HARMON v. KIJAKAZI

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF NORTH CAROLINA

MARY LU HARMON, )

)

Plaintiff, )

)

v. ) 1:20cv817

)

KILOLO KIJAKAZI, )

Acting Commissioner of Social )

Security,1 )

)

Defendant. )

MEMORANDUM OPINION AND RECOMMENDATION

OF UNITED STATES MAGISTRATE JUDGE

Plaintiff, Mary Lu Harmon, brought this action under the

Social Security Act (the “Act”) to obtain judicial review of a

final decision of Defendant, the Commissioner of Social Security,

denying Plaintiff’s claims for Disability Insurance Benefits

(“DIB”) and Supplemental Security Income (“SSI”) benefits. (Docket

Entry 1.) The Court has before it the certified administrative

record (cited herein as “Tr. __”), as well as the parties’ cross-

motions for judgment (Docket Entries 11, 14; see also Docket Entry

12 (Plaintiff’s Memorandum); Docket Entry 15 (Defendant’s

Memorandum)). For the reasons that follow, the Court should enter

judgment for Defendant.

1 President Joseph R. Biden, Jr., appointed Kilolo Kijakazi as the Acting

Commissioner of Social Security on July 9, 2021. Pursuant to Federal Rule of

Civil Procedure 25(d), Kilolo Kijakazi should be substituted for Andrew M. Saul

as the defendant in this suit. By reason of the last sentence of Section 205(g)

of the Social Security Act, 42 U.S.C. § 405(g), neither the Court nor the parties

need take any further action to continue this suit.

I. PROCEDURAL HISTORY

Plaintiff filed applications for DIB and SSI. (Tr. 258-77.)

Upon denial of those applications initially (Tr. 163-73) and on

reconsideration (Tr. 175-82, 187-96), she requested a hearing de

novo before an Administrative Law Judge (the “ALJ”) (see Tr. 197-

213). Plaintiff, her attorney, and a vocational expert (the “VE”)

attended the hearing. (See Tr. 40-70.) The ALJ subsequently ruled

Plaintiff not disabled under the Act. (Tr. 16-34.) The Appeals

Council denied her request for review (Tr. 1-6), making the ALJ’s

ruling the Commissioner’s final decision for purposes of judicial

review.

In rendering that disability determination, the ALJ made the

following findings later adopted by the Commissioner:

1. [Plaintiff] meets the insured status requirements of

the . . . Act through September 30, 2023.

2. [Plaintiff] engaged in substantial gainful activity

during the following periods: November 2017 through

December 2018.

. . . .

3. However, there has been a continuous 12-month

period(s) during which [Plaintiff] did not engage in

substantial gainful activity. The remaining findings

address the period(s) [Plaintiff] did not engage in

substantial gainful activity.

4. [Plaintiff] has the following severe impairments:

osteoarthritis, degenerative disc disease status post remote

cervical discectomy, chronic kidney disease, and obesity.

. . . .

2

5. [Plaintiff] does not have an impairment or

combination of impairments that meets or medically equals

the severity of one of the listed impairments in 20 CFR

Part 404, Subpart P, Appendix 1.

. . . .

6. . . . [Plaintiff] has the residual functional

capacity [(at times, the “RFC”)] to perform light work as

defined in 20 CFR 404.1567(b) and 416.967(b) except she

can frequently operate foot controls. She can frequently

operate hand controls bilaterally. She can frequently

push or pull with the right upper extremity. She can

frequently reach overhead with the right upper extremity.

She can frequently reach in all other directions with the

right upper extremity. She can frequently handle with

the bilateral upper extremities. She can frequently

climb[] ramps or stairs. She can never climb ladders,

ropes, or scaffolds. She can frequently balance, kneel,

crouch, or crawl. She can occasionally stoop. She must

avoid all exposure to unprotected heights and moving

mechanical parts. She can occasionally be exposed to

dust, odor, fumes, and pulmonary irritants in a work

environment.

. . . .

7. [Plaintiff] is capable of performing past relevant

work as a technical writer and operations research

analyst.[2] This work does not require the performance of

work-related activities precluded by [Plaintiff’s RFC].

. . . .

8. [Plaintiff] has not been under a disability, as

defined in the . . . Act, from November 30, 2017, through

the date of this decision.

(Tr. 21-29 (bold font and parenthetical citations omitted).)

II. DISCUSSION

Federal law “authorizes judicial review of the Social Security

Commissioner’s denial of social security benefits.” Hines v.

2 Both positions qualify as sedentary, skilled work. (See Tr. 28.)

3

Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). However, “the scope

of [the Court’s] review of [such a] decision . . . is extremely

limited.” Frady v. Harris, 646 F.2d 143, 144 (4th Cir. 1981).

Plaintiff has not established entitlement to relief under this

extremely limited review standard.

A. Standard of Review

“[C]ourts are not to try [a Social Security] case de novo.”

Oppenheim v. Finch, 495 F.2d 396, 397 (4th Cir. 1974). Instead,

the Court “must uphold the factual findings of the ALJ [underlying

the denial of benefits] if they are supported by substantial

evidence and were reached through application of the correct legal

standard.” Hines, 453 F.3d at 561 (brackets and internal quotation

marks 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, 401 (1971)).

“It consists of more than a mere scintilla of evidence but may be

somewhat less than a preponderance.” Mastro v. Apfel, 270 F.3d

171, 176 (4th Cir. 2001) (brackets and internal 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 (internal quotation marks

omitted).

4

“In reviewing for substantial evidence, the [C]ourt should not

undertake to re-weigh conflicting evidence, make credibility

determinations, or substitute its judgment for that of the [ALJ, as

adopted by the Commissioner].” Mastro, 270 F.3d at 176 (brackets

and internal 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

[Commissioner] (or the ALJ).” Id. at 179 (internal quotation marks

omitted). “The issue before [the 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 correct application of the relevant law.”

Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996).

When confronting that issue, the Court must take note that

“[a] claimant for disability benefits bears the burden of proving

a disability,” Hall v. Harris, 658 F.2d 260, 264 (4th Cir. 1981),

and that, 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 result 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)).3 “To regularize the

3 The “Act comprises two disability benefits programs. [DIB] . . . provides

benefits to disabled persons who have contributed to the program while employed.

The [SSI] Program . . . provides benefits to indigent disabled persons. The

(continued...)

5

adjudicative process, the Social Security Administration [(the

“SSA”)] has . . . detailed regulations incorporating longstanding

medical-vocational evaluation policies that take into account a

claimant’s age, education, and work experience in addition to [the

claimant’s] medical condition.” Id. “These regulations establish

a ‘sequential evaluation process’ to determine whether a claimant

is disabled.” Id.

This sequential evaluation process (the “SEP”) has up to five

steps: “The claimant (1) must not be engaged in ‘substantial

gainful activity,’ i.e., currently working; and (2) must have a

‘severe’ impairment that (3) meets or exceeds the ‘listings’ of

specified impairments, or is otherwise incapacitating to the extent

that the claimant does not possess the residual functional capacity

to (4) perform [the claimant’s] past work or (5) any other work.”

