Opinion
7:20-CV-229-M
03-01-2023
TONY SINGLETARY, Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant.
MEMORANDUM AND RECOMMENDATION
Brian S. Meyers United States Magistrate Judge.
This matter is before the court on the parties' cross-motions for judgment on the pleadings [DE-19, -22] pursuant to Fed.R.Civ.P. 12(c). Plaintiff Tony Singletary (“Plaintiff” or, in context, “Claimant”) filed this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the denial of his application for a period of disability and Disability Insurance Benefits (“DIB”). Both parties submitted memoranda in support of their respective motions. [DE-20, -23]. The time for filing responsive briefs has expired and the pending motions are ripe for adjudication. The motions were referred to the undersigned magistrate judge for a memorandum and recommendation pursuant to 28 U.S.C. § 636(b)(1). Having carefully reviewed the administrative record and the motions and memoranda submitted by the parties, it is recommended that Plaintiff's Motion for Judgment on the Pleadings [DE-19] be denied, Defendant's Motion for Judgment on the Pleadings [DE-22] be allowed, and the final decision of the Commissioner be upheld.
I. STATEMENT OF THE CASE
Plaintiff protectively filed an application for a period of disability and DIB on November 3, 2017, alleging disability beginning March 10, 2016. Transcript of Proceedings (“Tr.”) 73, 20205. His claim was denied initially. Tr. 61-73, 92-100. Plaintiff filed a request for reconsideration (Tr. 101), and was denied upon reconsideration on January 21, 2019 (Tr. 74-87, 102-09). On February 4, 2019, Plaintiff requested a hearing before the Administrative Law Judge (“ALJ”). Tr. 110-11. A hearing before the ALJ was held on January 13, 2020, at which Plaintiff, represented by counsel, and a vocational expert (“VE”) appeared and testified. Tr. 29-60. On January 29, 2020, the ALJ issued a decision denying Plaintiff's request for benefits. Tr. 11-28.
On March 9, 2020, Plaintiff requested a review of the ALJ's decision by the Appeals Council. Tr. 198-201. On September 23, 2020, the Appeals Council denied Plaintiff's request for review. Tr. 1-6. Plaintiff then filed a complaint in this court seeking review of the now-final administrative decision.
II. STANDARD OF REVIEW
The scope of judicial review of a final agency decision regarding disability benefits under the Social Security Act (“Act”), 42 U.S.C. § 301 et seq., is limited to determining whether substantial evidence supports the Commissioner's factual findings and whether the decision was reached through the application of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). “The findings of the Commissioner . . . as to any fact, if supported by substantial evidence, shall be conclusive ....” 42 U.S.C. § 405(g). Substantial evidence is “evidence which a reasoning mind would accept as sufficient to support a particular conclusion.” Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966). While substantial evidence is not a “large or considerable amount of evidence,” Pierce v. Underwood, 487 U.S. 552, 565 (1988), it is “more than a mere scintilla . . . and somewhat less than a preponderance.” Laws, 368 F.2d at 642. “In reviewing for substantial evidence, [the court should not] undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner].” Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996), superseded by regulation on other grounds, 20 C.F.R. § 416.927(d)(2)). Rather, in conducting the “substantial evidence” inquiry, the court's review is limited to whether the ALJ analyzed the relevant evidence and sufficiently explained his or her findings and rationale in crediting the evidence. Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997). “Judicial review of an administrative decision is impossible without an adequate explanation of that decision by the administrator.” DeLoatche v. Heckler, 715 F.2d 148, 150 (4th Cir. 1983).
III. DISABILITY EVALUATION PROCESS
The disability determination is based on a five-step sequential evaluation process as set forth in 20 C.F.R. § 404.1520 under which the ALJ is to evaluate a claim:
The claimant (1) must not be engaged in “substantial gainful activity [“SGA”],” i.e., currently working; and (2) must have a “severe” impairment that (3) meets or exceeds [in severity] the “listings” of specified impairments, or is otherwise incapacitating to the extent that the claimant does not possess the residual functional capacity [“RFC”] to (4) perform . . . past work or (5) any other work.Albright v. Comm'r of the Soc. Sec. Admin., 174 F.3d 473, 475 n.2 (4th Cir. 1999). “If an applicant's claim fails at any step of the process, the ALJ need not advance to the subsequent steps.” Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995) (citation omitted). The burden of proof and production during the first four steps of the inquiry rests on the claimant. Id. At the fifth step, the burden shifts to the ALJ to show that other work exists in the national economy which the claimant can perform. Id.
