The opinion
IN ‘THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF NORTH CAROLINA
ELIZABETH VICTORIA LAFFITTE, )
Plaintiff,
v. 1:20CV163
ANDREW SAUL,
Commissioner of Social Security, )
Defendant.
MEMORANDUM OPINION AND RECOMMENDATION
OF UNITED STATES MAGISTRATE JUDGE
Plaintiff Elizabeth Victoria Laffitte (“Plaintiff’) brought this action pursuant to
Sections 205(g) and 1631(c)(3) of the Social Security Act (the “Act”), as amended (42 U.S.C.
§§ 405(g) and 1383(¢)(3)), to obtain judicial review of a final decision of the Commissioner of
Social Security denying her claims for Disability Insurance Benefits (“DIB”) and Supplemental
Security Income (“SSI”) under, respectively, Titles II and XVI of the Act. The parties have
filed cross-motions for judgment, and the administrative record has been certified to the Court
for review.
L. PROCEDURAL HISTORY
Plaintiff protectively filed applications for DIB and SSI on September 28, 2016 and
January 25, 2018, respectively, alleging a disability onset date of August 6, 2016 in both
applications. (Tr. at 1010, 2082-85.)! Her applications were denied initially (Ir. at 1962-72,
i Transcript citations refer to the Sealed Administrative Record [Doc. #10, #11, #12].
1983-86) and upon reconsideration (T'r. at 1973-82, 1992-99). Thereafter, Plaintiff requested
an administrative hearing de novo before an Administrative Law Judge (“ALJ”). (Tr. at 2000-
06.) On November 9, 2018, Plaintiff, along with her attorney, attended the subsequent video
heating, during which an impartial vocational expert testified. (Tr. at 1010.) The ALJ
ultimately concluded that Plaintiff was not disabled within the meaning of the Act (Tr. at 1026-
27), and, on January 11, 2020, the Appeals Council denied Plaintiff's request for review of the
decision, thereby making the ALJ’s conclusion the Commissioner’s final decision for purposes
of judicial review (Ir. at 1-7).
Il. LEGAL STANDARD
Federal law “authorizes judicial teview of the Social Security Commissionet’s denial of
social security benefits.” Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). However, “the
scope of [the] review of [such an administrative] decision . . . is extremely limited.” Frady v.
Harris, 646 F.2d 143, 144 (4th Cir. 1981). “The courts are not to try the case de novo.”
Oppenheim v. Finch, 495 F.2d 396, 397 (4th Cir. 1974). Instead, “a reviewing court must
uphold the factual findings of the ALJ [underlying the denial of benefits] if they are supported
by substantial evidence and wete teached through application of the correct legal standard.”
Hancock v. Asttue, 667 F.3d 470, 472 (4th Cir. 2012) (internal brackets omitted).
“Substantial evidence means ‘such relevant evidence as a reasonable mind might accept
as adequate to support a conclusion.”’ Hunter v. Sullivan, 993 F.2d 31, 34 (4th Cir. 1992)
(quoting Richardson v. Perales, 402 U.S. 389, 390 (1971)). “It consists of more than a mete
scintilla of evidence but may be somewhat less than a preponderance.” Mastto v. Apfel, 270
F.3d 171, 176 (4th Cir. 2001) Gnternal citations and quotation marks omitted). “If there is
evidence to justify a refusal to direct a verdict were the case before a jury, then there is
substantial evidence.” Hunter, 993 F.2d at 34 (Gnternal quotation marks omitted).
“In reviewing for substantial evidence, the court should not undertake to re-weigh
conflicting evidence, make credibility determinations, or substitute its jadgment for that of the
[ALJ].” Mastro, 270 F.3d at 176 (internal brackets and quotation marks omitted). “Where
conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the
responsibility for that decision falls on the ALJ.” Hancock, 667 F.3d at 472. “The issue before
[the reviewing court], therefore, is not whether [the claimant] is disabled, but whether the
ALJ’s finding that [the claimant] is not disabled is supported by substantial evidence and was
reached based upon a cortect application of the relevant law.” Craig v. Chater, 76 F.3d 585,
589 (4th Cir. 1996).
In undertaking this limited review, the Court notes that in administrative proceedings,
claimant for disability benefits bears the burden of proving a disability.” Hall v. Harris,
658 F.2d 260, 264 (4th Cir. 1981). In this context, “disability” means the “inability to engage
in any substantial gainful activity by reason of any medically determinable physical or mental
impairment which can be expected to tesult in death or which has lasted or can be expected
to last for a continuous period of not less than 12 months.” Id. (quoting 42 U.S.C.
§ 423(d)(1)(A))?
2 The Social Security Act comprises two disability benefits programs. The Social Security Disability Insurance
Program ... ptovides benefits to disabled persons who have contributed to the program while employed. The
Supplemental Security Income Program . . . provides benefits to indigent disabled persons. The statutory
definitions and the regulations . . . for determining disability governing these two programs are, in all aspects
relevant here, substantively identical.” Craig, 76 F.3d at 589 n.1 (internal citations omitted).
