The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF NORTH CAROLINA
JAMES G., )
)
Plaintiff, )
)
v. ) 1:22CV956
)
MARTIN J. O7MALLEY;,! )
Commissioner of Social Security, )
)
Defendant. )
MEMORANDUM OPINION AND ORDER
OF UNITED STATES MAGISTRATE JUDGE
Plaintiff James G. (‘Plaintiff’) brought this action pursuant to Section 205(g) of the
Social Security Act (the “Act”), as amended (42 U.S.C. § 405(g)), to obtain judicial review of a
final decision of the Commissioner of Social Security denying his claim for Disability
Insurance Benefits (“DIB”) under Title II of the Act. The Parties have filed cross-motions
for judgment, and the administrative record has been certified to the Court for review.
I. PROCEDURAL HISTORY
Plaintiff protectively filed an application for DIB on October 23, 2020, alleging a
disability onset date of February 19, 2019. (T'r. at 25, 226-27.)? Plaintiffs application was
denied initially (Tr. 89-96, 111-20) and upon reconsideration (Ir. at 97-104, 122-31).
On December 20, 2023, Martin J. O'Malley was sworn in as Commissioner of Social Security, replacing Acting
Commissioner Kilolo Kijakazi. Pursuant to Rule 25(d) of the Federal Rules of Civil 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).
? Transcript citations refer to the Sealed Administrative Recotd [Doc. #4].
Thereafter, Plaintiff requested an administrative heating de novo before an Administrative
Law Judge (“ALJ”). (Tr. at 132.) On January 26, 2022, Plaintiff, along with his attorney,
attended the subsequent telephonic hearing, at which Plaintiff and an impartial vocational
expett testified. (T'r. at 25, 45-88.) Following the hearing, the ALJ concluded that Plaintiff
was not disabled within the meaning of the Act (T'r. at 40), and on September 14, 2022, the
Appeals Council denied Plaintiffs request for review of that decision, thereby making the
ALJ’s conclusion the Commissionet’s final decision for purposes of judicial review (I't. 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 courts 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. Asttue, 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 wete the case before a juty, 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 re-weigh
conflicting evidence, make credibility determinations, or substitute its judgment for that of the
[AL]].” Mastro, 270 F.3d at 176 (internal brackets and quotation omitted). “Where conflicting
evidence allows reasonable 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 AL]’s finding that [the claimant] is not disabled is
suppotted by substantial evidence and was teached based upon a cottect application of the
relevant law.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996).
In undertaking this limited review, the Court notes that “[a] claimant for disability
benefits beats the burden of proving a disability.” Hall v. Harris, 658 F.2d 260, 264 (4th Cir.
1981). In this context, “disability” means the “inability to engage in any substantial gainful
activity by reason of any medically determinable physical or mental impairment which can be
expected to result in death, or which has lasted or can be expected to last for a continuous
period of not less than 12 months.” Id. (quoting 42 U.S.C. § 423(d)(1)(A)).
3 “The Social Security Act comprises two disability benefits programs. The Social Security Disability Insurance
Program (SSDI), established by Title II of the Act as amended, 42 U.S.C. § 401 ef seq., provides benefits to
disabled persons who have contributed to the program while employed. The Supplemental Security Income
Program (SSI), established by Title XVI of the Act as amended, 42 U.S.C. § 1381 ef seg., provides benefits to
indigent disabled persons. The statutory definitions and the regulations promulgated by the Secretary for
determining disability, see 20 C.F.R. pt. 404 (SSDI); 20 C.F.R. pt. 416 (SSI), governing these two programs are,
in all aspects relevant here, substantively identical.” Craig, 76 F.3d at 589 n.1.
“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 period
of disability; (2) had a sevete 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 inquiry. For example, “[t]he first step
determines whether the claimant is engaged in ‘substantial gainful activity.’ If the claimant is
working, benefits are denied. The second step determines if the claimant is ‘severely’ disabled.
If not, benefits ate denied.” Bennett v. Sullivan, 917 F.2d 157, 159 (4th Cir. 1990).
