Opinion
C. A. 1:21-3753-MBS-SVH
07-25-2022
Harriet C.,[1] Plaintiff, v. Kilolo Kijakazi, Acting Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
Shiva V. Hodges United States Magistrate Judge
This appeal from a denial of social security benefits is before the court for a Report and Recommendation (“Report”) pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her claim for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein. Given the recommendation that the Commissioner's decision be reversed, the undersigned suspends as moot the deadline for filing of Plaintiff's reply to the Commissioner's brief.
I. Relevant Background
A. Procedural History
On May 1, 2017, Plaintiff protectively filed applications for DIB and SSI in which she alleged her disability began on March 1, 2009. Tr. at 241, 244, 521-22, 523-30, 531-36. Her applications were denied initially and upon reconsideration. Tr. at 354-57, 358-61, 362-65, 366-70. On April 25, 2019, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Tammy Georgian. Tr. at 72-102 (Hr'g Tr.). The ALJ issued an unfavorable decision on July 10, 2019, and the Appeals Council subsequently remanded the case to the ALJ to further consider evidence she failed to admit into the record prior to her decision, Plaintiff's past relevant work (“PRW”), opinions from Katrina B. Doig, M.D. (“Dr. Doig”), and Christine Thompson, M.D. (“Dr. Thompson”), Plaintiff's onset date of disability, and the prior ALJ's decision. Tr. at 297319 and 320-325. Plaintiff appeared for second and third hearings on October 27, 2020, and December 8, 2020. Tr. at 63-71 and 37-62. The ALJ issued a second unfavorable decision on January 13, 2021, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 9-36. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on November 16, 2021. [ECF No. 1].
B. Plaintiff's Background and Medical History
1. Background
Plaintiff was born on May 3, 1961. Tr. at 521. She was 53 years old on her date last insured (“DLI”) for DIB and 59 years old at the time of the most-recent hearing. Tr. at 40, 244. She completed a bachelor's degree. Tr. at 7879. Her PRW was as a telephone operator, a customer service representative for insurance and benefits, and a clerical checker. Tr. at 55-57. She alleges she has been unable to work since October 30, 2014.Tr. at 648.
Plaintiff's representative submitted a brief moving to amend her alleged onset date of disability to October 30, 2014, prior to the first hearing. Tr. at 648. The ALJ presumably granted this motion, as her decision reflects an amended alleged onset date of October 30, 2014. See Tr. at 13, 15.
The undersigned has summarized only the records relevant to Plaintiff's current claim. On January 17, 2017, the court issued an order affirming the ALJ's October 29, 2014 decision. Tr. at 144-91. The order included a comprehensive summary of Plaintiff's medical records for the period from October 19, 2007, through September 25, 2014. See Tr. at 145-57.
a. Evidence Before ALJ
Preeth A. Menon, M.D. (“Dr. Menon”), provided a statement that appears to be dated December 11, 2013, in which he indicated Plaintiff's disability was permanent “as of now.” Tr. at 1807. He noted Plaintiff was capable of sitting, standing, walking, climbing stairs/ladders, kneeling/squatting, bending/stooping, pushing/pulling, keyboarding, and lifting/carrying for less than two hours during a workday. Id. He stated Plaintiff could not lift objects weighing more than five pounds for more than 20 minutes per day. Id. He identified Plaintiff's impairments as cervicalgia and pain and stated she needed surgery. Tr. at 1808.
On September 25, 2014, magnetic resonance imaging (“MRI”) of Plaintiff's brain revealed a single, nonspecific T2 white matter hyperintensity in the right frontal lobe. Tr. at 1078-79.
On November 10, 2014, Plaintiff presented to the emergency room (“ER”) at McLeod Seacoast Hospital (“MSH”) for a headache she rated as a “10” on a 10-point scale. Tr. at 1175. Nurse practitioner Paula B. Parnell recorded normal findings on exam. Tr. at 1188-89. She assessed headache and trigeminal neuralgia and ordered a Toradol injection. Tr. at 1181, 1182.
Plaintiff complained of occipital headaches and sought to discuss surgery on November 11, 2014. Tr. at 1385. Dr. Menon recorded normal findings on exam. Id. He assessed radiculopathy. Tr. at 1386.
Plaintiff reported neck pain and muscle spasms, but denied weakness, numbness, and tingling on January 12, 2015. Tr. at 1383. Dr. Menon noted neck muscle spasms and dysthymic mood. Tr. at 1384. He assessed anxiety, radiculopathy, and backache and prescribed Klonopin 0.5 mg and Hydrocodone-Acetaminophen 10-325 mg. Id.
On February 4, 2015, Eugene Giddens, M.D. (“Dr. Giddens”), reviewed Plaintiff's September 2014 cervical MRI and noted it showed severe disc/osteophyte disease at ¶ 5-6 and C6-7 with foraminal exit stenosis and nerve root compression at these levels. Tr. at 1875.
Plaintiff complained of worsening symptoms and described neck pain on February 12, 2015. Tr. at 1380. She requested a referral to a cardiologist. Id. Dr. Menon recorded normal findings on exam. Tr. at 1381. He referred Plaintiff to a cardiologist and refilled Levothyroxine 25 mcg, HydrocodoneAcetaminophen 10-325 mg, and Lisinopril 5 mg. Tr. at 1382.
Plaintiff presented to Douglas S. Head, M.D. (“Dr. Head”), for a preoperative evaluation on March 3, 2015. Tr. at 1056. She denied chest pain, shortness of breath, palpitations, and orthopnea. Id. She had edema, but admitted she had not taken Lasix in over a month. Id. She reported a history of hypertension and coronary artery disease (“CAD”), although Dr. Head noted a nuclear stress test (“NST”) and echocardiogram (“echo”) in 2013 had produced normal results. Id. He further noted an esophagogastroduodenoscopy (“EGD”) in 2013 indicated gastritis and Barrett's esophagus, a colonoscopy in 2013 showed mild diverticulosis of the sigmoid colon, and an electrocardiogram (“EKG”) in 2015 indicated bradycardia. Tr. at 1057. Plaintiff reported neck pain and stiffness, but denied other symptoms. Id. Dr. Head recorded normal findings on exam. Tr. at 1058. He stated Plaintiff had low cardiovascular risk for surgery. Id. He noted Plaintiff had edema and swelling due to essential hypertension and should consider switching Lisinopril to an angiotensin receptor blocker or Norvasc. Id.
Plaintiff underwent anterior cervical discectomy and fusion (“ACDF”) at the C5-6 and C6-7 levels in March 2015. Tr. at 1873.
Plaintiff complained of dizziness, neck swelling, a gagging feeling, difficulty swallowing and breathing, and numbness in her arms on June 23, 2015. Tr. at 1377. Nurse practitioner Deborah Moyer (“NP Moyer”) described Plaintiff as appearing chronically ill, depressed, and fatigued. Id. She noted Plaintiff's neck was edematous anteriorly on the left with questionable nodule or scar tissue and her cervical spine was tender, demonstrated muscle spasm, had abnormal and painful motion, and showed weakness. Tr. at 1377-78. She stated Plaintiff had antalgic gait and walked with the assistance of a cane. Tr. at 1378. She noted the following abnormalities of mental status: decreased eye contact; guarded attitude; empty, unhappy, and depressed mood; flat affect; and slowed rate of thought. Id. NP Moyer assessed radiculopathy, ocular motility disorders, pain on swallowing, and memory lapses or loss. Id. She requested a neurology consultation, prescribed Valium 5 mg and Loratadine 10 mg, and refilled Lisinopril 5 mg. Id.
Plaintiff presented to the ER at MSH for a headache on July 2, 2015. Tr. at 1170. A computed tomography (“CT”) scan of Plaintiff's head revealed no evidence of acute intracranial pathology and chronic-appearing right maxillary sinus disease. Tr. at 1160. Stephen A. Harvey, M.D., diagnosed a tension type headache, ordered a Toradol injection, and discharged Plaintiff to her home. Tr. at 1160, 1164.
Plaintiff complained of daily headaches on July 14, 2015. Tr. at 1372. NP Moyer noted Plaintiff maintained poor eye contact and was overweight, pale, fatigued, depressed, and in pain due to headache. Tr. at 1373. She explained to Plaintiff that her thyroid ultrasound was unremarkable. Tr. at 1374. She increased Valium to twice a day for pain and administered a Toradol injection to treat Plaintiff's headache. Id.
On August 21, 2015, Dr. Giddens noted x-rays showed good positioning of interbody spacers and normal soft tissue density. Tr. at 1873. Plaintiff complained of occasional difficulty breathing and muscle spasm-like tightening upon turning her neck, as well as low back pain that radiated to her right leg. Id. Dr. Giddens indicated Plaintiff was likely experiencing muscle spasms. Id. He observed good ROM of the neck and diffuse weakness in the right leg. Id. He refilled Valium 5 mg and ordered an MRI of the lumbar spine. Id.
On August 21, 2015, George Sandoz, M.D. (“Dr. Sandoz”), noted normal findings, aside from muscle spasms in the cervical and lumbar spine and a score of 28/30 on the Mini-Mental State Exam. Tr. at 1847. He ordered an MRI of Plaintiff's brain. Id. He assessed headache due to occipital neuralgia or microvascular disease and recommended consideration of an occipital nerve block. Id. He also assessed memory loss of multifactorial etiology due to frontal lobe changes noted on MRI, likely due to dementia or depression from chronic pain syndrome. Id.
On September 10, 2015, Plaintiff presented to Dr. Sandoz with complaints of headache and memory loss. Tr. at 1084. She described moderate right parietal headaches that had occurred intermittently over the prior month. Id. She stated they were accompanied by memory impairment, neck stiffness, neurological symptoms, performance changes, and visual aura. Id. Lab studies showed elevated homocysteine and folic acid. Tr. at 1081.
On October 16, 2015, Plaintiff complained of decreased distance vision and blurred vision in the left greater than right eye. Tr. at 1111. She complained of pressure in the temporal frontal region of her head. Id. She stated she had trouble distinguishing colors and her vision flickered on and off at times, especially while driving. Id. Carl F. Sloan, M.D. (“Dr. Sloan”), diagnosed other secondary cataract of the left eye, recommended Yttrium Aluminum Garnet (“YAG”) capsulotomy of the left eye. Tr. at 1116.
Plaintiff complained of decreased vision on October 30, 2015. Tr. at 1093. Dr. Sloan recorded mostly normal findings on exam, except that Plaintiff had 2+ secondary ocular lens in place in the left eye and postcataract capsular haze. Tr. at 1096-97. He performed YAG capsulotomy on the left eye and prescribed Pred Forte 1% drops. Tr. at 1097.
On November 20, 2015, Plaintiff complained of blurred vision in her bilateral eyes and described a film-like sensation over her eyes that would temporarily resolve upon blinking. Tr. at 1087. She reported recent seizures she felt might have affected her vision. Id. Dr. Sloan prescribed Latanoprost 0.005% eye drops. Tr. at 1088. Plaintiff's vision was 20/25 in her right eye and 20/60 in her left. Tr. at 1089. Dr. Sloan noted intraocular pressure of 21 in Plaintiff's right eye and 16 in her left eye. Tr. at 1090. He assessed other secondary cataract in the left eye and mild primary open-angle glaucoma and prescribed new glasses, although he noted it was okay for Plaintiff to use over-the-counter readers as needed. Tr. at 1091.
Plaintiff reported neck pain and requested medication refills on December 30, 2015. Tr. at 1369. Dr. Menon recorded normal findings on exam. Tr. at 1371.
On February 2, 2016, NP Moyer indicated Plaintiff's lab studies were normal, aside from a thyroid-stimulating hormone (“TSH”) level close to four. Tr. at 1364. Plaintiff denied taking Levothyroxine daily due to cost. Id. NP Moyer noted Plaintiff weighed 180.4 pounds, was 63” tall, and had a body mass index (“BMI”) of 32 kg/m.2 Tr. at 1366. She otherwise recorded normal findings on physical exam. Tr. at 1366-67. She prescribed Valium 5 mg for neck pain and instructed Plaintiff to restart Levothyroxine 25 mcg. Tr. at 1368. She indicated Plaintiff should increase her physical activity as able and decrease her consumption of carbohydrates to address elevated BMI. Id.
