Arnold v. Social Security Administration Commissioner

IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

HOT SPRINGS DIVISION

TAMERA RENEE ARNOLD PLAINTIFF

v. Case No. 6:23-cv-6071

COMMISSIONER, SOCIAL SECURITY

ADMINISTRATION DEFENDANT

ORDER

Before the Court is a Report and Recommendation (“R&R”) issued by the Honorable Barry

A. Bryant, United States Magistrate Judge for the Western District of Arkansas. ECF No. 17.

Judge Bryant recommends that the Court affirm the Administrative Law Judge’s (“ALJ”) denial

of Plaintiff Tamera Renee Arnold’s application for social security disability benefits. Plaintiff filed

a timely objection. ECF No. 18. The Court finds the matter ripe for consideration.

I. BACKGROUND

On November 28, 2018, Plaintiff filed her initial application for disability benefits with the

Social Security Administration (“SSA”). Plaintiff alleged that a myriad of conditions rendered her

disabled, including ruptured and bulging discs in her neck and lower back, sciatica, plantar

fasciitis, arthritis, and depression. Plaintiff asserts November 26, 2018, as the onset of her disabled

status. The SSA denied Plaintiff’s application, both initially and upon reconsideration.

Plaintiff appealed the denial of her application. After an administrative hearing, the ALJ

denied Plaintiff’s application. The ALJ found that Plaintiff was not disabled from her alleged

onset date through December 16, 2019, the date of the ALJ’s decision. Plaintiff requested review

from the SSA Appeals Counsel, which issued a notice on September 1, 2020, stating that it

declined to review the ALJ’s denial of her application. On September 16, 2020, Plaintiff submitted

a separate application for disability benefits with a State agency.

On October 26, 2020, Plaintiff filed a complaint in this Court challenging the ALJ’s denial

of her first application for disability benefits.1 The Court reversed the ALJ’s decision and

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remanded Plaintiff’s case to the ALJ for further consideration pursuant to 42 U.S.C. § 405(g).2

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Upon remand, the SSA Appeals Council issued an Order on June 23, 2022, which noted that

Plaintiff’s second application for disability benefits with the State Agency was granted and that

Plaintiff was found to be disabled beginning on December 20, 2019. The Appeals Council

affirmed the State agency determination and remanded Plaintiff’s case to the ALJ to further

evaluate Plaintiff’s disabled status from her initial alleged onset date of November 26, 2018,

through December 20, 2019.

On January 31, 2023, the ALJ held a supplemental hearing to evaluate Plaintiff’s disability

status prior to December 20, 2019. Plaintiff and Vocational Expert (“VE”) Wilfred Roux testified

at this hearing. On February 17, 2023, the ALJ entered a decision finding that Plaintiff was not

disabled from her alleged onset date through November 20, 2019. On June 12, 2023, Plaintiff filed

her Complaint in this Court against the Commissioner of the Social Security Administration

(“Commissioner”), appealing the ALJ’s most recent denial of her application for disability

benefits. ECF No. 1. The official transcript of the proceedings has been filed. ECF No. 9

(hereinafter “Trans.”).3 The parties subsequently filed their appeal briefs. ECF Nos. 13 & 15. On

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May 16, 2024, Judge Bryant issued the instant R&R recommending the ALJ’s decision be

affirmed. Plaintiff then filed a timely objection. ECF No. 18.

1 Tamera Renee Arnold v. Kijakazi, Case No. 6:20-cv-6123-SOH, ECF No. 2.

2 Tamera Renee Arnold v. Kijakazi, Case No. 6:20-cv-6123-SOH, ECF No. 25 (adopting a Report and

Recommendation issued by United States Magistrate Judge Barry A. Bryant).

3 When referencing the official transcript, the Court will cite to the internal page number of the transcript and not the

ECF page number.

II. LEGAL STANDARD

A. Review of Magistrate Judge R&R

A party may submit written objections to a magistrate judge’s findings and

recommendations. Fed. R. Civ. P. 72(b)(2). The district court must conduct a de novo review of

“any part of the magistrate judge’s disposition that has been properly objected to.” Fed. R. Civ. P.

