The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF NORTH CAROLINA
BRANDON kK,, )
)
Plaintiff, )
)
V. ) 1:22CV1041
)
MARTIN J. O7MALLEY;,! )
Commissioner of Social Security, )
)
Defendant. )
MEMORANDUM OPINION AND ORDER
OF UNITED STATES MAGISTRATE JUDGE
Plaintiff Brandon K. (“Plaintiff’) brought this action pursuant to Section 1631(c)(3) of
the Social Security Act (the “Act”), as amended (42 U.S.C. § 1383(c)(3)), to obtain judicial
review of a final decision of the Commissioner of Social Security denying his claim for
Supplemental Security Income (“SSI”) under Title XVI of the Act. The Parties have filed
cross-briefs, and the administrative record has been certified to the Court for review.
L. PROCEDURAL HISTORY
Plaintiff initially recetved SSI benefits based on disability as a child. (Tr. at 151.)? As
tequited by law, the agency redetermined Plaintiffs eligibility for benefits under the rules for
determining disability in adults when Plaintiff turned 18. On October 25, 2019, it was
December 20, 2023, Martin J. O'Malley was sworn in as Commissioner of Soctal Security, replacing Acting
Commissioner Kilolo Kijakazi. Pursuant to Rule 25(d) of the Federal Rules of Ctvil Procedure, Martin J.
O’Malley should be substituted for Kilolo Kijakazi as Defendant in this suit. No further action need be taken
to continue this suit by reason of the last sentence of section 405(g) of the Social Security Act, 42 U.S.C.
§ 405(g).
2 Transcript citations refer to the Sealed Administrative Record [Doc. #4].
determined that Plaintiff was no longer disabled, and that decision was upheld upon
reconsideration. (Tr. at 151, 179-81.) Thereafter, Plaintiff requested an administrative hearing
de novo before an Administrative Law Judge (“ALJ”). (Tr. at 217-20.) On May 19, 2021,
Plaintiff, represented by an attorney, appeated and testified at the subsequent telephonic
hearing, at which both Plaintiff and an impartial vocational expert testified. (Tr. at 151.)
Following the hearing, the ALJ issued a decision concluding that Plaintiff was not disabled
within the meaning of the Act. (It. at 160.) However, in an order dated January 18, 2022, the
Appeals Council vacated the AL]’s decision and remanded the case for a new heating. (Tr. at
15, 167-74.) Accordingly, on May 31, 2022, the ALJ held a video heating at which Plaintiff
was again represented by an attorney and during which both Plaintiff and an impartial
vocational expert testified. (Ir. at 15.) In a decision dated June 9, 2022, the AL] again
concluded that Plaintiffs disability ended on October 25, 2019, and that Plaintiff had not
become disabled again since that date. (Tr. at 26.) On October 4, 2022, the Appeals Council
denied review of that decision, thereby making the ALJ’s conclusion the Commissionet’s final
decision for purposes of judicial review. (I'r. at 1-6.)
Il. LEGAL STANDARD
Federal law “authorizes judicial review 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 review of such a decision is “extremely limited.” Frady v. Harris, 646 F.2d 143, 144
(4th Cir. 1981). “The coutts ate 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
AL] if they are supported by substantial evidence and were reached through application of the
correct legal standard.” Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012) (internal brackets
and quotation 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. 1993)
(internal quotation omitted). “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)
(internal brackets and quotation 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 omitted).
“In reviewing for substantial evidence, the court should not undertake to te-weigh
conflicting evidence, make credibility determinations, or substitute its jadgment for that of the
[AL]].” Mastro, 270 F.3d at 176 (internal brackets and quotation omitted). “Where conflicting
evidence allows teasonable 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 (internal brackets
and quotation omitted). “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
teview, the Court notes that “[a] claimant for disability benefits bears the burden of proving a
disability.” Hall v. Harris, 658 F.2d 260, 264 (4th Cir. 1981).