On the other hand, if a claimant carries his or her burden at the first two steps, and if
the claimant’s impairment meets or equals a “listed impairment” at step three, the clatmant is
disabled. Mastro, 270 F.3d at 177. Alternatively, if a claimant clears steps one and two, but
falters at step three, ie., “[if a claimant’s impaitment 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 179.4 Step four then requires the ALJ to assess whether, based on
4 “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 require RFC to reflect claimant’s “ability to do sustained work-
related physical and mental activities in a work setting on a regular and continuing basis . . . [which] means 8
hours a day, for 5 days a week, or an equivalent work schedule” (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, ot very heavy work,” as well as “nonexertional limitations (mental, sensory, or
skin impaitments).” Hall, 658 F.2d at 265. “RFC is to be determined by the AL] only after [the AL]] considers
all relevant evidence of a claimant’s impaitments and any related symptoms (¢.g., pain).” Hines, 453 F.3d at
562-63.
that RFC, the claimant can “perform past relevant work”; if so, the claimant does not qualify
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 “requires the [Government] to prove that
a significant number of jobs exist which the claimant could perform, despite [the clatmant’s]
impaitments.” Hines, 453 F.3d at 563. In making this determination, the ALJ must decide
“whether the claimant is able to perform other work considering both [the claimant’s RFC]
and [the claimant’s] vocational capabilities (age, education, and past work experience) to adjust
to a new job.” Hall, 658 F.2d at 264-65. If, at this step, the 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.
IW. DISCUSSION
In the present case, the ALJ found that Plaintiff had not engaged in “substantial gainful
activity” since his alleged onset date of February 19, 2019. The ALJ therefore concluded that
Plaintiff met his burden at step one of the sequential evaluation process. (Tr. at 28.) At step
two, the ALJ further determined that Plaintiff suffered from the following severe impairments:
degenerative disc disease; obstructive sleep apnea; and obesity[.]
(Tr. at 28.) The ALJ found at step three that none of these impairments, individually or in
combination, met ot equaled a disability listing. (I'r. at 30-31.) Therefore, the ALJ assessed
Plaintiff's RFC and determined that he could perform a range of light work, defined as follows:
Specifically, [Plaintiff] can lift, carry, push, and pull 20 pounds occasionally and
10 pounds frequently; can sit up to 6 hours in an 8-hour workday; can stand
and/or walk up to 6 hours in an 8-hour workday; can frequently push and/or
pull with the bilateral upper extremities; can frequently perform handling,
fingering, and overhead reaching with the bilateral upper extremities[;] can
occasionally climb ladders, ropes and scaffolds, can frequently climb ramps and
staits; can frequently balance, as that term is defined in the Dictionary of
Occupational Titles, can frequently stoop, kneel, and crouch, but only
occasionally crawl. He should avoid concentrated exposure to fumes, odots,
gases, poor ventilation, or other pulmonary irritants, and should avoid even
occasional exposute to workplace hazards such as moving machinery and
unprotected heights.
(Tr. at 31.) At step four of the analysis, the ALJ found, based on the above RFC and the
vocational expert’s testimony, that Plaintiff was unable to perform any of his past relevant
work. (Tr. at 38.) However, the AL] determined at step five that, given Plaintiffs age,
education, work experience, RFC, and the testimony of the vocational expert as to these
factors, he could perform other jobs available in significant numbers in the national economy.
(Tr. at 39.) Therefore, the ALJ concluded that Plaintiff was not disabled under the Act. (Tt.
at 40.)
Plaintiff now contends that the AL] erred in two respects when assessing Plaintiffs
RFC. First, he argues that “the ALJ erred by failing to explain why she did not include a time
off task limitation due to medication side effects and the need to recline in the [RFC|
assessment.” (PL’s Br. [Doc. #9] at 1.) Second, Plaintiff asserts that “the ALJ erred by failing
to account for Plaintiffs limited ability to rotate, extend and flex his neck in the RFC.” (PL’s
Br. at 1.) The Court considers these claims together because they all relate to the setting of
the RFC.
