basic work activities. See 20 C.F.R. § 404.1521(a); Bowen v. Yuckert, 482 U.S. 137, 140-142 (1987). "Basic work activities" are "the abilities and aptitudes necessary to do most jobs," examples of which include "physical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling." 20 C.F.R. §§ 404.1522, 416.922.
The only other evidence to which the ALJ cites is within the Disability Determination Section (DDS), where a medical consultant reviewed Plaintiff's medical records and noted that Plaintiff's carpal tunnel syndrome affects both of her hands but still permits frequent use. R.pp. 24, 77. Although the ALJ found the DDS consultant's opinion only partially persuasive, it appears he relied on it when summarily concluding that Plaintiff can frequently use her hands for work. Notably, the DDS consultant's determination was based upon some of the same medical records summarized by the ALJ in his opinion. However, there is no evaluation by the ALJ of Plaintiff's testimony regarding the limited use of her hands, nor any explanation as to how this testimony may be inconsistent with any of the evidence in the record or why the ALJ drew the conclusion that he did. See SSR 16-3p, 2017 WL 5180304, at *8 (the ALJ must explain which of the claimant's symptoms the ALJ found "consistent or inconsistent with the evidence in [the] record and how [the ALJ's] evaluation of the individual's symptoms led to [the ALJ's] conclusions.")
The Commissioner highlights that Plaintiff only occasionally complained to her physicians of numbness and tingling in her hands, did not complain to them about difficulty with daily activities and did not follow up with a recommendation to see a hand specialist, suggesting that this condition was not as problematic as Plaintiff claims. ECF No. 18 at 15. However, the ALJ did not provide any such analysis or conclusion in his decision. See Kirk v. Comm'r of Soc. Sec. Admin., 987 F.3d 314, 321 (4th Cir. 2021)(noting courts may not accept counsel's post hoc rationalizations for agency action; rather, such action must be upheld, if at all, on the basis articulated by the agency itself (citations omitted)); see also Golembiewski v. Barnhart, 322 F.3d 912, 916 (7th Cir. 2003) ("[G]eneral principles of administrative law preclude the Commissioner's lawyers from advancing grounds in support of the agency's decision that were not given by the ALJ.").
The Commissioner argues that the ALJ "noted" that Plaintiff only occasionally complained of numbness and required no treatment for this condition apart from wrist splints. ECF No. 18 at 17. However, the page cited from the ALJ's decision, R.p. 22, does not contain any such notation. The Commissioner also states that Plaintiff "never complained of any difficulties in her activities of daily living due to this condition." Id. Presumably, the Commissioner is referring to complaints to health care professionals as, indeed, Plaintiff testified at the hearing about difficulties in her daily living activities from carpal tunnel syndrome.
An individual's medical treatment history is one of the factors that an ALJ may consider in assessing credibility. See Elmore v. Berryhill, No. 6:17-2480-RBH-KRM , 2018 WL 5724121 (D.S.C. October 12, 2018)(citing 20 C.F.R. §§ 404.1529(c), 416.929(c); SSR 96-7p, 1996 WL 374186, at *3), report and recommendation adopted, 2018 WL 5719643 (D.S.C. Oct. 31, 2018). However, while an ALJ may find the alleged intensity and persistence of an individual's symptoms are inconsistent with her subjective complaints if "the frequency or extent of the treatment sought...is not comparable with the degree of the individual's subjective complaints[,]" the ALJ must consider "possible reasons [she] may not comply with treatment or seek treatment consistent with the degree of [her] complaints." SSR 16-3p, 2017 WL 5180304, at *9. Here, there is no indication whether the ALJ considered Plaintiff's medical treatment history regarding her carpal tunnel syndrome, drew any conclusions therefrom or considered any explanations Plaintiff may have regarding the medical treatment history.
Without more, the Court's only option is to review the record in search of evidence that supports the ALJ's decision regarding Plaintiff's symptoms from her carpal tunnel syndrome. This task, however, exceeds the scope of the Court's appellate review and is committed to the Commissioner. Reynolds v. Berryhill, No. 1:16CV29 (N.D.W.Va. March 24, 2017)(citing Jackson v. Colvin, No. 3:14cv24834, 2015 WL 5786802, at *2 (S.D.W. Va. Sept. 30, 2015) ("It is not the role of the courts to search for reasons for a decision that were not furnished by the ALJ.").