Albright v. Commissioner of Soc. Sec. Admin., 174 F.3d 473, 475 n.2

(4th Cir. 1999).4 A finding adverse to the claimant at any of

several points in the SEP forecloses an award and ends the inquiry.

For example, “[t]he first step determines whether the claimant is

engaged in ‘substantial gainful activity.’ If the claimant is

working, benefits are denied. The second step determines if the

3 (...continued)

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 (citations omitted).

4 “Through the fourth step, the burden of production and proof is on the

claimant. If the claimant reaches step five, the burden shifts to the

[Commissioner] . . . .” Hunter, 993 F.2d at 35 (citation omitted).

6

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 three steps, “the claimant is disabled.” Mastro,

270 F.3d at 177. Alternatively, if a claimant clears steps one and

two, but falters at step three, i.e., “[i]f a claimant’s impairment

is not sufficiently severe to equal or exceed a listed impairment,

the ALJ must assess the claimant’s [RFC].” Id. at 179.5 Step four

then requires the ALJ to assess whether, based on that RFC, the

claimant can perform past relevant work; if so, the claimant does

not qualify as disabled. See id. at 179-80. However, if the

claimant establishes an inability to return to prior work, the

analysis proceeds to the fifth step, whereupon the ALJ must decide

“whether the claimant is able to perform 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

Commissioner cannot carry its “evidentiary burden of proving that

5 The “RFC is a measurement of the most a claimant can do despite [the

claimant’s] limitations.” Hines, 453 F.3d at 562 (noting that administrative

regulations require RFC to reflect claimant’s “ability to do sustained work-

related physical and mental activities in a work setting on a regular and

continuing basis . . . . [which] means 8 hours a day, for 5 days a week, or an

equivalent work schedule” (emphasis and internal 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. The “RFC is to be determined by the ALJ

only after [the ALJ] considers all relevant evidence of a claimant’s impairments

and any related symptoms (e.g., pain).” Hines, 453 F.3d at 562-63.

7

[the claimant] remains able to work other jobs available in the

community,” the claimant qualifies as disabled. Hines, 453 F.3d at

567.6

B. Assignments of Error

Plaintiff asserts that the ALJ erred by (1) “appl[ying] an

incorrect legal standard when she discounted [Plaintiff’s]

subjective complaints as inconsistent with the objective medical

evidence” (Docket Entry 12 at 5 (bold and all-cap font omitted));

(2) “assessing [Plaintiff’s RFC] pursuant to an incorrect framework

and without explaining the RFC-related findings in the manner

required by Social Security Regulations” (id. at 10 (bold and all-

cap font omitted)); and (3) “fail[ing] to properly document the

application of the special-technique assessment” (id. at 18 (bold

and all-cap font omitted)). Defendant contends otherwise,

asserting that “[t]he ALJ applied the correct law and relied on

substantial evidence to find Plaintiff not disabled,” and urges

affirmation of the ALJ’s decision. (Docket Entry 15 at 22.)

1. Subjective Complaints

In her first assignment of error, Plaintiff contends that,

“like Lewis[ v. Berryhill, 858 F.3d 858 (4th Cir. 2017)], the ALJ’s

6 A claimant thus can establish disability via two paths through the SEP. The

first path requires resolution of the questions at steps one, two, and three in

the claimant’s favor, whereas, on the second path, the claimant must prevail at

steps one, two, four, and five. Some short-hand judicial characterizations of

the SEP appear to gloss over the fact that an adverse finding against a claimant

at step three does not terminate the analysis. See, e.g., Hunter, 993 F.2d at

35 (“If the ALJ finds that a claimant has not satisfied any step of the process,

review does not proceed to the next step.”).

8

opinion should be vacated because she improperly increased

[Plaintiff’s] burden of proof by requiring objective proof of

symptoms, and offered no record evidence supporting her conclusions

that [Plaintiff’s] symptoms were not credible.” (Docket Entry 12

at 10 (citing Lewis, 858 F.3d at 869-70).) More specifically,

Plaintiff argues that “the ALJ ignored Fourth Circuit precedent and

the agency’s rules and regulations, by disregarding [Plaintiff’s]

subjective complaints due a lack of objective evidence” (id. at 6)

and that, “contrary to the ALJ’s arguments, the objective medical

evidence actually does support [Plaintiff’s] subjective complaints

in this case” (id. at 7-8). Plaintiff’s arguments lack merit.

As the United States Court of Appeals for the Fourth Circuit

has explained:

An ALJ assesses the credibility of a claimant’s

subjective statements about his condition as part of the

RFC assessment. When conducting the RFC assessment, the

ALJ must consider all relevant evidence in the record,

including medical records, reports of daily activities,

and “effects of symptoms, including pain, that are

reasonably attributed to a medically determinable

impairment.” SSR 96-8p[, 1996 WL 374184] at *7[ (Jul. 2,

1996)]. When a claimant makes statements about his

symptoms, the ALJ must determine the credibility of those

statements and explain his assessment. 20 C.F.R.

§§ 404.1529(c)(4), 416.929(c)(4); see SSR 96-7p, 1996 WL

374186 (Jul. 2, 1996). . . .

SSA regulations set out a two-step process that ALJs

must follow when evaluating a claimant’s subjective

statements about his impairments and symptoms. 20 C.F.R.

§§ 404.1529, 416.929. First, the ALJ considers the

objective medical evidence to determine whether the

claimant’s medical impairments “could reasonably be

expected to produce the pain or other symptoms alleged.”

Id. Second, the ALJ evaluates the “intensity and

9

persistence of [the claimant’s] symptoms” and

“determin[es] the extent to which [those] symptoms limit

[the claimant’s] capacity for work.” Id. At the second

step, the ALJ must “assess the credibility of the

claimant’s statements about symptoms and their functional

effects.” Lewis[, 858 F.3d at 866] (citing 20 C.F.R.

§§ 404.1529(c)(4), 416.929(c)(4)). . . .

When an ALJ makes a credibility determination, he

must “consider the entire case record, including the

objective medical evidence, the individual’s own

statements about symptoms, [and] statements . . . by

treating or examining physicians.” SSR 96-7p at *1. In

this analysis, the ALJ must “build an accurate and

logical bridge from the evidence to his conclusion that

the claimant’s testimony was not credible.” Brown v.

Comm’r Soc. Sec. Admin., 873 F.3d 251, 269 (4th Cir.

2017) (internal quotations and alterations omitted).

Ladda v. Berryhill, 749 F. App’x 166, 170 (4th Cir. 2018) (final

ellipsis and certain brackets in original).

Here, contrary to Plaintiff’s contentions, the ALJ did not

“increase [Plaintiff’s] burden of proof by requiring objective

medical evidence in support of her symptoms” (Docket Entry 12 at

7). (See Tr. 25-28.) Rather, the ALJ determined that the

objective medical evidence, including Plaintiff’s largely

conservative treatment history, her daily activities, the opinions

of medical examiners, and her substantial gainful activity and

receipt of unemployment during the relevant period undermined the

credibility of Plaintiff’s statements regarding the intensity,

persistence, and limiting effects of her symptoms. (See Tr. 25-28;

see also Tr. 26 (finding that, although Plaintiff’s “medically

determinable impairments could reasonably be expected to cause the

alleged symptoms[, her] statements concerning the intensity,

10

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” (emphasis

added).) The ALJ acted appropriately in considering such evidence.

