# Lockerby v. Saul

> District Court, W.D. North Carolina · January 30, 2020

URL: https://www.frixlaw.com/law-library/cases/10255501

## Case

- **Court:** District Court, W.D. North Carolina
- **Decided:** January 30, 2020
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/10255501

## How later opinions describe it (automated extraction)

- explaining “medical records often span [long time periods, so] it is inevitable that some evidence will show signs of a claimant’s improvement and other evidence will show signs of a claimant’s regression”
- explaining courts do not “min[e] facts from the [administrative] record to support the ALJ’s decisions”
- explaining courts do not “min[e] facts from the [administrative] record to support the ALJ’s decisions”

## Opinion text

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NORTH CAROLINA
ASHEVILLE DIVISION
DOCKET NO. 1:19-CV-00159-MOC

LEILA LOCKERBY, )
)
Plaintiff, )
)
vs. )
) ORDER
ANDREW M. SAUL, )
Commissioner of Social Security, )
)
Defendant. )
_______________________________________)

THIS MATTER is before the Court on review of a final decision of the Commissioner of
Social Security denying Plaintiff Leila Lockerby’s application for disability insurance benefits and
supplemental security income. Plaintiff filed a Motion for Summary Judgment, requesting an
order of reversal and remand for rehearing. (Doc. No. 9). The Commissioner in turn filed a Motion
for Summary Judgment, requesting affirmance. (Doc. No. 11). For reasons set forth below,
Plaintiff’s summary judgment motion is granted, the Commissioner’s summary judgment motion
is denied, and this matter is remanded for reconsideration consistent with this opinion.
I. BACKGROUND
A. Administrative Exhaustion
In January 2015, Plaintiff filed applications for a period of disability and disability
insurance benefits under Title II, and supplemental security income under Title XVI, of the Social
Security Act (the “Act”), alleging she had been disabled since February 27, 2014. (Tr. 11).
Plaintiff’s claims were denied initially and upon reconsideration, so she filed a written request for
a hearing before an Administrative Law Judge (“ALJ”). The ALJ held a hearing on October 30,
2017, for de novo consideration of Plaintiff’s claims. (Id.). On June 1, 2018, the ALJ issued a
decision, concluding Plaintiff was not disabled within the meaning of the Act. (Tr. 22). The
Appeals Council denied Plaintiff’s request for review on March 28, 2019, rendering the ALJ’s
decision final and thus reviewable by this Court. (Tr. 1). Plaintiff has exhausted available
administrative remedies, so this case is ripe for judicial review, pursuant to 42 U.S.C. § 405(g).
B. Sequential Evaluation Process

The Act provides that “an individual shall be considered to be disabled . . . if he is unable
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 twelve months.” 42 U.S.C. § 1382c(a)(3)(A); see
id. § 423(d)(1)(A). The Commissioner uses a five-step sequential evaluation process to determine
whether a claimant is disabled within the meaning of the Act:
1. An individual who is working and engaging in substantial gainful activity will
not be found to be “disabled” regardless of medical findings;

2. An individual who does not have a “severe impairment” will not be found to be
disabled;

3. If an individual is not working and is suffering from a severe impairment that
meets the durational requirement and that “meets or equals a listed impairment
in Appendix 1” of Subpart P of Regulations No. 4, a finding of “disabled” will
be made without consideration of vocational factors;

4. If, upon determining residual functional capacity (“RFC”), the Commissioner
finds that an individual is capable of performing work he or she has done in the
past, a finding of “not disabled” must be made;

5. If an individual’s residual functional capacity precludes the performance of past
work, other factors including age, education, and past work experience, must
be considered to determine if other work can be performed.

See 20 C.F.R. §§ 404.1520, 416.920. The claimant “bears the burden of production and proof
during the first four steps of the inquiry.” Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995). If
the claimant carries its burden through the fourth step, the burden shifts to the Commissioner to
show other work exists in the national economy that the claimant can perform. See id.
C. The Administrative Decision
The issue before the ALJ was whether Plaintiff was disabled from February 27, 2014, the
alleged disability onset date, to the date of the decision. Using the sequential evaluation process,

the ALJ concluded at step five that Plaintiff was not disabled within the meaning of the Act.
To begin, at step one, the ALJ recognized that Plaintiff had not engaged in substantial
gainful activity since the alleged onset date. (Tr. 13). Next, at step two, the ALJ found that
Plaintiff suffered from the following severe impairments: anxiety, depression, post-traumatic
stress disorder, schizophrenia, and obesity. (Id.). At step three, the ALJ further recognized that
Plaintiff suffered from: moderate limitations in interacting with others, concentrating, persisting,
and maintaining pace; and mild limitations in understanding, remembering, and applying
information. (Tr. 14). Even so, the ALJ decided this combination of impairments did not meet or
equal the severity of an impairment listed in 20 C.F.R. § 404, Subpart P, Appendix 1. (Id.).