When assessing the severity of mental impairments, the ALJ must do so in accordance with the “special technique” described in 20 C.F.R. §§ 404.1520a(b)-(c). This regulatory scheme identifies four broad functional areas in which the ALJ rates the degree of functional limitation resulting from a claimant's mental impairment(s): understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing oneself. Id. § 404.1520a(c)(3). The ALJ is required to incorporate into his written decision pertinent findings and conclusions based on the “special technique.” Id. § 404.1520a(e)(4).
IV. ALJ'S FINDINGS
Applying the above-described sequential evaluation process, the ALJ found Plaintiff “not disabled” as defined in the Act. Tr. 24. At step one, the ALJ determined Plaintiff had not engaged in substantial gainful employment since March 10, 2016, the alleged onset date. Tr. 16.
Next, at step two, the ALJ determined Plaintiff had the following severe impairments: obesity; degenerative disc disease of the cervical and lumbar spine; status post sinuplasty with residual symptoms; headache; bilateral sensorineural hearing loss; and Eustachian tube dysfunction. Tr. 16. However, at step three, the ALJ concluded these impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. Tr. 16.
Prior to proceeding to step four, the ALJ assessed Plaintiff's RFC, finding Plaintiff had the ability to perform light work with the following limitations:
“Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, you must have the ability to do substantially all of these activities. If an individual can perform light work, he or she can also perform sedentary work, unless there are additional limiting factors such as the loss of fine dexterity or the inability to sit for long periods of time.” 20 C.F.R. § 404.1567(b). “Sedentary work involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met.” 20 C.F.R. § 404.1567(a); S.S.R. 96-9p, 1996 WL 374185, at *3 (July 2, 1996). “Occasionally” generally totals no more than about 2 hours of an 8-hour workday. S.S.R. 96-9p, 1996 WL 374185, at *3. “Sitting” generally totals about 6 hours of an 8-hour workday. Id. A full range of sedentary work includes all or substantially all of the approximately 200 unskilled sedentary occupations administratively noticed in 20 C.F.R. Part 404, Subpart P, Appendix 2, Table 1. Id.
Frequent climbing of ramps and stairs, but only occasional climbing of stepladders up to 4 vertical feet in height, with no climbing of higher ladders or of ropes or scaffolds of any height - frequent balancing, kneeling, and crouching - occasional stooping and crawling - frequent overhead reaching bilaterally - frequent handling and fingering bilaterally -- frequent hearing - occasional exposure to vibration, moving mechanical parts, and high, exposed places - exposure up to and including moderate noise - no production pace work on assembly lines[.]Tr. 18. In making this assessment, the ALJ found Plaintiff's statements about his limitations not entirely consistent with the medical evidence and other evidence in the record. Tr. 19-20.
At step four, the ALJ concluded Plaintiff had the RFC to perform the requirements of his past relevant work as an area supervisor as actually performed. Tr. 22. Although the ALJ found that Plaintiff is capable of performing past relevant work, the ALJ specifically made alternative findings for step five. The ALJ found in the alternative, upon considering Plaintiff's age, education, work experience, and RFC, there are other jobs that exist in significant numbers in the national economy that Plaintiff can also perform. Tr. 22-23.
V. OVERVIEW OF PLAINTIFF'S CONTENTIONS
In this case, Plaintiff alleges that the ALJ erred by failing to include any limitations on concentration, persistence, or pace despite significant evidence of the limiting effects of Plaintiff's pain and side effects of medications. Pl.'s Mem. [DE-20] at 5.
VI. DISCUSSION
Plaintiff contends that the ALJ erred by failing to include any limitations for concentration, persistence, or pace despite significant evidence of the limiting effects of Plaintiff's pain and side effects of medications. Pl.'s Mem. [DE-20] at 5. Specifically, at issue is whether the ALJ's RFC evaluation, including the ALJ's apparent finding that Plaintiff suffered “absolutely no level of mental degradation or distraction[,]” is supported by substantial evidence. Id. at 5-10. Plaintiff argues that it is not, as Plaintiff “testified that due to the effects of pain and medication side-effects, he is unable to maintain concentration for more than 30 minutes at a time.” Id. at 7. In light of this testimony, Plaintiff argues that additional RFC limitations were warranted. The undersigned disagrees.