See 20 C.F.R. § 404.1529(c) (directing ALJs, when evaluating

intensity, persistence, and limiting effects of claimant’s

symptoms, to assess, inter alia, objective medical evidence,

medical opinions, daily activities, medication, and treatment other

than medication).

For instance, the ALJ first discussed Plaintiff’s description

of her daily activities, which include preparing her own meals each

day, “perform[ing] household chores, such as cleaning, laundry, and

taking out the trash,” driving, “shop[ping] for groceries and

household items twice a week,” singing in church choir on a weekly

basis, attending church, having dinner with friends, talking on the

telephone, and “stay[ing] connected on Facebook.” (Tr. 26 (citing

Ex. 4E).) The ALJ further noted that, per her own assessment,

Plaintiff “can pay attention for an hour without problems and

usually finishes what she starts” and also “follows instructions

well” and “can walk a quarter of a mile before needing to rest for

15 minutes.” (Tr. 26.) The ALJ also explained that “[Plaintiff]

worked throughout the relevant period and continues to work

part-time. She reported that one of her daily activities is to

look for work.” (Tr. 25.)

11

The ALJ then discussed Plaintiff’s medical evidence, which

included “unremarkable” physical exams, “[r]ecent labs indicat[ing]

that her condition remains stable,” use of only Acetaminophen for

pain relief, “no evidence of any significant treatment for any

spinal conditions other than two chiropractic visits in 2019,” and

a “grossly unremarkable” physical consultative examination. (Tr.

26-27.)

The ALJ also examined the medical opinion evidence, explaining

that she found “persuasive” the opinions of Dr. Strobel-Nuss and

Dr. Warren, the State Agency psychological consultants, which

“opined that [Plaintiff] had no more than mild limitations in

mental functioning and no severe mental impairments,” and of Dr.

Bessent and Dr. Linster, the State Agency medical consultants,

which “opined that [Plaintiff] could perform a range of light work”

(Tr. 27). (See Tr. 27-28.) The ALJ additionally discussed the

reasons that she found other medical opinion evidence less

persuasive than the State Agency opinions. (See Tr. 27-28.)

Finally, the ALJ explained that Plaintiff’s work history during the

relevant period undermined her subjective assessment of her

impairments. (See Tr. 27.) More specifically, the ALJ stated:

Records indicate that [Plaintiff] worked at the level of

substantial gainful activity for most of the relevant

period and only stopped working when a contract would run

out. When her contracts ran out, she immediately went on

unemployment and held herself out as ready, willing, and

12

able to engage in gainful activity, which is also grossly

contradictory to her allegations of disability.

(Tr. 27.)

Thus, rather than improperly increasing Plaintiff’s burden of

proof, the ALJ correctly considered the range of evidence in the

record in finding that Plaintiff’s statements regarding the

intensity, persistence, and limiting effects of her symptoms lacked

credibility. See Ladda, 749 F. App’x at 171-72.

Plaintiff contends, however, that the ALJ erred in her

assessment of the objective medical evidence. (See Docket Entry 12

at 7-10.) In this regard, Plaintiff first asserts that “the

medical evidence supports [Plaintiff’s] subjective complaints

because it shows she suffered from osteoarthritis, primarily of the

right shoulder, that caused bilateral should[er] pain, for which

she was given prednisone, recommended physical therapy, and

referred to orthopedics.” (Id. at 8; see also id. (“At the

hearing, she testified that she had pain in both of her shoulders,

and physical therapy was recommended, but she could not afford

it.”).) Yet, as the ALJ found, although “[r]ecords indicate

complaints of bilateral shoulder pain” (Tr. 26 (citing Ex. 12F)),

[p]hysical exams were unremarkable and indicated no

tenderness, no crepitus, normal stability, and normal

range of motion (12F p.3, 13F pp.7, 17, 15F pp.4-5, 17F

pp.37, 53, 68). Muscle tone, bulk, and strength were

normal and she had a normal gait (id.). One record

indicated some reduced range of motion in the right

shoulder (4F p.192). Imaging studies of the right

shoulder indicated mild osteoarthritic degenerative

change in the glenohumeral and acromioclavicular (AC)

13

joints (id.). The only medication she takes for pain

relief is Acetaminophen (12F, 13F, 15F, 17F).

(Tr. 26.) Moreover, Plaintiff’s 2018 physical consultative

examination “was grossly unremarkable” (Tr. 27), with Plaintiff

experiencing “no palpable muscle spasms and [her] muscle strength

and range of motion were normal throughout” (Tr. 27 (citing Ex. 5F

pp.4, 6)). The examination also indicated that Plaintiff was “able

to lift, carry, handle, and manipulate light objects.” (Tr. 27

(citing Ex. 5F p.5).)

Plaintiff next challenges the ALJ’s findings regarding her

kidney disease. (See Docket Entry 12 at 8.) In particular,

Plaintiff disputes the ALJ’s determination that Plaintiff’s

condition remained stable and criticizes the ALJ for “fail[ing] to

mention that [Plaintiff] suffers from hyperthyroidism secondary to

hypertensive chronic kidney disease, anemia associated with chronic

renal failure, hyperlipidemia, and diabetes mellitus with renal

complications.” (Id. (citing Tr. 381, 385-86, 395).) As a

preliminary matter, Plaintiff did not identify “hyperthyroidism

secondary to hypertensive chronic kidney disease, anemia associated

with chronic renal failure, [or] hyperlipidemia” on her SSI

application. (See Tr. 267.) Rather, Plaintiff identified simply,

inter alia, “Chronic Kidney Disease or Kidney Failure” and

“Diabetes, unknown type.” (Tr. 267.)

In any event, the ALJ addressed Plaintiff’s “history of

chronic kidney disease” (Tr. 26) and her diabetes (Tr. 23), in

14

addition to her hypertension and “mild vision loss” (Tr. 23),

finding that the latter three impairments qualified as “non-severe”

(Tr. 23).7 Moreover, medical records, including the records that

Plaintiff cites from Carolina Kidney Associates, repeatedly

describe Plaintiff’s kidney disease, anemia, hyperlipidemia, and

diabetes as “controlled” or “stable.” (See, e.g., Tr. 378, 381,

382, 386, 387, 391, 395, 670.) Further, as the ALJ observed,

although Plaintiff experienced one brief hospitalization “for acute

kidney injury” in 2019, she “recovered with approximately three

days of observation and was discharged in stable condition” and

“[r]ecent labs indicate that her condition remains stable. (Tr. 26

(citing Exs. 15F, 19F p.17); see Tr. 794-1034, 1129.)

Plaintiff next faults the ALJ for “fail[ing] to note that due

to her diabetes with renal complications, [Plaintiff] suffered from

diabetic retinopathy in her left eye” (Docket Entry 12 at 8 (citing

Tr. 660)), which Plaintiff testified “caused blurry vision” (id.).