On March 30, 2016, Plaintiff presented as a new patient to the Epilepsy Fellow Clinic at the Medical University of South Carolina (“MUSC”). Tr. at 1128. She reported a history of “spells,” headaches, and neck pain that had begun six years prior, following a motor vehicle accident in which she was rear-ended. Tr. at 1128-29. She indicated she had experienced six events over the prior month and as many as 10 to 15 events per month. Tr. at 1129.
She described dizziness, greying of her peripheral vision, and feelings of “waviness” and “things closing in.” Id. She indicated the events sometimes led to her passing out, being unconscious for one to five hours thereafter, having no recollection of the event, and developing a headache and tiredness. Id. She stated her son had observed trembling in her arms and legs, but no major shaking or jerking. Id. Ekrem Kutluay, M.D. (“Dr. Kutluay”), recorded normal findings on physical exam. Tr. at 1130-31. He did not consider it likely Plaintiff's symptoms were consistent with epileptic seizures, but indicated she might be experiencing psychogenic non-epileptic events or cardiac symptoms. Tr. at 1131. He ordered a routine electroencephalogram (“EEG”) and an MRI and noted that if the routine EEG was normal, Plaintiff should be admitted to the epilepsy monitoring unit. Tr. at 1131.
Plaintiff presented for an initial physical therapy evaluation on April 13, 2016. Tr. at 1230. She demonstrated impaired posture and gait, 3+/5 strength in her bilateral lower extremities, and 3/5 strength on hip extension. Id. She endorsed a need for frequent breaks while performing chores due to pain and decreased mobility. Id. Plaintiff subsequently participated in aquatic therapy, but reported little improvement. Tr. at 1232-41.
On April 14, 2016, an MRI of Plaintiff's brain showed focal T2 hyperintensity in the subcortical white matter of the posterior aspect of the right frontal lobe. Tr. at 1132-34. This was a nonspecific finding, but considered potentially related to microangiopathy. Id. Plaintiff underwent a routine EEG the same day that produced normal results. Tr. at 1139-40.
On April 18, 2016, Plaintiff described a “squishy” feeling in her chest and chest pain that occurred more often at night than during the day. Tr. at 1361. Nurse practitioner Jodie Webb recorded normal findings on physical exam, except for bradycardia. Tr. at 1363. She assessed generalized anxiety disorder (“GAD”), severe recurrent major depression, combined systolic and diastolic elevation, hypothyroidism, and bradycardia. Id.
Plaintiff presented to Amit Pande, M.D. (“Dr. Pande”), for evaluation of bradycardia on May 16, 2016. Tr. at 1294. She complained of chest pain, shortness of breath when exposed to high temperatures, and palpitations and requested her diuretic medication be refilled, as she felt she was retaining fluids. Tr. at 1288. Dr. Pande recorded normal findings on physical exam. Tr. at 1288-89.
On May 25, 2016, the echo indicated normal left ventricular size and systolic function, normal left ventricular ejection fraction (“LVEF”) of 6065%, normal diastolic function, no hemodynamically significant valvular disease, normal estimated peripheral arterial systolic pressure, and no significant change from the prior study. Tr. at 1299.
On June 2, 2016, a lexiscan myoview stress test showed normal LVEF of 71% and a fixed breast attenuation artifact. Tr. at 1298.
Plaintiff followed up on June 7, 2016, following the echo and NST. Tr. at 1291. Dr. Pande noted test results were normal. Id. He recorded normal findings on physical exam and noted the evidence was not suggestive of hearing failure. Tr. at 1291-92. He ordered a Lifewatch monitor for Plaintiff to wear for three weeks to assess for significant arrhythmia. Id. The Lifewatch monitor showed an average heartrate of 68 beats per minute, tachycardia 1% of the time, and bradycardia 24% of the time. Tr. at 1629. Plaintiff manually triggered an indicator 42 times over the 21-day monitoring period to signal chest pain, rapid heart rate/palpitations/flutter, or dizziness/lightheadedness. Tr. at 1629.
Physical therapist Camila Tepper discharged Plaintiff from physical therapy on June 24, 2016, after she attended only two sessions over the prior month and made limited progress toward her goals. Tr. at 1229. She noted Plaintiff's cardiac workup had limited her physical therapy attendance and ability to perform her home exercise program. Id.
On June 28, 2016, Plaintiff reported to Dr. Menon with concerns that she might have had a stroke. Tr. at 1359. She described feeling weak and dragging her foot after spending time in a hot apartment. Id. She weighed 191 pounds, was 63” tall, and had a BMI of 33.8 kg/m.2 Tr. at 1360. Dr. Menon noted dysfunction of symmetric power in the bilateral lower extremities on motor exam. Id. He assessed GAD, hypothyroidism, and combined systolic and diastolic elevation. Id.
On July 19, 2016, Dr. Pande noted normal findings on physical exam. Tr. at 1289. He recommended Plaintiff continue a low-salt diet, monitor her blood pressure at home, and follow up with her primary care physician as to hypothyroidism. Id.
On August 4, 2016, Plaintiff's TSH level was elevated at 5.00. Tr. at 1421.
Plaintiff underwent an ambulatory EEG on August 26, 2016, that recorded multiple non-epileptic events, but no seizures. Tr. at 1134-38.
Plaintiff returned to the Epilepsy Fellow Clinic on September 16, 2016. Tr. at 1120. Puneet Dabas, M.D. (“Dr. Dabas”), recorded normal findings on exam. Tr. at 1121-22. He wrote:
I do not feel that these events are consistent with non-epileptic seizures given the semiology (length, eyes closed, waxing-waning course). I explained the possibility of psychogenic non-epileptic events to the patient. I explained the possibility of some cardiac cause given her pre-syncopal symptoms, but only the very beginning of the events seem pre-syncopal, not the extended loss of consciousness. Also the presence of [headache] after the event is consistent with migraine with aura.
Tr. at 1122. He increased Amitriptyline to 50 mg and instructed Plaintiff to take Sumatriptan as needed for headaches, keep a headache diary, practice proper sleep hygiene, and eat regular meals. Id.
Plaintiff requested a prescription for Amitriptyline for headaches and a referral for an MRI of her back on December 12, 2016. Tr. at 1353. NP Moyer noted Plaintiff appeared depressed, fatigued, and overweight and had 1+ pedal edema. Tr. at 1354. She assessed neck pain, chronic tension-type headache, and generalized soft tissue swelling. Id. She restarted Lasix for edema and Amitriptyline for headaches. Tr. at 1355.
On January 9, 2017, Plaintiff complained her left foot was turning inward and affecting her knee and she was experiencing similar symptoms on the right. Tr. at 1350. She reported swelling in her bilateral lower legs, but admitted she had not taken Lasix for a week or two. Id. NP Moyer noted Plaintiff's daily use of 325 mg of aspirin was contributing to her edema. Id. She observed Plaintiff to appear tired and chronically ill, to have abnormal appearance and deformity in her feet, and to use a cane. Tr. at 1351. She noted the following abnormal psychiatric findings: psychomotor retardation; negativism; inability to engage; bitter attitude; empty, unhappy, despairing, and irritable mood; and flat affect. Id. She refilled Lasix and referred Plaintiff to physical therapy for bilateral, left-greater-than-right foot drop, post-stroke. Tr. at 1268, 1352.
Plaintiff initially presented to ATI Physical Therapy for evaluation on January 18, 2017. Tr. at 1305. She complained of abnormal gait, left foot drop, bilateral ankle/foot pain, and difficulty walking. Id. She rated her pain as a zero at rest and a nine with activity and endorsed difficulty standing and walking for long periods. Id. She was using a cane. Id. She demonstrated ankle dorsiflexion to 10 degrees on the right and three degrees on the left, plantar flexion to 40 degrees on the right and 31 degrees on the left, ankle inversion to 15 degrees on the right and 20 degrees on the left, and ankle eversion to 15 degrees on the right and 25 degrees on the left. Id. She had hip flexion of 4/5 on the right and 3+/5 on the left, knee extension to 4/5 on the right and 3+/5 on the left, and knee flexion to 4-/5 on the right and 3+/5 on the left. Id. She endorsed tenderness along the insertion of the heel cord. Id.
On January 23, 2017, Plaintiff complained of low back pain that radiated to her bilateral hips and reported no improvement from physical therapy. Tr. at 1155. She reported some bowel difficulty. Id. Dr. Giddens observed Plaintiff to have obvious low back discomfort, tenderness to palpation (“TTP”) of the low back, stooped posture, antalgic gait, and difficulty with flexion and extension at the waist. Tr. at 1156. He referred Plaintiff for an MRI of the lumbar spine. Id. On February 9, 2017, the MRI showed mild lower lumbar stenosis. Tr. at 1742-43.
On February 16, 2017, an MRI of Plaintiff's brain showed no change in the T2 hyperintense focus in the posterior right fontal lobe subcortical white matter. Tr. at 1132.
Plaintiff followed up with Dr. Giddens to discuss the MRI of her lumbar spine on February 16, 2017. Tr. at 1153. She continued to complain of midline low back pain that radiated to her hips. Id. Dr. Giddens noted the MRI showed only very mild degenerative changes. Id. He observed Plaintiff to appear uncomfortable and very somnolent and sedated. Tr. at 1154. He noted some TTP in the low mid-lumbar area, stooped posture, and antalgic gait, but indicated Plaintiff was able to flex and extend and had good lower extremity strength. Id. He assessed chronic midline low back pain without sciatica and other chronic pain. Id. He referred Plaintiff to a pain management physician for evaluation for a spinal cord stimulator. Id.
Plaintiff was discharged from physical therapy on February 24, 2017, after failing to report for additional treatment. Tr. at 1305.
On March 14, 2017, Plaintiff complained of neck pain and requested Dr. Menon complete paperwork for the South Carolina Department of Social Services (“SCDSS”). Tr. at 1345. Dr. Menon noted normal findings on exam, including euthymic mood. Tr. at 1346. He assessed neck pain, severe recurrent major depression, and combined systolic and diastolic elevation. Id.
Plaintiff presented to the ER at MSC on March 14, 2017, with complaints of jaw clenching, chest pain, and feeling woozy. Tr. at 1194. Timothy Carr, M.D., recorded normal findings on physical exam. Tr. at 1 209 10. He assessed acute anxiety, hypokalemia, and chest pain and prescribed Hydroxyzine HCl 50 mg and potassium chloride 20 mEq. Tr. at 1200, 1213.
Dr. Menon noted dysthymic, anxious mood, generalized soft tissue swelling, and gait demonstrating foot drop on March 30, 2017. Tr. at 1344. He prescribed potassium chloride and Lexapro. Id. He assessed overanxious disorder. Id.
Plaintiff presented to Vaishali M. Swami, M.D. (“Dr. Swami”), for evaluation of fluid retention on April 18, 2017. Tr. at 1279. She reported worsening edema, despite daily use of Lasix. Id. She endorsed daily chest pain, feeling tired constantly, elevated blood pressure, dizziness, and knee and back pain. Tr. at 1280, 1281. An EKG showed normal sinus rhythm. Tr. at 1280. Dr. Swami noted Plaintiff ambulated with a cane and had moderate lower abdominal central obesity, but otherwise had normal findings on physical exam. Tr. at 1281-82. He ordered lab studies, refilled potassium chloride and Lasix, and increased Lisinopril 5 mg to twice a day. Tr. at 1279.
Dr. Menon ordered a venous Doppler duplex color-flow ultrasound of Plaintiff's extremities on April 18, 2017. Tr. at 1342.
On April 20, 2017, a thyroid panel revealed slightly-elevated thyroxine. Tr. at 1272.
Plaintiff returned to ATI Physical Therapy for evaluation of abnormal gait, difficulty walking, and left foot drop on April 24, 2017. Tr. at 1438. She demonstrated reduced strength of 3/5 on bilateral hip flexion, hip extension, hip abduction, knee flexion, and knee extension and 2/5 on bilateral ankle dorsiflexion with knee flexed, ankle dorsiflexion with knee extended, ankle plantar flexion, ankle inversion, and ankle eversion. Tr. at 1321. She had bilateral stiffness in her feet, soft tissue swelling, loss of balance on single-leg standing, and use of a cane. Id. Physical therapist Melissa Breeden recommended Plaintiff participate in two physical therapy sessions per week for six weeks. Tr. at 1439. Plaintiff was discharged from physical therapy on May 2, 2017, after cancelling the evaluation four times prior to undergoing it and then cancelling scheduled sessions. Tr. at 1319-20.