As set out above, “[a] Social Security claimant’s RFC represents ‘the most [he] can still
do despite [his] limitations.”” Dowling v. Comm’t of Soc. Sec. Admin., 986 F.3d 377, 387 (4th
Cir. 2021) (quoting 20 C-F.R. § 416.945(a)(1)). In assessing a claimant’s RFC, the AL] must
consider that individual’s “ability to meet the physical, mental, sensory, and other requirements
of work.” 20 C.F.R. § 404.1545(a)(4).
As Social Security Ruling (“SSR”) 96-8p instructs, “[t]he RFC assessment must first
identify the individual’s functional limitations or restrictions and assess his or het work-related
abilities on a function-by-function basis,” including the functions listed in the regulations.
Social Security Ruling 96-8p: ‘Titles II and XVI: Assessing Residual Functional Capacity in
Initial Claims, SSR 96-8p, 61 Fed. Reg. 34474, 34475, 1996 WL 374184, at *1 (July 2, 1996).
“Only after such a function-by-function analysis may an ALJ express RFC in terms of the
exertional levels of work.” Monroe v. Colvin, 826 F.3d 176, 179 (4th Cir. 2016) (internal
quotation omitted). Further, the “RFC assessment must include a narrative discussion
describing how the evidence supports each conclusion, citing specific medical facts (e.g.,
laboratory findings) and nonmedical evidence (e.g., daily activities, observations).” SSR 96-
8p, 61 Fed. Reg. at 34478, 1996 WL 374184, at *7. An ALJ 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) (internal brackets,
emphases, and quotation omitted).
The Fourth Circuit has noted that a per se rule requiring remand when the ALJ does not
perform an explicit function-by-function analysis “is inappropriate given that remand would
ptove futile in cases where the ALJ does not discuss functions that are ‘irrelevant or
uncontested.”” Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting Cichocki v.
Asttue, 729 F.3d 172, 177 (2d Cir. 2013) (per curiam)). Rather, remand may be appropriate
“where an AL] fails to assess a claimant’s capacity to perform relevant functions, despite
conttadictoty evidence in the record, or where other inadequacies in the AL]’s analysis
frustrate meaningful review.” Mascio, 780 F.3d at 636 (quoting Cichocki, 729 F.3d at 177).
The court in Mascio concluded that remand was appropriate because it was “left to guess
about how the ALJ atrived at his conclusions on [the claimant’s] ability to perform relevant
functions” because the AL] had “said nothing about [the claimant’s] ability to perform them
for a full workday,” despite conflicting evidence as to the claimant’s RFC that the ALJ did not
address. Mascio, 780 F.3d at 637. The Fourth Circuit has further explained that “a proper
REC analysis has three components: (1) evidence, (2) logical explanation, and (3) conclusion.”
Thomas v. Berryhill, 916 F.3d 307, 311 (4th Cir. 2019). The ALJ “must include a narrative
discussion describing how the evidence supports each conclusion, citing specific medical facts
(e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations).”
Montoe, 826 F.3d at 189 (quoting Mascio, 780 F.3d at 636).
In the present case, Plaintiff contends that the ALJ failed to include limitations relating
to his contested abilities to rotate, extend, and flex his neck or, in the alternative, explain the
omission of such limitations. Plaintiff further argues that the ALJ failed to explain why she
omitted limitations relating to Plaintiff's alleged need to recline and medication side effects,
including time off task. Ultimately, none of these omissions require remand under Mascio,
Dowling, and their progeny.
In setting the RFC, the ALJ noted Plaintiffs testimony that he has a neck injury and
neck pain that makes it “difficult for him to turn his neck, look down, or look up.” (Tr. at
32.) The ALJ also quoted Plaintiffs testimony about his need to recline, specifically that he
“has to lay down on his left side ‘in a weitd position to relieve pressure.” (Tr. at 32.) The
ALJ also noted Plaintiffs testimony that he “takes muscle relaxers twice a day but avoids pain
pills as he does not want to become addicted.” (Tr. at 32.)