“The Commissioner uses a five-step process to evaluate disability claims.” Hancock,
667 F.3d at 472 (citing 20 C-F.R. §§ 404.1520(a)(4); 416.920(a)(4)). “Under this process, the
Commissioner asks, in sequence, whether the claimant: (1) worked duting the alleged period
of disability; (2) had a severe impairment; (3) had an impairment that met or equaled the
requitements of a listed impairment; (4) could return to her past relevant work; and (5) if not,
could perform any othet work in the national economy.” Id.
A finding adverse to the claimant at any of several points in this five-step sequence
forecloses a disability designation and ends the inquity. For example, “[t]he first step
determines whether the claimant is engaged in ‘substantial gainful activity.’ If the claimant is
working, benefits ate denied. The second step determines if the claimant is ‘severely’ disabled.
If not, benefits are denied.” Bennett v. Sullivan, 917 F.2d 157, 159 (4th Cir. 1990).
On the other hand, if a claimant carries his or her burden at each of the first two steps,
and establishes at step three that the impairment “equals or exceeds in severity one of mote
of the impairments listed in Appendix I of the regulations,” then “the claimant is disabled.”
Mastro, 270 F.3d at 177. Alternatively, if a claimant clears steps one and two, but falters at
step thtee, i.e., “[i]fa claimant’s impairment is not sufficiently severe to equal ot exceed a listed
impairment, the ALJ must assess the claimant’s residual function|al] capacity (“(RFC’).” Id. at
179.3 Step four then tequites the ALJ to assess whether, based on that RFC, the claimant can
3 “REC is a measurement of the most a claimant can do despite [the claimant’s] limitations.” Hines, 453 F.3d
at 562 (noting that pursuant to the administrative regulations, the “RFC is an 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... [which] means 8 houts a day, for 5 days a week, ot an equivalent work schedule” (internal emphasis
and quotation marks omitted)). The RFC includes both a “physical exertional or strength limitation” that
assesses the claimant’s “ability to do sedentary, light, medium, heavy, or very heavy work,” as well as
“nonexertional limitations (mental, sensory, or skin impairments).” Hall, 658 F.2d at 265. “RFC is to be
AL
“perform past relevant work’; if so, the claimant does not qualify as disabled. Id. at 179-80.
However, if the claimant establishes an inability to return to prior work, the analysis proceeds
to the fifth step, which “requires the Commissioner to prove that a significant number of jobs
exist which the claimant could perform, despite [the claimant’s] impairments.” Hines, 453
F.3d at 563. In making this determination, the ALJ must decide “whether the claimant is able
to petform other work considering both [the claimant’s RFC] and [the claimant’s] vocational
capabilities (age, education, and past work experience) to adjust to a new job.” Hall, 658 F.2d
at 264-65. If, at this step, the Government cannot catry its “evidentiary burden of proving
that [the claimant] remains able to work other jobs available in the community,” the claimant
qualifies as disabled. Hines, 453 F.3d at 567.
I. DISCUSSION
In the present case, the ALJ found that Plaintiff had not engaged in “substantial gainful
activity” since August 6, 2016, the alleged onset date. Plaintiff therefore met her burden at
step one of the sequential evaluation process. At step two, the ALJ further determined that
Plaintiff suffered from the following severe impairments:
obesity; lumbar degenerative disc disease with spondylosis and radiculopathy;
cetvical degenerative disc disease with stenosis and radiculopathy; degenerative
scoliosis; left knee degeneration; and bilateral hip degeneration|.]
determined by the AL] only after [the ALJ] considers all relevant evidence of a claimant’s impairments and any
related symptoms (eg, pain).” Hines, 453 F.3d at 562-63.
(Tr. at 1013.) The ALJ found at step three that none of these impairments, individually or in
combination, met or equaled a disability listing. (Tr. at 1016-17.) Therefore, the ALJ assessed
Plaintiffs RFC and determined that:
[Plaintiff] has the residual functional capacity to perform light work, as defined
in 20 CFR 404.1567(b) and 416.967(b), except that [she] can frequently operate
hand conttols, push, pull, reach, handle, finger, and feel with both upper
extremities. She also can occasionally push ot pull or operate foot controls with
both lower extremities. [Plaintiff] can occasionally kneel, crouch, stoop,
balance, and crawl, and can occasionally climb ramps and stairs. She can never
climb laddets, topes and scaffolds, and can never be exposed to unprotected
heights, and moving mechanical parts. [Plaintiff] can have occasional exposute
to dust, mists, gases, noxious odors, fumes, pulmonaty irritants, and poor
ventilation. [She] can tolerate occasional exposure to vibration. [Plaintiff]
requites a cane to ambulate. She is able to understand, carry out, and remember
simple instructions, and make simple work related decisions. She also will be
off task ten percent of the workday.