Plaintiff complained of neck pain and generalized soft tissue swelling on June 27, 2017. Tr. at 1342. Dr. Menon noted bradycardic pulse and elevated blood pressure. Id. He assessed overanxious disorder and chronic tension-type headache without intractable headache. Id.
Plaintiff presented to Coastal Kidney Center for an initial consultation on July 28, 2017. Tr. at 1637. She reported problems with fluid retention with swelling in her legs, abdomen, and back over the prior year. Id. She stated she felt very fatigued and had gait instability. Id. She also endorsed anhedonia and impaired memory. Id. She indicated she had been unable to afford medication for hypothyroidism. Id. Maryam Gondal, M.D. (“Dr. Gondal”), noted Plaintiff was 63” tall, weighed 217 pounds, and had a BMI of 38.4 kg/m.2 She indicated Plaintiff had 1+ edema and appeared to be depressed. Id. She stated Plaintiff's edema was related to venous insufficiency and hypothyroidism. Tr. at 1639-40. She noted Plaintiffs renal function was uncompromised. Tr. at 1640. She advised Plaintiff to continue to take Lasix, to use compression stockings, to elevate her legs to prevent dependency-associated edema, and to fill her thyroid medication for $4 at Walmart. Id.
On November 11, 2017, Plaintiff presented to Stefan M. Dylewski, M.D. (“Dr. Dylewski”), for a consultative medical exam. Tr. at 1453-57. She complained of severe cervical pain with a history of ACDF, as well as lumbar pain. Tr. at 1454. She reported residual left-sided weakness due to a history of stroke, hypertension, CAD, mitral regurgitation, hypothyroidism, depression, and epilepsy. Id. She indicated her neck pain was triggered by most activities and denied being able to drive due to inability to turn her neck. Id. She described tightness and sharp pain, but denied radicular/shooting pain. Id. She noted her pain was decreased by rest and changes of position. Id. She endorsed use of a neck brace and cane. Id. She complained of general malaise, inconsistent sleep pattern, moderate exercise intolerance, mild-to-moderate palpitations, left-sided weakness, episodical paresthesia in her bilateral upper extremities, daily headaches, periods of depression and difficulty concentrating related to pain, and decreased range of motion (“ROM”), crepitus, functional deficit, and arthritis in her neck and low back. Tr. at 1456.
Dr. Dylewski described Plaintiff as “cooperative” and “exhibit[ing] full effort throughout the examination.” Id. He noted Plaintiff was able to perform the exam without the Aspen collar on her neck and used her cane for mobility. Id. He observed Plaintiff to be in mild distress/discomfort. Id. He described Plaintiff's gait as “labored, uneven, and heavy with particular difficulty on the left side when she walks with a cane.” Id. He stated Plaintiff almost lost her balance while performing the heel-to-toe walk. Id. He noted mild swelling in Plaintiff's bilateral feet and ankles and mild TTP over her greater trochanters, at her hips, and in her low back. Tr. at 1457. He recorded normal ROM, aside from decreased lumbar lateral flexion to 15/25 degrees, cervical flexion to 5/50 degrees, cervical extension to 5-10/60 degrees, cervical lateral flexion to 5-10/45 degrees, and cervical rotation to 510/80 degrees. Tr. at 1453. He observed normal hands, negative Phalen's and Tinel's signs, 2+ bilateral reflexes, 4/5 strength in the bilateral upper and lower extremities, and normal abilities to squat, tandem walk, heel walk, and toe walk with the assistance of a cane. Tr. at 1455. He wrote:
Based on my exam and my assessment, I feel Ms. C[] has severe cervicalgia without radiculopathy and severe osteoarthritis of her neck, in addition to lumbago. In my opinion, her cervical pain and osteoarthritis combined with her history of stroke and residual left-sided weakness, as well as functional limitations and
inability to turn and move her neck and head cause her to have very significant disability, making it very difficult to perform any work reliably as she has days that she is better than she was today, but she states that she has many more days that she is functioning worse off than she was today. Neither she nor I believe that her lumbago/low back pain is less of a limitation for her functioning; however, in light of her left-sided weakness from her stroke, I do believe that it does limit her to an extent. I do not believe, as far as her physical capabilities, that she will be able to perform at work, she would be unable to lift, carry, push or pull any weight over approximately 2 to 3 pounds. She is able to sit and stand for a short period of time, roughly 30 minutes to an hour at a time, and is able to walk a city block with being allowed to stop and catch her breath/balance. She is able to bend while using a cane and is unable to climb or use a ladder of any sort. She has good fine motor skills today on exam, though did state that there were times when she did not have feeling or ability to grip using her hands, usually her left. She is unable to reach very far overhead and over about a shoulder's height, as she has had rotator cuff arthropathy as well in bilateral shoulders.Id.
On November 16, 2017, x-rays of Plaintiff's lumbar spine showed degenerative disc disease (“DDD”) of the lower thoracic and upper lumbar spine and facet arthrosis of the lower lumbar spine. Tr. at 1460.
Plaintiff presented to Eva Merhi, O.D. (“Dr. Merhi”), for a consultative vision exam on November 17, 2017. Tr. at 1462. She complained of blurriness, glare, and fading vision that was worse on the left than the right. Tr. at 1363. Dr. Merhi noted normal muscle function, abnormal confrontation visual field, and abnormal color perception. Tr. at 1465. She assessed stable primary open angle glaucoma, heteronymous bilateral field defect, and stable presence of intraocular pressure. Tr. at 1466. She noted Plaintiff's condition was permanent and progressive. Id.
On December 19, 2017, Plaintiff reported a one-year history of heart racing with any stress or exertion. Tr. at 1573. Danny M. Kass, M.D. (“Dr. Kass”), noted normal findings on exam, aside from 1+ edema. Tr. at 1574. He refilled potassium chloride, prescribed Valium 5 mg, ordered lab studies, and referred Plaintiff to a cardiologist. Tr. at 1574-75.
Plaintiff presented to Michael F. Fielding, Ph.D. (“Dr. Fielding”), for a consultative mental status evaluation on December 20, 2017. Tr. at 1472. She reported spinal pain, short-term memory loss, left-sided weakness, foot deformity, seizures, anxiousness, history of traumatic brain injury (“TBI”), history of heart attack, history of stroke, and numbness in her feet, legs, and hands. Tr. at 1473-74. She reported staying away from others and denied having been involved in a relationship over the prior 19 years. Tr. at 1474. She denied shopping for groceries, driving, and managing the household finances, but indicated she performed independent grooming and hygiene, prepared meals, performed light chores, and did laundry with her son's assistance. Tr. at 1476. She indicated she required “a lot of rest breaks” while performing tasks. Id. She reported a history of suicide attempts, but denied current suicidal ideation. Id. She indicated she had difficulty interacting with others, variable sleep and appetite, a negative world view, and good self-esteem. Id. Plaintiff endorsed hearing voices that shamed her and tried to make her feel worthless. Id.
Dr. Fielding observed:
The claimant had a lot to say today, trying to fit everything she could think of about her conditions in the one-hour examination. She seemed to be annoyed if the examiner cut her off, stating she had answered the question adequately and needed to move on to the next question. She felt anything she said was important and should be included in the report regardless of how long it took for her to be evaluated.
Tr. at 1473. He also suspected Plaintiff's “personality dynamics and medical problems ha[d] interfered with her work for a number of years most likely.” Tr. at 1475. He noted Plaintiff “appeared extremely suspicious about the intentions of others that took up a paranoid flavor at times and that was noted on examination today.” Id. He observed that Plaintiff demonstrated “frequent hand wringing as if she was highly anxious.” Id. He described Plaintiff's affect as flat and noted she had “constant apprehensive expectation, always anticipating the other shoe to drop.” Tr. at 1476. He noted Plaintiff's thought processes were generally logical and organized, but reflected some “very unusual” thought patterns. Id. He indicated Plaintiff demonstrated “some type of delusional process” when talking about her emotional state of mind. Id. He stated Plaintiff was alert and had an attitude highly suspicious of others' intentions. Id. He observed Plaintiff could be somewhat impulsive. Id. He noted Plaintiff was fully oriented to time, place, person, and situation. Tr. at 1477. He described Plaintiff's tone as adequate with constant, non-stop, and one-sided speech. Id. He wrote: “In terms of concentration, focus, and attention, she was best described as being extremely self-absorbed in her overall symptom picture and all the events that occurred in her life in a negative way.” Id. He indicated Plaintiff appeared to demonstrate adequate memory, but had limited insight into her overall symptom picture. Id. He noted no deficit in Plaintiff's ability to make daily decisions and perform basic tasks. Id.
Dr. Fielding provided the following clinical impressions: (1) anxiety and depression due to general medical condition; (2) unspecified personality disorder with rule out for paranoid features; (3) rule out unspecified psychotic disorder; (4) rule out neurocognitive disorder; (5) rule out posttraumatic stress disorder (“PTSD”); and (6) unspecified anxiety and depression, aside from that related to medical problems. Tr. at 1478. He stated Plaintiff had “very poor people skills and remain[ed] angry, projecting the blame for most of her problems to others, taking very little ownership herself.” Tr. at 1477. He noted Plaintiff had “a tendency to over react to minor obstacles or frustrations, making something very small into something very major in her mind” and “always sees things from her perspective, giving little credence to another person's point of view.” Id. He indicated Plaintiff had “a general feeling that people are out to purposely hurt her.” Id. He “d[id] not want to state that [Plaintiff was] exaggerating or malingering,” but was confident that she was “presenting mental health issues that were not in any of the records sent for review.” Id. He wrote:
At the present time, she would have a difficult time accepting an[y] instructions from supervisors as she could not even do that in this examination today. She had to get her story out on her own terms regardless of how many interruptions were made by the examiner encouraging her to move to the next question because a sufficient amount of information was already obtained. This will be noted by coworkers and supervisors and the public and will most likely get in the way of productivity.Id. He stated Plaintiff's “concentration was very strong at presenting her story today but less so trying to answer the examiner's questions” and her pace was often rapid with “her storyline seemingly never ending at times.” Id. He opined that “[t]his would interfere with her ability to acquire and use information and take advantage of community resources by herself.” Id. Although Plaintiff demonstrated abilities to understand and comprehend, Dr. Fielding stated “her overall symptom picture would interfere with her ability to perform detailed and complex tasks, and at times simple and repetitive tasks as noted in the past.” Id. He summarized: “So the bottom line is, she is able to maintain focus and persistence telling her story of being disabled both psychologically and medically from her perspective but struggles when questions are presented to her that are not germane to where her mind set is at that time.” Id. He felt that Plaintiff would “struggle maintaining regular attendance in a workplace” and would struggle even with additional special supervision. Id. He wrote: “The bottom line is this woman is not going to be able to complete a normal work day, let alone work week or work month without constant interruption from the symptoms and demeanor presented in this examination today.” Id. He considered her capable of managing her own funds. Id.
On January 16, 2018, Plaintiff complained of problems with her heart rate, difficulty walking, gait disturbance, and increased arthritis pain. Tr. at 1568. Dr. Kass noted Plaintiff was 63” tall, weighed 221.6 pounds, and had a BMI of 39.3 kg/m.2 Tr. at 1569. He continued Plaintiff's medications for depression, indicated her hypothyroidism and anxiety were stable, and advised her to follow up with a special surgeon as to back pain and a cardiologist as to valvular heart disease and CAD. Id.
On January 18, 2018, Dr. Doig, a state agency medical consultant, assessed Plaintiff's physical residual functional capacity (“RFC”) as follows: occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or walk for a total of two hours in an eight-hour workday; sit for a total of about six hours in an eight-hour workday; occasionally balance, stoop, kneel, crouch, crawl, and climb ramps/stairs; never climb ladders/ropes/scaffolds; occasionally reach overhead with the bilateral upper extremities; frequently use field of vision; and avoid even moderate exposure to hazards. Tr. at 209-13, 233-37. Dr. Thompson, a second state agency medical consultant, assessed the same physical RFC on May 8, 2018. See Tr. at 261-65, 284-87.