Before turning to the next step, the ALJ found Plaintiff had the residual functional capacity
to perform light work, as defined in 20 C.F.R. §§ 404.1567 and 416.967, except she was limited
to: simple, routine, repetitive tasks; a “non-production pace”; a stable work setting; only occasional
and superficial public contact; frequent interactions with supervisors and co-workers without
teamwork; and jobs without conflict resolution. (Tr. 15–20). In so finding, the ALJ recognized
that Plaintiff suffers from “anxiety, depression, schizophrenia, and PTSD” and that those disorders
create “some mental health limitations.” (Tr. 17, 19). Still, the ALJ reasoned that the “longitudinal
evidence of record . . . clearly shows that once the claimant began receiving regular mental health
treatment and taking psychotropic medications on a regular basis, she had significant
improvements of her mental health symptoms.” (Tr. 20).
Based on these findings, the ALJ concluded at step four that Plaintiff was unable to perform
past relevant work as a customer service representative, a nursing assistant, a counter attendant, or
an appliance assembler. (Tr. 20). Still, at step five, the ALJ found that Plaintiff could perform

various jobs that existed in significant numbers in the national economy, including: cleaning and
housekeeping, officer helping, and marking. (Tr. 21). Because such jobs existed, the ALJ held
that Plaintiff was not disabled within the meaning of the Act. (Id.).
II. DISCUSSION
In considering cross-motions for summary judgment, this Court “examines each motion
separately, employing the familiar standard” provided by Federal Rule of Civil Procedure 56.
Desmond v. PNGI Charles Town Gaming, 630 F.3d 351, 354 (4th Cir. 2011). Thus, each motion
is reviewed “on its own merits ‘to determine whether either of the parties deserve judgment as a
matter of law.’” Rossignol v. Voorhaar, 316 F.3d 516, 523 (4th Cir. 2003) (citation omitted).

When reviewing a disability determination, the Court “is required to uphold the
determination when an ALJ has applied correct legal standards and the ALJ’s factual findings are
supported by substantial evidence.” Bird v. Comm’r of Soc. Sec. Admin., 699 F.3d 337, 340 (4th
Cir. 2012). Courts do not conduct de novo review of the evidence. See Smith v. Schweiker, 795
F.2d 343, 345 (4th Cir. 1986). Instead, our inquiry is limited to whether there is “such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.” Hancock v.
Astrue, 667 F.3d 470, 472 (4th Cir. 2012) (quoting Richardson v. Perales, 402 U.S. 389, 401
(1971)). It “consists of more than a mere scintilla evidence but may be less than a preponderance.”
Id. The Court will not “reweigh conflicting evidence, make credibility determinations, or
substitute [its] judgment for that of the ALJ.” Id. (alterations omitted). Put simply, “[w]here
conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the
responsibility for that decision falls on the ALJ.” Id. (alterations omitted).
“A necessary predicate to engaging in substantial evidence review is a record of the basis
for the ALJ’s ruling.” Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013). Thus, “[t]he record

should include a discussion of which evidence the ALJ found credible and why, and specific
application of the pertinent legal requirements to the record evidence.” Id. If the Court has “no
way of evaluating the basis for the ALJ’s decision, ‘the proper course, except in rare circumstances,
is to remand to the agency for additional investigation or explanation.’” Id. (quoting Florida Power
& Light v. Lorion, 470 U.S. 729, 744 (1985)); see Brown v. Colvin, 639 F. App’x 921, 922 (4th
Cir. 2016) (explaining courts do not “min[e] facts from the [administrative] record to support the
ALJ’s decisions”). This ensures the ALJ can “adequately explain his reasoning . . . in the first
instance.” Radford, 734 F.3d at 296.
On judicial review, Plaintiff contends the ALJ failed to adequately weigh and consider the

medical opinion evidence of Plaintiff’s treating mental health expert. As discussed below, the
Court agrees with Plaintiff, and thus remands this case to the ALJ for reconsideration.1
When making a disability determination, the ALJ has an obligation to consider all relevant
evidence. See Lewis v. Berryhill, 858 F.3d 858, 869 (4th Cir. 2017); 20 C.F.R. §§ 404.1520(a)(3),
416.920(a)(3). To that end, the ALJ’s final decision “must both identify evidence that supports
his conclusion and build an accurate and logical bridge from that evidence to his conclusion.”
Woods v. Berryhill, 888 F.3d 686, 694 (4th Cir. 2018) (alterations omitted). An accurate and