(Ir. at 1017.) Based on this determination and the testimony of a vocational expert, the AL]
determined at step four of the analysis that Plaintiff could not return to any of her past relevant
wotk. (Tr. at 1024-25.) However, the ALJ found at step five that, given Plaintiffs age,
education, work expetience, RFC, and the testimony of the vocational expert as to these
factors, she could perform other jobs available in significant numbers in the national economy.
(Tr. at 1025-26.) Therefore, the ALJ concluded that Plaintiff was not disabled under the Act.
(Tr. at 1026-27.)
Plaintiff now challenges the AL]’s RFC assessment on multiple fronts. Specifically,
Plaintiff argues that the ALJ (1) failed to properly evaluate her subjective complaints in
accotdance with 20 C.F.R. 404.1529 and Social Security Ruling (“SSR”) 16-3p, (2)
mischaractetized or improperly discounted evidence of her standing and walking difficulties
in finding her capable of light work, and (3) failed to properly explain how Plaintiffs obesity
affected her RFC. After a thorough teview of the record, the Coutt finds that Plaintiffs first
and second contentions merit remand. Because the AL]’s failure to properly consider all of
the televant evidence impacts the ALJ’s evaluation of Plaintiffs subjective complaints, the
Court addresses these arguments in reverse order.
A. Walking and standing limitations
As indicated at both step two of the sequential analysis and in testimony, Plaintiff's
back impairments, including “lumbar degenerative disc disease with spondylosis and
radiculopathy; cervical degenerative disc disease with stenosis and radiculopathy; [and]
degenerative scoliosis,” comprised the bulk of not only her impairments, but her related,
alleged limitations, including standing and walking restrictions. Plaintiff now alleges that the
ALJ failed to mention, let alone discuss, significant evidence relating to her back conditions,
and improperly discounted opinion evidence regarding her physical limitations.
The AL]’s discussion of the objective evidence supporting Plaintiffs claims, including
MRIs, othet imaging, and clinical evidence, consists of a single paragraph:
Magnetic resonance imaging in 2011 .. . revealed degenerative changes along
[Plaintiffs] cervical spine, including spurting. (F/1.) Imaging in June 2017
identified degenerative changes in both [Plaintiffs] lumbar spine (20F/53), and
cetvical spine (20F/46), including disc height loss (20F/53), and degenerative
osteophytes (20F/46). X-rays in October 2017 further revealed “mild
tticompattmental” degenerative changes (20F/198), and x-rays have divulged
“mild bilateral hip” degenerative process 3F/21). Finally, imaging has also
revealed scoliosis in [Plaintiffs] lumbar spine. (9F/1.) Providers have treated
[Plaintiffs] symptoms surgically; for instance, sources have completed a cervical
discectomy (5F/109). [Plaintiffs] symptoms, however, have remained
substantially unchanged over the petiod in issue. On clinical examination,
soutces have objectively observed [Plaintiff] ambulating with an abnormal gait
(40F/2), and exhibiting decreased sensation (39F/81). Providers have also
obsetved spinal tenderness. (334F/7.)
(Tr. at 1018-19.)
While this summaty briefly mentions Plaintiffs 2016 cervical fusion, it entirely omits
Plaintiff's two more recent spinal surgeries, both of which occutted during the time period at
issue. Specifically, the evidence reflects that on August 24, 2016, shortly after her alleged
disability onset date, Plaintiff underwent cervical fusion surgery. Soon after that surgery,
Plaintiff's claims were reviewed by a state agency physician, Dr. Clayton, who noted that he
would “[e]xpect routine healing following neck surgery,” so that “within 12 mo[nths] of 8/16,
[she] would be capable of RFC as written.” (Tr. at 1979). However, after the administrative
denial of her claim, Plaintiff experienced further degeneration in her lumbar spine, and
underwent lumbar surgery on August 23, 2017, with placement of bilateral pedicle screws at
L2, L3, L4, L5, and $1; bilateral L4-L5 and L5-S1 facetectomies; L4-L5 and L5-S1
laminectomies; placement of intervertebral mechanical spacer slush device at L4-L5 and L5-
S1; and posterior lateral arthrodesis from L2-S1. (I't. at 2783.) She went home, but fell 10
days later when trying to stand up from bed, and was admitted to the hospital on September
3, 2017, and underwent another lumbar surgery. (Tt. 2798, 2801, 2810.) She was discharged
on September 12, 2017, to a residential rehabilitation facility, where she stayed until September
26, 2017. (T'r. at 3894-4014.) During October and November 2017, she received rehabilitation
setvices at het home (T't. 2559-2631), and then qualified for 60 hours per week of in-home
cate through Medicaid, which continued through the date of the heating in November 2018.