On January 26, 2018, state agency psychological consultant Jennifer Steadham, Ph.D. (“Dr. Steadham”), reviewed the record and completed a psychiatric review technique. Tr. at 205-07, 229-30. She considered Listings 12.04 for depressive, bipolar, and related disorders, 12.06 for anxiety and obsessive-compulsive disorders, and 12.08 for personality and impulse-control disorders and assessed mild restrictions in Plaintiff's abilities to understand, remember, or apply information, interact with others, concentrate, persist, or maintain pace, and adapt or manage oneself. Id. Accordingly, she found Plaintiff's mental impairments to be non-severe. Id. A second state agency psychological consultant, Lisa Clausen, Ph.D. (“Dr. Clausen”), reviewed the record on April 6, 2018, and reached the same conclusion. See Tr. at 256-58, 279-81.
Plaintiff presented to Jerry E. Watson, M.D. (“Dr. Watson”), for evaluation of palpitations on February 14, 2018. Tr. at 1491. She reported chest pain and shortness of breath upon ascending stairs and indicated her symptoms had worsened over the prior year. Id. Dr. Watson noted normal findings on exam, except that Plaintiff was using a cane. Tr. at 1492. He assessed precordial pain, palpitations, essential hypertension, dyslipidemia, and non-rheumatic mitral regurgitation. Id. He ordered an NST, an EKG, a 30-day event monitor, and an echo. Tr. at 1492-93.
On March 22, 2018, Plaintiff presented to Grand Strand Regional Medical Center (“GSRMC”), after a sudden onset of tachypnea while undergoing an NST. Tr. at 1696. She reported bilateral upper extremity tremors, headache, and numbness. Tr. at 1697. Radley Short, M.D. (“Dr. Short”), observed a tremor in Plaintiff's arms and hands. Tr. at 1699. EKGs were normal. Tr. at 1701. Plaintiff's symptoms resolved after administration of Ativan. Id. Dr. Short indicated Plaintiff likely had an adverse reaction to the agent provided for the NST. Id.
Plaintiff continued to report occasional chest pain on March 23, 2018. Tr. at 1487. She indicated she lacked confidence in the results of the NST because she suffered a seizure and did not complete the second imaging. Id. Dr. Watson assessed precordial pain, palpitations, essential hypertension, dyslipidemia, and non-rheumatic mitral regurgitation. Tr. at 1488. He indicated the NST showed no ischemia and LVEF of greater than 70%. Id. He discussed, and Plaintiff agreed to proceed with left heart catheterization. Id.
Dr. Kass noted back stiffness on April 6, 2018. Tr. at 1564. He continued Plaintiff's medications and instructed her to follow up with a neurologist and a cardiologist. Id.
Plaintiff underwent cardiac catheterization on April 9, 2018. Tr. at 1705. It showed angiographically normal coronary arteries and normal left ventricular systolic function and filling pressure. Id. Randall N. Goodroe, M.D. (“Dr. Goodroe”), assessed non-cardiac chest pain and discharged Plaintiff to follow up with her primary care physician. Tr. at 1689.
Plaintiff presented to H. Rubin Vision Center on May 25, 2018. Tr. at 1509. She requested a refill on Latanoprost and indicated she was unable to follow up with Dr. Sloan until August. Id. She endorsed a grey haze and spotted vision in her left eye and described reduced vision in her left eye over the prior two weeks. Id. Plaintiff returned for a vision recheck on June 6, 2018. Tr. at 1508. Her glaucoma symptoms were improved. Id.
Plaintiff reported increased back pain and requested medication refills on July 11, 2018. Tr. at 1557. Dr. Kass ordered x-rays of the lumbar spine and lab studies and continued Plaintiff's medications. Tr. at 1558. The x-rays showed normal vertebral body heights, disc spaces, and alignment, minimal degenerative osteophytes, mild facet degenerative change, normal SI joints, and no evidence of compression fracture or focal bony abnormality. Tr. at 1580.
On October 10, 2018, Plaintiff reported feeling “pretty rough” and was walking with a cane and wearing a cervical collar. Tr. at 1550. She complained of back pain, bilateral leg numbness, and bilateral hand tremor.
Id. Dr. Kass noted Plaintiff's complaints of fatigue and muscle weakness, but observed no abnormalities on exam. Tr. at 1551. He indicated Plaintiff should continue Levothyroxine for hypothyroidism, follow up with a neurologist about back and neck pain, follow up with a cardiologist as to valvular heart disease, and follow up with ophthalmologist regarding glaucoma. Id.
Plaintiff presented to the ER at MSH with shortness of breath on December 15, 2018. Tr. at 1659. Chest x-rays and other tests were normal and Plaintiff's vital signs were stable. Tr. at 1669.
Plaintiff followed up with Dr. Kass on January 4, 2019, following presentation to the ER for shortness of breath. Tr. at 1546. She endorsed multiple physical and neurological complaints. Id. Dr. Kass noted 1+ edema and mild weakness to Plaintiff's right upper and lower extremities. Tr. at 1547. He continued Lasix for hypertension and edema, Levothyroxine for hypothyroidism, and Lexapro for anxiety. Id. He referred Plaintiff for a neurology consultation. Id.
Plaintiff presented to Steve T. McGown, M.D. (“Dr. McGown”), to establish care on January 9, 2019. Tr. at 1597. She was 5'4” tall, weighed 209 pounds, and had a BMI of 35.9 kg/m.2 Id. Dr. McGown noted mostly normal findings on exam, aside from psychomotor retardation and neutral facial expressions. Tr. at 1597-98. He referred Plaintiff to a neurologist and a gynecologist. Tr. at 1599.
Plaintiff complained of altered mentation, decreased color vision, and light sensitivity on February 26, 2019. Tr. at 1755. Dr. Sandoz noted pain with cervical flexion, decreased ROM of the cervical spine, pain with lumbar extension, and decreased ROM of the lumbar spine. Tr. at 1756. He recorded normal findings on motor and reflex exams and indicated normal gait. Id. He stated Plaintiff's altered mental state could be associated with PTSD or seizure disorder due to a history of TBI, but was unlikely associated with multiple sclerosis (“MS”). Id. Nevertheless, he ordered a lumbar puncture after an MRI. Tr. at 1757.
On April 9, 2019, Plaintiff complained of foggy vision and intermittent appearance of a black ring in her peripheral vision. Tr. at 1818. Dr. Sloan noted the following abnormalities on exam: 2+ meibomian glandular dysfunction in the bilateral eyes; trichiasis of the right lower eyelid; severe, diffuse superficial punctate keratitis in the bilateral eyes; 1+ posterior chamber interocular lens in place with posterior chamber haze in the right eye; increased cup-to-disc-ratio in both eyes; peripapillary atrophy causing small disc diameter in both eyes; and 1+ disc pallor in the left eye. Tr. at 1822-23. He assessed bilateral primary open-angle glaucoma, squamous blepharitis of the right upper eyelid, trichiasis without entropion of the right lower eyelid, and severe dry eye syndrome of the bilateral lacrimal glands causing fluctuation in vision. Tr. at 1823-24. He performed eyelash epilation, instructed Plaintiff to apply warm compresses and use eyelid massage, instructed her as to eye hygiene and lid scrubs, continued Latanoprost, prescribed Erythromycin ointment, and instructed her to use artificial tears as needed. Id.
On May 6, 2019, Dr. Sandoz assessed MS by history and clinical presentation imaging studies. Tr. at 1796. He ordered an MRI of the cervical spine and prescribed Aubagio for MS. Id. He also assessed altered mental status, possibly secondary to microvascular disease changes on her brain due to either MS or vascular disease. Id. He noted Plaintiff was tolerating Sumatriptan well for common migraine and continued the medication. Id.
Plaintiff presented to Strand GI Associates Endoscopy Center for an abdominal CT scan and a colonoscopy on May 23, 2019. Tr. at 1833-34. John Edmison, M.D., assessed non-alcohol fatty liver disease, change in stool consistency, and hematochezia. Id.
On June 15, 2019, Plaintiff an MRI of Plaintiff's cervical spine showed prior ACDF at ¶ 5-6 and C6-7 with residual endplate osteophytosis, uncovertebral hypertrophy and possible significant foraminal narrowing at ¶ 5-6. Tr. at 559-60.
Plaintiff presented to Grand Strand Health for abdominal pain on August 26, 2019. Tr. at 1832.
On October 11, 2019, Dr. Edmison wrote a note indicating Plaintiff experienced inguinal pain upon ascending stairs. Tr. at 1865. He stated Plaintiff had no gastrointestinal abnormalities and suspected her symptoms were due to musculoskeletal versus neuropathic etiology. Id.
On or about September 4, 2020, Dr. Kass authorized a renewal of Plaintiff's disabled placard/license plate. Tr. at 558. He represented Plaintiff was unable to ordinarily walk 100 feet nonstop without aggravating an existing medical condition and indicated her disability was permanent. Id.
On October 14, 2020, an MRI of Plaintiff's cervical spine showed posterior disc osteophyte complex at ¶ 5-6, causing mild spinal canal stenosis, as well as moderate right and mild left neural foraminal stenosis at ¶ 5-6. Tr. at 561, 563.
On October 20, 2020, thyroid peroxidase antibodies were present on testing, confirming a diagnosis of Hashimoto's disease. Tr. at 1903.
On November 9, 2020, Dr. Sandoz noted the presence of two to three lesions on Plaintiff's brain suggested MS. Tr. at 1909. He indicated Plaintiff opted to continue her current management, as opposed to undergoing additional treatment. Id. He assessed early post-surgical myelopathic changes to the cervical spine and lumbar spondylosis. Id. He indicated Plaintiff had difficulty ambulating and bladder issues, but was not a surgical candidate. Id. He continued Amitriptyline and Sumatriptan for migraines. Id.
b. Evidence Submitted to Appeals Council
On December 30, 2015, Dr. Menon indicated in a medical release/physician's statement for SCDSS that Plaintiff's disability was permanent, she was unable to work, and she could engage in no physical activity due to osteoarthritis/DDD and cervical osteoarthritis, status postsurgery. Tr. at 104-05.
On or about March 9, 2016, Dr. Menon completed a disabled placard and license plate application on Plaintiff's behalf, noting her disability was permanent; she was unable to ordinarily walk 100 feet nonstop without aggravating an existing medical condition, including the increase of pain; she was unable to ordinarily walk without the use of or assistance an assistive device; and she was substantially limited in her ability to walk due to an arthritic, neurological, or orthopedic condition. Tr. at 108. On May 2, 2016, Dr. Menon wrote a prescription authorizing a disabled placard/license plate. Tr. at 109.
On April 11, 2019, Dr. Kass completed a medical source statement of ability to do work-related activities. Tr. at 110-11. He opined that Plaintiff could sit for four-to-six hours and stand/walk for one hour during an eighthour workday. Tr. at 110. He indicated Plaintiff could never engage in lifting/carrying, pushing/pulling, and manipulating objects. Id. He noted Plaintiff's experience of pain or other symptoms was occasionally severe enough to interfere with attention and concentration needed to perform even simple work tasks. Tr. at 111. He stated Plaintiff should avoid hazards and dust. Id.
On April 15, 2019, Dr. Kass provided a letter stating Plaintiff resided with her son, who served as her primary caregiver, assisted her with activities of daily living (“ADLs”), dispensed her medications, provided her transportation, and performed household duties. Tr. at 112.
C. The Administrative Proceedings
1. The Administrative Hearing
a. Plaintiff's Testimony
i. April 25, 2019
Plaintiff appeared in-person and was represented by an attorney during the first hearing. Tr. at 75. She testified she was 5'4” tall and weighed about 200 pounds, although her weight varied from 180 to 212 pounds. Tr. at 85. She said she lived with her 20-year-old son, who served as her live-in aide and performed full-time construction work. Tr. at 77. She clarified that her son picked up her medications, shopped for the household, transported her to medical appointments, and checked in on her. Id. She denied having any source of income other than her son's income from working, but noted she lived in Section 8 housing and received $72 per month in food stamps. Tr. at 77-78. She confirmed she had a driver's license that was last renewed in 2013, but denied driving due to seizures. Tr. at 78.
Plaintiff testified she last worked full-time in 2012 at Advanced Call Center Technologies, where she reviewed medical billing records for accuracy. Tr. at 79. She stated she previously worked full-time for Sykes Enterprises, where she answered calls and responded to questions from Bank of America customers who were facing foreclosure. Id. She said she had worked briefly for a company that made porcelain and had performed a full-time job as a security guard. Tr. at 80. She explained she had worked for Pearson Government Solutions, where she answered calls from Medicare beneficiaries with insurance questions. Tr. at 81. She said she had reviewed medical billing while working for Advanced Call Center. Id. She stated she had previously served as the office accountant for Black Mountain Utility District. Tr. at 82.