The AL] then considered the medical evidence at length, which reflected initial visits
and imaging in February/March 2019, chiropractor visits in 2019 and 2020, several visits to
an otthopedist in July/August 2020, a Consultative Examination in February 2021, along with
ongoing healthcare at the VA throughout the relevant period. As explained by the ALJ, these
records reflect that although the orthopedist noted significant findings and offered surgery in
July 2020, at Plaintiffs last visit with the orthopedist in August 2020:
[Plaintiff] reported to Dr. Daubert on August 31, 2020 that “his neck pain has
significantly improved with stretching and using a roller to decompress.” His
neck range of motion was now “fairly good” and he was “now able to bend
ovet, when he was unable to in the past.” On examination, Dr. Daubert noted
the claimant as having intact strength in his bilateral upper extremities,
improved bilateral range of motion of his neck and normal reflexes, though the
Hoffman sign was still positive. He added that the claimant was not ready to
consider sutgety. They did agree to obtain a CT angiogram “to track the
position of the vertebral artery” and to follow-up in three months.
(Tr. at 35, 329-31.) Plaintiff did not return to the orthopedist, and at a visit four months later
at the VA, he confirmed his continued improvement, noting that:
The claimant was seen by Dr. Paruchuri with the Kernersville VA Clinic on
December 17, 2020. He reported “doing better of late with significant
imptovement in his pain levels in the neck and lower back” which he attributed
to his chiropractic treatment sessions. He denied having any new weakness in
the extremities and Dr. Paruchuri observed that [Plaintiff] was “actually
ambulating quite well and is able to do most of his daily activities ... including
yatdwork.” He noted [Plaintiff's] gait was normal, and there was no paraspinal
tenderness in the lumbosacral region. Similarly there were no focal motor
deficits, and the claimant’s extremities had no edema and distal pulses were
palpable.
(Tr. at 32, 592) (omission in original). The ALJ also considered the results of the Consultative
Examination two months later in February 2021:
On February 2, 2021, [Plaintiff] underwent a consultative medical examination
with Mohammed Ali-Eltom, M.D. He reported having chronic neck pain and
back pain, and feeling numbness in his hands and feet. He can drive himself,
take cate of personal needs, and go shopping, but has limitations carrying heavy
weights and he “feels stiff and lays down” after mowing the yard. Dr. Ali-Eltom
observed [Plaintiff] having a steady and symmettic walking gait, but he was
unable to tise from a seated position without arm assistance. He could squat
with moderate difficulty, but his toe and heel walking and tandem walk were
normal. [Plaintiffs] muscle strength was full in all muscle groups, and his
muscle bulk and tone were normal. Sensory exams showed light touch and
pinprick were grossly intact throughout the bilateral upper and lower
extremities. Dr. Ali-Eltom diagnosed the claimant with cervical myelopathy
with radiculopathy, lumbar spinal canal stenosis, and a history of calcification
of the longitudinal ligament.
(Tr. at 35-36, 505-09.) The ALJ also found persuasive the opinions of the state agency medical
consultants, Dr. Karen Roane and Dr. Nancy Simpkins. Dr. Roane and Dr. Simpkins both
reviewed all of the imaging cited by Plaintiff, as well as the medical records and the
Consultative Examination, and found that Plaintiff was capable of working, specifically:
Karen Roane, M.D., a State agency medical consultant, examined the claimant’s
medical records on February 16, 2021 and found that the claimant could
perform work at the light exertional level except he could frequently but not
constantly push and pull due to his chronic neck pain, can frequently engage in
balancing, stooping, kneeling, crouching, crawling, and climbing of stairs and
ramps, but can occasionally climb ropes, ladders, or scaffolds. He is also limited
to frequent but not constant reaching overhead, and should avoid concentrated
exposute to fumes, odots, gases, poor ventilation, or other pulmonary irritants,
as well as to workplace hazards such as moving machinery and unprotected
heights. On June 29, 2021, Nancy Simpkins, MD, another State agency medical
consultant, also reviewed the available evidence and endorsed Dr. Roane’s
findings. The undersigned finds these findings mostly persuasive, but finds that
the claimant’s cervical degenerative disc disease does support additional
limitations regarding the claimant’s capacity to perform handling and fingering
to the extent described above.