“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 during the alleged petiod
of disability; (2) had a severe impairment; (3) had an impairment that met or equaled the
requirements of a listed impairment; (4) could return to her past relevant work; and (5) if not,
could perform any other 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 are 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 catties his or her burden at the first two steps, and if
the claimant’s impairment meets or equals a “listed impairment” at step three, the claimant is
disabled. Mastto, 270 F.3d at 177. Alternatively, if a claimant clears steps one and two, but
falters at step three, ie., “[iJf a claimant’s impairment is not sufficiently severe to equal or
exceed a listed impairment,” then “the ALJ must assess the claimant’s residual functional
capacity (RFC?).” Id. at 179.3 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
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 administrative regulations requite 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” (internal emphasis and quotation 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 determined by the ALJ only after [the ALJ] considers
all relevant evidence of a claimant’s impairments and any related symptoms (¢,g, pain).” Hines, 453 F.3d at
562-63.
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 “requites the [Government] 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 AL] must decide
“whether the claimant is able to perform other work considering both [the clatmant’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 carty 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.
IH. DISCUSSION
As set out above, Plaintiff received SSI benefits as a child. Following the
redetermination after he became an adult, the Social Security Administration found that he
was no longer disabled under the Act as of October 25, 2019. (Tr. at 17.) Notably, the first
step of the sequential evaluation process does not apply in redetermination cases. See 20
CER. § 416.987(b). The ALJ therefore proceeded to step two, where she determined that
Plaintiff suffered from the following severe impairments:
[RJemitting, relapsing multiple sclerosis; bilateral carpal tunnel syndtome;
lumbar radiculopathy; cervical radiculopathy; peripheral neuropathy; cervical
degenerative disc disease and bulging; lumbar degenerative disc disease and
degenerative joint disease; and type I diabetes mellitus and neuropathy[.]
(I't. at 17.) The ALJ found at step three that none of these impairments, individually or in
combination, met ot equaled a disability listing. (It. at 18-21.) Accordingly, the ALJ
determined that Plaintiff could perform light work with the following, non-exertional
limitations:
[Plaintiff] can occasionally lift and carry 20 pounds and frequently lift and carry
10 pounds; can stand and/ot walk 4 hours; can sit for 6 hours; frequently push,
pull, and operate hand controls with the bilateral upper extremities; frequently
climb tramps and staits; occasionally stoop, kneel, crouch, crawl, and balance;
frequently handle and finger with the bilateral upper extremities; can tolerate
frequent exposute to extreme cold, extreme heat, concentrated dusts, fumes,
odors, and gases; no climbing ladders, ropes, or scaffolds; no exposute to
hazards, such as unprotected heights and large moving machinery; able [to]
understand, remember, and carty out simple instructions; able to stay on task
and to sustain attention and concentration for 2 hour periods in order to
complete simple, repetitive, routine tasks; [can] work in a setting that does not
requite strict production quotas or a steady fast pace (no high speed conveyor
belt assembly line work); able to interact occasionally with the public, but not
able to provide direct customer service; can tolerate occasional changes in the
work setting and duties; and will need an unscheduled 15 break during the work
day.
(Tr. at 21.) At step four of the analysis, the ALJ found that Plaintiff had no past relevant work.
(Tr. at 25.) However, the AL] concluded at step five that, given Plaintiff's age, education,
work experience, and RFC, along with the testimony of the vocational expert regarding those
factots, Plaintiff could perform other jobs available in the national economy and therefore was
not disabled under the Act. (Tr. at 25-26.)
Plaintiff now contends that the ALJ erred in three respects when assessing Plaintiff's
RFC. Specifically, he argues that the ALJ erred by (1) “failing to account for Plaintiffs need
to take regular breaks from activity due to chronic fatigue from multiple sclerosis (“MS’),” (2)
“failing to perform a function-by-function evaluation of Plaintiffs contested and relevant
abilities to stand and walk,” and (3) failing to properly evaluate “the medical opinion of treating
neurologist Dr. Andreas Runheim.” (PL’s Br. [Doc. #12] at 1.) After a thorough review of
the record, the Court agrees that Plaintiffs third contention merits remand for the reasons
discussed below. Plaintiffs first two claims are impacted by the ALJ’s considerations of Dr.