72(b)(3); and see 28 U.S.C. § 636(b)(1). Objections must be specific to trigger a de novo review,

and the lack of specific objections permits a court to only review the recommendations for clear

error. See Griffini v. Mitchell, 31 F.3d 690, 692 (8th Cir. 1994). Plaintiff’s objections are

sufficiently specific to require a de novo review of Judge Bryant’s R&R.

B. Review of ALJ Decision

A court must affirm an ALJ decision “if the ALJ made no legal error and the ALJ’s decision

is supported by substantial evidence on the record as a whole.” Austin v. Kijakazi, 52 F.4th 723,

728 (8th Cir. 2022) (internal quotation omitted). “Substantial evidence means ‘less than a

preponderance, but enough that a reasonable mind might accept as adequate to support a

conclusion.’” Id. (internal quotation omitted). “[T]he threshold for such evidentiary sufficiency

is not high. Substantial evidence, this Court has said, is ‘more than a mere scintilla.’” Biestek v.

Berryhill, 587 U.S. 97, 103 (2019) (quotation omitted). A court will only rebuke the ALJ’s

decision if it “falls outside the available zone of choice.” Austin, 52 F.4th at 728 (internal quotation

omitted). “An ALJ’s decision is ‘not outside the zone of choice’ simply because [a court] ‘might

have reached a different conclusion had we been the initial finder of fact.’” Kraus v. Saul, 988

F.3d 1019, 1024 (8th Cir. 2021) (internal quotation omitted). If the evidence permits drawing two

inconsistent conclusions, one of which is the ALJ’s ultimate finding, then the reviewing court must

affirm. See Scott v. Berryhill, 855 F.3d 853, 856 (8th Cir. 2017) (citation omitted).

III. DISCUSSION

The Court will first outline the general process of making disability determinations, with

more elaboration on the stages of the process currently in dispute. The Court will then summarize

the ALJ’s findings that Plaintiff contests before analyzing the parties’ arguments and Judge

Bryant’s R&R.

A. Disability Determinations

An individual is disabled if they have an “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[.]” 42 U.S.C. § 423(d)(1)(A); and see 42 U.S.C § 1382c(a)(3)(A).

Determining whether an individual is disabled and eligible for disability benefits requires engaging

in the five-step analysis described in 20 CFR § 404.1520(a)(4).

At Step One, the ALJ considers the individual’s work activity and if they are currently

engaged in substantial gainful activity. 20 CFR § 404.1520(a)(4)(i). If the individual is currently

working or engaging in substantial gainful activity, they are not disabled regardless of their

medical condition. Id.; 20 CFR § 404.1520(b).

At Step Two, the ALJ considers the medical severity of any physical or mental

impairments, as well as their duration. 20 CFR § 404.1520(a)(4)(ii). If the individual’s

impairments do not significantly limit their ability to do basic work activities, then they are not

disabled. 20 CFR § 404.1520(c). In assessing the severity of any impairment from mental

disorders, the four broad areas of mental functioning found in 20 CFR, Part 404, Subpart P,

Appendix 1 must be evaluated. The four functional areas are: 1) understanding, remembering, or

applying information, 2) interacting with others, 3) concentrating, persisting, or maintaining pace,

and 4) adapting or managing oneself. 20 CFR, Part 404, Subpart P, Appendix 1, 112.00(A)(2)(b);

and see 20 CFR § 404.1520a(c)(3)-(4). The degree of limitation in those four functional areas is

assessed on a five-point scale, which includes “[n]one, mild, moderate, marked, and extreme.” 20

CFR § 404.1520a(c)(4).

At Step Three, the ALJ considers the medical severity of the individual’s impairments and

whether the impairments meet or equal one of the listings in 20 CFR Part 404, Subpart P, Appendix

1 (“Appendix 1”). 20 CFR § 404.1520(a)(4)(iii). If the impairments meet or equal a listing in

Appendix 1 and meet the duration requirement, the individual is disabled. 20 CFR § 404.1520(d).