Plaintiff stated she was unable to work because she had sustained a TBI to the right frontal lobe of her brain in 2012. Id. The ALJ asked Plaintiff's attorney to clarify her severe impairments. Tr. at 83. He identified impairments of DDD of the lumbar spine, DDD of the cervical spine, seizure disorder, edema, and frequent headaches. Id.
Plaintiff testified her regular medications included Diazepam for neck pain, Lisinopril for blood pressure, Fluticasone for breathing problems, Levothyroxine for thyroid disorder, aspirin as a blood thinner, a statin, potassium, and Furosemide for edema. Tr. at 83-84. She denied smoking, drinking alcohol, and using recreational drugs. Tr. at 84. She confirmed she was using a cane and indicated Dr. Minon had recommended she buy one in 2014 or 2015, but had not written a prescription for one. Id. She stated she was wearing sunglasses during the hearing because exposure to light caused shooting, stabbing pain in her eyes due to glaucoma. Id. She said she had seen Dr. Sloan within the prior two-month period and he had prescribed Latanoprost drops, Systane gel lubricating drops, and an antibiotic salve. Tr. at 84-85.
Plaintiff testified her daily routine included getting up in the morning, taking medications, spending time with her son before he left for work, checking Facebook for messages from a daughter in the military and other family members, reading, if able, and lying back down. Id. She said she usually felt very tired after performing those tasks and sometimes experienced seizures due to her extreme fatigue. Id. She stated she would take her afternoon medications at 1:00 PM, including medication for acute depression and Amitriptyline to prevent headaches. Tr. at 86. She indicated she would prepare a light lunch consisting of a sandwich and a glass of milk, check her email and Facebook, sometimes start a small load of laundry, and lie back down. Id. She said she typically waited for her son to return home before getting up for any significant period or engaging in chores. Id. She denied attending activities outside her home, but noted her son would take her out to dinner less than once a month, if she was feeling well. Id. She denied current hobbies. Tr. at 87. She stated she had previously enjoyed embroidery, but could no longer do it because of her vision problems. Id.
Plaintiff confirmed that she was wearing a neck brace during the hearing. Id. She stated she wore it daily to support her neck and stop her from nodding her head. Tr. at 87-88. She said she used it when she performed tasks such as doing laundry, lifting, and cooking. Tr. at 88. She confirmed that she continued to experience neck pain she rated as a six to seven. Tr. at 88-89. She said her pain increased with activity, sometimes to an eight or nine, and radiated to her arms and head. Tr. at 89. She said she experienced headaches throughout most of a typical day. Tr. at 90. She confirmed that she had back problems, but denied having had surgery. Id. She rated intermittent lower back pain as a seven to eight, noting it occurred daily and increased with activity. Tr. at 90-91.
Plaintiff estimated she could sit for 20 minutes at a time before needing to get up due to numbness in her legs. Tr. at 91. She stated she could stand for five minutes at a time and noted her standing ability was limited by back pain. Tr. at 91-92. She indicated she could walk for 10 minutes prior to experiencing increased pain. Tr. at 92. She explained that she needed the cane for balance and walking. Tr. at 92-93. She said she felt dizzy and extremely tired prior to experiencing a seizure. Tr. at 91. She stated her chronic fatigue was caused by her spinal problems, seizures, and blood flow problems in her brain. Tr. at 93. She indicated she could perform a household task for 10 to 15 minutes before requiring a break for at least four hours. Id. She said she spent at least six hours lying down each day. Tr. at 94. She stated she was usually up and about for 20 to 30 minutes, but no more than an hour at a time during the day. Id. She testified she felt worse than usual on three to four days per month due to increased seizure activity. Tr. at 95. She stated she had last visited the hospital for intravenous medication to stop a seizure in February or March of the prior year. Id. She described swelling in her throat, legs, and throughout her body. Id. She indicated her swelling was caused by problems with circulation, tachycardia, and bradycardia. Tr. at 96.
Plaintiff testified her doctor had instructed her not to lift her arms above her head and not to be on her feet for longer than five minutes. Tr. at 101-02.
ii. October 27, 2020
Plaintiff appeared by telephone and without representation for a second hearing. Tr. at 66. She stated she was homebound and her daughter had been unable to travel from Mississippi to help her find an attorney. Id.
The ALJ informed Plaintiff of her right to counsel, and Plaintiff expressed a desire to return with counsel for a rescheduled hearing on December 8. Tr. at 68.
iii. December 8, 2020
Plaintiff appeared by telephone and indicated her desire to proceed without representation at the third hearing. Tr. at 40. She stated she had received confirmation of Hashimoto's disease since the 2019 hearing and had initially been diagnosed with the impairment eight or nine years prior. Tr. at 43-44. She indicated Dr. Sandoz had also confirmed a diagnosis of MS and the presence of two to three lesions on her brain. Tr. at 44. She stated her vision was deteriorating, as expected given the progressive nature of her disease. Id. She said her doctors could perform no additional surgical interventions on her eyes. Id. She indicated her arthritis was worsening as expected, given its progressive nature. Id.
Plaintiff stated she had declined to start the medication for MS because her first grandchild was due to be born in a few weeks and she did not want to take the risk that an adverse reaction would prevent her from meeting him. Id. She indicated she had also sustained a recent bite from a brown recluse spider and needed to confirm with her doctor that it would not affect her immune response to treatment. Id. She stated her doctors had “wanted [her] to already be on” the medication, but she was hoping another medication with fewer side effects would become available. Tr. at 45.
Plaintiff testified she had worked at Advanced Call Center, where she reviewed medical records for accuracy. Id. She could not recall how long she had worked in the job. Id. She stated she worked full-time at Sykes Enterprises, fielding calls from people facing foreclosures. Tr. at 45-46. She said she worked for Pearson Government Solutions, where she answered incoming calls from Medicare recipients about their benefits. Tr. at 46. She indicated she worked for CDT at a call center. Tr. at 50-51.
Plaintiff testified that on a typical day, she would get up, wake her son, take her dog outside her to use the bathroom, and bring her dog back inside her apartment. Tr. at 52. She said she would take her morning medication and stay up if she felt well or lie back down if she was in pain. Id. She indicated she would sometimes try to find something to do, but spent most of the day trying to rest due to her pain. Id. She said she often lost track of time and had difficulty remaining awake. Id. She stated she would typically prepare something light and easy for dinner. Id. She noted she often felt nauseated. Id. She reported she did not feel safe in her home because a neighbor had pointed a gun at her and other neighbors had harassed her and attempted to take her cane when she went to collect her mail. Tr. at 53. She said she had difficulty climbing stairs. Tr. at 54. She indicated the last doctor who treated her in the ER had suspended her driving privileges pending follow up with another physician. Tr. at 60.
b. Vocational Expert Testimony
i. April 25, 2019
Vocational Expert (“VE”) Ashley Harrelson Johnson reviewed the record and testified at the first hearing. Tr. at 96-101. The VE categorized Plaintiff's PRW as a customer service representative, Dictionary of Occupational Titles (“DOT”) No. 241.367-014, requiring sedentary exertion and a specific vocational preparation (“SVP”) of 5; a checker, DOT No. 209.687-010, requiring sedentary exertion and an SVP of 4; a security guard, DOT No. 372.667-034, requiring light exertion and an SVP of 3; a customer service clerk, DOT No. 249.262-010, requiring sedentary exertion and an SVP of 6; and an accountant, DOT No. 160.162-018, requiring sedentary exertion and an SVP of 8. Tr. at 97. The ALJ described a hypothetical individual of Plaintiff's vocational profile who could perform light work; frequently sit, stand, and walk; occasionally climb, stoop, kneel, crouch, and crawl; never climb ladders, ropes, and scaffolds; frequently reach overhead with the bilateral supper extremities; and must avoid concentrated exposure to hazards. Tr. at 98. The VE testified that the hypothetical individual would be able to perform all of Plaintiff's PRW. Id. The ALJ asked if there would be transferable skills to other jobs at the light exertional level. Id. The VE stated there would be transferable skills to sedentary jobs, but not to light jobs. Id. The ALJ asked the VE to identify the skills that would transfer to other sedentary jobs. Tr. at 99. The VE indicated transferable skills would include utilizing office equipment and computers, providing customer service, resolving complaints, and analyzing financial data. Id. She identified other sedentary jobs the individual could perform as that of an appointment clerk, DOT No. 237.367-010, SVP of 3, with 60,000 positions and an account information clerk, DOT No. 210.367-010, SVP of 6, with 47,000 positions. Id. The ALJ asked the VE if her testimony had been consistent with the DOT. Id. The VE noted her testimony as to overhead reaching had been based on her experience and training, as the DOT does not specifically address overhead reaching. Tr. at 99-100.
Plaintiff's attorney asked the VE to consider that the individual would require a sit-stand option for five minutes out of every 30-minute period. Tr. at 100. He asked if that would have an impact on sedentary or light work. Id. The VE stated it would depend on the employer at the light level because the individual would need a chair or stool at the workstation. Id. She testified the restriction should not impact the sedentary jobs, provided the individual would need to stand for five minutes, twice an hour. Id. Plaintiff's attorney asked the VE how much time off-task was considered too much. Id. The VE testified that greater than 10% of time off-task would generally cause an individual to be unemployable. Id. She confirmed this was consistent with no more than six minutes of time off-task per hour. Id. Plaintiff's attorney asked the VE what threshold would be tolerated for monthly absenteeism. Id. The VE testified that one absence per month would generally be tolerated and that consistent absences beyond that would likely result in termination. Tr. at 100-01. Plaintiff's attorney asked the VE if use of a handheld assistive device would affect an individual's ability to perform light or sedentary jobs. Tr. at 101. The VE testified use of a handheld assistive device would preclude performance of Plaintiff's prior work as a security guard, but would allow for performance of her other PRW, provided she could carry up to 10 pounds with the other arm. Id.
ii. December 8, 2020
VE Tina Stambaugh reviewed the record and testified at the hearing. Tr. at 54-59. She identified Plaintiff's PRW as a telephone operator, DOT No. 235.662-022, requiring sedentary exertion and an SVP of 3; a customer service representative, insurance and benefits, DOT No. 219.387-014, requiring exertion and an SVP of 4; and a clerical checker, DOT No. 209.687010, requiring sedentary exertion and an SVP of 4. Tr. at 55-57.
The ALJ described a hypothetical individual of Plaintiff's vocational profile who could perform work at the sedentary exertional level with the following restrictions: occasionally climb ramps and stairs; never climb ladders, ropes, and scaffolds; occasionally stoop, kneel, crouch, and crawl; frequently reach overhead with the bilateral upper extremities; and avoid even moderate exposure to hazards. Tr. at 57-58. She asked if the individual would be able to perform Plaintiff's PRW. Tr. at 58. The VE testified the individual would be able to perform all of Plaintiff's PRW. Id. The ALJ asked the VE if her testimony had been consistent with the DOT. Id. The VE stated it had been, except that the DOT did not address reaching in any specific direction. Id. She explained that element of her testimony was based on her experienced in the field. Id.
Plaintiff asked the VE to consider that her doctor had taken away her driving privileges due to seizure activity, that she was not supposed to be out alone because she experienced mental lapses, and that she had cognitive difficulties. Id. The ALJ rephrased Plaintiff's question, asking the VE if an individual limited to simple, routine tasks would be able to perform Plaintiff's PRW. Tr. at 59. The VE stated “no.” Id. She explained that, in a competitive work environment, an individual would need to be able to maintain attention and concentration for at least two hours at a time before taking a break. Id.
2. The ALJ's Findings
In her January 13, 2021 decision, the ALJ made the following findings of fact and conclusions of law:
1. Claimant meets the insured status requirements of the Social Security Act through December 31, 2014.
2. Claimant has not engaged in substantial gainful activity since October 30, 2014, the amended alleged onset date (20 CFR 404.1571, et seq., and 416.971, et seq.).
3. Claimant has the following severe impairments: degenerative disc disease, history of transient ischemic attack (TIA), and glaucoma (20 CFR 404.1520(c) and 416.920(c)).