The ALJ acknowledged, though, that Plaintiff suffered from “mild

vision loss.” (Tr. 23.) As, inter alia, Plaintiff’s “[v]isual

7 The State Agency opinions, which the ALJ found persuasive (see Tr. 27-28),

also acknowledge Plaintiff’s hypothyroidism, hyperlipidemia, anemia, eye

problems, diabetes, and hypertension (see, e.g., Tr. 91, 97, 99, 104, 109-11,

113, 117, 129, 131, 133, 135-37), but nevertheless “opined that [Plaintiff] could

perform a range of light work” and suffered from “no more than mild limitations

in mental functioning and no severe mental impairments” (Tr. 27). Dr. Darji’s

physical consultive examination similarly recognizes Plaintiff’s “diabetic

retinopathy in the left eye” (Tr. 688), hypothyroidism (Tr. 689), and kidney

disease (Tr. 688-89), but also notes that Plaintiff “[wa]s not experiencing any

symptoms from [her chronic kidney disease]” (Tr. 688). Dr. Darji concluded that

Plaintiff’s diabetes, hypertension, eye problems, kidney problems, and assorted

other ailments, including “depression, chronic pain in the shoulder, [and]

osteoarthritis in the upper body,” “are well controlled on current therapies and

[are] not causing current functional limitations” (Tr. 694).

15

acuity with corrective lenses was 20/30 in each eye individually

and 20/20 in both eyes,” the ALJ found that this mild vision loss

qualified as non-severe and “no more than minimally affect[s

Plaintiff’s] ability to perform basic work related activities.”

(Tr. 23.) Plaintiff also takes issue with the ALJ’s finding

regarding the lack of “significant complaints of neck or back pain

during the relevant period” (Docket Entry 12 at 9 (internal

quotation marks omitted)), given the ALJ’s failure to explicitly

acknowledge that the doctor’s note from Plaintiff’s 2019

chiropractor visits “stated [that Plaintiff] was having ‘a lot of

low back pain.’” (Id. (quoting Tr. 762).) However, Plaintiff does

not dispute that, as the ALJ found, “[t]here [we]re no new imaging

studies of the spine and no evidence of any significant treatment

for any spinal conditions other than two chiropractic visits in

2019” (Tr. 26 (citing chiropractor’s records)) and, as Defendant’s

Memorandum points out (see Docket Entry 15 at 9), “[t]he only

medication [Plaintiff] takes for pain is Acetaminophen” (Tr. 26).

(See Docket Entry 12 at 9.) Moreover, in critiquing the ALJ’s

alleged “attempt[] to discount [Plaintiff’s] credibility as to her

degenerative disc disease” (id.), Plaintiff neither acknowledges

that the ALJ gave Plaintiff “the benefit of the doubt and

considered [Plaintiff’s degenerative disc disease] when formulating

[Plaintiff’s RFC]” (Tr. 26) nor identifies any RFC limitation that

the ALJ allegedly erroneously omitted based on her assessment of

16

Plaintiff’s degenerative disc disease symptoms. (See Docket Entry

12 at 9.)

Plaintiff further contests the ALJ’s statement that

“‘[Plaintiff] has been continuously counseled of the need to reduce

her weight because it would provide significant symptom relief for

most of her conditions. However, she has failed to comply with

this medical advice.’” (Id. (quoting Tr. 26).) According to

Plaintiff, the record does not support this finding. (See id.) To

the contrary, the record repeatedly notes both Plaintiff’s need to

follow a healthy diet, lose weight, and exercise and her compliance

issues with such diet, weight loss, and exercise. (See, e.g., Tr.

409, 425-26, 431, 538, 722, 860, 872, 884, 928, 1003, 1122, 1125-

26.) Finally, Plaintiff contends that “the ALJ failed to explain

why [Plaintiff’s] complaints of fatigue were not credible, despite

this being her most prolific symptom.” (Docket Entry 12 at 9.)

However, the ALJ did explain this finding, noting that “[r]ecords

indicate that [Plaintiff] gets eight to twelve hours of sleep per

night and is compliant with using her CPAP machine,” as well as

that Plaintiff “reported to Dr. Darji that she did not always feel

refreshed after sleep, but she did not fall asleep during the day.”

(Tr. 28 (citing Ex. 5F p.1).)

In sum, the ALJ neither increased Plaintiff’s burden of proof

nor “reject[ed Plaintiff’s subjective symptom] statements out of

hand. Instead, [s]he compared them with the other evidence on the

17

record, including objective medical evidence and [Plaintiff’s own]

statements. The weight [the ALJ] assigned to [Plaintiff’s]

statements after comparing them with other evidence is therefore

supported by substantial evidence.” Ladda, 749 F. App’x at 171.

Accordingly, Plaintiff’s first assignment of error fails to justify

reversal.

2. RFC Assessment

In her next assignment of error, Plaintiff contends that the

ALJ applied an incorrect framework for assessing her RFC, including

by expressing Plaintiff’s RFC without first engaging in a function-

by-function analysis; failed to adequately explain her findings;

and failed to consider and include all of Plaintiff’s limitations.

(See Docket Entry 12 at 10-18.) These assertions fail to justify

remand.

The RFC measures the most a claimant can do despite any

physical or mental limitations. Hines, 453 F.3d at 562; 20 C.F.R.

§§ 404.1545(a), 416.945(a). An ALJ must determine a claimant’s

exertional and non-exertional capacity only after considering all

of a claimant’s impairments, as well as any related symptoms. See

Hines, 453 F.3d at 562–63; 20 C.F.R. §§ 404.1545(b)-(d),

416.945(b)-(d). The ALJ then must match the claimant’s exertional

abilities to an appropriate level of work (i.e., sedentary, light,

medium, heavy, or very heavy). See 20 C.F.R. §§ 404.1567, 416.967.

Any non-exertional limitations may further restrict a claimant’s

18

ability to perform jobs within an exertional level. See 20 C.F.R.

§§ 404.1569a(c), 416.969a(c).

An ALJ need not discuss every piece of evidence in making an

RFC determination. See Reid v. Commissioner of Soc. Sec., 769 F.3d

861, 865 (4th Cir. 2014). Nevertheless, “the ALJ must both

identify evidence that supports [her] conclusion and build an

accurate and logical bridge from that evidence to [her]

conclusion.” Woods v. Berryhill, 888 F.3d 686, 694 (4th Cir. 2018)

(emphasis, internal quotation marks, and brackets omitted). As to

the role of the function-by-function analysis in that

determination, the relevant administrative ruling states: “The RFC

assessment must first identify the individual’s functional

limitations or restrictions and assess his or her work-related

abilities on a function-by-function basis[] . . . . Only after

that may RFC be expressed in terms of the exertional levels of

work, sedentary, light, medium, heavy, and very heavy.” SSR 96-8p

at *1. “[The Fourth Circuit] ha[s] explained that expressing the

RFC before analyzing the claimant’s limitations function by

function creates the danger that the adjudicator will overlook

limitations or restrictions that would narrow the ranges and types

of work an individual may be able to do.” Monroe v. Colvin, 826

F.3d 176, 187 (4th Cir. 2016) (internal quotation marks and

brackets omitted).