If the impairment does not meet or equal a listing in Appendix 1, the ALJ proceeds to Step Four.

20 CFR § 404.1520(e).

At Step Four, the ALJ will assess the individual’s “residual functional capacity” (“RFC”)

and their past relevant work. 20 CFR § 404.1520(a)(4)(iv). An individual’s RFC is assessed

pursuant to 20 CFR § 404.1545. 20 CFR § 404.1520(e). RFC is the most an individual can do

despite their physical and mental limitations. 20 CFR § 404.1545(a)(1); Martise v. Astrue, 641

F.3d 909, 923 (8th Cir. 2011). An RFC determination is based “on all relevant evidence,” which

includes medical records, personal observations from treating physicians and others, and an

individual’s own evaluation of their capacity. 20 CFR § 404.1545(a)(3); Boyd v. Colvin, 831 F.3d

1015, 1020 (8th Cir. 2016). If the individual’s RFC shows that they are able to do their past

relevant work, then the individual is not disabled. 20 CFR §§ 404.1520(e)-(f).

At Step Five, an ALJ considers an individual’s RFC and their age, education, and

experience to determine if that individual can “make an adjustment to other work.” 20 CFR §

404.1520(a)(4)(v). If the individual can make an adjustment to other work, the individual is not

disabled; if the individual cannot make an adjustment to other work, they are disabled. 20 CFR §

404.1520(g)(1).

B. Relevant ALJ Determinations

Plaintiff’s objections focus on the ALJ’s findings at Steps Two and Four of the disability

evaluation process. The Court will briefly summarize the relevant findings of the ALJ below.

At Step One, the ALJ determined that Plaintiff did not engage in substantial gainful activity

from her alleged onset date through December 20, 2019. Trans. at 1084-85. Proceedings to Step

Two, the ALJ determined that Plaintiff had the following severe physical impairments: cervical

degenerative disc disease, headaches, asthma, bronchitis, obesity, history of shoulder discomfort,

history of plantar fasciitis, and history of carpal tunnel syndrome. Trans. at 1085. These

impairments “significantly limit the ability to perform basic work activities[.] Trans. at 1085. The

ALJ then assessed any limitations resulting from Plaintiff’s history of depression, finding that it

“does not cause more than minimal limitation in the claimant’s ability to perform basic mental

work activities and is therefore nonsevere.” Trans. at 1086. Elaborating on his assessment of the

four areas of mental functioning, the ALJ determined that the evidence indicated that Plaintiff had

no limitation in interacting with others. Trans at 1086. For the three remaining areas of mental

functioning, the ALJ determined that the evidence was “indicative of an individual who retains

generally intact functioning and support[s] no more than mild limitations.” Trans at 1086.

Proceeding to Step Three, the ALJ determined that Plaintiff did not have an impairment or

combination of impairments that equaled the severity of an impairment listed in 20 CFR Part 404,

Subpart P, Appendix 1. Trans. 1087-89. Proceeding to Step Four, the ALJ ultimately formulated

Plaintiff’s RFC as follows:

After careful consideration of the entire record, the undersigned finds that the

claimant has the residual functional capacity to perform sedentary work as defined

in 20 CFR 404.1567(a) except the claimant can occasionally stoop, crouch, bend,

kneel, and crawl. The claimant is limited to occasional overhead reaching and

frequent fingering and handling. She can tolerate occasionally exposure to dust,

smoke, fumes, and other pulmonary irritants. The claimant will be unable to tolerate

work around heavy hand tools such as repetitive machinery such as jack hammers,

drills, and band saws.

Trans. at 1089. The ALJ subsequently outlined the rationale and evidence in the record underlying

that formulation. Trans. at 1089-1094. The ALJ then determined that Plaintiff’s RFC meant that

she could perform her past relevant work as an “eligibility worker” and thus Plaintiff was not

disabled during the relevant timeframe. Trans. at 1094-95.