4. Claimant 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, 404.1526, 416.920(d), 416.925 and 416.926).
5. After careful consideration of the entire record, I find that claimant has the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a) and 416.967(a) with some non-exertional limitations. Specifically, claimant can lift and carry up 10 pounds occasionally and lesser amounts frequently. She can sit for 6 hours in an 8-hour day, and stand and walk occasionally. She can never climb ladders, ropes, or scaffolds. She occasionally can stoop, kneel, crouch, crawl, and climb ramps and stairs. Can frequently can reach overhead with the bilateral upper extremities. She must avoid even moderate exposure to hazards.
6. Claimant is capable of performing past relevant work as a clerical checker, telephone operator, and customer service representative. This work does not require the performance of work-related activities precluded by claimant's residual functional capacity (20 CFR 404.1565 and 416.965).
7. Claimant has not been under a disability, as defined in the Social Security Act, from October 30, 2014, through the date of this decision (20 CFR 404.1520(f) and 416.920(f)).
Tr. at 15-26.
II. Discussion
Plaintiff alleges the Commissioner erred for the following reasons:
1) the ALJ improperly evaluated the severity of multiple impairments and failed to consider them in assessing her RFC;
2) the ALJ failed to evaluate the medical opinions in accordance with the applicable regulations;
3) the ALJ applied an incorrect legal standard in discounting her complaints of pain and fatigue as inconsistent with the objective medical evidence;
4) the ALJ did not consider the combined effects of her multiple mental and physical impairments;
5) the ALJ erred in finding her impairment did not meet or equal Listing 1.04;
6) the ALJ erroneously stated she did not use a transcutaneous epidural nerve stimulation (“TENS”) unit;
7) the ALJ improperly concluded she could perform frequent overhead reaching;
8) the ALJ erred in accepting the VE's testimony that she could work instead of adopting the state's conclusion that her impairments exempted her from volunteer requirements for the Temporary Aid to Needy Families program; and
9) the Appeals Council erred in declining to exhibit and consider additional evidence.
The Commissioner counters that substantial evidence supports the ALJ's findings and that the ALJ committed no legal error in her decision.
A. Legal Framework
1. The Commissioner's Determination-of-Disability Process
The Act provides that disability benefits shall be available to those persons insured for benefits, who are not of retirement age, who properly apply, and who are under a “disability.” 42 U.S.C. § 423(a). Section 423(d)(1)(A) defines disability as:
the inability to engage in 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 at least 12 consecutive months.42 U.S.C. § 423(d)(1)(A).
To facilitate a uniform and efficient processing of disability claims, regulations promulgated under the Act have reduced the statutory definition of disability to a series of five sequential questions. See, e.g., Heckler v. Campbell, 461 U.S. 458, 460 (1983) (discussing considerations and noting “need for efficiency” in considering disability claims). An examiner must consider the following: (1) whether the claimant is engaged in substantial gainful activity; (2) whether she has a severe impairment; (3) whether that impairment meets or equals an impairment included in the Listings; (4) whether such impairment prevents claimant from performing PRW; and (5) whether the impairment prevents her from doing substantial gainful employment. See 20 C.F.R. §§ 404.1520, 416.920. These considerations are sometimes referred to as the “five steps” of the Commissioner's disability analysis. If a decision regarding disability may be made at any step, no further inquiry is necessary. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4) (providing that if Commissioner can find claimant disabled or not disabled at a step, Commissioner makes determination and does not go on to the next step).
The Commissioner's regulations include an extensive list of impairments (“the Listings” or “Listed impairments”) the Agency considers disabling without the need to assess whether there are any jobs a claimant could do. The Agency considers the Listed impairments, found at 20 C.F.R. part 404, subpart P, Appendix 1, severe enough to prevent all gainful activity. 20 C.F.R. §§ 404.1525, 416.925. If the medical evidence shows a claimant meets or equals all criteria of any of the Listed impairments for at least one year, she will be found disabled without further assessment. 20 C.F.R. § 404.1520(a)(4)(iii), 416.920(a)(4)(iii). To meet or equal one of these Listings, the claimant must establish that her impairments match several specific criteria or are “at least equal in severity and duration to [those] criteria.” 20 C.F.R. §§ 404.1526, 416.926; Sullivan v. Zebley, 493 U.S. 521, 530 (1990); see Bowen v. Yuckert, 482 U.S. 137, 146 (1987) (noting the burden is on claimant to establish his impairment is disabling at Step 3).
In the event the examiner does not find a claimant disabled at the third step and does not have sufficient information about the claimant's past relevant work to make a finding at the fourth step, he may proceed to the fifth step of the sequential evaluation process pursuant to 20 C.F.R. §§ 404.1520(h), 416.920(h).
A claimant is not disabled within the meaning of the Act if she can return to PRW as it is customarily performed in the economy or as the claimant actually performed the work. See 20 C.F.R. Subpart P, §§ 404.1520(a), (b), 416.920(a), (b); Social Security Ruling (“SSR”) 82-62 (1982). The claimant bears the burden of establishing her inability to work within the meaning of the Act. 42 U.S.C. § 423(d)(5).
Once an individual has made a prima facie showing of disability by establishing the inability to return to PRW, the burden shifts to the Commissioner to come forward with evidence that claimant can perform alternative work and that such work exists in the economy. To satisfy that burden, the Commissioner may obtain testimony from a VE demonstrating the existence of jobs available in the national economy that claimant can perform despite the existence of impairments that prevent the return to PRW. Walls v. Barnhart, 296 F.3d 287, 290 (4th Cir. 2002). If the Commissioner satisfies that burden, the claimant must then establish that she is unable to perform other work. Hall v. Harris, 658 F.2d 260, 264-65 (4th Cir. 1981); see generally Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987) (regarding burdens of proof).
2. The Court's Standard of Review
The Act permits a claimant to obtain judicial review of “any final decision of the Commissioner [] made after a hearing to which he was a party.” 42 U.S.C. § 405(g). The scope of that federal court review is narrowly-tailored to determine whether the findings of the Commissioner are supported by substantial evidence and whether the Commissioner applied the proper legal standard in evaluating the claimant's case. See Richardson v. Perales, 402 U.S. 389, 390 (1971); Walls, 296 F.3d at 290 (citing Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990)).
The court's function is not to “try these cases de novo or resolve mere conflicts in the evidence.” Vitek v. Finch, 438 F.2d 1157, 1157-58 (4th Cir. 1971); see Pyles v. Bowen, 849 F.2d 846, 848 (4th Cir. 1988) (citing Smith v. Schweiker, 795 F.2d 343, 345 (4th Cir. 1986)). Rather, the court must uphold the Commissioner's decision if it is supported by substantial evidence. “Substantial evidence” is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson, 402 U.S. at 390, 401; Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005). Thus, the court must carefully scrutinize the entire record to assure there is a sound foundation for the Commissioner's findings and that her conclusion is rational. See Vitek, 438 F.2d at 1157-58; see also Thomas v. Celebrezze, 331 F.2d 541, 543 (4th Cir. 1964). If there is substantial evidence to support the decision of the Commissioner, that decision must be affirmed “even should the court disagree with such decision.” Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).
B. Analysis
1. Severity of Impairments
Plaintiff argues the ALJ erred in considering hypertension, Hashimoto's disease, MS, depression, and anxiety as non-severe impairments. [ECF No. 25 at 15, 19-22]. She maintains the ALJ improperly considered limitations imposed by fibromyalgia and multiple impairments causing vision loss. Id. at 7, 13-14. She asserts the ALJ relied on evidence from Dr. Fielding's report that supported her conclusion and rejected evidence to the contrary. Id. at 22.
The Commissioner maintains substantial evidence supports the ALJ's conclusions that hypertension, Hashimoto's disease, MS, depression, and anxiety were non-severe impairments. [ECF No. 26 at 11]. She notes the ALJ explained that she found hypertension to be non-severe, given treatment records that failed to regularly document significantly elevated blood pressure and treatment consisting of medication only. Id. at 12. She states the ALJ found Hashimoto's disease to be non-severe because it was only diagnosed through bloodwork three months prior to the hearing and the evidence did not show that it had persisted for 12 consecutive months. Id. at 12-13. She contends the ALJ considered MS non-severe because Plaintiff underwent no treatment for the impairment between May 2019 and November 2020. Id. at 13. She further maintains MS did not impose any functional limitations in addition to those included in the RFC assessment. Id. She notes the ALJ found depression and anxiety to be non-severe because Plaintiff did not routinely report bothersome symptoms to her providers and her medical records failed to document abnormal findings on mental status exams. Id. She asserts the ALJ properly documented and supported her application of the special technique in evaluating the severity of Plaintiff's mental impairments. Id. at 13-14. She specifically maintains the evidence shows no visual limitations, despite a diagnosis of glaucoma. Id. at 19.
The ALJ must consider the severity of the claimant's impairments at step two. 20 C.F.R. § 404.1520(c), 416.920(c). A medical impairment “must result from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques” and “must be established by objective medical evidence from an acceptable medical source.” 20 C.F.R. §§ 404.1521, 416.921. A severe impairment “significantly limits [a claimant's] physical or mental ability to do basic work activities.” 20 C.F.R. §§ 404.1520(c), 416.920(c). Examples of basic work activities include: (1) physical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling; (2) capacities for seeing, hearing, and speaking; (3) understanding, carrying out, and remembering simple instructions; (4) use of judgment; (5) responding appropriately to supervision, coworkers, and usual work situations; and (6) dealing with changes in a work setting. 20 C.F.R. §§ 404.1522(b), 416.922(b). “An impairment or combination of impairments is found ‘not severe' and a finding of ‘not disabled' is made at [step two] when the medical evidence establishes only a slight abnormality or a combination of slight abnormalities which would have no more than a minimal effect on an individual's ability to work even if the individual's age, education, and work experience were specifically considered (i.e., the person's impairment(s) has no more than a minimal effect on his or her physical or mental ability(ies) to perform basic work activities).” SSR 85-28.
An ALJ's error in assessing the severity of an impairment may be harmless, provided she assesses at least one impairment as severe and moves to the third step of the evaluation process. See Carpenter v. Astrue, 537 F.3d 1264, 1266 (10th Cir. 2008) (“[A]ny error here became harmless when the ALJ reached the proper conclusion that [claimant] could not be denied benefits conclusively at step two and proceeded to the next step of the evaluation sequence.”).
An ALJ may remedy an error in evaluating the severity of a claimant's impairment by considering the functional limitations it imposes in assessing her RFC. See Washington v. Astrue, 98 F.Supp.2d 562, 580 (D.S.C. 2010) (providing that the court “agrees with other courts that find no reversible error where the ALJ does not find an impairment severe at step two provided that he or she considers that impairment in subsequent steps”). 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 [the claimant's] ability to work.'” Thomas v. Berryhill, 916 F.3d 307, 311 (4th Cir. 2019) (quoting Monroe v. Colvin, 826 F.3d 176, 188 (4th Cir. 2016)); see also 20 C.F.R. § 404.1545(a)(2) (providing the adjudicator should consider all the medically-determinable impairments of which he is aware, including those that are not “severe”). The ALJ “must explain how any material inconsistencies or ambiguities in the case record were considered and resolved” in the RFC assessment. SSR 96-8p, 1996 WL 374184, at *7.
Here, any error in assessing the severity of Plaintiff's impairments was harmless at step two, as the ALJ found some of Plaintiff's impairments to be severe and proceeded to additional steps in the evaluation process. Nevertheless, the undersigned has considered whether substantial evidence supports the ALJ's conclusion that fibromyalgia, hypertension, Hashimoto's disease, MS, depression, anxiety, and visual impairments imposed no functional limitations.
Plaintiff argues the ALJ erred in failing to account for the effects of fibromyalgia in assessing her RFC, but the undersigned's review of the record fails to yield evidence of a medically-determinable impairment of fibromyalgia. It does not appear that Plaintiff's providers indicated a diagnosis of fibromyalgia in their records. See, e.g., Tr. at 1343-44 (reflecting the following diagnoses in Dr. Menon's March 30, 2017 record: cataract, glaucoma, CAD, acute myocardial infarction, hypertension, esophageal reflux, osteoarthritis, backache/cervical disc disease, lumbar disc disease, migraine headache, epilepsy and recurrent seizures, transient ischemic attack (“TIA”), and stroke syndrome/CVA); Tr. at 1547 (indicating Dr. Kass's assessment of the following impairments in a January 4, 2019 treatment note: valvular heart disease; myocardial infarction arrhythmias; soft tissue swelling; epilepsy and recurrent seizures; history of TIA; overanxious disorder; combined systolic and diastolic elevation; hypertension/edema; hypothyroid; and anxiety).