“A Social Security claimant's RFC represents ‘the most [she] can still do despite [her] limitations.'” Dowling v. Comm'r of Soc. Sec. Admin., 986 F.3d 377, 387 (4th Cir. 2021) (quoting 20 C.F.R. § 416.945(a)(1)). It is “an administrative assessment of ‘an individual's ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis despite impairments and related symptoms.” Brooks v. Berryhill, No. 2:16-CV-80-FL(2), 2018 WL 944382, at *3 (E.D. N.C. Jan. 23, 2018) (quoting S.S.R. 96-8p, 1996 WL 374184, at *1 (July 2, 1996)). In making this assessment, “the ALJ must consider all of the claimant's medically determinable impairments of which the ALJ is aware, including those not labeled severe at step two.” Shinaberry v. Saul, 952 F.3d 113 (4th Cir. 2020) (quoting Monroe v. Colvin, 826 F.3d 176, 178 (4th Cir. 2016)). Further, an RFC assessment must be “based on all of the relevant medical and other evidence.” Ward v. Colvin, 90 F.Supp.3d 510, 513 (E.D. N.C. 2015) (citing 20 C.F.R. § 404.1545(a)(3)).
“[A] proper RFC analysis has three components: (1) evidence, (2) logical explanation, and (3) conclusion.” Thomas v. Berryhill, 916 F.3d 307, 311 (4th Cir. 2019). The ALJ “must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations).” Monroe, 826 F.3d at 189 (quoting Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015)). Where a court is “left to guess about how the ALJ arrived at his conclusions on [claimant's] ability to perform relevant functions . . ., remand is necessary.” Mascio, 780 F.3d at 637.
Additionally, “[r]emand may be appropriate . . . where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite contradictory evidence in the record, or where other inadequacies in the ALJ's analysis frustrate meaningful review.” McNeill v. Saul, No. 5:20-CV-244-M, 2021 WL 3701348, at *3 (E.D. N.C. June 2, 2021) (alterations in original) (quoting Mascio, 780 F.3d at 636). And while there is no “per se rule requiring remand when the ALJ does not perform an explicit function-by-function analysis[,]” courts have found remand warranted where the ALJ fails to assess a “contested” function that is “critically relevant to determining [a claimant's] disability status ....” Dowling, 986 F.3d at 388-89 (remanding case where the ALJ failed to evaluate the plaintiff's ability to sit when it was a contested function critical to determining the plaintiff's disability status, and stating that the ALJ should have included “an analysis [of plaintiff's ability to sit] that was separate from the ALJ's appraisal of [the plaintiff's] ability to perform other functions, and [this analysis] should have been accompanied by ‘a narrative discussion describing' the evidence supporting it”).
Here, the ALJ found that Plaintiff had the following RFC:
After careful consideration of the entire record, the undersigned finds that, through the date last insured, [Plaintiff] had the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) except: Frequent climbing of ramps and stairs, but only occasional climbing of stepladders up to 4 vertical feet in height, with no climbing of higher ladders or of ropes or scaffolds of any height - frequent balancing, kneeling, and crouching - occasional stooping and crawling - frequent overhead reaching bilaterally - frequent handling and fingering bilaterally -frequent hearing - occasional exposure to vibration, moving mechanical parts, and high, exposed places - exposure up to and including moderate noise - no production pace work on assembly lines.Tr. 18. Absent in the RFC are any limitations relating to Plaintiff's ability to concentrate, persist, or maintain pace. Plaintiff argues that this is an error, as evidence supports that Plaintiff was limited in these abilities due to his pain and the side effects of his medications. In support of this argument, Plaintiff cites to his own testimony and subjective complaints, “that due to the effects of his pain and medication side-effects, he is unable to maintain concentration for more than 30 minutes at a time.” Pl.'s Mem. [DE-20] at 7. Plaintiff asserts that the medical records support that he “consistently reported ongoing subjective pain” throughout his treatment. Id. at 7-8.