Ruhnheim’s opinion, and can be considered further on remand and need not be separately
addressed at this time.
With respect to the opinion evidence, for Title XVI claims that are filed, or considered
filed, before Match 27, 2017, ALJs evaluate the medical opinion evidence in accordance with
20 C.E.R. § 416.927(c).4 See Brown v. Comm’r Soc. Sec. Admin., 873 F.3d 251, 255 (4th Cit.
2017); Testamark v. Berryhill, 736 F. App’x 395, 398 n.1 (4th Cir. 2018). “Medical opinions”
ate “statements from acceptable medical sources that reflect judgments about the nature and
severity of your impaitment(s), including your symptoms, diagnosis and prognosis, what you
can still do despite impairment(s), and your physical or mental restrictions.” Brown, 873 F.3d
at 255 (internal quotation omitted). While the regulations mandate that the ALJ evaluate each
medical opinion presented to her, generally “more weight is given to the medical opinion of a
source who has examined you than to the medical opinion of a medical source who has not
examined you.” Brown, 873 F.3d at 255 (internal quotation omitted). 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 sevetity of a claimant’s impairment, based on the ability of treating sources to:
provide a detailed, longitudinal picture of [the claimant’s] medical impairment(s)
[which] may bring a unique perspective to the medical evidence that cannot be
4 As noted above, Plaintiff was found disabled as a child, and his claim was redetermined after he turned 18 in
2014. His filing date is therefore considered the day before his 18th birthday, which would be November 23,
2014. (Tr. at 17, 168, citing HALLEX I-5-3-30 IV.B.Note.)
obtained from the objective medical findings alone or from reports of individual
examinations, such as consultative examinations or brief hospitalizations.
20 CFR. § 416.927(c)(2). However, if a 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
CER. § 416.927(c)(2); see also Social Security Ruling 96-2p, Policy Interpretation Ruling Titles
ILand XVI: Giving Controlling Weight to Treating Source Medical Opinions, SSR 96-2p, 1996
WL 374188, at *4 (July 2, 1996); Brown, 873 F.3d at 256; Craig, 76 F.3d at 590; Masttro, 270
F.3d at 178.5 If it is not given controlling weight, the opinion must be evaluated and weighed
using all of the factors provided in 20 C.F.R. § □□□□□□□□□□□□□□□□□□□□□ including (1) the length
of the treatment relationship, (2) the frequency of examination, (3) the nature 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.
The Fourth Circuit confirmed the application of the treating physician rule in Arakas
v. Commissioner, Social Security Administration, 983 F.3d 83 (4th Cir. 2020) and Dowling v.
Commissioner of Social Security, 986 F.3d 377 (4th Cir. 2021). In Arakas, the Fourth Circuit
5 For claims filed after Match 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 Soctal
Security Administration “will not defer or give any specific evidentiary weight, including controlling weight, to
any medical opinion(s) or prior administrative medical finding(s), including those from your medical sources.”
20 C.F.R. § 416.920c. However, the claim tn the present case was filed before March 27, 2017, and the Court
has therefore analyzed Plaintiff's claims pursuant to the treating physician rule set out above.
“emphasized that the treating physician rule is a robust one: “The opinion of a claimant’s
treating physician must be given great weight and may be disregarded only if thete is persuasive
contradictory evidence.” Arakas, 983 F.3d at 107 (internal brackets omitted) (quoting
Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987)). Thus, “the opinion must be given
controlling weight unless it is based on medically unacceptable clinical or laboratory diagnostic
techniques ot is contradicted by the other substantial evidence in the record.” Id. Similarly, in
Dowling, the Fourth Circuit emphasized that even if a “medical opinion was not entitled to
conttolling 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 required 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 factor-by-factor analysis in order to
discount a medical opinion from a treating physician, it must nonetheless be apparent from
the AL]’s decision that he meaningfully considered each of the factors before deciding how
much weight to give the opinion.” Id.