Pursuant to SSR 12-2p, to establish a diagnosis of fibromyalgia, a claimant may meet either the 1990 American College of Rheumatology (“ACR”) Criteria for the Classification of Fibromyalgia or the 2010 ACR Preliminary Diagnostic Criteria. Plaintiff references “A.R. 357-58, 502” and maintains the record contains a statement from Dr. Menon that findings were “in accordance with the diagnostic criteria of the American College of Rheumatology,” ECF No. 25 at 7, but Tr. at 357-58 and Tr. at 502 fail to support a diagnosis of fibromyalgia, and the undersigned has not discovered any such indication from Dr. Menon within the record. Even if Dr. Menon made such a statement, there is no indication that he ruled out other disorders that could cause the repeated manifestation of symptoms, signs, or co-occurring conditions, which is required to establish a diagnosis of fibromyalgia under the SSR. See SSR 12-2p, 2012 WL 3104869, at *3. Because a diagnosis of fibromyalgia was not established under the applicable criteria, the ALJ did not err in failing to consider it at step two and subsequent steps.
In addressing Plaintiff's hypertension, the ALJ acknowledged the diagnosis, but concluded it was a non-severe impairment because “[n]o more than medication management ha[d] been recommended” and “treatment records d[id] not regularly document significantly elevated blood pressure readings.” Tr. at 16. The undersigned rejects Plaintiff's argument that the ALJ improperly considered the severity of hypertension because the ALJ's explanation is supported by the record, which documents generally well-controlled blood pressure and no specific functional limitations due to hypertension.
The ALJ considered Hashimoto's disease a non-severe impairment, explaining as follows: “An October 2020 laboratory result confirmed the diagnosis of Hashimoto's disease (exhibit B64F), but the evidence contains no medical findings establishing this condition has persisted for 12 continuous months. Additionally, no more than routine medication management has been recommended for Hashimoto's disease.” Tr. at 16.
Plaintiff correctly asserts that substantial evidence does not support the ALJ's conclusion that Hashimoto's disease had not persisted for 12 continuous months. Although Hashimoto's disease was confirmed in October 2020, the record reflects Plaintiff's lengthy history of hypothyroidism. See Tr. at 1081, 1272, 1364-68, 1383, 1418, 1421, 1424, 1569, 1578, 1582, 1637-40. In fact, the test results specify: “It does not change anything, just confirming the diagnosis.” Tr. at 1903. Despite the ALJ's error as to the persistence of the impairment, she was correct that no more than routine medication management had been recommended. Plaintiff's hypothyroidism was consistently treated with Levothyroxine, which was increased from 25 mcg to 75 mcg over time. Tr. at 1368, 1382, 1547, 1552. Although the record contains some abnormal thyroid function panels, Plaintiff's thyroid function improved after she followed Dr. Gondal's advice to obtain her medication for $4 at Walmart and her Levothyroxine dose was increased. See Tr. at 1578, 1582, 1640. Thus, the ALJ's assessment of the impairment as non-severe is supported by the condition's response to medication and a lack of evidence that it significantly limited Plaintiff's “physical or mental ability to do basic work activities.” See 20 C.F.R. §§ 404.1520(c), 416.920(c).
The ALJ explained her assessment of MS as a non-severe impairment as follows:
Claimant's neurologist George Sandoz, M.D., noted an assessment of multiple sclerosis during a May 2019 visit and advised Plaintiff to start on Aubagio (Exhibit B50F). Thereafter, however, it does not appear that claimant has undergone any treatment for multiple sclerosis. Notably, the evidence contains few references to this condition again until November 2020, at which time the claimant told Dr. Sandoz that she did not want to undergo medical treatment for multiple sclerosis (Exhibit B65F). While asked about this at the hearing, claimant testified she initially postponed treatment because of the impending birth of her grandchild. She further testified that she was later bitten by a brown recluse spider, which could impact her immune system, so she needed to continue to postpone treatment for multiple
sclerosis. Claimant submitted a December 2020 emergency room visit discharge summary documenting the spider bite (B66F). Given the lack of any documented treatment for this condition between May 2019 when Dr. Sandoz recommended Aubagio and claimant's November 2020 statement to Dr. Sandoz that she did not undergo treatment, however, I find the evidence supports a conclusion that multiple sclerosis does not impose any functional limitation beyond those set forth below in the residual functional capacity.
Tr. at 17.
The record contains little evidence as to MS and its functional effects. Dr. Sandoz diagnosed the impairment in May 2019, but Plaintiff's next treatment record with him is dated November 19, 2020. See Tr. at 1796, 1909. It is unclear if Plaintiff treated with Dr. Sandoz over the period between these visits. Aside from Dr. Sandoz's notation in his May 2019 treatment note that Plaintiff's altered mental status may be due to MS, it is unclear how he believed MS affected Plaintiff's ability to perform basic work activities. However, the undersigned notes Plaintiff alleged MS further reduced her physical and mental abilities. Tr. at 44.
The ALJ essentially concluded that Plaintiff would have opted to pursue treatment if the impairment had imposed significant functional limitations. In reaching this conclusion, the ALJ considered some, but not all the reasons Plaintiff provided for declining to pursue treatment. Pursuant to SSR 16-3p:
[I]f the frequency or extent of the treatment sought by an individual is not comparable with the degree of the individual's subjective complaints, or if the individual fails to follow prescribed treatment that might improve symptoms, we may find the alleged intensity and persistence of an individual's symptoms are inconsistent with the overall evidence of record. We will not find an individual's symptoms inconsistent with the evidence in the record on this basis without considering possible reasons he or she may not comply with treatment or seek treatment consistent with the degree of his or her complaints.
2017 WL 5180304, at *9. In addition to the reasons the ALJ mentioned, Plaintiff explained that she had been reluctant to pursue treatment for MS because of the expected side effects and that she had researched and planned to pursue other treatments not yet available that appeared to have fewer side effects. See Tr. at 45. The SSR specifies “[a]n individual may not agree to take prescription medications because the side effects are less tolerable than the symptoms” as one reason supporting a claimant's failure to pursue treatment. See id. at 10. The ALJ is required to explain how she “considered the individual's reasons” in her evaluation of the individual's symptoms. Id. The ALJ erred to the extent that she rejected Plaintiff's assertion that MS negatively impacted her ability to perform basic work activities without addressing her aversion to the anticipated side effects of treatment.
In explaining her findings that depression and anxiety were non-severe impairments, the ALJ wrote:
[C]laimant has not routinely reported bothersome psychological symptoms, nor do treatment records regularly document
abnormal mental status findings. The evidence documents little, if any, treatment from a mental health professional during the relevant period. Thus, claimant's medically determinable mental impairments of depression and anxiety, considered singly and in combination, do not cause more than minimal limitation in claimant's ability to perform basic mental work activities and are, therefore, non-severe.
Tr. at 17.
The ALJ stated she applied the special technique in 20 C.F.R. § 404.1520a and § 416.920a, which showed only mild limitation in all four functional areas. Tr. at 17-18. She explained a finding of mild limitation in understanding, remembering, or applying information was supported for the following reasons:
Dr. Michael Fielding noted adequate memory. She could spell world backwards, perform serial threes, and perform basic math (Exhibit B33F). Although claimant has made some reports of memory problems to providers in association with her applications, treatment records document few, if any, findings of memory deficits. Likewise, treating providers have documented few, if any other abnormal findings relating to this area of functioning.
Tr. at 17. She stated Plaintiff had mild limitation in interacting with others because she lived with her adult son; she reported she did not interact with others due to fatigue; her treating providers documented few, if any, observations of difficulty in this area; and Dr. Fielding noted she was cooperative, but suspicious. Id. She found Plaintiff had a mild limitation in concentrating, persisting, or maintaining pace because: “Dr. Fielding noted adequate memory. She could spell world backwards, perform serial threes, and perform basic math (Exhibit B33F). Treating providers have documented few, if any, abnormal findings relating to this area of functioning.” Tr. at 1718. She assessed mild limitation in adapting or managing oneself because Plaintiff reported “ironing, cleaning[,] doing laundry, shopping, preparing simple meals . . . managing money, and tending to her personal care” and her treating providers “documented few, if any, abnormal findings relating to this area of functioning.” Tr. at 18.
Aside from the ALJ's acknowledgment that Plaintiff reported memory loss and altered mental status to Dr. Sandoz, Tr. at 21, her explanation of the RFC assessment fails to address mental symptoms. See Tr. at 19-24. The ALJ stated she was persuaded by the state agency consultants' conclusions that Plaintiff's mental impairments were non-severe because they were “consistent with and supported by the overall evidence of record.” Tr. at 22. However, the ALJ ignored evidence contrary to her conclusion, including assessments of severe depression and anxiety from multiple providers. Tr. at 1200, 1342, 1344, 1346, 1354, 1363, 1384, 1847. She also neglected abnormal mental status exam findings. See Tr. at 1344 (stating Plaintiff had dysthymic, anxious mood), 1351 (noting psychomotor retardation; negativism; inability to engage; bitter attitude; empty, unhappy, despairing, and irritable mood; and flat affect), 1373 (observing poor eye contact and depressed and fatigued appearance), 1378 (documenting decreased eye contact; guarded attitude; empty, unhappy, and depressed mood; flat affect; and slowed rate of thought), 1597-98 (indicating psychomotor retardation and neutral facial expressions), 1637 (recognizing she appeared depressed). Her decision does not reflect her thorough consideration of Dr. Fielding's observations and opinion, as further detailed below. The ALJ also neglected to address impressions from Drs. Kutluay and Dabas that Plaintiff's perceived seizures could be psychogenic non-epileptic events. See Tr. at 1131, 1122. Because the ALJ did not reconcile this evidence with her conclusions that anxiety and depression were non-severe impairments and her exclusion of mental restrictions from the RFC assessment, she did not adequately comply with the provisions of SSR 96-8p.
Despite her recognition of glaucoma as a severe impairment at step two and her finding that the impairment “significantly limited [Plaintiff's] ability to perform basic work activities,” Tr. at 15, the ALJ did not include any visual restrictions in the RFC assessment or explain how any environmental or other restriction addressed the severe impairment of glaucoma. See Tr. at 19-24. She addressed glaucoma as follows:
[I]n November 2015, claimant was assessed with mild open angle glaucoma (Exhibit 19F). A consultative ophthalmologic exam in November 2017 reported that best corrected vision was 20/20 on the right and 20/30 on the left. She was assessed with stable glaucoma and a stable visual field deficit from a remote brain
injury (Exhibit B32F). Vision records reveal examinations that were outside of normal limits in May 2018 and October 2019 (Exhibits B54F and B60F). In October 2018, claimant underwent selective laser trabecutoplasty on both eyes. She reported intermittently seeing a black ring in the periphery during a follow-up visit in April 2019. Nevertheless, at the April 2019 visit, claimant's distance and intermediate vision without correction was 20/25 on the right and 20/30 on the left. Her provider noted that her fluctuation in vision was due to dry eyes and he advised her to use artificial tears in addition to Latanoprost, which was prescribed for glaucoma (Exhibit B55F). No additional surgery has since been recommended. Claimant reported to neurologist Dr. Sandoz in February 2019 that she was sensitive to light, but there are few other statements in the record to corroborate claimant's testimony that she is not able to tolerate light well due to glaucoma. Dr. Sandoz's exam in February 2019 revealed the optic nerves were normal in color and contour and claimant's pupils reacted to light and dark (Exhibit B49F).
Tr. at 21. The ALJ noted she was “partially persuaded” by the state agency consultants' opinions, finding the postural and environmental limitations to be supported by the record, but the overall record to support sedentary, as opposed to light, exertional demands and frequent overhead reaching with the bilateral upper extremities. Tr. at 23. However, she said nothing about the restriction to frequent use of field of vision that the state agency consultants included in their assessments and declined to include such a restriction in the RFC assessment. In the absence of further explanation, the undersigned is unable to discern how the ALJ accounted for glaucoma or any other visual impairment in the RFC assessment.
In sum, the ALJ's decision fails to apply the proper legal standards in evaluating the severity of and functional limitations imposed by MS, depression, anxiety, and glaucoma and other visual impairments.