During the petiod from November 2017 through the hearing in November 2018, she
underwent several additional procedutes to try to control her pain, including placement of a
permanent spinal cord stimulator. (T't. at 3009-10, 2913-15, 3061-73.) As noted above, the
AL}’s decision briefly mentions Plaintiffs August 2016 cervical fusion surgery, but failed to
mention either of het lumbar surgeties or subsequent procedures in 2017 and 2018.
The decision also fails to mention any of the imaging after Plaintiffs August 2017
sutgery, particularly Plaintiff's September 2017 MRI of her lumbar spine and CT of her lumbar
spine, which objectively describes the state of Plaintiffs back impairment after her August
2017 surgery. (It. at 2816-18.) In pertinent part, the MRI in question revealed the following
abnormal findings:
e 110-T11: Broad-based disc bulge with a super-imposed disc herniation,
ligamentum flavum thickening, and bilateral facet hypertrophy. “These changes
tesult in moderate canal and lateral recess stenosis as well as left greater than
tight foraminal stenosis, similar to prior.”
e 111-112: “Broad-based disc bulge and ligamentum flavum thickening as well
as facet joint hypertrophy resulting in mild canal and left greater than right
foraminal stenosis, similar to prior.”
e 12-13: “Broad-based disc bulge, ligamentum flavum thickening and facet
hypertrophy resulting in mild left foraminal narrowing.”
e 13-L4: “Disc dessication with a broad-based disc bulge, ligamenta flavum
thickening and facet hypertrophy resulting in severe canal and right foraminal
stenosis. There is also moderate left foraminal stenosis.”
e 14-L5: “Status post dorsal decompression with improved canal stenosis, now
mild. Residual bilateral foraminal nattowing following facetectomy, although
evaluation is limited by hardware.”
9g
e [5-S1: “Interval dorsal decomptession with placement of an interbody spacer.
Abnormal tissue in the left lateral canal causing mass effect on the left thecal
sac (series 5, image 30), likely reflecting granulation tissue and/or developing
scat. This likely causes mass effect on the descending S1 nerve root. There ate
degenerative facet changes bilaterally resulting in mild left foraminal stenosis.
Evaluation limited by hardware.”
(It. at 2816.) The impression reflects that even following surgery, there was “persistence of
sevete canal and tight greater than left foraminal stenosis at L3-L4” and “[l]ikely granulation
tissue and/or developing scat at the level of L5-S1, which causes mass effect on the left lateral
canal and may impinge the descending S1 nerve root.” (Tr. at 2816.) The impression on the
CT scan notes “{mfultilevel mild to moderately severe spondylosis contributing to multilevel
mild-to-moderate neural foraminal stenosis, acquited spinal canal stenosis at L3-L4 and mild
to moderately severe effacement of subarticular recesses greatest at L3-L4 on the tight
otherwise detailed above.” (Ir. at 2818.)
Despite the extensive and latgely abnormal findings set out in Plaintiffs September
2017 MRI ant CT tesults, Defendant argues that the ALJ’s omission of the most recent
imaging evidence was inconsequential, as an AL] “need not discuss every piece of evidence in
making an RFC determination.” (Def.’s Br. [Doc. #21] at 13) (citing Reid v. Comm’ of Soc.
Sec., 769 F.3d 861, 865 (4th Cit. 2014)). Nevertheless, an ALJ may not selectively quote the
record, omitting evidence favorable to Plaintiff. Lewis v. Berryhill, 858 F.3d 858, 869 (4th Cir.
2017). In the present case, it appears that the AL] did just that.
an
In addition, throughout his RFC analysis, the AL] repeatedly discounted the opinion
evidence, testimony, and abnormal test results based solely on treatment records noting
notmal gait, sensation, and strength. (See Tr. at 1018-1024.) In doing so, the ALJ
mischatactetized or completely ignored evidence of greater limitations, and discounted all of
the opinions of Plaintiffs treating physicians and thitd party assessments. For example,
Plaintiff underwent a North Carolina Division of Medical Assistance assessment in her home
in October 2017 with regatd to her need for in-home healthcate services, which reflects as
follows:
Obsetved beneficiary transfer in/out of shower on/off the shower chair by
holding onto the back of the chair with one hand and her rollator with the other
hand but requites supervision due to impaired balance, pain and limited ROM
in her lumbat and cervical spine due to recent back surgery. She demonstrated
washing her face, front upper body to her waist; she is unable to reach below
her waist due to back pain and limited ROM and requires assistance with
washing her legs, feet and back. . . . [She] requires assistance with shampooing
hair due to impaited endurance and back pain. ... She was unable to complete
the task of donning/removing pants on/off over her feet due to difficulty
bending from back pain and limited ROM in her cervical and lumbar spine due
to recent back surgery but she was able to pull her pants up/down around her
waist from her thigh level. She requites assistance with donning/removing
socks, shoes and assisting with foot brace on her left ankle as she is unable to
bend at the waist. ... Observed beneficiaty transfer on/off chait/bed by balling
up het fists and pushing herself off of the furniture and then grabbing the arms
of het rollator but tequites supervision to prevent injury due to impaired
balance, pain and limited ROM in her back. She is able to turn and position
herself in bed and she ambulated around her home using her rollator with a
slow, steady gait..... She was able to demonstrate the use of her microwave
and can make small meals for herself such as making a sandwich or a bowl of
ceteal with set up of supplies but she was unable to prepare larger meals due to
impaired balance, pain and limited ROM in her back causing her pain while
standing or sitting for long periods of time.