1 Plaintiff points to several additional errors that the ALJ purportedly made, but because the Court
remands for reconsideration, the Courts declines to consider those alleged errors at this juncture.
logical bridge must consider both favorable and unfavorable evidence; in other words, the ALJ
“cannot simply cherrypick facts that support a finding of non-disability while ignoring evidence
that points to a disability finding.” Lewis, 858 F.3d at 869 (citation omitted).
In evaluating relevant evidence, the ALJ must “always consider the medical opinions in
[a] case.” 20 C.F.R. §§ 404.1527(b), 416.927(b).2 And where the ALJ receives a medical opinion

from a treating physician, the ALJ must give that opinion “controlling weight” if the opinion is
“well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not
inconsistent with the other substantial evidence in the claimant’s case record.” Lewis, 858 F.3d at
867 (citing 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2)). When the ALJ rejects a treating
physician’s opinion, they must provide more than a “perfunctory” explanation for doing so. Id.
From at least April 2017 to August 2017, Plaintiff was evaluated monthly by her treating
mental health provider, Dr. Terrence Snyder, a psychiatrist at RHA Behavioral Health. Dr. Snyder
created written summaries of each visit, and those summaries were before the ALJ when making
his decision. In April, Plaintiff reported a host “depressive symptoms” and “PTSD symptoms”

commensurate with prior diagnoses. (Tr. 780). After the visit, Dr. Snyder further diagnosed
Plaintiff with schizophrenia and polysubstance use disorder and recognized that her insight and
judgment were impaired. (Tr. 786–88). In May and June, Plaintiff reported improvements in her
condition, (Tr. 795, 803), and in June, Dr. Snyder himself opined that Plaintiff’s “insight and
judgment improved,” (Tr. 806). But by July, Plaintiff’s condition worsened, as she was “possibly
taking too much ibuprofen” and engaging in “risky behaviors,” including “walking in the middle
of the road, . . . lying in the road[,] . . . and sleeping too much during the day.” (Tr. 812). Based

2 Plaintiff’s claims were filed before March 27, 2017, so relevant opinion evidence is evaluated
according to the procedures provided by 20 C.F.R. §§ 404.1572 and 416.927.
on these “recent poor choices,” Dr. Snyder opined that Plaintiff again exhibited “impaired insight
and poor judgment.” (Tr. 815). In August, Dr. Snyder again thought that Plaintiff’s “insight and
judgment [were] improving.” (Tr. 824). He specifically noted that Plaintiff reported “she has not
had hallucinations in about 4 months.” (Tr. 821). Still, Plaintiff continued to report “depressive
symptoms,” including “oversleeping,” feeling “sometimes grumpy,” “more down than up,”

“occasional feelings of worthlessness,” and “a lot of negative self thoughts.” (Tr. 821). With
knowledge of this treatment history, Dr. Snyder opined in August that Plaintiff “could work a few
hours a week in the right kind of job, but [was] not ready for full-time work.” (Tr. 821).
In determining that Plaintiff was not disabled, the ALJ acknowledged that Dr. Snyder
believed she was not ready for full-time work, but determined that opinion was worthy of “[l]ittle
weight.” (Tr. 20). According to the ALJ, this opinion was “[in]consistent with the mental health
treatment notes, which clearly show an excellent response to treatment and medications with
resolution of her anxiety and hallucinations and improvement of her mood.” (Id.).3 Several
problems arise from the ALJ’s brief rejection of Dr. Snyder’s treating medical opinion.

First, even assuming Plaintiff’s mood had “improved,” such improvements are hardly
dispositive on the issue of disability. As several courts have recognized, “improvement is a relative
concept and, by itself, does not convey whether a patient has recovered sufficiently to no longer
be deemed unable to perform work on a sustained basis.” Martz v. Comm’r, Soc. Sec. Admin.,
649 F. App’x 948, 960 (11th Cir. 2016); see Boulis-Gasche v. Comm’r of Soc. Sec., 451 F. App’x
488, 494 (6th Cir. 2011) (“By concluding that some unspecified improvement in Plaintiff’s mood