19

Notably, the “[Fourth Circuit] ha[s] not adopted a rule of per

se reversal for errors in expressing the RFC before analyzing the

claimant’s limitation function by function.” Id. at 188; see also

Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (explaining

“that a per se rule is inappropriate given that remand would prove

futile in cases where the ALJ does not discuss functions that are

irrelevant or uncontested” (internal quotation marks omitted)).

Instead, “remand 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.” Monroe, 826

F.3d at 188 (internal quotation marks omitted).

As an initial matter, Plaintiff asserts that the ALJ relied on

an incorrect regulatory framework, arguing that, “just like in

Dowling[ v. Commissioner of Social Security Administration, 986

F.3d 377 (4th Cir. 2021)],” the ALJ “based her [RFC] determination

on SSR 16-3p and failed to cite to 20 C.F.R. § 416.945 or SSR

96-8p.” (Docket Entry 12 at 11.) Contrary to Plaintiff’s claims,

the ALJ specifically cited to both 20 C.F.R. § 416.945 and SSR 96-

8p in discussing the law applicable to the RFC determination. (See

Tr. 21.) Moreover, unlike in the referenced decision, the ALJ’s

opinion “indicate[s] that h[er] RFC assessment was rooted in a

function-by-function analysis of how [Plaintiff’s] impairments

impacted her ability to work,” Dowling, 986 F.3d at 387, rather

20

than being “based entirely” on an analysis of whether “the alleged

severity of [Plaintiff’s] symptoms is supported by the record,” id.

(See, e.g., Tr. 27 (“Otherwise, there has not been any significant

treatment of physical impairments during the relevant period.

There is no evidence of any significant limitations in

[Plaintiff’s] ability to stand, walk, or sit. Consequently, the

[ALJ] finds that [Plaintiff’s] impairments and any exacerbating

effects of her obesity warrant the limitations outlined above in

the [RFC].”).) Plaintiff’s contentions on this front thus do not

warrant remand.

Plaintiff also urges remand on the grounds that the ALJ

“erroneously assessed [Plaintiff’s] RFC by stating her RFC first,

then identifying evidence and attempting to explain how it

supported the ALJ’s predetermined conclusion.” (Docket Entry 12 at

13.) This alleged failure, Plaintiff contends, in and of itself

necessitates vacating the ALJ’s decision. (Id.) However, the mere

failure to engage in a function-by-function analysis does not

necessitate reversal, see Monroe, 826 F.3d at 188, and, as

discussed below, no other deficiencies justify relief on this

basis.

Plaintiff next contends that the ALJ “failed to build an

accurate and logical bridge from the evidence to her conclusion.”

(Docket Entry 12 at 14.) More specifically, Plaintiff argues that

“[t]he ALJ’s discussion of the medical evidence does not explain

21

how this evidence supports her RFC findings.” (Id. at 16.)

According to Plaintiff, “the ALJ’s opinion should be vacated

because her lack of explanation frustrates meaningful review.”

(Id.) In fact, the record establishes the opposite, as the ALJ’s

detailed discussion of the evidence, including the medical

opinions, provides “an accurate and logical bridge” to her

conclusion that Plaintiff can engage in modified light work. (See

Tr. 25-28.)

For instance, the ALJ explained that the “persuasive” opinions

of Dr. Strobel-Nuss and Dr. Warren indicate that Plaintiff “had no

more than mild limitations in mental functioning and no severe

mental impairments.” (Tr. 27.) She further explained that the

“somewhat less persuasive” opinion of Dr. Smith generally indicates

that [Plaintiff] did not have any limitations and did not

opine on the degree of limitation she had related to

stress and pressure associated with day-to-day work,

which makes his opinion somewhat vague. Nevertheless, no

more than mild limitations are supported by and

consistent with the objective medical evidence discussed

above, which showed no psychiatric hospitalizations, only

12 sessions of outpatient counseling, unremarkable mental

status exams, and good control of symptoms with common

mental health medication.

(Tr. 27; see also Tr. 23-24 (analyzing mental health impairments

and explaining that “[Plaintiff] handles stress and changes in

routine well (4E p.7). [Dr. Smith] opined that [Plaintiff’s]

ability to tolerate the stress and pressure associated with

day-to-day work was limited, but did not opine on the degree of

22

limitation (18F p.3). The objective medical evidence warrants no

more than a mild limitation.”).)

The ALJ further explained that Dr. Linster and Dr. Bessent

“persuasive[ly ]opined that [Plaintiff] could perform a range of

light work.” (Tr. 27.) The ALJ observed that “[t]hese opinions

are supported by and consistent with the objective medical evidence

discussed above, which showed unremarkable physical exams with only

one exam mentioning limited range of motion in the right shoulder.

Additionally, her treatment consists entirely of routine follow-ups

for medication refills and her symptoms are well managed.” (Tr.

27.) The ALJ also noted that “[t]here have been no new imaging

studies, no participation in physical therapy, no participation in

pain management, and no recommendations for surgery.” (Tr. 27-28.)

The ALJ then discussed the opinion of Dr. Darji, the results

of which the ALJ had earlier analyzed. (See Tr. 27-28.) As the

ALJ explained:

The examination was grossly unremarkable and noted that

[Plaintiff’s] concentration was good, she had a steady

symmetric gait, and did not require and assistive device

for ambulation (5F p.4). She had no palpable muscle

spasms and muscle strength and range of motion were

normal throughout (5F pp.4, 6). Straight leg raising was

negative and sensation to light touch was intact

throughout (5F p.4). She was able to lift, carry,

handle, and manipulate light objects (5F p.5). She was

able to squat and rise with ease (id.). She was able to

rise from a sitting position without difficulty and did

not require assistance getting off the exam table (id.).

She walked on her heels and toes with ease (id.). Tandem

walking was normal and she was able to hop on one foot at

a time bilaterally (id.).

23

(Tr. 27.) The ALJ found Dr. Darji’s opinion “somewhat persuasive,”

explaining that “Dr. Darji opined that based on his examination,

there was not enough evidence to state any functional limitations.”

(Tr. 28.) Nevertheless, “[b]ased on other evidence discussed [in

the ALJ’s opinion], the [ALJ gave Plaintiff] the benefit of the

doubt and assigned the limitations outlined above in the [RFC].

The [RFC] . . . more than adequately accommodates any limitations

that [Plaintiff] may have.” (Tr. 28.)

Finally, the ALJ explained why she found Dr. Dohmeier’s

opinion “unpersuasive” and fatigue-related RFC restrictions

unwarranted. (Tr. 28 (citing Ex. 16F); see also Tr. 23.)

Specifically, the ALJ noted that Dr. Dohmeier “opined that

[Plaintiff’s] sleep apnea caused severe daytime somnolence that was

severe enough to prevent work, but also acknowledged that this was

based entirely on [Plaintiff’s] own subjective report.” (Tr. 28.)