(Tr. at 37-38, 91-95, 99-103) (internal citations to record omitted). The AL] then set the RFC,
specifically based on:
the extensive objective diagnostic imaging reports, the treatment notes of the
claimant’s primary care physician, his examining orthopaedic specialist, and the
consulting medical examiner Dr. Ali-Eltom, the clatmant’s noted response to
treatment, especially chiropractic cate, and the findings of the State agency
10
medical consultants. Such a residual functional capacity reasonably
accommodates the claimant’s consistent and supported limitations.
(Ir. at 38.) Thus, this is not a case where the ALJ failed to explain her reasoning , and the
evidence cited by the AL] provides substantial evidence to support her conclusions.
With regard Plaintiffs ability to rotate and extend his neck, Plaintiff relies on an
unpublished case from the Eastern District of North Carolina. In Salter v. Kijakazi, No. 2:20-
CV-43-BM, 2021 WL 4501871, at *4-5 (E.D.N.C. Sept. 30, 2021), the court found that “at
least contradictory evidence exist[ed] regarding [the plaintiffs] ability to rotate and twist his
neck” and that “[t]he assessment of this function [was] critically relevant to, and potentially
outcome determinative of, [the plaintiffs] disability status.” The court concluded that it was
“fncumbent upon the ALJ to assess [the plaintiff's] ability to rotate and twist his neck, and to
explain whether [the plaintiff] requires any additional functional limitation in his RFC related
to this ability.” Salter, 2021 WL 4501871, at *5. However, in Salter, at least some of the
medical treatment and opinion evidence suggested that the plaintiff in that case would require
neck-related limitations which were ultimately omitted, without explanation, from the RFC
assessment. In contrast, in the present case, as set out in the ALJ’s decision, the providers
who issued medical opinions in this case all acknowledged that Plaintiff experienced chronic
neck pain which caused significant limitations. The ALJ, the state agency consultants, and the
consultative examiner, Dr. Mohammed Ali-Eltom, all recounted Plaintiffs MRI results and
physical examinations related to his cervical impairments. In light of these findings, Dr. Al-
Eltom opined that Plaintiff was only capable of work at the light exertional level and that he
could only perform occasional climbing and crawling. (Tr. at 509.) The state agency medical
consultants at the initial and reconsideration levels issued similar opinions based on a review
11
of the entite medical record. ‘The state agency consultant at the initial level, Dr. Karen Roane,
set out at length Plaintiffs imaging results (Ir. at 91), treatment records, and the results of the
Consultative Examination (Ir. at 93), and specifically concluded that Plaintiff could still
perform light work involving standing and/or walking for 6 hours and sitting for 6 hours in
an 8 hour workday, but was limited to frequent-but-not-constant pushing and pulling “due to
chronic neck pain” and light exertion “given pain/cervical stenosis.” (Tr. at 93.) Dr. Roane
further limited Plaintiff to only occasional ladders and ropes due to “cervical spine disease
with painful neck rom [range of motion].” (Tr. at 94.) In addition, Dr. Roane limited Plaintiff
to “no unprotected heights given cervical disc disease with painful neck rom [range of
motion].” (Tr. at 94.)
On reconsideration, the state agency consultant Dr. Nancy Simpkins similarly reviewed
the imaging, the treatment records, and the Consultative Examination, and similarly concluded
that Plaintiff could still perform light work involving standing and/or walking for 6 hours and
sitting for 6 houts in an 8 hour workday, but was limited to frequent-but-not-constant pushing
and pulling “due to chronic neck pain” and light exertion “given pain/cervical stenosis.” (Tr.
at 101.) Dr. Simpkins further limited Plaintiff to only occasional ladders and topes due to
“cervical spine disease with painful neck rom [range of motion]” (Tr. at 102), and limited
Plaintiff to “no unprotected heights given cervical disc disease with painful neck rom [range
of motion].” (Tt. at 103.) Thus, these physician opinions specifically considered Plaintiffs
limited range of motion in his neck, and included provisions in the proposed RFC to account
for those limitations. As noted above, the ALJ found these opinions persuasive and included
all of these limitations, but also determined that Plaintiffs “cervical degenerative disc disease
12
does support additional limitations regarding [his] capacity to perform handling and fingering.”