(Tr. at 2965.) A follow-up evaluation in Januaty 2018 is similar. (I'r. at 2931-2947.) The AL]
gave these evaluations “no weight” because “[t]hese documents do not indicate that this
17
ptovider applied Social Secutity’s rules, regulations, or standards in making these assessments”
and the form “does not evidence consideration of the claimant’s whole medical evidence of
record.” (It. at 1021). The ALJ also cited treatment records noting normal sensation, and
strength. (See at 1021.) The aide who ultimately provided in-home services to Plaintiff
Ms. Campbell, provided a report in September 2018, noting that she spent 2 hours a day with
Plaintiff in Plaintiff's home, every day for 10 months (61 hours pet month), with the folowing
obsetvations:
I am present on a daily basis when she takes her first round of medication,
bathes, and dresses. She uses a transfer bench in the shower on which she can
sit and slide into the shower without having to step over the side. While she is
bathing, I am doing light housekeeping (wash dishes, dust, sweep, mop, take the
gatbage out, otganize her meals for the day, make her bed, straighten her room,
make things she may need accessible for her). After her bath, I comb her hair.
She has made changes to het watdtobe to accommodate her limitations so that
she can dtess herself on most days, but if she requites assistance in dressing on
any particular day, then I help her dress. After she is dressed, she performs het
stretching exercises. At the end of my shift, we walk up and down the length of
her driveway for about 15 minutes. Twice pet week, I wash, fold, and put away
clothes; make prepared meals that are stored in plastic containers so that they
can be watmed in the microwave. Once per week, I tender basic foot and nail
cate to het, and I assist her with washing her hair. I organize the dosages of her
medications for each week. I check the bathroom daily, and I clean the
bathroom thoroughly each week.
Ms. Laffitte requites my services because of her limitations in twisting, bending,
stooping, crouching, walking, sitting, reaching, lifting, pushing, and pulling. |
see on a daily basis how het limitations affect her life in her performance of all
of her activities of daily living. She has to take breaks to lie down after engaging
in most activities because of exacerbations of her level of pain. She is visibly
uncomfortable standing for any length of time because of the instability and
weakness of her left leg, and she rately sits for longer than 15-30 before she is
repositioning herself or standing up. She has to eat her meals in her bed while
she is lying on het left side because of the pain that she experiences while sitting
at a table. She also experiences pain, tremors, and muscle cramps in her right
hand making it hard to do many things that would tequite fine motor skills.
Many times, her pain makes her lose concenttation and focus on what she may
12
be doing at the time. When that happens, she will leave it to go lie down to ease
the pain.
... Het medical conditions and the limitations they have imposed upon her
have prevented her from functioning both physically and mentally to the degree
that she once functioned. She has already come a long way, but she still has a
long way to go in adjusting to her limitations.
(I'r. at 2183-84.) The ALJ gave this statement “significant weight” as to the “nature of
[Plaintiffs] limitations” but “little weight” otherwise because it was “based substantially on
[Ms. Campbell’s] own subjective observations of [Plaintiff] rather than objective medical data.”
The AL] also cited to treatment records noting normal range of motion. (See Tr. at 1023.)
The AL} similarly gave limited weight to the opinions of Nutse Tabitha Hollins and
Plaintiffs treating physician Dr. Abigail Smith. In an opinion letter in September 2018, Nurse
Hollins said:
[Plaintiff] has a histoty of chronic neck pain and cervical spondylotic
myeloradiculopathy fot which she underwent a C4-C6 anterior cervical
discectomy and fusion on 8/24/16. She recovered well from this surgery. She
had some chronic remaining myelopathy symptoms from prior to sutgery which
included hypoesthesia right hand laterally and weakness right grip. She also has
a histoty of levo convex scoliotic curvature with mechanical instability and
tadiculopathy lower extremity. She underwent a L2-S1 posterior lumbar
interbody fusion with hatdwate on 08/23/2017, she also recovered well from
this surgery. Unfortunately she had a fall and developed recutrent left leg pain
and a new left lez weakness in the setting of stenosis thus she underwent L3-4
decompression on 9/7/17. She continues to have significant pain/patesthesia’s
left lez unfortunately regardless of the surgery after the fall thus we referred her
to pain management for evaluation and treatment options as there is no surgical
option.