The ALJ continued:

Records indicate that [Plaintiff] gets eight to twelve

hours of sleep per night and is compliant with using her

CPAP machine. [Plaintiff] reported to Dr. Darji that she

did not always feel refreshed after sleep, but she did

not fall asleep during the day (5F p.1). Dr. Dohmeier

essentially just recited the claimant’s subjective

complaints and did not offer any supporting evidence or

rationale for her opinion. Additionally, the statements

relating to the claimant’s ability to work, are issues

reserved to the Commissioner and consequently, no

analysis is required because the statement is inherently

neither valuable nor persuasive (20 CFR 404.1520B.(c) and

416.920b.(c)).

24

(Tr. 28.)°

Thus, the ALJ sufficiently explained why the medical opinions

supported her modified light work RFC determination. See Ladda,

749 F, App’x at 172 (explaining that, “[i]n Monroe, an ALJ’s RFC

assessment was not supported by substantial evidence when he failed

to explain his decision to rely on certain medical records while

ignoring others and when he failed to include a narrative

discussion describing how he decided to weigh the evidence,” but

that, “the ALJ sufficiently explained his conclusions when

conducting the RFC assessment” in Ladda because he “used evidence

from the record to explain his finding that [the claimant] was

capable of light work,” precluding remand); cf. Monroe, 826 F.3d at

190-91 (finding ALJ’s explanation necessitated remand where ALJ

(1) failed to specify what evidence he found undermined medical

® Significantly, Dr. Dohmeier’s own evaluation of Plaintiff, conducted in June

2019 with the stated intent from Plaintiff of “assistance with disability” (Tr.

767; see also Tr. 768 (“Trying to get disability — working with a lawyer — needs

sleep specialist to help with that”)), provides record support for the ALJ’s

finding that Plaintiff receives eight to twelve hours of sleep and remains

compliant with her CPAP machine. (See, e.g., Tr. 767-69, 774; see also Tr. 23

(citing, inter alia, Ex. 13F (i.e., Dr. Dohmeier’s June 2019 records) for support

of sleep-related findings).) Dr. Dohmeier’s notes from that evaluation reflect

that, based on her assessment of Plaintiff, Dr. Dohmeier “see[s] no way to

provide [sic] disability for a hypersomnia sleep disorder - not enough organic

abnormalities while on CPAP.” (Tr. 774.) Nevertheless, Dr. Dohmeier’s December

2019 opinion (see Tr. 1036) reflects that Dr. Dohmeier’s last contact with

Plaintiff occurred in June 2019; that Plaintiff suffered from “[h] ypersomnia[;]”

that, “by Pt Report,” Plaintiff suffers from “[slevere” excessive daytime

somnolence sufficient to prevent work; and that, “per subjective report,”

Plaintiff’s impairments lasted or could be expected to last for at least twelve

months. (Tr. 1035.) Notwithstanding these subjective reports, the opinion

provides no answers in the section asking for Dr. Dohmeier’s estimates regarding

any functional limitations on Plaintiff’s abilities in a competitive work

situation, including any need to take unscheduled breaks (associated with chronic

fatigue or any other reason, including “[a]dverse effects of medication”), any

days missed from work, or any time “off task.” (Tr. 1035-36 (emphasis omitted) .)

25

opinions indicating need for limitations and (2) “gave similarly

conclusory analysis of other opinions,” such as by stating only

that “‘[t]he [ALJ] gives the consultative examiner’s findings some

weight, to the extent that it is consistent with the [RFC],’” and

that “‘[t]he consultative examiner’s opinion is supported by the

objective evidence,’” explaining that, “[w]ithout more specific

explanation of the ALJ’s reasons for the differing weights he

assigned various medical opinions, neither [the Fourth Circuit] nor

the district court can undertake meaningful substantial-evidence

review”).

Plaintiff contends, though, that

[t]his case is like Monroe because here, the ALJ

failed to assess [Plaintiff’s] capacity to perform

relevant functions, despite contradictory evidence in the

record. TR 25-28; 826 F.3d at 188. For example, the

ALJ’s assigned RFC provides for frequent operation of

hand controls bilaterally; frequent pushing or pulling

with the right upper extremity; frequent reaching

overhead and in all directions with the right upper

extremity; and frequent handling with the right upper

extremity. TR 25. However, the ALJ failed to explain

how [Plaintiff] can perform work five days per week,

eight hours per day that requires such frequent operation

of hand controls, pushing, pulling, reaching and handling

with the right upper extremity, when [Plaintiff] suffers

from osteoarthritis of the right upper extremity, which

causes her severe pain, limited range of motion, and

inhibits her ability to do household chores. TR 63, 317,

670, 673-74, 765.

(Docket Entry 12 at 17-18.)9

9 Plaintiff does not specify any other functions that the ALJ allegedly failed

to assess. (See id. at 10-18.)

26

This contention entitles Plaintiff to no relief, because, as

discussed above, the ALJ thoroughly examined the impact of

Plaintiff’s osteoarthritis on her ability to function. (See Tr.

26-27.) The ALJ further found persuasive the State Agency medical

consultants’ opinions (see Tr. 27), which determined that, although

Plaintiff suffered from some push/pull limitations in both upper

extremities and her right lower extremity, she could

“[f]requent[ly] push/pull,” which “includ[ed] operation of hand

and/or foot controls” (Tr. 97, 115, 135, 153). They further found

that, despite limitations on Plaintiff’s ability to reach with her

right arm and engage in handling (i.e., gross manipulation) with

either arm, she remained subject to only “[f]requent manipulative

limitations.” (Tr. 98, 116, 136, 154.) The ALJ also observed that

Dr. Darji “opined that based on his examination, there was not

enough evidence to state any functional limitations,” but that the

ALJ gave Plaintiff “the benefit of the doubt and assigned the

limitations outlined” in the RFC (Tr. 28), including those that

Plaintiff now challenges. In any event, requesting further

explanation as to the osteoarthritis-impacted functions highlighted

by Plaintiff would not alter the outcome in this case, given that

the finding of no disability turned on Plaintiff’s ability to

“perform[] past relevant work as a[n] . . . operations research

analyst (DOT# 020.067-018. . .)” (Tr. 28), which does not involve

frequent reaching or handling, see Dictionary of Occupational

27

Titles, Operations-Research Analyst, 1991 WL 646468 (4th ed. rev.

1991); see also Fisher v. Bowen, 869 F.2d 1055, 1057 (7th Cir.

1989) (observing that “[n]o principle of administrative law or

common sense requires us to remand a case in quest of a perfect

opinion unless there is reason to believe that the remand might

lead to a different result”).

Plaintiff additionally contends that the ALJ, without

explanation, “failed to provide for any limitations due to

[Plaintiff’s] significant fatigue, depression, anemia, poorly

controlled blood pressure, side effects from medications such as

drowsiness, diabetic retinopathy of the left eye, sleep apnea and

hyper-somnolence, and hyperthyroidism.” (Docket Entry 12 at 18.)

As a preliminary matter, the State Agency medical consultants

considered, inter alia, Plaintiff’s chronic kidney disease,

depression, fatigue, pain, hypertension, diabetes, sleep-related

breathing disorders, chronic respiratory disorders (see, e.g., Tr.