In this case, Plaintiff presented opinion evidence from Dr. Andreas Runheim, at Salem
Neurological Center. (Trt. at 1076-78.) Dr. Runheim was Plaintiffs treating neurologist for
his multiple sclerosis, and the record reflects that Plaintiff had been seeing Dr. Runheim for
many years, with treatment records for visits every 6 months, sometimes more frequently, and
with at least 14 visits from 2017 through 2022. Dr. Runheim’s opinion is dated May 12, 2021,
and in that opinion Dr. Runheim relied on an October 5, 2020 MRI of Plaintiff's cervical
spine. According to Dr. Runheim’s opinion letter, the 2020 MRI showed “multiple T2
hyperintense cervical cord lesions” consistent with Plaintiffs diagnosis of multiple sclerosis
(Ir. at 1076), and Dr. Runhiem’s records reflect that Plaintiff has “spinal cord predominant”
multiple sclerosis. Dr. Runheim’s opinion letter also confirms that the 2020 MRI showed
“cervical cord volume loss suggestive of chronic encephalomalacia.” (Tt. at 1076.) Dr.
Runheim further confirmed that the 2020 MRI showed “moderate to high grade bilateral
neural foraminal stenosis at multiple levels in the cervical spine with central canal stenosis.”
(Ir. at 1077.) Dr. Runheim opined that Plaintiff could not stand and walk more than two
hours in a day, could not perform handling or fingering more than three hours a day, and
would not have the stamina to work on a tegular and continuous basis as a result of his MS-
related symptoms. (T'r. at 1077.)
In her decision, the ALJ addressed this opinion evidence as follows:
In May 2021, Andreas Runheim, M.D., opined that the claimant is unable to
stand and walk for more than 2 hours per day, perform bilateral handling and
fingering for three hours or mote, and that he would have significant fatigue
and difficulties with stamina that would prevent him from working a continuous
8-hour day. This is given little weight, as it is inconsistent with, and unsupported
by, the provider’s own office records and examination findings, which indicate
that the claimant is far less limited as well as the overall medical record as
discussed above.
(Ir. at 24) (internal citation to record omitted). Thus, the reason given for rejecting Dt.
Runheim’s opinion was that it was inconsistent with and unsupported by (1) Dr. Runheim’s
office tecords and examination findings; and (2) the overall medical record discussed in the
decision. (Tt. at 24.) However, as to the first of these rationales, it is not cleat how Dt.
Runheim’s opinion is inconsistent with or unsupported by his own treatment records. ‘The
treatment records reflect that Plaintiff saw Dr. Runheim every six months related to his
multiple sclerosis and fatigue, and at those visits Plaintiff continued to raise neck pain, back
10
pain, limb weakness, numbness, tingling, and fatigue, and examinations reflected an abnormal
gait and ataxia. (I't. at 604, 608, 620, 623, 624, 724, 726, 763, 764, 852, 853, 855, 860, 992,
1411, 1416, 1423, 1428).7 These records reflect that in September 2020, and into 2021,
Plaintiff began complaining of increasing back and neck pain, and Dr. Runheim ordered an
updated MRI. (Tr. at 860-61, 992, 1411.) That October 2020 cervical MRI reflects cervical
cotd lesions telated to his multiple sclerosis with “cervical cord volume loss suggestive of
chronic encephalomalacia.”® (Tr. at 1000). In addition, the MRI reflects:
Chronic degenerative changes with posterior disc bulge and uncovertebral
hypertrophy contribute to moderate to high-grade bilateral foraminal stenosis
at C3-4, high-grade bilateral foraminal stenosis at C4-5,[] and [] mild to
moderate bilateral foraminal stenosis at C5-6 and C6-7. There is also central
canal stenosis which appeats to be secondary to a combination of congenital
spinal canal narrowing as well as posterior disc bulges, especially at C3-4, C4-5,
C5-6, and C6-7.