(Tr. at 4018). Plaintiffs treating physician, Dr. Smith, also provided an opinion letter in
September 2018, noting that Plaintiff had “lumbat spinal stenosis, cervical spinal stenosis”
with limited range of motion, muscle attophy in her left leg with a 1 inch citcumferential
difference, inability to walk on heels, inability to walk on toes, inability to atise from a squatting
13
position, and “weakness and decreased sensation of left leg.” (Tr. at 4019.) Dr. Smith noted
that her opinion was based on Plaintiff's MRI and physical examination. Dr. Smith’s treatment
recotd for September 27, 2018, the same day as the opinion, sets out Plaintiff's prior CT and
MRI tesults, and reflects that on physical examination Plaintiff was positive for back pain,
joint pain, myalgias, dizziness, tingling, tremors, and focal weakness. She had reduced strength
on her left side (4/5 in left arm, 3/5 in left leg), was unable to squat unassisted, unable to toe
ot heel walk on left foot, had decreased sensation to light touch in her left leg, and had muscle
attophy with “decreased citcumference in L thigh compared to R thigh.” (Ir. at 4095-4102.)
The ALJ gave the opinions of Nutse Hollins and Dr. Smith “limited weight”, citing other
treatment tecords reflecting a “normal gait.” (Tr. at 1022, 1023.) In rejecting Dr. Smith’s
treating physician opinion, the ALJ also said that Dr. Smith’s opinion “contained few citations
ot teferences to other objective medical evidence” and did not indicate that Dr. Smith had
“considered all of [Plaintiff's] whole objective medical documentation.” (Tr. at 1023.)
This tejection of Dr. Smith’s treating physician opinion is contrary to recent guidance
from the Court of Appeals for the Fourth Circuit. For claims like Plaintiffs that are filed
before Match 27, 2017, ALJs evaluate the medical opinion evidence in accordance with 20
C.E.R. § 404.1527(c). Brown v. Comm’t Soc. Sec., 873 F.3d 251, 255 (4th Cir. 2017). “Medical
opinions” are “statements from acceptable medical sources that reflect judgments about the
nature and severity of your impairment(s), including yout symptoms, diagnosis and ptognosis,
what you can still do despite impaitment(s), and your physical or mental restrictions.” Id.
(citing 20 C.F.R. § 404.1527(a)(1)). While the regulations mandate that the ALJ evaluate each
medical opinion presented to her, generally “more weight is given ‘to the medical opinion of
1A
a soutce who has examined you than to the medical opinion of a medical source who has not
examined you.” Brown, 873 F.3d at 255 (quoting 20 C.F.R. § 404.1527(¢)(1)).. And, under
what is commonly referred to as the “treating physician rule,” the ALJ generally accords the
greatest weight—controlling weight—to the well-supported opinion of a treating source as to
the nature and severity of a claimant’s impairment, based on the ability of treating sources to
ptovide a detailed, longitudinal picture of [the claimant’s] medical impairment(s)
[which] may bring a unique perspective to the medical evidence that cannot be
obtained from the objective medical findings alone or from reports of individual
examinations, such as consultative examinations or brief hospitalizations.
20 C.F.R. § 404.1527(c)(2). However, ifa treating source’s opinion is not “well-supported by
medically acceptable clinical and laboratory diagnostic techniques” or is “inconsistent with
other substantial evidence in [the] case record,” it is not entitled to controlling weight. 20
C.F.R. § 404.1527(c)(2); see also Social Security Ruling (“SSR”) 96-2p, 1996 WL 374188, at *4;
Brown, 873 F.3d at 256; Craig, 76 F.3d at 590; Mastto, 270 F.3d at 178.+ Instead, the opinion
must be evaluated and weighed using all of the factors provided in 20 C.F.R. § 404.1527(c)(2)-
(c)(6), including (1) the length of the treatment relationship, (2) the frequency of examination,
(3) the natute and extent of the treatment relationship, (4) the supportability of the opinion,
(5) the consistency of the opinion with the record, (6) whether the soutce is a specialist, and
(7) any other factors that may support or contradict the opinion.
4 Bor claims filed after March 27, 2017, the regulations have been amended and several of the prior Social
Security Rulings, including SSR 96-2p, have been rescinded. The new regulations provide that the Social
Security Administration “will not defer or give any specific evidentiaty weight, including controlling weight, to
any medical opinion(s) or prior administrative medical finding(s), including those from your medical sources.”
20 C.E.R. § 404.1520c. However, the claim in the present case was filed before March 27, 2017, and the Court
has therefore analyzed Plaintiffs claims pursuant to the treating physician rule set out above.