3 On judicial review, the Government now asserts Dr. Snyder’s opinion reached an issue that was
“reserved to the Commissioner.” (Doc. No. 12 at 7). But it is well-established that courts will
“not create post-hoc rationalizations to explain the Commissioner’s treatment of evidence when
that treatment is not apparent from the Commissioner’s decision itself.” Grogan v. Barnhart, 399
F.3d 1257, 1263 (10th Cir. 2005) (citing SEC v. Chenery Corp., 318 U.S. 80, 87 (1943)).
cured any anxiety or depression that Plaintiff was experience, ‘the ALJ impermissibly substituted
his own judgment for that of a physician.’” (citation and alterations omitted)); see also Tanner v.
Comm’r of Soc. Sec., 602 F. App’x 95, 100 (4th Cir. 2015) (explaining “medical records often
span [long time periods, so] it is inevitable that some evidence will show signs of a claimant’s
improvement and other evidence will show signs of a claimant’s regression”).

Second, in summarily finding that Plaintiff’s mood had improved, the ALJ failed to grapple
with contrary evidence indicating that Plaintiff continued to suffer from ongoing mental
limitations. As noted above, in July 2017—just one month before issuing his medical opinion—
Dr. Snyder determined that Plaintiff suffered from “impaired insight and poor judgment” in light
of her “recent poor choices.” (Tr. 815). Rather than address this finding, the ALJ simply noted
that Plaintiff reported being in “descent” condition during her July evaluation. (Tr. 19).
Finally, the record contains several additional unaddressed medical opinions which bolster
Dr. Snyder’s continued concerns. See Lewis, 858 F.3d at 866. For example, in August 2017,
Plaintiff was evaluated by a Licensed Professional Counselor for the Family Preservation Services

of North Carolina. Like Dr. Snyder, the LPC opined that Plaintiff’s “psychotic symptoms are well
controlled,” but she “continues to have significant symptoms of Bipolar Disorder, mostly
hypomanic at this time, . . . and has significant anxiety.” (Tr. 561).4 Likewise, in January 2018,

4 Notably, the ALJ failed to acknowledge the LPC’s concurring opinion. LPCs are not “acceptable
medical sources,” but their opinions “may provide insight into the severity of the claimant’s
impairment(s) and how it affects the individual’s ability to function,” so their “opinions are entitled
to consideration.” Whitfield v. Saul, No. 1:19-CV-31, 2019 WL 4635652, at *3 (W.D.N.C. Sept.
23, 2019) (collecting cases). The ALJ’s complete failure to grapple with this contrary opinion
provides an additional basis to reverse and remand for reconsideration. See id.
Laura Brooks, PA, evaluated Plaintiff and found that she continued to struggle with Bipolar
Disorder and anxiety. (Tr. 714, 716, 730).5
In sum, by failing to address evidence that was inconsistent with his finding of
“improvement,” the ALJ failed to consider all relevant evidence. See Lewis, 858 F.3d at 869.
Therefore, the decision of the ALJ is reversed and remanded for fuller consideration.

5 Additionally, in assessing Plaintiff’s residual functional capacity, the ALJ “must consider
limitations and restrictions imposed by all of an individual’s impairments.” SSR 96-8p, 1996 WL
374184, at *5. Here, the ALJ mentioned Plaintiff’s diagnoses of Bipolar Disorder and Borderline
Personality Disorder, but entirely failed to explain what limitations followed from those diagnoses.
(Tr. 14–15). As discussed, the record suggests Plaintiff continued to struggle with limitations from
her Bipolar Disorder in August 2017—even while symptoms from other disorders improved. The
failure to address these limitations likewise warrants remand for reconsideration. See, e.g., Crystal
Louise H. v. Comm’r, Soc. Sec. Admin., No. 18-CV-3922, 2019 WL 5309997, at *6 (D. Md. Oct.
21, 2019); McGinnis v. Saul, No. 3:18-CV-797, 2019 WL 5275536, at *8 (E.D. Va. Sept. 23,
2019), report and recommendation adopted, 2019 WL 5269098 (E.D. Va. Oct. 17, 2019).
ORDER
IT IS, THEREFORE, ORDERED that Plaintiff's Motion for Summary Judgment (Doc.
No. 9) is GRANTED and the Commissioner’s Motion for Summary Judgment (Doc. No. 11) is
DENIED. Pursuant to the power of this Court to enter a judgment affirming, modifying, or
reversing the decision of the Commissioner under 42 U.S.C. § 405(g), the ALJ’s final decision is
REVERSED, and this case is hereby REMANDED for a decision consistent with this Order.

Signed: January 30, 2020

agen
Max O. Cogburn i )
United States District Judge ttget

10

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10255501. Public record. Not legal advice.