Here, the ALJ may have summarized and referenced the medical evidence generally in his decision, but he failed to "build an accurate and logical bridge from the evidence to his conclusion[s]" regarding the subjective statements of Plaintiff. Id. (citing Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000); accord Forquer v. Colvin, No. 1:15cv57, 2016 WL 4250364, at *8 (N.D.W. Va. Aug. 11, 2016) (holding that an ALJ "failed to sufficiently explain how he derived his opinion" when he discounted all opinion evidence on the basis of the evidence of record and the claimant's activities of daily living)); see also Brown, 873 F.3d at 269 (internal citation and quotations omitted). At no point in his opinion does the ALJ identify how Plaintiff's statements regarding the limited use of her hands are inconsistent with the medical or other evidence in the record or otherwise explain how his evaluation of Plaintiff's symptoms led to his conclusions regarding the use of her hands. See SSR 16-3p, 2017 WL 5180304, at *8. Without further explanation from the ALJ regarding how he reconciled any inconsistencies in the record and reached his conclusions, the Court is unable to conduct meaningful appellate review of the ALJ's decision, such that remand is warranted.
2. Residual Functional Capacity
Similarly, the ALJ failed to "build an accurate and logical bridge" from the evidence to his conclusion on Plaintiff's physical RFC, such that the Court's ability to conduct meaningful appellate review is frustrated. See Woods v. Berryhill, 888 F.3d 686, 694 (4th Cir. 2018) (quoting Monroe, 826 F.3d at 189).
A claimant's RFC represents "the most [she] can still do despite [her] limitations." 20 C.F.R. § 404.1545(a)(1). Pursuant to SSR 96-8p, an ALJ's RFC assessment must evaluate the claimant's ability to perform the physical functions listed in 20 C.F.R. § 404.1545(b)—"sitting, standing, walking, lifting, carrying, pushing, pulling, or other physical functions (including manipulative or postural functions, such as reaching, handling, stooping or crouching) [that] may reduce [a claimant's] ability to do past work and other work." 20 C.F.R. § 404.1545(b); SSR 96-8p, 1996 WL 374184, at *1 (S.S.A. July 2, 1996). As a result, an ALJ's "RFC 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)." SSR 96-8p, 1996 WL 374184, at *7. Moreover, the ALJ "must discuss the individual's ability to perform sustained work activities in an ordinary work setting on a regular and continuing basis (i.e., 8 hours a day, for 5 days a week, or an equivalent work schedule), and describe the maximum amount of each work-related activity the individual can perform based on the evidence available in the case record." Id.
In evaluating a claimant's RFC, the ALJ must "consider all of the claimant's 'physical and mental impairments, severe and otherwise, and determine, on a function-by-function basis, how they affect [her] ability to work.'" Thomas v. Berryhill, 916 F.3d 307, 311 (4th Cir. 2019) (quoting Monroe, 826 F.3d at 188). "Only after such a function-by-function analysis may an ALJ express RFC in terms of the exertional levels of work" of which he believes the claimant capable. Monroe, 826 F.3d at 179 (internal quotation marks omitted); see also Dowling v. Comm'r of Soc. Sec. Admin., 986 F.3d 377, 387-88 (4th Cir. 2021). Consequently, "a proper RFC analysis has three components: (1) evidence, (2) logical explanation, and (3) conclusion." Thomas, 916 F.3d at 311. The ALJ's logical explanation is just as important as the ALJ's discussion of evidence and his conclusion. Id. Thus, in conducting an RFC analysis, an ALJ must identify both the evidence that backs his conclusion, and "build an accurate and logical bridge" from that evidence to his conclusion. Woods, 888 F.3d at 694 (quoting Monroe, 826 F.3d at 189).
Here, the ALJ ultimately concluded that "the longitudinal record in this case simply does not support a more limiting residual functional capacity than the one detailed [by the ALJ]." R.p.25 Of particular relevance in this matter, the ALJ found that Plaintiff has the RFC "to perform medium work as defined in 20 CFR 404.1567(c) except: she is limited to lifting and carrying up to 20 pounds occasionally and 10 pounds frequently with the left arm only; however, she is able to lift and carry up to 50 pounds occasionally and 25 pounds frequently using the left arm as an assist to the right arm . . . ." Id. In reaching this conclusion, the ALJ addressed the evidence pertaining to Plaintiff's left shoulder injury, noting "the physical exams support the finding that [Plaintiff] has some ongoing limitation due to her left shoulder impairment post surgery. However, her more recent records contain physical exam which consistently show her to be alert, in no acute distress with . . . . 5/5 strength in her upper and lower extremities." R.p. 25.
While this explanation may provide some support for the limitation on lifting and carrying up to 20 pounds occasionally and 10 pounds frequently, it is unclear it supports the ALJ's conclusion that Plaintiff can use her left arm "as an assist to the right arm" when lifting and carrying 50 pounds occasionally and 25 pounds frequently. Indeed, while the ALJ acknowledges there are no limitations in the medical records with regard to Plaintiff's right arm, there is no explanation as to how the ALJ determined, or reference to any evidence supporting, that Plaintiff can use her left arm to assist with lifting 25 pounds frequently, especially where the ALJ simultaneously found Plaintiff was limited to lifting 10 pounds frequently with her left arm. Perhaps there may be evidence supporting and a logical explanation for this conclusion; however, the ALJ did not cite to or provide any. See Thomas, 916 F.3d at 311 (noting "a proper RFC analysis has three components: (1) evidence, (2) logical explanation, and (3) conclusion" and that the ALJ's logical explanation is just as important as the ALJ's discussion of evidence and her conclusion).