at 1000.) Dr. Runheim saw Plaintiff again in December 2020 to review the MRI, and
noted that Plaintiffs neck and back pain were getting worse, with numbness, tingling, and
weakness in his legs. (Tr. at 992.) In light of the findings on the MRI, Dr. Runheim referred
6 “Ataxia describes poor muscle control that causes clumsy movements. It can affect walking and balance,
hand coordination, speech and swallowing, and eye movements. Ataxia usually results from damage to the patt
of the brain called the cerebellum or its connections. The cerebellum controls muscle coordination. Many
conditions can cause ataxia, including genetic conditions, stroke, tumors, multiple sclerosis, [and] degenerative
diseases.” Ataxia, Mayo Clinic (Jan. 30, 2024), _ https:// www.mayoclinic.org/diseases-
conditions /ataxia/symptoms-causes/syc-20355652.
7 The records ate more limited for Plaintiff's telehealth visits during the COVID-19 pandemic in late 2020 and
eatly 2021, since those telehealth visits do not reflect a physical examination, although they still note Plaintiffs
complaints of pain and fatigue.
8 Encephalomalacia is the “softening of the brain due to degenerative changes in nervous tissue.”
Encephalomalacia, Merriam-Webster, https: //wwwmertiam-webster.com/medical/encephalomalacia (last
visited Mar. 28, 2024).
11
Plaintiff to a neurosurgeon, Dr. Wesley Hsu, who saw Plaintiff in January 2021. (Tr. at 940-
44.) At intake, Plaintiff described his pain and limitations in detail. (Tr. at 986-90) and Dr.
Hsu summarized Plaintiff's presentation as:
a tight hand dominant 24-yr-old male referred for evaluation of neck pain. He
is accompanied by his mother. He has past medical history of hypothyroidism
and pseudo-hypoparathyroidism, multiple sclerosis, Diabetes Mellitus ‘Type I
diagnosed at age of 10, has a insulin pump and follows with endocrinology, pes
planus deformity bilateral lower extremities. He reports neck pain and low back
pain for many years that has progressed. Neck and low back pain constant 5 /10
neck can radiate into bilateral upper extremities or down the spine into lower
lumbat where it encompasses the entire lumbat area bilateral. He denies any
focal weakness of atms ot legs. He reports numbness in fingers for a long time.
He denies any bowel/bladder dysfunction. He has had therapy in the past
without lasting benefit, takes hydrocodone morning and night. Balance
difficulty for many yeats along with the bilateral foot pain seen orthopedics in
past.
(Tr. at 940.) On examination, Dr. Hsu noted his “short stature and short appendages not able
to stand on toes is off balance, not able to walk on heels.” (Tr. at 944.) After examination
and review of the imaging, Dr. Hsu set out the treatment plan as follows:
We reviewed the surgical details and postoperative expectations typical of a C3-
7 laminectomy and fusion. I also considered an anterior C3-7 ACDF.
Postsurgical options have [thei] pluses and minuses which we discussed []. We
teviewed all prior imaging relevant to the clinical coutse, including cervical MRI
demonstrating moderate to severe spinal cord stenosis from C3-C7. ‘This is
progtessed since the initial MRI in [the] system. [It] is clear that he will need
cetvical decompression at some point in his life. However, surgery can
potentially be quite morbid. I do not think a decompression and fusion will
help his neck pain. He wants to be followed closely instead of moving forward
with surgery, and we will accommodate this. Warned of signs and symptoms
of myelopathy. I will see him back in 4 months. He knows to go to the ER if
he has any new problems.
(Tr. at 944.) Dr. Hsu provided this evaluation to Dr. Runheim in January 2021, prior to Dt.
Runheim’s opinion letter, and they continued to coordinate Plaintiffs care. (I't. at 958.)