2. Medical Opinions
Plaintiff asserts the ALJ did not give proper weight to the physicians' opinions of record. [ECF No. 25 at 15, 23-24]. She maintains Drs. Menon, Kass, Fielding, and Dylewski opined that she would be unable to engage in substantial gainful activity. Id. at 23-24.
The Commissioner argues the ALJ is not required to defer to any medical opinion of record in assessing a claimant's RFC. [ECF NO. 26 at 21]. She maintains the ALJ complied with the requirements in the new regulations in evaluating the persuasiveness of the medical opinions of record. Id. at 22.
Sections 404.1513(a)(2) and 416.913(a)(2) define a medical opinion as “a statement from a medical source about what you can still do despite your impairment(s) and whether you have one or more impairment-related limitations or restrictions in the following abilities:
(1) Your ability to perform physical demands of work activities, such as sitting, standing, walking, lifting, carrying, pushing, pulling, or other physical functions (including manipulative or postural functions, such as reaching, handling, stooping, or crouching);
(2) Your ability to perform mental demands of work activities, such as understanding; remembering; maintaining concentration, persistence, or pace; carrying out instructions; or responding appropriately to supervision, coworkers, or work pressures in a work setting;
(3) Your ability to perform other demands of work, such as seeing, hearing, or using other senses; and
(4) Your ability to adapt to environmental conditions, such as temperature extremes or fumes.
The ALJ must consider in the decision how persuasive she found all the medical opinions based on the following factors: (1) supportability; (2) consistency; (3) relationship with the claimant; (4) specialization; and (5) other factors that tend to support or contradict a medical opinion. 20 C.F.R. §§ 404.1520c(b), (c), 416.920c(b), (c). Supportability and consistency are considered the most important factors in assessing the persuasiveness of an opinion, and the ALJ must articulate how she considered those two factors in evaluating each medical opinion. 20 C.F.R. §§ 404.1520c(a), (b)(2), 416.920c(a), (b)(2). Relevant to the supportability evaluation, “[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 opinion . . . will be.” 20 C.F.R. §§ 404.1520c(c)(1), 416.920c(c)(1). In evaluating the consistency factor, “[t]he more consistent a medical opinion . . . is with the evidence from other medical sources and nonmedical sources in the claim, the more persuasive the medical opinion . . . will be.” 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2). Failure to consider supportability or consistency will likely necessitate remand. See Bonnett v. Kijakazi, 859 Fed.Appx. 19 (Mem.) (8th Cir. 2021) (concluding remand was required for further evaluation of physician's opinion where “the ALJ adequately evaluated the supportability” of the opinion, but “did not address” whether it “was consistent with the other evidence of record, as required by the applicable regulation”).
The court reviews the ALJ's conclusions as to the supportability and consistency of a medical opinion to determine whether substantial evidence supports them. The court may order remand if the ALJ materially errs in evaluating these factors. See Joseph M. v. Kijakazi, C/A No. 1:20-3664-DCC-SVH, 2021 WL 3868122, at *13 (D.S.C. Aug. 19, 2021) (finding the ALJ erred in assessing a medical opinion pursuant to 20 C.F.R. § 404.1520c and § 416.920c because he erred in stating the date the plaintiff last saw the medical provider, neglected the continuing treatment relationship, and erroneously claimed the last treatment visit was prior to the plaintiff's alleged onset date), adopted by 2021 WL 3860638 (D.S.C. Aug. 30, 2021).
The record sometimes includes statements that do not qualify as medical opinions under the regulations. ALJs are not required to provide any analysis in their decisions as to how they considered statements on issues reserved to the Commissioner, such as statements that a claimant is or is not blind, disabled, able to work, or able to perform regular or continuing work; has severe impairments; has impairments that meet the duration requirement; has an impairment or combination of impairments that meet or equal a listing; has a particular RFC, based on use of programmatic terms about functional exertional levels; is or is not able to perform PRW; meets or fails to meet a medical-vocational rule; or has a disability that continues or has ended. 20 C.F.R. §§ 404.1520b(c), 416.920b(c). These statements are considered “inherently neither valuable nor persuasive.” Id.
The record before the ALJ included only one statement from Dr. Menon. See Tr. at 1805-08. The ALJ addressed it as follows:
I am not persuaded by the medical source statement of claimant's primary care provider at Exhibit B53F. On the form, the provider indicates exertional, postural, and manipulative limitations in excess of those assigned in this decision. The extent of limitations reported by the provider, however, are not supported by the findings in primary care treatment records, and they are not consistent with the overall evidence of record. In addition, the provider noted on the form that claimant was disabled, and as noted above the determination of disability is reserved to the Commissioner. Even so, the provider also indicated claimant to be disabled, “as of now,” thus calling into question whether the provider believed all or part of the limitations on this form to be only temporary.
Tr. at 24. The ALJ adequately explained that she declined to accord persuasive authority to Dr. Menon's opinion based on its lack of supportability in his records and a lack of consistency with the other evidence of record. The undersigned further notes this opinion was issued in December 2013 and pertained to the previously-adjudicated period.
The only statement from Dr. Kass in the record before the ALJ was one in which he authorized a renewal of Plaintiff's disabled placard/license plate, represented she was unable to ordinarily walk 100 feet nonstop without aggravating an existing medical condition, and indicated her disability was permanent. See Tr. at 558. Dr. Kass's impression that Plaintiff's disability was permanent was “inherently neither valuable nor persuasive” and did not require specific consideration pursuant to 20 C.F.R. § 404.1520b(c) and § 416.920b(c). Although the ALJ did not specifically address Dr. Kass's impression that Plaintiff could not ordinarily walk 100 feet nonstop without aggravating an existing medical condition, she did so indirectly, noting the fact that Plaintiff had a disability placard was “not inconsistent with the ability to perform sedentary work.” Tr. at 24. In restricting Plaintiff to work at the sedentary exertional level, the ALJ impliedly considered persuasive the medical opinion portion of Dr. Kass's statement.
Additional statements from Drs. Menon and Kass were not included in the record before the ALJ, but were instead submitted to the Appeals Council. The Appeals Council properly declined to exhibit the statements, as “this evidence [did] not show a reasonable probability that it would change the outcome of the decision.” See Tr. at 2. Much of the evidence was duplicative of the providers' earlier statements and several of the statements were statements on issues reserved to the Commissioner that were “inherently neither valuable nor persuasive” and would not have required analysis under 20 C.F.R. § 404.1520b(c) and § 416.920b(c). See Tr. at 104-05, 108, 109, 110-11, 112.
The ALJ noted she had considered Dr. Dylewski's opinion “regarding claimant's limitations and his conclusion that claimant has significant disability that would make it difficult for her to perform any work.” Tr at 23. She considered it “not persuasive as it is unsupported by and inconsistent with the weight of the medical evidence of record, including the findings of his own exam, and appears to be based primarily on claimant's subjective symptoms, which, for reasons stated in detail above, are not reliable.” Id. She further noted Dr. Dylewski examined Plaintiff only once and lacked the benefit of a longitudinal treating relationship with her. Id. Finally, she indicated the determination of disability is reserved to the Commissioner. Id.
The undersigned finds the ALJ erred in considering the supportability of Dr. Dylewski's opinion based on his exam findings. In summarizing evidence from the exam, the ALJ wrote:
When claimant presented to Dr. Stefan Dylewski for an orthopedic consultative exam in November 2017, she was able to perform the exam without her cervical collar. She was 5'4” tall and weighed 215 pounds. She had difficulty with her gait on the left side. She had difficulty with heel-toe walking while using her
cane. There was no joint deformity. She had mild swelling of her feet and ankles. There was mild tenderness of the greater trochanters, hips, and low back. Range of motion was limited in the cervical spine. Range of motion of the lumbar spine was reduced in flexion and extension. Straight leg raising was normal. Hand strength was normal. She had 2/4 strength in the extremities. There was no significant atrophy of the extremities (Exhibit B30F).
Tr. at 21-22.
The ALJ's dismissal of the specific restrictions Dr. Dylewski provided as appearing to be based primarily on Plaintiff's subjective symptoms fails to reconcile some of the findings the ALJ cited above, which arguably support the restrictions. Dr. Dylewski's opinion that left-sided weakness from Plaintiff's stroke and lumbago restricted her to lifting, carrying, pushing, and pulling two to three pounds, sitting and standing for no more than 30 minutes to an hour at a time, walking a city block, bending with use of a cane, and doing no crouching, kneeling, crawling, balancing, or climbing appears to be based, in part, on his observations that Plaintiff had reduced ROM in her cervical and lumbar spine, swelling in her feet and ankles, TTP in multiple areas, nearly lost her balance in performing heel-to-to walk, and had “labored, uneven, and heavy” gait “with particular difficulty on the left side when she walks with a cane.” Tr. at 1456. Dr. Dylewski's opinion that Plaintiff was unable to turn and move her neck and head appears to be consistent with his observation of significantly reduced ROM of the cervical spine. See Tr. at 1456, 1457. Even if Dr. Dylewski partially based his opinion on Plaintiff's report of subjective symptoms, this was not impermissible, as he found Plaintiff to be cooperative and to provide full effort throughout the exam. See Tr. at 1456. Because the ALJ did not thoroughly consider the evidence in determining the supportability of Dr. Dylewski's opinion, she erred in evaluating its overall persuasiveness.
The ALJ gave a similar explanation for finding Dr. Fielding's opinion “unpersuasive, as it [was] unsupported by and inconsistent with the weight of the medical evidence of record, including the findings of his own exam.” Tr. at 24. She again noted the opinion appeared to be based on Plaintiff's subjective symptoms, that Dr. Fielding had examined Plaintiff on only one occasion, and that his impression that Plaintiff would be unable to complete a normal workday and workweek was a decision reserved to the Commissioner. Id.
In reaching this conclusion, the ALJ ignored Plaintiff's providers' observations that suggested she had mental functional limitations, as discussed above. See Tr. at 1200, 1342, 1344, 1346, 1354, 1363, 1373, 1378, 1384, 1597-98, 1637, 1847.
The ALJ cherrypicked Dr. Fielding's observations, noting he considered Plaintiff to be cooperative and observed her to have adequate memory and abilities to spell “world” backwards and perform serial threes and basic math, but making no mention of his overwhelming impressions during the exam.
See Tr. at 17-18, 24. “An ALJ has the obligation to consider all relevant 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). Dr. Fielding stressed that Plaintiff would have difficulty accepting instruction from supervisors, working with coworkers and the public, and maintaining productivity based on her inability to respond appropriately during his interview. Tr. at 1479. This impression was more specifically based on his observations that Plaintiff “appeared extremely suspicious about the intentions of others,” was somewhat paranoid, demonstrated “frequent hand wringing as if she was highly anxious,” showed flat affect, had “constant apprehensive expectation, always anticipating the other shoe to drop,” and endorsed thoughts characterized by “very unusual thought patterns” and “some type of delusional process,” although they were generally logical and organized. Tr. at 1475-76. He described Plaintiff as having limited insight and constant, non-stop speech flow and one-sided speech that reflected she was “extremely self-absorbed in her overall symptom picture and all the events that occurred in her life in a negative way.” Tr. at 1477. Because the ALJ ignored this evidence that arguably supported Dr. Fielding's impressions, she failed to appropriately evaluate the opinion's supportability.
Given errors in the ALJ's assessment of the supportability of Dr. Dylewski's opinion and the supportability and consistency of Dr. Fielding's opinion, the undersigned recommends the case be remanded for reconsideration of the persuasiveness of the medical opinions.
3. Additional Allegations of Error
Plaintiff raises several additional challenges to the ALJ's decision. However, given the undersigned's recommendation that the court remand the case for reconsideration of the severity and functional limitations imposed by Plaintiff's impairments and the medical opinions of record, the undersigned declines to address the remaining allegations of error.
III. Conclusion and Recommendation
The court's function is not to substitute its own judgment for that of the ALJ, but to determine whether the ALJ's decision is supported as a matter of fact and law. Based on the foregoing, the court cannot determine that the Commissioner's decision is supported by substantial evidence. Therefore, the undersigned recommends, pursuant to the power of the court to enter a judgment affirming, modifying, or reversing the Commissioner's decision with remand in Social Security actions under sentence four of 42 U.S.C. § 405(g), that this matter be reversed and remanded for further administrative proceedings. In accordance with this recommendation, the deadline for filing of Plaintiff's reply to the Commissioner's brief is hereby suspended as moot.
IT IS SO RECOMMENDED.