The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF NORTH CAROLINA
YESENIA G., )
Plaintiff,
v. 1:23CV308
MARTIN J. O7MALLEY;!
Commissioner of Social Security, )
Defendant.
MEMORANDUM OPINION AND ORDER
OF UNITED STATES MAGISTRATE JUDGE
Plaintiff Yesenia G. (“Plaintiff”) brought this action pursuant to Sections 205(g) and
1631(c)(3) of the Social Security Act (the “Act”), as amended (42 U.S.C. §§ 405(g) and
1383(c)(3)), to obtain judicial review of a final decision of the Commissioner of Social Security
denying her claims for Disability Insurance Benefits under Title IT of the Act and her claim
for Supplemental Security Income (“SSI”) under Title XVI 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 applications her Title II applications on February 11, 2020
and her Title XVI application on January 22, 2020. (Tr. at 19, 567-84.)? In both applications,
1 On December 20, 2023, Martin J. O’Malley was sworn in as Commissioner of Social Secutity, replacing Acting
Commissioner Kilolo Kajakazi. 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
o. this suit by reason of the last sentence of section 405(g) of the Social Security Act, 42 U.S.C. §
2 Transcript citations refer to the Sealed Administrative Record [Doc. #5].
she alleged disability beginning June 28, 2019, the day after a previous disability claim was
denied. (Tr. at 19, 21, 173.) Plaintiffs applications were denied initially (Ir. at 197-231, 359-
69) and upon reconsideration (Tr. at 235-54, 275-94, 374-83). Thereafter, Plaintiff requested
an administrative hearing de novo before an Administrative Law Judge (“ALJ”). (Tr. at. 405-
17.) On April 21, 2022, Plaintiff, along with her attorney, attended the subsequent telephonic
heating, at which both Plaintiff and an impartial vocational expert testified. (Tr. at 19.)
Following this hearing, the ALJ concluded that Plaintiff was not disabled within the meaning
of the Act (Tr. at 37), and on February 9, 2023, the Appeals Council denied Plaintiff's request
for review of the decision, thereby making the ALJ’s conclusion the Commissionet’s final
decision for purposes of judicial review (T'r. at 4-9).
Il. LEGAL STANDARD
Federal law “authorizes judicial review of the Social Security Commissioner’s dental 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 are 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
ALJ if they ate supported by substantial evidence and were reached through application of the
cottect legal standard.” Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012) (Gnternal
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)
(quoting Richardson v. Perales, 402 U.S. 389, 390 (1971)). “It consists of more than a mete
scintilla of evidence but may be somewhat less than a preponderance.” Mastro v. Apfel, 270
F.3d 171, 176 (4th Cir. 2001) Gnternal citations and quotation marks omitted). “If there is
evidence to justify a refusal to direct a verdict were the case before a jury, then there is
substantial evidence.” Hunter, 993 F.2d at 34 (internal quotation marks 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
[ALJ].” Mastto, 270 F.3d at 176 (internal brackets and quotation marks 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. “The issue before
[the reviewing court], therefore, is not whether [the claimant] is disabled, but whether the
ALJ’s finding that [the claimant] is not disabled is supported by substantial evidence and was
reached based upon a 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 bears 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
petiod 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 US.C. § 401 et seq., provides benefits to
disabled persons who have contributed to the progtam while employed. The Supplemental Security Income
Program (SSI), established by Title XVI of the Act as amended, 42 U.S.C. § 1381 et seq., provides benefits to
indigent disabled persons. The statutory definitions and the regulations promulgated by the Secretary for
“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 severe impairment; (3) had an impairment that met or equaled the
tequitements 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 are 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 cleats steps one and two,
but falters at step three, ie., “[i]fa claimant’s impairment is not sufficiently severe to equal or
exceed a listed impairment,” then “the ALJ must assess the claimant’s residual functional
capacity (RFC’).” Id. at 179.4 Step four then requires the ALJ to assess whether, based on
determining disability, see 20 C.F.R. pt. 404 (SSDI); 20 C.F.R. pt. 416 (SSI), governing these two programs ate,
in all aspects relevant here, substantively identical.” Craig, 76 F.3d at 589 n.1.