15
The Fourth Circuit has recently confirmed the application of the treating physician rule
in Arakas v. Commissioner, 983 F.3d 83 (4th Cir. 2020) and Dowling v. Commissioner, 986
F.3d 377 (4th Cir. 2021). In Arakas, the Fourth Circuit “emphasized that the treating physician
tule is a robust one: ‘[I]he opinion of a claimant’s treating physician [must] be given great
weight and may be distegatded only if there is persuasive contradictory evidence.” Atakas,
983 F.3d at 107 (quoting Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987)). Thus, “the
opinion must be given controlling weight wales it is based on medically unacceptable clinical ot
laboratory diagnostic techniques or is contradicted by the other substantial evidence in the
recotd.” Id. (emphasis in original). Similarly, in Dowling, the Fourth Circutt emphasized that
even if a “medical opinion was not entitled to controlling weight, it does not follow that the
ALJ had free reign to attach whatever weight to that opinion that he deemed fit. The ALJ was
requited to consider each of the six 20 C-F.R. § 404.1527(c) factors before casting [treating
physician] opinion aside.” Dowling, 986 F.3d at 385. “While an ALJ is not required to set
forth a detailed factot-by-factor analysis in order to discount a medical opinion from a treating
physician, it must nonetheless be apparent from the ALJ’s decision that he meaningfully
considered each of the factors before deciding how much weight to give the opinion.” Id.
Here, the ALJ did not analyze the relevant factors and summarily dismissed the opinion
evidence, including the treating physician opinion of Dr. Smith. As noted above, the ALJ
repeatedly discounted the opinion evidence based solely on treatment records noting normal
gait, sensation, and strength. (See Tr. at 1018-1024.) However, the treatment records do not
ptovide a basis for discounting the opinion evidence, nor do they support the ALJ’s ultimate
REC determination. For example, the ALJ tepeatedly cites (at least seven times) the same
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treatment records for the proposition that Plainitff had a “normal gait” and was “ambulating
normally.” (Tr. at 1014, 1016, 1017, 1019, 1020, 1022, 1023). In support of this repeated
assettion, the ALJ cites the same seven treatment notes. (Tr. at 1014, 1016, 1017, 1019, 1020,
1022, 1023 (citing Tr. at 3547, 2320, 2672, 2428, 3022, 3161, 4034.)) However, two of those
treatment records are for unrelated visits prior to the alleged onset date. (Tr. at 3547 June 29,
2013), Tr. at 2320 (April 28, 2016). In addition, two of the treatment records are duplicate
citations to the same visit. (It. at 3022, 3161.) ‘Thus, there ate only four treatment records
cited for the period after the August 2016 alleged onset date. The first treatment record is for
an April 10, 2017 visit to Nurse Navey at the Neurology Clinic, and reflects that Plaintiff's
“routine gait is normal’ but also that she is a “Fall Risk” and was “instructed to ask for
assistance with ambulation” and was being seen for left arm weakness and advanced cervical
scoliosis. (T't. at 2670-73.) The second treatment record is for a June 14, 2017 physical therapy
visit that includes the notation “Gait: Normal” but also reflects a functional limitation of
“walking overt 15 minutes,” motor deficits in her left and tight hips, a positive straight leg raise,
major movement loss, and a problem list of “Decreased strength, Difficulty with prolonged
standing, Impaited [activities of daily living], Impaired ambulation, Difficulty with prolonged
sitting.” (Tr. at 2427-30.) The third treatment record is for a November 9, 2017 visit to the
pain clinic a few weeks after her release from the hospital and rehabilitation facility following
het two lumbar surgeties. That treatment note does include a notation of “Normal Gait” but
also notes a positive straight leg raise, a history of recent spinal fusion surgery, ongoing pain,
a plan to schedule a left L5 and S1 nerve block, and a discussion of a possible spinal cord
stimulator implantation. (Tr. at 3156-63, 3022-23.) Finally, the fourth treatment note is a
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September 4, 2018 visit to the pain clinic that similarly includes a notation of “Normal Gait”
but also reflects a positive straight leg raise on the left, use of a mobility device, identification
as a fall tisk, and a problem list reflecting impaired functional mobility (Tr. at 4034, 4040,
4046.) These records do not support the ALJ’s repeated citation of them for the proposition
that Plaintiff could ambulate normally. Ultimately, the ALJ’s reliance on mischaracterized
and cherty-picked “normal” exam findings to summarily dismiss virtually all of the opinion
evidence as “inconsistent” with the record renders the decision unsupported. The AL]’s
incomplete and cursoty teview of Plaintiff's imaging and failure to even mention her two
lumbar surgeries further compounds this problem. Further, Plaintiffs documented need for
both a home health cate aide and a rolling walker and/or cane after her surgeries also strongly
contradicts the ALJ’s findings, particularly that Plaintiffs symptoms (1) were largely
unchanged during her alleged disability petiod and (2) allowed her to walk and stand for up to
6 houts in an 8-hour workday. Because the AL] failed to propertly consider the above
evidence in formulating Plaintiffs RFC, including her ability to stand and walk, substantial
evidence fails to support the ALJ’s decision.
