MADDY v. COMMISSIONER OF SOCIAL SECURITY

IN THE UNITED STATES DISTRICT COURT

FOR THE WESTERN DISTRICT OF PENNSYLVANIA

JANICE M. MADDY )

)

Plaintiff, )

)

-vs- ) Civil Action 18-261

)

ANDREW M. SAUL, )

)

Defendant. )

AMBROSE, Senior District Judge.

OPINION AND ORDER

Synopsis

Plaintiff Janice M. Maddy (“Maddy”) brought this action for review of the final

decision of the Commissioner of Social Security denying her claim for a period of

disability and disability insurance benefits (“DIB”). Maddy contends that she became

disabled on August 20, 2014. (R. 10) She was represented by counsel at a hearing

before an Administrative Law Judge (“ALJ”) during which both she and a vocational

expert (“VE”) appeared and testified. (R. 10) Following the hearing the ALJ received

additional evidence which was admitted into the record. (R. 10) Ultimately, the ALJ

denied benefits. (R. 10) Maddy subsequently filed a Request for Review with the

Appeals Council. The Appeals Council denied the request. (R. 1-6) Maddy then filed

this appeal. The parties have filed Cross-Motions for Summary Judgment. See ECF

Docket Nos. 11 and 15.

Opinion

1. Standard of Review

Judicial review of the Commissioner’s final decisions on disability claims is provided

by statute. 42 U.S.C. §§ 405(g) and 1383(c)(3)(7). Section 405(g) permits a district court

to review the transcripts and records on which a determination of the Commissioner is

based, and the court will review the record as a whole. See 5 U.S.C. § 706. When

reviewing a decision, the district court’s role is limited to determining whether the record

contains substantial evidence to support an ALJ’s findings of fact. Burns v. Barnhart,

312 F.3d 113, 118 (3d Cir. 2002). Substantial evidence has been defined as “more than

a mere scintilla. It means such relevant evidence as a reasonable mind might accept as

adequate.” Ventura v. Shalala, 55 F.3d 900, 901 (3d Cir. 1995), quoting Richardson v.

Perales, 402 U.S. 389, 401 (1971). Determining whether substantial evidence exists is

“not merely a quantitative exercise.” Gilliland v. Heckler, 786 F.2d 178, 183 (3d Cir.

1986) (citing Kent v. Schweiker, 710 F.2d 110, 114 (3d Cir. 1983)). “A single piece of

evidence will not satisfy the substantiality test if the secretary ignores, or fails to resolve,

a conflict created by countervailing evidence. Nor is evidence substantial if it is

overwhelmed by other evidence – particularly certain types of evidence (e.g., that

offered by treating physicians).” Id. The Commissioner’s findings of fact, if supported by

substantial evidence, are conclusive. 42 U.S.C. §405(g); Dobrowolsky v. Califano, 606

F.2d 403, 406 (3d Cir. 1979); Richardson, 402 U.S. at 390, 91 S. Ct. 1420.

A district court cannot conduct a de novo review of the Commissioner’s decision, or

re-weigh the evidence; the court can only judge the propriety of the decision with

reference to the grounds invoked by the Commissioner when the decision was

rendered. Palmer v. Apfel, 995 F.Supp. 549, 552 (E.D. Pa. 1998); S.E.C. v. Chenery

Corp., 332 U.S. 194, 196-7, 67 S.Ct. 1575, 91 L.Ed. 1995 (1947). Otherwise stated, “I

may not weigh the evidence or substitute my own conclusion for that of the ALJ. I must

defer to the ALJ’s evaluation of evidence, assessment of the credibility of witnesses,

and reconciliation of conflicting expert opinions. If the ALJ’s findings of fact are

supported by substantial evidence, I am bound by those findings, even if I would have

decided the factual inquiry differently.” Brunson v. Astrue, 2011 WL 2036692, 2011 U.S.

Dist. LEXIS 55457 (E.D. Pa. Apr. 14, 2011) (citations omitted).

II. The ALJ’s Decision

Here, at step one, the ALJ determined that Maddy had not engaged in

substantial gainful activity since her onset date of August 20, 2014 through her date last

insured of December 31, 2017. (R. 12) At step two, the ALJ concluded that Maddy has

had the following medically determinable impairments: osteoarthritis, lumbar spine

degenerative disc disease, diabetes mellitus, obesity and asthma. (R. 12-14) At step

three, the ALJ found that those impairments, considered singly or in combination, do not

meet or medically equal the severity of a listed impairment. (R. 15) The ALJ then

determined that Maddy had the residual functional capacity (“RFC”) to perform light

work, with certain restrictions. (R. 15-20) At the fourth step, the ALJ concluded that

Maddy can perform her past relevant work as a circuit board assembler. (R. 20-21)

Consequently, the ALJ found that Maddy was not under a disability during the relevant

period. (R. 21)

III. Discussion

Maddy raises two challenges to the ALJ’s RFC findings. First, she urges that the

RFC fails to account for the ALJ’s own findings regarding a non-severe anxiety

impairment at the second step of the analysis. Second, she contends that the RFC is

not supported by substantial evidence of record. For the reasons set forth below, I reject

both contentions.