As noted by Defendant, Plaintiff does not appear to contend that he suffers from any additional medically determinable impairment, or that the ALJ erred by not finding any additional medically determinable impairment. See Def.'s Mem. [DE-23] at 6. Rather, Plaintiff's argument here is that additional RFC limitations are warranted to account for his pain and the side effects of his medications.
However, contrary to Plaintiff's assertion, the ALJ's RFC assessment “include[s] a narrative discussion describing how the evidence supports [his] conclusions” and is supported by substantial evidence. Monroe, 826 F.3d at 189 (quoting Mascio, 780 F.3d at 636). As discussed below, the ALJ fully considers Plaintiff's subjective complaints that he is limited by pain and that he suffers side effects from his medications, but adequately explains his decision not to include any RFC limitations to account for these complaints.
In assessing Plaintiff's RFC, the ALJ here states that he has considered all of Plaintiff's symptoms in accordance with the applicable regulations, 20 C.F.R. § 404.1529 and Social Security Ruling 16-3p. Tr. 18. The ALJ notes that “[a]t the hearing [Plaintiff] testified . . . his neck and low back pain caused him to lose focus and concentration[,]” and that Plaintiff “takes pain medication that help [his pain] but expressed side effects in his concentration.” Tr. 19. However, after considering the evidence of record, the ALJ finds that Plaintiff's “statements concerning the intensity, persistence and limiting effects of [his] symptoms are not entirely consistent with the medical evidence and other evidence in the record for the reasons explained in [his] decision.” Tr. 19-20. More specifically, the ALJ later explains that Plaintiff's “subjective pain complaints have been considered, but the whole record does not warrant reducing [Plaintiff] to unskilled work, as his pain appears to be controlled with medication management.” Tr. 21.
Supporting this finding, the ALJ cites to medical records which consistently show that although Plaintiff does suffer from pain, it has been manageable. For example, the ALJ cites to medical records from July of 2017, in which Plaintiff “reported that medication was moderately effective (Exhibit 4F).” Tr. 20; see also Tr. 330 (“Pt is currently taking Hydrocodoneacetaminophen .... The medication is moderately effective in providing relief.”). The ALJ also cites to medical records from May of 2018, in which Plaintiff “reported that he was ‘doing good' and his pain was noted to be stable (Exhibit 10F, p. 7).” Tr. 20; see also Tr. 465 (“Patient words: pt states ‘I'm doing good'.”). The ALJ notes that Plaintiff began chiropractic treatment in July of 2018, and “reported improvement as a result of the treatment (Exhibit 11F).” Tr. 20; see also Tr. 460 (“[Plaintiff's] prognosis is good at this time. [Plaintiff] felt better after the treatment and has experienced an increase in passive joint motion and a decrease in his symptoms since treatment began. [Plaintiff] reported feeling better.”). And, that “pain management records for the remainder of 2018 continued to indicate his condition was stable with little or no change in the exam notes” and “[t]his trend continued into 2019 . . . (Exhibit 14F).” Tr. 20; see also Tr. 529 (“The patient feels well with minor complaints.”). Additionally, the ALJ explicitly finds that Plaintiff has “consistently reported that his medications were working well without side effects . . . (Exhibit 14F).” Tr. 20 (emphasis added); see also Tr. 529 (“Current medication use: no side effects, compliant with dosing regimen and considered effective by patient.”); Tr. 532 (“Current medication use: no side effects, compliant with dosing regimen and considered effective by patient. . . . Patient states that his current medication is working well to control his pain without adverse side effects.”); Tr. 537 (“Current medication use: no side effects, compliant with dosing regimen and considered effective by patient.... Patient states that his current medication is working well to control his pain without adverse side effects.”). Notably, aside from his own subjective statements that he was limited in his ability to concentrate, persist, and maintain pace, Plaintiff cites to no medical record or opinion finding that he required additional RFC limitations to account for his pain and the side effects of medications.