B. Consideration of Mental Limitations in RFC

Plaintiff argues that the ALJ fundamentally erred in failing to include mental limitations in

formulating the RFC and failing to consider those limitations in determining if she could perform

past relevant work. ECF No. 13, p. 18-23. Plaintiff emphasizes that the ALJ determined that she

had “mild limitations” in three areas of mental functioning but did not include those limitations

within the RFC. Plaintiff contends that such limitations, even if mild, must be included in the RFC

because they might combine with more severe impairments to preclude the ability to perform past

relevant work. Plaintiff further contends that such consideration is required by Social Security

Ruling (“SSR”) 96-8p, which states that mental limitations found in Step 2 of the process require

a “more detailed assessment” as Step Four. SSR 96-8p, 1996 WL 374184, at *4. Without a proper

discussion or inclusion of mental limitations in formulating the RFC, Plaintiff argues that the ALJ

did not properly develop the record or provide sufficient basis for his decision. Moreover, Plaintiff

asserts that failing to include mental limitations in the RFC also pollutes the weight of the VE’s

opinions because any hypothetical questions regarding Plaintiff’s ability to perform work were

based on incomplete information.

In response, the Commissioner argues that the ALJ properly evaluated Plaintiff’s mental

limitations in formulating her RFC. ECF No. 15, p. 3-7. The Commissioner states that the ALJ’s

formulation of Plaintiff’s RFC at Step Four is fully understood and supported in the greater context

of the decision. Citing Chismarich v. Berryhill, 888 F.3d 978 (8th Cir. 2018), the Commissioner

contends that the ALJ’s finding of mild mental limitations at Step Two can be “harmonized” with

the Step Four discussion of Plaintiff’s demonstrated mental functioning and the corresponding

absence of any functional mental limitations included in the RFC. Noting the deference that must

be given to the ALJ’s determination, the Commissioner concludes that the ALJ’s RFC

determination was sufficiently supported by the record and must be affirmed. In reply, Plaintiff

argues that the Commissioner admits that the ALJ failed to include all limitations in Plaintiff’s

RFC formulation as required. ECF No. 16, p. 1-4. Plaintiff then asserts that the Commissioner’s

citation to Chismarich does not support its argument because the ALJ decision challenged in that

case included mental limitations in the RFC after finding limitations at Step Two. Plaintiff asserts

that there is no such harmony or consistency within the ALJ’s denial of her application.

Judge Bryant recommends finding that the ALJ appropriately considered Plaintiff’s mild

impairments found in Step Two while formulating the RFC at Step Four. ECF No. 17, p. 5-6.

Judge Bryant first notes that the ALJ does discuss Plaintiff’s reported mental limitation when

explaining the RFC formulation. Judge Byrant further notes that the ALJ also explains why other

evidence made Plaintiff’s self-reported limitations less credible and insufficient to require

including them in the RFC. Plaintiff’s objection to the R&R reiterates her prior arguments that

the ALJ’s RFC formulation improperly excluded the mild mental limitations that were

acknowledged at Step Two. ECF No. 18, p. 1-4. Plaintiff contends that the finding of mild

limitations in three areas of mental functioning is irreconcilable with an RFC that did not recognize

any mental limitations in Plaintiff’s ability to perform work.

The Court finds that there is no fatal inconsistency or error regarding the absence of mental

limitations within Plaintiff’s RFC. Though less than ideal in its clarity, the whole of the ALJ’s

decision allows for a reading that is not inherently contradictory. See Chismarich, 888 F.3d at

989-90 (“[O]ur deferential standard of review precludes us from labeling findings as inconsistent

if they can be harmonized.”); and see Owen v. Astrue, 551 F.3d 792, 801 (8th Cir. 2008) (stating

that poor opinion writing does not invalidate an otherwise supportable decision).