A. Mild Limitations Associated with Anxiety Disorder

At the second step of the analysis, the ALJ determined that although Maddy’s

anxiety constitutes a medically determinable impairment, it does not cause more than

minimal limitation in her ability to perform basic mental work activities. (R. 13)

Consequently, the impairment is “non-severe.” (R. 13) Maddy urges that in formulating

the RFC, the ALJ was obligated to consider her anxiety, even though it was a non-

severe impairment.1

I agree that an ALJ must consider all impairments, whether severe or not, in

assessing a claimant’s RFC. Kobulnicky v. Astrue, Civ. No. 11-1349, 2013 WL

1290955, at * 7 (W.D. Pa. March 27, 2013) (stating that, even if substantial evidence

supported the ALJ’s Step Two finding that a claimant’s mental impairments were not

severe, the ALJ is “required to analyze what limitations her non-severe impairments

cause in constructing his RFC finding.”); see also 20 C.F.R. § 404.1545(a)(2). “[T]he

RFC must consider all functional limitations, including mild limitations from impairments

that the ALJ has previously determined to be non-severe.” Zapata-Alvarez v. Colvin,

Civ. No. 14-2830, 2015 WL 5179477, at * 7 (E.D. Pa. Sept. 4, 2015); Curran v. Astrue,

Civ. No. 11-5894, 2012 WL 5494616, at * 5 (E.D. Pa. Nov. 13, 2012). Although a non-

severe impairment alone “may not significantly limit an individual’s ability to do basic

work activities, it may - when considered with limitations or restrictions due to other

impairments – be critical to the outcome of the claim.” S.S.R. 96-8p. The responsibility

for deciding a claimant’s RFC rests with the ALJ and is based on the entire record. 20

1 Maddy does not challenge the ALJ’s finding at step two, that her anxiety was a non-severe impairment.

C.F.R. §§ 404.1545, 404.1546. In making an RFC assessment, the “ALJ must describe

how the evidence supports his conclusion and explain why certain limitations are not

accepted as consistent with the medical or other evidence.” Noah v. Astrue, Civ. No. 12-

091, 2013 WL 364235, at * 2 (W.D. Pa. Jan. 30, 2013) (citations omitted). Here, the ALJ

acknowledged as much. (R. 15) (stating that, “[i]n making this finding, the undersigned

has considered all symptoms….”) (emphasis added).

Further, the assessment of mental impairments done at Step Four is qualitatively

different than that done at Step Two. “The mental RFC assessment used at steps 4 and

5 of the sequential evaluation process requires a more detailed assessment by

itemizing various functions contained in the broad categories found in [the] paragraph[ ]

B [criteria] ….” Booker v. Colvin, Civ. No. 14-4984, 2017 WL 914911, at * 6 (E.D. Pa.

March 7, 2017). As stated by the Third Circuit Court: the psychiatric review techniques

described in 20 C.F.R. § 404.1520a and 416.920a on the:

Psychiatric Review Technique Form (PRFT) requires adjudicators to assess an

individual’s limitations and restrictions from a mental impairment(s) in categories

identified in the “paragraph B” and “paragraph C” criteria of the adult mental

disorders listings. The adjudicator must remember that the limitations identified in

the “paragraph B” and “paragraph C” criteria are not an RFC assessment but are

used to rate the severity of mental impairment(s) at steps 2 and 3 of the sequential

evaluation process. The mental RFC assessment used at steps 4 and 5 of the

sequential evaluation process requires a more detailed assessment by itemizing

various functions contained in the broad categories found in paragraphs B and C of

the adult mental disorders listings in 12.00 of the Listing of Impairments, and

summarized on the PRFT.

Ramirez v. Barnhart, 372 F.3d 546, 551 (3d Cir. 2004), citing SSR 96-8p.

The question before me then, is whether the ALJ discharged this duty. I find that

the ALJ did. The ALJ noted that, in formulating the RFC, she “considered all symptoms

and the extent to which these symptoms can reasonably be accepted as consistent with

the objective medical evidence and other evidence….” (R. 15) Indeed, the ALJ

specifically acknowledged Maddy’s claims that “she experiences recurring anxiety,

panic attacks, and stress. She mentioned that her stress has been related to several

deaths in her family. The claimant expressed concern that she tends to have poor

concentration and becomes emotional at times.” (R. 16) Yet the ALJ found that Maddy’s

statements in this regard were not entirely consistent with the evidence of record. (R.

16) That finding is supported by substantial evidence of record. There is no opinion of

record indicating that Maddy’s anxiety results in any specific functional limitations.

Further, Maddy never treated with a mental health specialist. There are no medical

records suggesting that Maddy received inpatient or emergent mental health services.