12
Dr. Runheim then ordered a lumbar MRI, which was conducted in March 2021, and
which reflected “facet atthropathy with somewhat congenitally shortened pedicles” at L2-L3
and L3-L4, and “facet atthropathy with ligamentum flavum thickening slightly crowd the
descending netve roots contributing to relatively mild central stenosis and mild to moderate
natrowing of the lateral recesses as well as mild to moderate bilateral foraminal stenosis” at
L4-L5, and “congenitally shortened pedicles [that]do contribute to mild to moderate bilateral
foraminal narrowing” at L5-S1. (Ir. at 1675-76.)
Dr. Hsu saw Plaintiff again in August 2021, and noted Plaintiffs Martin-Albright
Syndrome (T't. at 1636), also known as Albright hereditary osteodystrophy, a progressive
parathyroid disorder, in addition to his multiple sclerosis and diabetes.? Dr. Hsu noted that
Plaintiff presented with:
many yeats of neck pain, thoracic spine pain, and lumbar spine pain. Pain
exacetbates in different areas depending on what is going on at the time|.]
[R]ight now it is a little worse [in his] lumbar [spine] than it is [in] his neck. He
denies any arm symptoms or any radicular symptoms in his legs.... He has
chronic numbness in his fingers unchanged. He has had balance issues for years
and bilateral foot pain.
(Tr. at 1636.) Dr. Hsu again noted upon examination that Plaintiff had a short statute, short
appendages, and was not able to stand on his toes without assistance or walk on his heels,
9 This genetic condition causes multiple life-long issues, including defective bone development secondary to
disturbances in calcium metabolism, characterized by “more than two features, especially brachydactyly, but
also short stature, obesity, round face and neurobehavioral abnormalities.” Diagnostic Approach to Disorder
of Extraskeletal Bone Formation, Mayo Clinic (June 9, 2018), https://www.mayoclinic.org/medical-
professionals endocrinology/news/ diagnostic-approach-to-disorders-of-extraskeletal-bone-formation /mac-
20429760; Pediatric Metabolic Bone Disorders Clinic, Mayo Clinic, https://www-mayoclinic.org/departments-
centers /childrens-center /ovetview/specialty-groups/ pediatric-metabolic-bone-disorders-clinic (last visited
Mar. 28, 2024).
13
which is consistent with Martin-Albright Syndrome. (Tr. at 1638.) Dr. Hsu also noted that
Plaintiffs “Knowledge” was “poot” and that Plaintiff had “Abnormal comprehension.” (Tr.
at 1638.) With respect to the treatment plan, Dr. Hsu noted that:
[w]e reviewed the surgical details and postoperative expectations typical of a
posterior cervical laminectomy and fusion. We reviewed all prior imaging
televant to the clinical course, including cervical MRI demonstrating moderate
to severe stenosis and congenital stenosis from C2-C7. There is evidence of
myelomalacia throughout the cervical spine. He is neurologically intact. I think
it would be best for him given his syndrome and multiple medical problems to
hold off on surgery as long as possible. I will see him back regularly for routine
neurological checks.
(Ir. at 1639) (emphases omitted).!° Thus, in light of Plaintiff's Martin-Albright Syndrome and
his other medical problems (including diabetes and multiple sclerosis), Dr. Hsu advised that it
was best to hold off on surgery as long as possible. As noted above, Dr. Hsu provided Dr.
Runheim with his records and coordinated care with Dr. Runheim.
In light of these records, it is not at all clear how Dr. Runheim’s opinion is inconsistent
with his treatment tecotds. In evaluating the treatment records, the ALJ addressed an earlier
2018 MRI, but did not address the October 2020 MRI relied on by Dr. Runheim and Dr. Hsu.
In addition, nothing in the AL}’s decision indicates that she recognized the interconnectedness
of Plaintiff's impairments, including that his parathyroid condition, which the ALJ found non-
severe at step two of the sequential analysis, was inextricably linked with his neurological and
degenerative disorders. On three occasions, the ALJ cited to a single page of Dr. Hsu’s
10 Myelomalacia is the softening of the tissues of the spinal cord, often associated with an impaired blood supply
ot compression of the cord. Myelomalacia, Oxford English Dictionary, https://www.oed.com/
dictionary myelomalacia_n?tab=meaning_and_use#11943505 (last visited Mar. 28, 2024).