At Step Two, the ALJ acknowledged that Plaintiff had a medically determinable mental

impairment from depression. Trans. at 1085-1087. The ALJ’s evaluation of any limitations caused

by Plaintiff’s depression, which is based entirely off Plaintiff’s self-reported issues to the ALJ or

to medical providers,4 found that the record supports “no more than mild limitations” for the three

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relevant functional areas. Trans. at 1086. When formulating Plaintiff’s RFC at Step Four, the ALJ

discussed Plaintiff’s reported mental limitations at some length. Trans. at 1089-90. However, the

ALJ determined that other evidence in the record of Plaintiff’s daily activities precluded finding

that any mental limitations were significant enough to interfere with her ability to perform work,

stating that “[w]hile the claimant does experience some limitations as a result of her impairments,

the record evidence fails to indicate that her limitations are totally work preclusive, or greater than

provided in the residual functional capacity adopted.” Trans. at 1090 (emphasis added). With an

eye toward harmony, the Court finds that the ALJ determined that the mild limitations from Step

Two were contradicted by other evidence in the record to such a degree than the RFC formulation

at Step Four did not require the inclusion of any mental limitations. Further, any hypothetical

4 Two physician consultants examined and questioned Plaintiff regarding her application. Trans. at 78-84, 92-99.

questions the ALJ posed to the VE were not fundamentally flawed because the ALJ did not need

to include impairments that the record indicated posed no limitations on Plaintiff’s functional

abilities. See Owen, 551 F.3d at 801-02. Accordingly, the Court finds that the ALJ did not commit

reversable error by declining to include any mental limitations in formulating Plaintiff’s RFC.

B. Substantial Evidence Supporting RFC

Plaintiff also argues that the ALJ’s RFC formulation is not supported by substantial

evidence. ECF No. 13, p. 23-32. Plaintiff emphasizes that a significant portion of the medical

records relied upon from the ALJ were from visits prior to the alleged onset date of disability and

that the medical records from the applicable period contradict the ALJ’s assessment of her

functional abilities. Plaintiff disputes that her treatments for spinal issues can be considered

conservative because they involved significant efforts in pain management, which included

physical therapy, prescription medication, and injections. Plaintiff also contends that the ALJ

placed too much weight on Plaintiff’s mere ability to perform some daily living activities without

also acknowledging how limited they were in scope and intensity. Plaintiff concludes that viewing

the record as a whole demonstrates that the ALJ’s decision is contradicted by the overall weight

of the evidence and must be reversed and remanded for reconsideration.

In response, the Commissioner argues that there is sufficient evidence in the record to

support the ALJ’s determination that Plaintiff could still perform sedentary work with some

modifications and restrictions. ECF No. 15, p. 8-14. The Commissioner first notes that the ALJ

did cite medical examinations from the alleged disability period in assessing Plaintiff’s RFC. The

Commissioner also emphasizes that medical records and Plaintiff’s self-reports demonstrate that

her neck movement and upper extremity strength, while limited in varying severity, did not

completely preclude sedentary work. The Commissioner then notes that medical records also

show that her walking gait was often normal and unassisted, that she was satisfied with her current

pain management treatments, and that treating physicians consistently recommended a

continuation of conservative treatments. Lastly, the Commissioner points to Plaintiff’s self-reports

regarding daily activities for the time period at issue as providing further support for the ALJ’s

decision. The Commissioner notes that these activities included some household chores, driving,

grocery shopping alone, and caring for a household pet, which indicates that Plaintiff could

perform the limited sedentary work detailed in the RFC. In reply, Plaintiff argues that the evidence

noted by the Commissioner does not validate the ALJ’s decision when compared to the

contradictory evidence in the record. ECF No. 16, p. 4-7. Plaintiff also disputes that Plaintiff’s

treatments can be legitimately viewed as conservative in the context of her prior neck surgery and

ongoing use of strong pain medications. Plaintiff also asserts that the ALJ failed to acknowledge

that her daily activities were limited to such an extent that they cannot support the RFC

formulation.