Rather, she presented only to her primary care physician and received the same anti-

depressant medication throughout treatment. (R. 14, 16, 291) Her primary physician’s

records do not contain any notations regarding mental health findings, nor does Maddy

identify any. It is well-established that the ALJ “need only include in the RFC those

limitations which he finds credible.” Garrett v. Comm’r. of Soc. Sec., 274 Fed. Appx.

159, 163 (3d Cir. 2008) To the extent that the ALJ omitted from the RFC any restrictions

related to Maddy’s anxiety, she did so because she found those limitations were not

credible. I find that the ALJ incorporated into the RFC all the limitations that were

credibly established, and that substantial evidence supports her findings in this regard.

B. RFC

Maddy also challenges the RFC. She urges that her testimony and the record

evidence establish that she has a limited ability to sit, stand and walk for prolonged

periods and that the ALJ erred in failing to account for these limitations in the RFC.

Maddy points to evidence which she contends supports her position. Yet the question

before me is not:

whether substantial evidence supports Plaintiff’s claims, or whether there is

evidence that is inconsistent with the ALJ’s findings…. Substantial evidence could

support both Plaintiff’s claims and the ALJ’s finding because substantial evidence is

less than a preponderance. Jesurum v. Sec’y. of Health & Human Services, 48 F.3d

114, 117 (3d Cir. 1995) (citing, Richardson v. Perales, 402 U.S. 389, 401) (1971)). If

substantial evidence supports the ALJ’s finding, it does not matter if substantial

evidence also supports Plaintiff’s claims. Reefer v. Barnhart, 326 F.3d 376, 379 (3d

Cir. 2003).

Hundley v. Colvin, 2016 WL 6647913, at * 2 (W.D. Pa. Nov. 10, 2016). Consequently,

Maddy’s arguments in this respect are not convincing.

Additionally, that Maddy may have testified and / or reported to medical providers

that she cannot sit or stand for very long due to pain and that she spends most of her

day on the couch as a result is not determinative. As set forth above, the ALJ found that

Maddy’s statements concerning the intensity, persistence, and limiting effects of her

symptoms are not entirely consistent with the medical evidence and other evidence in

the record. (R. 16) Further, the medical records support the ALJ’s findings in this regard.

For instance, as the ALJ noted, a July 2017 study showed “minimal degenerative

changes at L2-L3 with normal disc spaces” and earlier imaging studies of the cervical

spine and left knee revealed only minimal degenerative changes. (R. 16, citing Exhibits

2F, 5F) Moreover, as the ALJ noted, Maddy’s pain treatment consisted chiefly of

medication rather than invasive procedures. (R. 17) During the consultative

examination, Maddy displayed 5/5 strength in the upper and lower extremities “with no

muscle atrophy, had no sensory deficits, had normal range of motion in the knees, hips,

and ankles with negative straight leg raising bilaterally, exhibited a normal gait, walked

on the heels and toes without difficulty, squatted fully, and needed no help changing for

the examination, getting on and off the examination table, and arising from a chair

without difficulty.” (R. 16, citing, Exhibit 4F) The expert opinions similarly supported the

ALJ’s conclusions. Dr. Khan’s opined that, during an 8-hour workday, Maddy could

stand for up to 4 hours, walk for up to 2 hours, and sit for up to 8 hours, with 2 hours

continuous standing at a time, 1 hour continuous walking at a time, and 8 hours

continuous sitting at a time. (R. 18) Similarly, Dr. Kar, the state agency medical

consultant, opined that Maddy could stand and / or walk, with normal breaks, for about 6

hours in an 8-hour workday and could sit, with normal breaks, for about 6 hours in an 8-

hour workday. (R. 19) Further, contrary to Maddy’s suggestions, Dr. McKendree, her

treating physician, did not opine that she was unable to stand and walk for 6 hours of an

8-hour workday. See ECF Docket No. 12, p. 10. Rather, Dr. McKendree offered no

opinion regarding sit / stand / walk limitations. Moreover, he found Maddy’s statements

regarding her symptoms only “partially credible”; declined to label the symptoms as

“disabling”; and opined that it was “unknown” whether Maddy’s stomach, leg, knee and

back pain would require her to go off task for unscheduled breaks during the day or

would cause her to limit her activities in an effort to relieve her symptoms. (R. 341-42)

Because the ALJ’s RFC is supported by substantial evidence of record, I find no basis

for remand.

IN THE UNITED STATES DISTRICT COURT

FOR THE WESTERN DISTRICT OF PENNSYLVANIA

JANICE M. MADDY )

Plaintiff, )

)

-vs- ) Civil Action No. 18-261

)

ANDREW M. SAUL, )

)

Defendant. )

AMBROSE, Senior District Judge.

ORDER OF COURT

Therefore, this 31st day of January, 2020, it is hereby ORDERED that the Motion

for Summary Judgment (Docket No. 15) is GRANTED and the Motion for Summary

Judgment (Docket No. 11) is DENIED. It is further ORDERED that the Clerk of Court

mark this case “Closed” forthwith.

BY THE COURT:

/s/ Donetta W. Ambrose

Donetta W. Ambrose

United States Senior District Judge