Notably, the ALJ's decision seemingly conflicts with the DDS consultant's opinion regarding Plaintiff's RFC. The ALJ appears to have given "some weight" to the DDS medical consultant's opinion, finding it "partially persuasive," explaining the following:
As for the opinion evidence, the Disability Determination Section (DDS) medical consultants reviewed the record and accorded an RFC, which resulted in a determination that the claimant was limited to a reduced range of light work activity. (Exhibit 1A). I have considered the findings made by the DDS consultant and has [sic] found them to be partially persuasive because they are only partially consistent with the overall medical record in this case. I also note that I have interpreted based on my review of the entire record that the lift/carry/reach limitations affect the claimant's left arm only and there are no limitations on the right arm, the overall record supports medium lifting/carrying limitations. . . .R.p. 24.
The Commissioner argues that the ALJ appropriately determined the DDS medical consultant's opinion was not persuasive, citing to 20 C.F.R. § 404.1527(c)(4) for the proposition that "more weight will be given to medical opinions that are consistent with the overall record evidence." ECF No. 18 at 17. In this instance, however, the DDS medical consultant's opinion appears, in fact, to be consistent with the overall record evidence, in which case the ALJ's rationale is illogical, if not incorrect. See McWhorter v. Astrue, No. 3:11-185-MGL-JRM, 2012 WL 4478960, *4 (D.S.C. September 26, 2012)("While an ALJ may not reject medical evidence for no reason or for the wrong reason . . . an ALJ may, under the regulations, assign no or little weight to a medical opinion, even one from a treating source . . .if he sufficiently explains his rationale and if the record supports his findings.")(citing King v. Califano, 615 F.2d 1018, 1020 (4th Cir.1980)).
Specifically, the DDS medical consultant noted that Plaintiff's statements were only "partially consistent" with the medical and non-medical evidence in the file; that her exertional limitations were with regard to her left upper extremities only; and that her reaching was limited as to her left overhead only. R.pp. 71-73. There is nothing in the DDS consultant's opinion that indicates there are any limitations to Plaintiff's right arm. The ALJ provided no explanation for his statement that the DDS consultant's opinion was "only partially consistent with the overall medical record in this case." R.p.24. To the extent the ALJ somehow determined the DDS medical consultant's opinion was inconsistent with the lift/carry/reach limitations found in the entire record for this case, he did not accurately or adequately explain how or to what extent evidence in the record contradicts the restrictions set forth in the DDS medical consultant's opinion or otherwise explain his reasoning.
Under these circumstances identified above, the Court is left to guess how the ALJ reached his decision. The Fourth Circuit has repeatedly criticized such conjecture by courts and has admonished ALJs to be more explicit in their reasoning. See Fox v. Colvin, 632 F. App'x 750, 755 (4th Cir. 2015) (unpublished) ("[I]t is not our role to speculate as to how the ALJ applied the law to its findings or to hypothesize the ALJ's justifications that would perhaps find support in the record."); Mascio, 780 F.3d at 637 ("Because we are left to guess about how the ALJ arrived at his conclusion on [the claimant's] ability to perform relevant functions and[,] indeed, remain uncertain as to what the ALJ intended, remand is necessary."); Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013) ("A necessary predicate to engaging in substantial evidence review is a record of the basis for the ALJ's ruling. The 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.") (internal citation omitted). Therefore, the Court is constrained to remand the case.
3. Remaining allegations of error
In light of the recommendation to remand for further consideration, the undersigned declines to address the remaining claims of error, 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). With respect to any remaining claims of error, the ALJ will be able to reconsider and re-evaluate the evidence in toto as part of the reconsideration. See Hancock v. Barnhart, 206 F.Supp.2d 757, 763 n.3 (W.D. Va. 2002) (noting the ALJ's prior decision has no preclusive effect, as it is vacated, and the new hearing is conducted de novo).
IV. RECOMMENDATION
It is RECOMMENDED that the decision of the Commissioner be REVERSED and REMANDED pursuant to 42 U.S.C. § 405(g) for further administrative review.
/s/_________
Molly H. Cherry
United States Magistrate Judge April 22, 2021
Charleston, South Carolina
The parties are directed to the next page for their rights to file objections to this
recommendation.
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
Post Office Box 835
Charleston, South Carolina 29402
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).