14
treatments notes as evidence of “normal” clinical findings, while ignoring the abnormal
balance findings on the same page and the more than 60 additional pages of that exhibit. (See
Tr. at 20, 22, 24, 1638.)
With respect to the other opinion evidence, the ALJ noted the opinion of Dr. Dorothy
Linster, the state agency medical consultant at the initial level. (See Tr. at 24, 140.) Dr. Linster
provided opinion evidence regarding Plaintiffs ability to stand and/or walk for up to 4 houts
in an 8-hour workday, and his ability to frequently handle and finger, in addition to other
postural and environmental limitations. (Tr. at 141-42.) As noted in the administrative
decision, Dr. Linster issued her determination in October 2019. Accordingly, she did not have
the benefit of reviewing Plaintiffs October 2020 cervical MRI or Match 2021 lumbar MRI, or
any of the records of Dr. Hsu or the later records of Dr. Runheim. The only medical source
to take these objective test results into account was Dr. Runheim, who opined that Plaintiff
could stand and walk for no more than two houts pet workday, and could handle and finger
no mote than three hours per workday. (Tr. at 24, 1077.) The ALJ apparently recognized
some of the problem with relying on Dr. Linster’s opinion and assigned Dr. Linstet’s opinion
“little weight,” and specifically explained that Dr. Linster’s findings were
inconsistent with, and unsupported by, [Plaintiffs] progress reports and
examination findings, which indicate that [his] ability to stoop, kneel, crouch,
and crawl ate somewhat more limited. For example, at times, [Plaintiff]
presented with ankle swelling, ataxic gait, and erythema.
15
(Tr. at 24.)!1 The ALJ similarly noted the opinion evidence from the medical examiner Dr.
Melvin Clayton in February 2020. (Tr. at 24.) Dr. Clayton also did not have the benefit of
any of the October 2020 or March 2021 imaging or later medical records. Notably, the ALJ
also assigned Dr. Clayton’s opinion “little weight” as it was “inconsistent with, and
unsuppotted by, [Plaintiffs treatment history, imaging studies, and examination findings.”
(Tr. at 24.)
Asa tesult of these determinations, the ALJ assigned “little weight” to all of the medical
opinion evidence in this case, including the opinions of Dr. Runheim and Dr. Linster and Dr.
Clayton. (Tr. at 24.) In discounting this evidence, the ALJ generally noted that each opinion
in question is “inconsistent with, and unsupported by” the overall medical record, including
Plaintiffs treatment history, examination findings, and imaging. (T'r. at 24.) Thus, the ALJ
appeats to have based the RFC in this case largely, and inappropriately, on her own
interpretation of the raw medical evidence, and rejected the opinion of Plaintiff's treating
neurologist in a medically complex case without any other medical review of the relevant
imagining and tecords from 2020 through 2022.
In the AL]’s discussion of the medical record, the ALJ did repeatedly state that Plaintiff
“has generally presented with .. . mostly normal findings” including “normal gait.” (Ir. at 22,
23, 24.) However, as Plaintiff correctly notes, many of these “normal” findings came from
appointments during which Plaintiff's mobility was not tested or at issue, such as visits to the
11 The ALJ determined that, in light of Plaintiffs examination findings, which included swollen ankles and
walking difficulties, Plaintiff required greater postural limitations than those opined by Dr. Linstet, but the AL]
failed to explain why this would not also impact the standing and walking limitations opined by Dr. Linster.