+ “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 marks
omitted)). The RFC includes both a “physical exertional or strength limitation” that assesses the claimant’s
“ability to do sedentary, light, medium, heavy, or very heavy work,” as well as “nonexertional limitations
(mental, sensory, or skin impaitments).” Hall, 658 F.2d at 265. “RFC is to be determined by the ALJ only after
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 claimant’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.
Ill. DISCUSSION
In the present case, the ALJ found that Plaintiff had not engaged in “substantial gainful
activity” since her alleged onset date. The ALJ therefore concluded that Plaintiff met her
burden at step one of the sequential evaluation process. (It. at 24.) At step two, the ALJ
further determined that Plaintiff had the following severe impairments:
migraines; obstructive sleep apnea; degenerative disc disease, depression; mild
intellectual disability; and cellulitis[.]
(Tr. at 24.) The AL] determined at step three that none of the impairments identified at step
two, individually or in combination, met or equaled a disability listing. (Ir. at 25-27.) He
[the ALJ] considers all relevant evidence of a claimant’s impairments and any related symptoms (2,,, pain).”
Hines, 453 F.3d at 562-63.
therefore assessed Plaintiff's RFC and determined that Plaintiff could perform light work with
the following, non-exertional limitations:
[Plaintiff is capable of] sitting for 6 hours with the need to alternate to standing
for 5 to 10 minutes after every 1 hour of sitting; standing for 6 hours with the
need to alternate to sitting for 5 to 10 minutes after every 1 hour of standing;
and walking for 6 hours with the need to alternate to sitting for 5 to 10 minutes
after every 1 hour of walking. She has frequent ability to reach overhead
bilaterally. She can occasionally climb ramps and staits, but never climb ladders,
ropes or scaffolds. She can occasionally balance and stoop, but never kneel,
crouch ot crawl. [Plaintiff] can never be exposed to unprotected heights,
moving mechanical parts, or vibration. [Her] ability to understand, remember,
and catty out instructions could be accommodated by the performance of
simple, routine, repetitive tasks done not at a production rate pace (e.g. assembly
line work). She is able to perform simple work-related decisions in the exercise
of her judgment. She is able to interact and respond appropriately with
supetvisots, coworkers, and the public on an occasional basis. She is able to
make simple work-related decisions in dealing with changes in the work setting.
[Plaintiff's] time off-task would be accommodated by the performance of
simple, routine, repetitive tasks.
(Tr. at 27-28.) Based on this determination and the testimony of a vocational expert, the ALJ
determined at step four of the analysis that Plaintiffs past relevant work exceeded her RFC.
(Tr. at 35.) However, the ALJ found at step five that, given Plaintiff's age, education, work
experience, RFC, and the testimony of the vocational expert as to these factors, she could
perform other jobs available in significant numbers in the national economy. (Tr. at 35-36.)
The AL} therefore concluded that Plaintiff was not disabled under the Act. (Ir. at 37.)
Plaintiff now raises two challenges to the ALJ’s RFC assessment. Fitst, she contends
that the AL] failed to “account for the vocationally limiting effects of Plaintiffs chronic
migraines in the [RFC.]” (PL’s Br. [Doc. #12] at 1, 5-11.) Second, Plaintiff argues that the
AL] failed to “perform a proper function-by-function evaluations of Plaintiffs ability to
handle and finger with the non-dominant left upper extremity.” (PI.’s Br. at 1, 12-16.) After
a thorough review of the record, the Court finds no basis for remand.
A. Migraines
Plaintiff first argues that, in assessing her RFC, the ALJ failed to include any RFC
resttictions to account for the limiting effects of Plaintiffs frequent migraine headaches or, in
the alternative, explain the absence of such restrictions. Plaintiff contends that she presented
ample evidence of her ongoing migraine symptoms during the time period at issue, including
light sensitivity, intractable pain, and extended recovery times. The ALJ included migraines
among Plaintiffs severe impaitments at step two of the sequential analysis, but Plaintiff
contends that the RFC contains no limitations specifically addressing headaches or theit effect
on Plaintiffs ability to work.