110-12, 131, 133), thyroid disorders, and visual impairment (see,

e.g., Tr. 131, 133) in reaching their determination that Plaintiff

could engage in modified light work. They also specifically

identified, inter alia, Plaintiff’s chronic fatigue, diabetes,

chronic kidney disease, and blood pressure as justification for

their recommended functional limitations (see, e.g., Tr. 115, 135),

which the ALJ adopted (see Tr. 25). Similarly, the ALJ explained

that she considered persuasive the State Agency psychological

28

consultants’ opinions, which found that Plaintiff “had no more than

mild limitations in mental functioning and no severe mental

impairments.” (Tr. 27.) The ALJ also explained the issues with

Dr. Smith’s “somewhat vague” opinion, which “generally opined that

the claimant did not have any limitations and did not opine on the

degree of limitation she had related to stress and pressure

associated with day-to-day work.” (Tr. 27.) The ALJ then detailed

why the evidence supported “no more than mild limitations” on that

front. (Tr. 27.)

As discussed previously, the ALJ also specifically analyzed

the evidence regarding Plaintiff’s kidney disease and fatigue.

(See Tr. 26, 28.) The ALJ additionally evaluated Plaintiff’s

“hypertension, diabetes, sleep related breathing disorders, and

mild vision loss,” explaining why they qualified as “non-severe

impairments” and “no more than minimally affect [Plaintiff’s]

ability to perform basic work related activities.” (Tr. 23.) In

this regard, the ALJ stated:

The record indicates that these impairments either were

acute illnesses, lasting for less than 12 months, or are

well controlled on medication. These impairments no more

than minimally affect [Plaintiff’s] ability to perform

basic work related activities. All objective studies,

such as physical exams, lab work, and imaging studies

related to these impairments were unremarkable or within

normal limits (4F, 5F, 7F, 13F, 15F p.206, 17F). She has

good control of her sleep apnea with a CPAP machine and

downloads indicated eight hours of use per night (id.).

Records indicate her diabetes is well controlled and she

does not check her blood sugar at home (id.). Recent lab

work indicated an A1C of 6.0, which is consistent with

good control for adults with diabetes (19F pp.18-19).

29

Visual acuity with corrective lenses was 20/30 in each

eye individually and 20/20 in both eyes (5F p.3).

Additionally, she has been advised to restrict her diet,

lose weight, and exercise. Consequently, the [ALJ] finds

that these impairments are non-severe. The [ALJ]

considered all of the claimant’s medically determinable

impairments, including those that are not severe, when

assessing [Plaintiff’s RFC].

(Tr. 23.) Finally, as discussed below, the ALJ analyzed

Plaintiff’s depression (see Tr. 23-24), finding that it “does not

cause more than minimal limitation in [her] ability to perform

basic mental work activities and is therefore non-severe” (Tr. 23).

Thus, Plaintiff errs in asserting both that the ALJ “failed to

provide for any limitations” regarding these medical issues and

that the ALJ failed to explain why she declined to impose

additional limitations on those fronts. (Docket Entry 12 at 18.)

Here, the ALJ “addressed conflicting evidence in the record,”

Ladda, 749 F. App’x at 173, and “used evidence from the record to

explain [her] finding that [Plaintiff] was capable of [modified]

light work,” id. at 172. Accordingly, the Court should “uphold the

ALJ’s RFC assessment as supported by substantial evidence rather

than remand.” Id. at 173.

3. Special-Technique Assessment

In her final assignment of error, Plaintiff contends that,

“like in Patterson[ v. Commissioner of Social Security

Administration, 846 F.3d 656 (4th Cir. 2017)], the ALJ failed to

properly document the special technique assessment.” (Docket Entry

12 at 19; see also id. at 18.) The special-technique assessment

30

governs an ALJ’s evaluation of a claimant’s alleged mental

impairments at steps one through four of the SEP. See Patterson,

846 F.3d at 659. As the Fourth Circuit has explained:

Under the special-technique regulation, if the ALJ

determines that a mental impairment exists, he “must

specify the symptoms, signs, and laboratory findings that

substantiate the presence of the impairment(s) and

decument [his] findings.” [20 C.F.R.] § 404.1520a(b) (1).

The ALJ must also document “a specific finding as to the

degree of limitation in each of” the four areas of

functional limitation listed in § 404.1520a(c) (3). Id.

§ 404.1520a(e) (4). . . . Next, the ALJ must determine if

the mental impairment is severe, and if so, whether it

qualifies as a listed impairment. Id. § 404.1520a(d).

If the mental impairment is severe but is not a listed

impairment, the ALJ must assess the claimant’s RFC in

light of how the impairment constrains the claimant’s

work abilities. See id. § 404.1520a(d) (3). The

regulation specifically provides that the ALJ must

document all of the special technique’s steps. Id.

§ 404.1520a(e) (4).

Patterson, 846 F.3d at 659.

Here, Plaintiff concedes that the ALJ ‘“rate[d Plaintiff’s]

four areas of functional limitation listed in § 404.1520a(c) (3).”

(Docket Entry 12 at 19.)*° Plaintiff maintains, though, that “the

ALJ failed to adequately explain how she weighed all relevant

evidence and how she reached her conclusions about the severity of

the mental impairment.” (Id.) In particular, Plaintiff faults the

ALJ for “only cit[ing] to one medical record,” namely Dr. Smith’s

10 In light of that concession, Patterson lacks applicability to this case. See

Patterson, 846 F.3d at 660 (“The SSA concedes that the ALJ did not document

application of the special technique in reaching [his RFC and disability]

findings, or explicitly adopt physician findings that could possibly qualify

alone as a surrogate for the special-technique assessment.”).

31

opinion (id.),11 and disputes the ALJ’s findings that Plaintiff’s

mental exams qualified as unremarkable and that her symptoms

remained “well managed with her medication” (id. at 21 (internal

quotation marks omitted)). Plaintiff further faults the ALJ for

allegedly “fail[ing] to explain how she considered evidence of

[Plaintiff’s] testimony and evidence contained in her function

report.” (Id.)

Contrary to Plaintiff’s contentions, the ALJ provided a

thorough explanation regarding her assessment of Plaintiff’s mental

impairments and their effect on her RFC. (See Tr. 23-27.) For

instance, the ALJ determined that Plaintiff experienced no

limitation in the first functional area (understanding,

remembering, and applying information). (Tr. 23.) As support for

this conclusion, the ALJ explained that Plaintiff possesses a

“master’s degree with a focus in technical writing and operations

management,” as well as a “spontaneous and well organized” stream

of mental activity, perfect recall, an adequate fund of

information, and above-average estimated intellectual functioning.

(Tr. 23.) The ALJ further noted that “[t]he psychological

consultative examiner opined that the claimant’s ability to

understand, retain, and follow instructions was not limited.” (Tr.

23.) The ALJ next found that Plaintiff experiences a mild

limitation in the “interacting with others” functional area. (Tr.

11 This argument overlooks the ALJ’s citation to the records involving

Plaintiff’s 2018 counseling sessions. (See Tr. 24 (citing Ex. 8F).)