(Tr. at 37-38.) No provider, treating or otherwise, opined that Plaintiff required any additional
neck-related limitations. Thus, given the extensive exertional, postural, handling, and
environmental limitations already included in the RFC and expressly based, in large part, on
Plaintiffs neck impairment, the Court finds no basis for remand.
Plaintiff also challenges the ALJ’s failure to include his claimed limitations regarding
the need for both time off task and a reclined position. Both of these alleged limitations rest
entitely on Plaintiffs subjective complaints. In pertinent part, and as recounted in the AL]’s
decision, Plaintiff testified that, if he “sits in one position for too long he will get a sharp pain
up his right side ‘all the way up to [his head]”” and “has to lay down on his left side ‘tn a weird
position to relieve [the] pressure.” (Tr. at 32.) He typically uses either a bed with pillows or
a teclinet to achieve the “semi-fetal position” in which he “stay[s] most of the time.” (T'. at
69.) In terms of time off task, Plaintiff testified that he dislikes taking pills, and that he has
consistently declined taking the pain pills prescribed to him. (See Tr. at 32, 72-73.) However,
he typically takes muscle relaxers twice a day, “[uJnless [he has] to go somewhere,” in which
case he avoids taking them because they make him feel tired. (Tr. at 32, 73.)
Under the applicable regulations, the AL]’s decision must “contain specific reasons for
the weight given to the individual’s symptoms, be consistent with and supported by the
evidence, and be clearly articulated so the individual and any subsequent reviewer can assess
how the adjudicator evaluated the individual’s symptoms.” Social Security Ruling 16-3p, Titles
II and XVI: Evaluation of Symptoms in Disability Claims, SSR 16-3p, 2017 WL 5180304, at
*10 (Oct. 25, 2017) (SSR 16-3p”); see also 20 C.F.R. § 404.1529. Moreover, in Arakas v.
13
Commissioner, Social Security, 983 F.3d 83 (4th Cir. 2020), the Fourth Circuit clarified the
procedure an ALJ must follow when assessing a claimant’s statements:
When evaluating a claimant’s symptoms, ALJs must use the two-step
framework set forth in 20 C.F.R. § 404.1529 and SSR 16-3p, 2016 WL 1119029
(Mar. 16, 2016). First, the ALJ must determine whether objective medical
evidence presents a “medically determinable impairment” that could reasonably
be expected to produce the claimant’s alleged symptoms. 20 C.F.R.
§ 404.1529(b); SSR 16-3p, 2016 WL 1119029, at *3.
Second, after finding a medically determinable impairment, the ALJ must assess
the intensity and persistence of the alleged symptoms to determine how they
affect the claimant’s ability to work and whether the claimant is disabled. See 20
CF.R. § 404.1529(c); SSR 16-3p, 2016 WL 1119029, at *4. At this step,
objective evidence is zof required to find the claimant disabled. SSR 16-3p, 2016
WL 1119029, at *4-5. SSR 16-3p recognizes that “symptoms cannot always be
measured objectively through clinical or laboratory diagnostic
techniques.” Id. at *4. Thus, the AL] must consider the entire case record and
may “not disregard an individual’s statements about the intensity, persistence,
and limiting effects of symptoms solely because the objective medical evidence
does not substantiate” them. Id. at *5.
983 F.3d at 95 (internal brackets omitted).
Here, the ALJ considered Plaintiffs subjective allegations, including pain and fatigue
due to medication use, and found as follows:
[Plaintiff] does have underlying medically determinable impairments that could
and reasonably do cause some symptomatology. However, the pivotal question
is not whether such symptoms exist, but whether those symptoms occur with
such frequency, duration or severity as to reduce [Plaintiffs] residual functional
capacity as set forth above or to preclude all work activity on a continuing and
regular basis.