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endocrinologist or dermatologist, or telehealth visits with no examination. As set out above,
Plaintiff's examinations with Dr. Runheim consistently reflected abnormal gait and stance and
ataxia, and the record also reflects Plaintiff's ongoing complaints to Dr. Runhetm and other
providers regarding neck and back pain and fatigue (Tr. at (Tr. at 604, 608, 620, 623, 624, 724,
726, 763, 764, 852, 853, 855, 860, 992, 1411, 1416, 1423, 1428, 642-44, 645, 741, 779, 792, 880,
884, 1448). The ALJ also listed Plaintiff's activities as evidence that he was less limited than
alleged, noting that Plaintiff was “able to do chores or play [video] games for 30-45 minutes,
make his bed, take care of his dogs, help take care of his mother, and vacuum.” (Tr. at 23.)
Notably, none of these abilities, as described in Plaintiff's testimony, would be inconsistent
with the limitations opined by Dr. Runheim, including the 2-hour per day walking and standing
limitation, the 3-hour per day handling and fingering limitation, and the MS-related fatigue
and lack of stamina that would interfere with his ability to work for 8 hours per day for 5 days
pet week. (See Tr. at 46-49, 55.) The ALJ also cited Plaintiffs “mostly conservative
treatment,” but the ALJ fails to note what, if any, mote extensive treatment Plaintiff may have
requited for his conditions. (Tr. at 23.) The ALJ noted Plaintiff's use of hydrocodone twice
a day to treat pain in his back, neck, and extremities, and that, although Plaintiff would require
spinal surgery in the future, it was not recommended as of January 2021. (Ir. at 23, 944, 1419,
1423.) In doing so, the ALJ failed to acknowledge that (1) Plaintiff's spinal condition had
deteriorated since his previous MRI (Tt. at 944) and that (2) Plaintiffs neurologist Dr. Hsu
specifically stated that the surgery “can potentially be quite morbid” given Plaintiff's
conditions (Tt. at 944), and that “it would be best for [Plaintiff] given his syndrome and
multiple medical problems to hold off on surgery as long as possible” (T'r. at 1639). ‘Thus, the
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AL] impropetly chetry-picked “normal” examination findings and emphasized activities and
treatments which had little beating on the limitations opined by Dr. Runheim.
As set out above, the regulations applicable in this case required the ALJ to give
controlling weight to Dr. Runheim’s opinion as the treating physician, unless the opinion was
not well supported by clinical and laboratory diagnostic techniques ot was inconsistent with
the other evidence in the record. Based on the records noted above, it is not clear how or why
the ALJ concluded that Dr. Runheim’s opinion was not well supported or was not consistent
with the record. In addition, as explained by the Fourth Circuit in Dowling, even if the ALJ
had a basis to decline giving controlling weight to Dr. Runheim’s opinion, the ALJ was still
required to address the remaining regulatory factors in weighing the opinion evidence.
Dowling, 986 F.3d at 385 (“While an ALJ is not required to set forth a detailed factor-by-
factor analysis in order to discount a medical opinion from a treating physician, it must
nonetheless be appatent from the ALJ’s decision that he meaningfully considered each of the
factots before deciding how much weight to give the opinion.”). The ALJ did not undertake
such an analysis here. As noted above, the ALJ also discounted all of the medical opinion
evidence of record in favor of her own interpretation of the evidence. In short, multiple
“inadequacies in the ALJ’s analysis frustrate meaningful review” of this case, and the matter
therefore requires remand.
IT IS THEREFORE ORDERED that the Commissioner’s decision finding no
disability is REVERSED, and that the matter is REMANDED to the Commissioner under
sentence four of 42 U.S.C. § 405(g). The Commissioner is directed to remand the matter to
the AL] for further consideration of Plaintiffs claim. Accordingly, Defendant’s Dispositive
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Brief [Doc. #17] is DENIED, and Plaintiffs Dispositive Brief [Doc. #12] is GRANTED to
the extent set out herein. However, to the extent Plaintiff seeks an immediate award of
benefits, his Motion is DENIED.
This, the 28% day of March, 2024.
/s/ Joi Elizabeth Peake
United States Magistrate Judge
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