32

23.) As support for this finding, the ALJ explained that Plaintiff

(1) displayed good cooperation and attitude, (2) reported receiving

assistance with her living expenses from friends and church,

(3) reported getting along well with coworkers, and (4) attended

church and sang in the choir each week, although she stated that

she found it exhausting. (Tr. 23 (citing, inter alia, Plaintiff’s

function report).) The ALJ further noted that “[t]he psychological

consultative examiner opined that [Plaintiff’s] ability to relate

with coworkers and supervisors was not limited.” (Tr. 23.)

The ALJ similarly found that Plaintiff experiences a mild

limitation in the third functional area of “concentrating,

persisting or maintaining pace.” (Tr. 23.) In this regard, the

ALJ noted that Plaintiff “reported some difficulty focusing on her

job,” but “did not exhibit involuntary movements” (Tr. 23) and “was

alert and oriented in all spheres” and “able to correctly perform

serial sevens” with a “reasonable” “ability to sustain

concentration and attention” (Tr. 23-24). The ALJ also observed

that “[t]he psychological consultative examiner opined that

[Plaintiff’s] ability to sustain attention for performing simple,

repetitive tasks for brief periods was not limited.” (Tr. 24.)

Finally, the ALJ determined that Plaintiff experiences a mild

limitation in the fourth functional area (adapting and managing

oneself). (Tr. 24.) The ALJ explained that:

[Plaintiff] drove herself to the evaluation and arrived

on time (18F p.1). Her overall appearance, grooming, and

33

personal hygiene were good (id.). She reported

difficulty sleeping (id.). Generally, she has no

problems performing personal care activities other than

a lack of motivation and energy to take care of her

appearance (id.). She prepares her own meals daily (4E

p.3). She performs household chores, such as cleaning,

laundry, and taking out the trash (id.). She can drive

and she shops for groceries and household items twice a

week (4E p.4). She handles stress and changes in routine

well (4E p.7). The psychological consultative examiner

opined that the claimant’s ability to tolerate the stress

and pressure associated with day-to-day work was limited,

but did not opine on the degree of limitation (18F p.3).

The objective medical evidence warrants no more than a

mild limitation.

(Tr. 24.)

As such, the ALJ determined:

[Plaintiff] has no more than mild limitations in

mental functioning. She has never been hospitalized for

psychiatric or mental health issues (18F p.1). She

participated in 12 sessions of counseling during 2018 and

then stopped because she could not afford it (8F). There

is no evidence of ongoing participation in outpatient

counseling. She reported being prescribed Escitalopram

(Lexapro), a common mental health medication, by a

primary care provider (12E). Mental status exams were

unremarkable throughout the record and records suggest

that her symptoms are well managed with her medication.

Because [Plaintiff’s] medically determinable mental

impairment causes no more than “mild” limitation in any

of the functional areas and the evidence does not

otherwise indicate that there is more than a minimal

limitation in the claimant’s ability to do basic work

activities, it is non-severe (20 CFR 404.1520a(d)(1) and

416.920a(d)(1)).

(Tr. 24.)

Observing that the foregoing analysis addressed only the

severity of Plaintiff’s mental health impairments, the ALJ then

noted that the mental health RFC assessment “require[d] a more

detailed assessment.” (Tr. 24.) As discussed above, in conducting

34

that assessment, the ALJ analyzed the opinions of the psychological

consultants and noted that Plaintiff displayed good concentration

during her 2018 physical consultative examination. (See Tr. 27.)

The ALJ also explained that “[Plaintiff] worked throughout the

relevant period and continues to work part-time[ and] reported that

one of her daily activities is to look for work.” (Tr. 25 (citing

Plaintiff’s function report).) The ALJ further noted that,

“[g]enerally, [Plaintiff] has no problems performing personal care

activities other than a lack of motivation and energy to take care

of her appearance,” and that Plaintiff engages in a variety of

household chores and social activities. (Tr. 26 (citing

Plaintiff’s function report).) In addition, the ALJ observed that,

by her own admission, “[Plaintiff] can pay attention for an hour

without problems and usually finishes what she starts” and also

“follows instructions well.” (Tr. 26 (citing Plaintiff’s function

report).) Finally, the ALJ noted that medical records describe

Plaintiff as “delightful.” (Tr. 26.)

In sum, contrary to Plaintiff’s position, the ALJ “adequately

explain[ed] how she weighed all relevant evidence and how she

reached her conclusions about the severity of the mental

impairment” (Docket Entry 12 at 19). Nevertheless, Plaintiff

contends that the ALJ erred in her findings regarding Plaintiff’s

mental health examinations and the control of her symptoms via

medication. (See id. at 21 (citing Tr. 653, 669, 673, 709, 712,

35

1104).) However, even those citations reflect that, inter alia,

Plaintiff’s “[d]epression [is] managed with escitalopram,” without

any “adverse effects,” and that, although Plaintiff “[r]eports that

her mood is down, depressed[, she f]eels that this a situational

depression, [as she] works with a temp agency[ and] lost an

opportunity to obtain a permanent job and has difficulty with the

stress of looking for a secure job.” (Tr. 653.) The most recent

of the cited medical records, from February 12, 2019, assess her

“[m]ood, memory, affect and judgment [as] normal,” explaining that

she appeared “[t]earful at time[s] when her situation is discussed

but she is most of the time [normal] — not wanting to increase her

depression medications — she feels like her mood decrease is mostly

situational and she is working on her situation.” (Tr. 1104-05.)

Other records during the relevant time period likewise describe

Plaintiff as possessing “a normal mood and affect” with “normal”

behavior. (Tr. 798; accord, e.g., Tr. 752, 1052, 1089.)

Additionally, although Plaintiff’s treating therapist in 2018

initially diagnosed Plaintiff as “severely depressed” (Tr. 709),

her records indicate that during the sessions Plaintiff “was

feeling better about things” (Tr. 717) and, by the end of the

allotted sessions, the therapist had “obeserv[ed Plaintiff make]

progress” on her goals of “mood management and confidence-

building.” (Tr. 732.) As such, the ALJ did not reversibly err in

her findings regarding Plaintiff’s mental health exams and

36

symptoms. See Ladda, 749 F. App’x at 172 (explaining that courts

“look to whether the ALJ’s decision was supported by substantial

evidence, and in doing so, ‘[courts] do not undertake to reweigh

. . . [the] evidence’” (ellipsis and final set of brackets in

original); Craig, 76 F.3d at 589 (explaining that, “[u]nder the

[Act, courts] must uphold the factual findings of the [ALJ] if they

are supported by substantial evidence and were reached through

application of the correct legal standard”).

Put simply, the ALJ appropriately conducted the special-

assessment technique and substantial evidence supports her

findings. Under the circumstances, Plaintiff has failed to

demonstrate entitlement to relief on the basis of the mental RFC.

III. CONCLUSION

Plaintiff has established no grounds for relief.

IT IS THEREFORE RECOMMENDED that the Commissioner’s decision

finding no disability be affirmed, that Plaintiff’s Motion for

Summary Judgment (Docket Entry 11) be denied, that Defendant’s

Motion for Judgment on the Pleadings (Docket Entry 14) be granted,

and that this case be dismissed with prejudice.

This 23rd day of February, 2022.

/s/ L. Patrick Auld

L. Patrick Auld

United States Magistrate Judge

37