Plaintiff argues that the ALJ erred in finding Plaintiffs statements regarding the limiting
effects of her headaches less than fully consistent with the medical evidence and other
evidence of record. Under the applicable regulations, the ALJ’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 I] and XVI: Evaluation of Symptoms in Disability Claims, 2017 WL
5180304 (Oct. 25, 2017) (“SSR 16-3p”); see also 20 C.F.R. § 404.1529. Moreover, in Arakas
v. Commissioner of 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
C.E.R. § 404.1529(c); SSR 16-3p, 2016 WL 1119029, at *4. At this step,
objective evidence is mot requited to find the claimant disabled. SSR 16-3p, 2016
WL 1119029, at *4-5. SSR 16-3p recognizes that “[s]ymptoms cannot always
be measured objectively through clinical or laboratory diagnostic
techniques.” Id. at *4. Thus, the ALJ 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.
Arakas, 983 F.3d at 95. Thus, the second part of the test requires the ALJ to consider all
available evidence, including Plaintiffs statements about her pain, in order to evaluate “the
intensity and persistence of the claimant’s pain, and the extent to which it affects [her] ability
to work.” Craig, 76 F.3d at 595. This approach facilitates the ALJ’s ultimate goal, which is to
accurately determine the extent to which Plaintiffs pain or other symptoms limit her ability to
perform basic work activities. Relevant evidence for this inquiry includes Plaintiffs “medical
history, medical signs, and laboratory findings,” Craig, 76 F.3d at 595, as well as the following
factors set out in 20 C.F.R. § 416.929(c)(3) and 20 C.F.R. § 404.1529(c) (3):
(1) [Plaintiff's] daily activities;
(ii) The location, duration, frequency, and intensity of [plaintiffs] pain or
other symptoms;
(ii) Precipitating and aggravating factors;
(iv) The type, dosage, effectiveness, and side effects of any medication
[Plaintiff] take[s] or [has] taken to alleviate [her] pain or other symptoms;
(v) Treatment, other than medication, [Plaintiff] receive[s] or [has] received
for relief of [her] pain or other symptoms;
(vi) Any measures [Plaintiff] use[s] or [has] used to relieve [her] pain or other
symptoms (e.g., lying flat on [her] back, standing for 15 to 20 minutes
evety hour, sleeping on a board, etc.); and
(vit) Other factors concerning [Plaintiffs] functional limitations and
resttictions due to pain or other symptoms.
In the present case, contrary to Plaintiff's assertions, the ALJ provided more than
conclusory statements discounting Plaintiffs testimony. As instructed by the regulations, the
ALJ considered the entire case record and explained his reasons for deviating from Plaintiff's
statements regarding the impact of her symptoms on her ability to work. This explanation
was provided throughout the ALJ’s RFC discussion. For example, the ALJ considered
Plaintiffs treatment records regarding her headaches at great length. The ALJ noted that
Plaintiff sought treatment for her migraines on multiple occasions throughout the time period
at issue, typically in the emergency room setting. (I't. at 29-30) (see also Tr. at 925, 972, 700,
1000, 1026, 1040, 1055, 1621). On each occasion, she was given a “migraine cocktail” and
discharged. (Tr. at 29-30, 700, 972, 1000, 1026, 1040, 1054-55, 1626.)
Upon teferral to a neurologist in March 2020, Plaintiff reported that she had 23
migraines a month which could last “24-82 hours.” (T'r. at 1363.) Plaintiff further indicated
that she “never sleeps well,” snores, and “wakes frequently.” (Tr. at 1363.) She was previously
diagnosed with sleep apnea, but was not in treatment for that condition. (Tr. at 1368.) The
neurologist, Dr. Antonia Ahern, concluded that Plaintiff “needs to address sleep apnea and
have that treated, then I can revisit headaches if necessary.” (It. at 1368.) During a return
visit to neutology in October 2020, the provider noted that Plaintiff had 92 percent compliance
with CPAP usage over the preceding 90 days, and that using the CPAP machine had
dramatically improved Plaintiff's headaches. (T'r. at 31,1556.) In fact, Plaintiff endorsed only
one headache per week. (Tr. at 31, 1556.) Although Plaintiff indicated that some of these
headaches wete still of longer duration, she stated that they were considerably shortened when
she took Excedrin Migraine neat the time of onset. (Tt. at 31, 1556.)