B. Subjective complaints
‘The failure to consider all of the relevant objective evidence was not the only error
committed by the ALJ. The ALJ also failed to properly weigh Plaintiff's subjective complaints
when determining her disability status. Throughout his decision, the ALJ cited the lack of
significant physical abnormalities upon exam as the basis for discrediting the limitations
5 The Plaintiff's use of significant assistance between her sutgeties in August and September of 2017 and her
hearing in Novembet 2018 also suggest that Plaintiff may have qualified for disability from the time of her
sutgeries forward, a possibility the ALJ did not consider. To the extent the evidence supports such a possibility,
it should be addressed on remand.
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teported by both Plaintiff and her providers, including physicians, nurses, and home health
cate ptoviders. (See, e.g., Tt. at 1018-24.) In doing so, however, the AL] failed to consider
Plaintiff's abnormal MRI results and CT results, failed to even mention her two lumbar
sutgeties, and failed to consider subsequent interventions including nerve blocks and
implantation of a spinal cord stimulator, as discussed at length above. The ALJ essentially
omitted the bulk of the objective evidence and then asserted that Plaintiffs claims were not
supported by objective evidence. This ettor likewise renders the decision unsupported by
substantial evidence. Moreover, the ALJ also ignored the potential impact of both pain and
intermittent symptoms on Plaintiffs functional abilities. See also Arakas, 983 F.3d at 95-96
(“Here, the ALJ disregarded this longstanding precedent and the agency’s own policy by
improperly discounting Arakas’s subjective complaints of pain and fatigue, based largely on
the lack of objective medical evidence substantiating her statements... . Because Atakas was
entitled to rely exclusively on subjective evidence to prove that her symptoms wete so
continuous and/or so sevete that [they] prevented] [her] from working a full eight hour day,
the ALJ applied an incorrect legal standard in discrediting her complaints based on the lack of
objective evidence corroborating them.” (internal quotations omitted)).
In the present case, as discussed above, Plaintiff suffered from numerous back
impairments, including “lumbar degenerative disc disease with spondylosis and tadiculopathy;
cetvical degenerative disc disease with stenosis and radiculopathy; [and] degenerative
scoliosis.” (Tr. at 1013.) Plaintiff further testified that these well-documented and
longstanding impaitments caused the vast majority of her symptoms and limitations. (Tt. at
1018, 1931-38, 1940-45.) The ALJ summarized this testimony as follows:
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[Plaintiff] allege[d] that conditions including cervical radiculopathy, chronic pain
syndtome, and upper extremity weakness prohibit h[er] from working. 3H.) As
a tesult of these conditions, [Plaintiff] report[ed] that she finds a substantial
tange of activities to be extremely difficult. (8E.) For example, [Plaintiff]
testified that her conditions impair her ability to lift and walk. She testified, e.g.,
that she is not able to lift a gallon of milk. [Plaintiff] testified that [she] can lift
half a gallon of milk, but can carry it no further than ten feet. [She] has also
reported that she requites an aide to assist her in completing activities of daily
living. (2D.) At hearing, when asked how long she can stand in one place,
[Plaintiff] responded that sitting and standing always cause her pain.
(Tr. at 1018.) Despite the ALJ’s assertions elsewhere in the decision that his dismissal of
Plaintiff's statements was based on “objective medical and other evidence” (see, e.g., Tr. at
1018, 1024), the evidence cited by the AL] in support of his symptom evaluation consists
entirely of treatment records that the ALJ selectively cites as purportedly reflecting normal
ambulation, strength, sensation, coordination, and range of motion as evidence that Plaintiffs
symptoms were less severe than she alleged. (Tr. at 1019-20.) In making this determination,
the ALJ not only mischaracterized the records and ignored a plethora of contrary evidence
throughout the neatly 4000 pages of medical evidence, as discussed in greater detail above, he
also omitted the objective evidence that did support her claims, as noted above, and
“improperly increased [Plaintiffs] burden of proof by effectively requiring her subjective
descriptions of her symptoms to be supported by objective medical evidence” in the first place.
Arakas, 983 F.3d at 95-96 (quotation omitted). This error clearly presents an additional and
independent basis for remand. In light of the recommended remand, the Court need not
reach the final issue presented by Plaintiff.
IT IS THEREFORE RECOMMENDED that the Commissioner’s decision finding
no disability be REVERSED, and that the matter be REMANDED to the Commissioner
under sentence four of 42 U.S.C. § 405(g). The Commissioner should be ditected to remand
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the matter to the AL] for proceedings consistent with this Recommendation. To this extent,
Defendant’s Motion for Judgment on the Pleadings [Doc. #20] should be DENIED, and
PlaintifPs Motion for Judgment on the Pleadings [Doc. #14] should be GRANTED.
However, to the extent that Plaintiffs motion seeks an immediate award of benefits, it should
be DENIED.
This, the 22nd day of February, 2021.
[s/ loi Blizabeth Peake
United States Magistrate Judge
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