Although Plaintiff may reference medical records in which his subjective complaints of severe pain are noted, and that Plaintiff alleges contradict the ALJ's finding that Plaintiff's pain appeared to be controlled, it is not for the court to “re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment” for that of the ALJ. Stokes v. Berryhill, 294 F.Supp.3d 460, 462 (E.D. N.C. 2018) (citing Craig, 76 F.3d at 589). Whereas here, the ALJ properly considered all potentially relevant limitations and the ALJ cites to substantial evidence in support of his RFC findings, the court's review is satisfied. In sum, “reading the ALJ's decision as a whole, the ALJ built the requisite, accurate and logical bridge from the evidence in the record to his finding as to [P]laintiff's residual functional capacity.” Emanuel v. Saul, No. 7:19-CV-202-FL, 2021 WL 1217309, at *4 (E.D. N.C. Mar. 31, 2021); see also Arakas v. Comm'r, Soc. Sec. Admin., 983 F.3d 83, 95 (4th Cir. 2020). The court is not “left to guess about how the ALJ arrived at his conclusions [about Plaintiff's] ability to perform relevant functions ....” Mascio, 780 F.3d at 637; see also Dennis v. Berryhill, 362 F.Supp.3d 303, 310 (W.D. N.C. 2019). Therefore, the undersigned finds that the ALJ here properly evaluates both Plaintiff's RFC and Plaintiff's symptoms, in accordance with the applicable caselaw and regulations. The undersigned finds that remand is not warranted for this issue, and recommends that the final decision of the Commissioner be upheld.
To the extent Plaintiff also attempts to argue that the ALJ erred by discrediting Plaintiff's subjective complaints about pain and the side effects of him medication, the court finds any such argument unpersuasive. The regulations provide “a two-step analysis when considering a claimant's subjective statements about impairments and symptoms.” Lewis v. Berryhill, 858 F.3d 858, 867 (4th Cir. 2017) (citing 20 C.F.R. §§ 404.1529(b)-(c), 416.929(b)-(c)). Further, “[a]n ALJ may [generally] find a claimant's statements regarding the severity of her symptoms less credible if these statements are inconsistent with the medical evidence in the record and if the ALJ explains how she weighed all of the relevant evidence, including the claimant's statements.” Brooks v. Berryhill, No. 2:16-CV-80-FL(2), 2018 WL 944382, at *4 (E.D. N.C. Jan. 23, 2018) (citing S.S.R. 96-7p, 1996 WL 374186, at *2 (July 2, 1996); Mascio, 780 F.3d at 636-37). As discussed above, the ALJ here explains his analysis in reaching his conclusion that “[Plaintiff's] statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record for the reasons explained in this decision.” Tr. 19-20. In particular, the ALJ cites to both objective and other evidence of record that is inconsistent with Plaintiff's statements.
VII. CONCLUSION
For the reasons stated above, IT IS RECOMMENDED that Plaintiff's Motion for Judgment on the Pleadings [DE-19] be DENIED, Defendant's Motion for Judgment on the Pleadings [DE-22] be ALLOWED, and the final decision of the Commissioner be UPHELD.
IT IS DIRECTED that a copy of this Memorandum and Recommendation be served on each of the parties or, if represented, their counsel. Each party shall have until August 19, 2022 to file written objections to this Memorandum and Recommendation. The presiding district judge must conduct his own review (that is, make a de novo determination) of those portions of the Memorandum and Recommendation to which objection is properly made and may accept, reject, or modify the determinations in the Memorandum and Recommendation; receive further evidence; or return the matter to the magistrate judge with instructions. See, e.g., 28 U.S.C. § 636(b)(1); Fed.R.Civ.P. 72(b)(3); Local Civ. R. 1.1 (permitting modification of deadlines specified in local rules), 72.4(b), E.D. N.C. Any response to objections shall be filed within 14 days of the filing of the objections.
If a party does not file written objections to the Memorandum and Recommendation by the foregoing deadline, the party will be giving up the right to review of the Memorandum and Recommendation by the presiding district judge as described above, and the presiding district judge may enter an order or judgment based on the Memorandum and Recommendation without such review. In addition, the party's failure to file written objections by the foregoing deadline will bar the party from appealing to the Court of Appeals from an order or judgment of the presiding district judge based on the Memorandum and Recommendation. See Wright v. Collins, 766 F.2d 841, 846-47 (4th Cir. 1985).