Judge Bryant recommends finding that the ALJ’s formulation of Plaintiff’s RFC is

supported by substantial evidence. ECF No. 17, p. 6-8. Judge Bryant reasons that the medical

evidence and Plaintiff’s testimony on her personal activities is sufficient to support the sedentary

work ability outlined in the RFC. Plaintiff’s objection to the R&R argues that the ALJ’s

consideration of certain evidence supporting the decision does not overcome that the record as a

whole undermines the validity of the RFC formulation. ECF No. 18, p. 4-5. Plaintiff also

continues to assert that the ALJ erred in evaluating her daily activities by not considering their

limited intensity.

The Court finds that the ALJ’s Step Four evaluation of Plaintiff’s RFC must be affirmed.

Though Plaintiff has highlighted substantial evidence supporting her assertion of disability, the

Court’s review is not an evaluation of what other conclusions the ALJ could reach or what the

Court would have determined. See Kraus, 988 F.3d at 1024; Scott, 855 F.3d at 856. Plaintiff cites

medical records that align with her assertion of disability, but they do not overwhelm the medical

evidence from the relevant period that indicates her neck and spinal issues5 and movement issues6

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were not so debilitating that they would preclude the sedentary work outlined in the RFC.

Evidence in the record also weighs against Plaintiff’s allegations regarding the severity of her pain,

as she reported during two medical appointments in the relevant period that her prescriptions for

pain management were satisfactory and did not want to make any changes. Trans. at 784, 910;

and see Brown v. Astrue, 611 F.3d 941, 955 (8th Cir. 2010) (“If an impairment can be controlled

by treatment or medication, it cannot be considered disabling.”) (quotation omitted). The ALJ’s

evaluation is further supported by Plaintiff’s self-reported ability to perform various tasks alone

during this period, such as grocery shop, drive, attend church, perform some household chores,

and care for herself and a household pet. Trans. at 213-16, 1132-34. While Plaintiff argues that

the ALJ did not acknowledge the limitations she experienced in performing those tasks, those

limitations are roughly consistent with the RFC’s significantly limited assessment of Plaintiff’s

function. Accordingly, evaluating the record as a whole, the ALJ’s decision regarding Plaintiff’s

RFC and corresponding denial of Plaintiff’s application for disability benefits must affirmed.

5 A February 2019 examination notes that Plaintiff was “[n]egative for back pain.” Trans. at 820. A March 2019

examination notes that Plaintiff was negative for any back, neck, or joint pain. Trans. at 832-33. A May 2019

examination notes neck pain but only slight deficits in upper extremity strength. Trans. at 923. A June 2019

examination noted that Plaintiff had stable posture and only slight deficits in upper extremity strength. Trans. at 1023-

24. An August 2019 examination notes that Plaintiff’s neck movement was limited, but that Plaintiff did not have

notable loss of strength in her upper extremities. Trans. at 909. That August 2019 examination also notes that an

MRI did not show a pathology that would correlate with Plaintiff’s symptoms, and that Plaintiff should continue her

pain management regime and consider physical therapy. Trans. at 909-10.

6 A March 2019 examination noted that Plaintiff had an “awkward and limping gait” but that she could walk unassisted.

Trans. at 1055, 1056. A June 2019 (Trans. at 1024) examination noted that Plaintiff’s walking gait was “wnl”, which

is a medical abbreviation for “within normal limits.” RXLIST, Definition of WNL,

https://www.rxlist.com/wnl/definition.htm (last visited September 26, 2024). A July 2019 examination noted that

Plaintiff had a steady gait without the use of an assistive device. Trans. at 1001. Two August 2019 examinations

noted that Plaintiff had a normal walking gait. Trans at 909, 967.

IV. CONCLUSION

Upon de novo review and for the reasons stated above, the Court hereby adopts Judge

Bryant’s R&R (ECF No. 17) in toto. The ALJ’s denial of Plaintiff’s application for social security

disability benefits is hereby AFFIRMED.

IT IS SO ORDERED, this 27th day of September, 2024.

/s/ Susan O. Hickey

Susan O. Hickey

Chief United States District Judge