In this case, a cateful review of the tecotd does not document sufficient
objective medical evidence to substantiate the severity of the pain and degree
of functional limitations alleged by [Plaintiff]. While [Plaintiff] was injured in a
motot vehicle accident that coincided with his alleged onset date of disability,
he has benefited from conservative treatment. Although a surgeon did
recommend a spinal fusion, [Plaintiff] declined to have that surgery and
treatment notes at the time show his condition was stable, his symptoms
tolerable, and his ability to perform activities fairly robust. Contrary to
14
[Plaintiffs] testimony, the record does not show that he was advised that a
spinal fusion would leave him in more pain than before such surgery. He
cettainly has some ongoing limitations resulting from his injuries and his other
impairments, but the range of light work provided should adequately account
for his symptoms and limitations.
(Tr. at 36) (internal citation to record omitted). The ALJ then assessed the RFC in detail as
set out above, and concluded that “to the extent that [Plaintiff] alleges limitations greater than
those set forth in the current residual functional capacity finding, [the ALJ] finds those claims
ate not consistent with or supported by the evidence.” (Tr. at 38.)
In short, the ALJ determined at the second step of her subjective symptom analysis
that Plaintiff was not limited to the full extent he alleged. The ALJ provided an adequate basis
for her findings regarding Plaintiffs alleged symptoms, and the Court finds no basis to disturb
these determinations. Plaintiff specifically points to his testimony regarding his need to recline, □
but Plaintiff points to no evidence, including treatment notes or medical opinions, supporting
his testimony that he must recline in a “semi-fetal position,” let alone that he must do so for
most of the day. With respect to side effects from his medication, Plaintiff testified that he
typically took muscle relaxers twice daily, but he also stated that, when he had plans during the
day, such as activities outside the house, he skipped his medication to avoid being tired. (T't.
at 73.) The record reflects that he was prescribed the muscle relaxer cyclobenzaprine (Flexeril),
but Plaintiff does not point to any basis in the record to support his claim of daytime tiredness
based on the Flexeril.5 Ultimately, the AL] made her symptom evaluation and assessed the
5 Notably, the medical record reflects that in March 2019, shortly after his accident, Plaintiff reported feeling
“motion sickness” that he attributed to the Flexeril, so his primary cate doctor tried methocarbamol for muscle
spasms in March/April of 2019, but the records note that methocarbamol “causes drowsiness,” and it was
discontinued in April 2019. (Tr. at 679, 682, 687, 692, 695, 697, 767.) Over a year later, in June 2020, Plaintiff
was seen for back pain, and the provider noted that he was “apparently using an old RX of hydrocodone, which
[they] encouraged him to avoid” and they instead prescribed the “intermittent cyclobenzaprine which he has
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RFC in detail as set out above, and concluded that “to the extent that [Plaintiff] alleges
limitations greater than those set forth in the current residual functional capacity finding, [the
ALJ] finds those claims are not consistent with or supported by the evidence.” Plaintiff
provides no basis to question that determination.
Here, the ALJ reviewed the evidence, explained her decision, and clearly explained the
reasons for her determination. That determination is supported by substantial evidence in the
record. Plaintiff has not identified any errors that require remand, and Plaintiff's Motion to
Reverse the Decision of the Commissioner should therefore be denied.
IT IS THEREFORE ORDERED that the Commissionet’s decision finding no
disability is AFFIRMED, that Plaintiffs Dispositive Brief [Doc. #9] is DENIED, that
Defendant’s Dispositive Brief [Doc. #12] is GRANTED, and that this action is DISMISSED
with prejudice.
This, the 20% day of March, 2024.
/s/ Joi Elizabeth Peake
United States Magistrate Judge
used in the past.” (Tr. at 618.) The records reflect that from June 2020 through November 2021, he was
specifically prescribed cyclobenzaprine (Flexeril) “one tablet by mouth at bedtime as needed.” (I'. at 364, 369,
377, 517, 520, 525, 528, 540, 557, 561, 569, 575, 580, 584, 587, 592, 596, 600, 606, 746, 748, 757.) There is no
record of any report of side effects, and no report of daytime tiredness as a result of the medication, which was
to be taken at bedtime. Thus, the record indicates only two reports of side effects: a possible association with
motion sickness in March 2019, but no subsequent reports of any such issues after it was prescribed from June
2020 to November 2021, and a noted side effect of drowsiness caused by a different medication that was
ptescribed only in March/April 2019.
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