Notably, a primary care treatment note dated April 23, 2021 reads as follows:
Patient reports that she stopped taking all of her medications greater than 3
months ago, and is requesting refills of all of her regularly scheduled
medications to get back on track. ... Reports that she had tolerated all of her
medications well, but that life got hectic and busy and she stopped taking them.
(Tr. at 1761.) Plaintiff reported at that time that she was “doing well” despite her lack of
medications. (Tr. at 32, 1761.) However, at a follow-up primary care appointment in June
2021, Plaintiff indicated that she “had recently given up driving due to excessive sleepiness”
(Tr. at 32, 1898), and she testified at the administrative hearing that she was no longer using a
CPAP machine (Tr. at 145.) Moreover, Plaintiff was dismissed from her previous neurology
practice on April 14, 2021 “due to several no-shows and last minute cancellations.” (Tt. at 33,
1898.)
Overall, in finding Plaintiff less limited than alleged, the ALJ relied on Plaintiffs
“consetvative treatment history showing good control of [her] symptoms” when using
medications and other treatments as prescribed. (Tr. at 29, 31, 33.) This is further developed
by the ALJ’s discussion of Plaintiffs treatment with medication (Ir. at 30-31), her significant
improvement and reduction of headaches when using her CPAP machine (Tt. at 31, 1556),
and her ability to manage the headaches with Excedrin (T't. at 31, 1556), as of her October
2020 appointment with her neurologist (I't. at 1556). The ALJ also relied on the treatment
5 That appointment note reflects that Plaintiff's neurologist expected that with continued use of the CPAP, her
migraines may continue to improve, and advised her to take Excedrin as soon as she feels she is getting a
migraine, and also noted the availability of other medications to address migraines as well. (Tr. at 1561.)
10
recotds and examinations, specifically “physical examinations generally showing no significant
neurological defects,” (Tr. at 29-30), and the ALJ also noted Plaintiff's failure to follow up and
seek further treatment such that she was dismissed from the neurology practice in April 2021
“due to several no-shows and last minute cancellations.” (Tr. at 32-33.) In the briefing,
Plaintiff cites to the medical treatment records, but consistent with the AL]’s analysis, these
records appear to teflect only one medical visit involving treatment for headaches after
October 2020, specifically when Plaintiff sought treatment in June 2021 for swelling and falling
asleep while driving, and received a Kenalog injection for her headache. (It. at 32-33, 1895,
1904.) The ALJ also relied on Plaintiffs “extensive activities of daily living.” (Tr. at 33), as
well as the prior decision dated June 29, 2019, denying Plaintiff's previous claim for disability
(Tr. at 34, 164). The AL] also relied on the opinions of the state agency consultants, including
Dr. Celeste Williams, who found that Plaintiffs migraines were a severe impaitment
sufficiently addressed by an exertional limitation to light work with postural limitations and a
limitation to no concenttated exposute to hazards such as machinery or heights. (Ir. at 189-
91.) In addition, the AL] specifically noted that Plaintiffs time off-task as a result of her
symptoms “would be accommodated by the performance of simple, routine, repetitive tasks.”
(Tr. at 28.) Plaintiff, who beats the burden of proving disability, presents no evidence that her
headaches would cause any specific work limitations. Even Plaintiffs own testimony does not
address or raise any limitations as a result of her migraines, and none of Plaintiffs providers
6 After the hearing, Plaintiff submitted additional medical records reflecting her treatment during 2021, none
of which included complaints or treatment for headaches. These records also reflect that tn October 2021,
Plaintiff reported to her doctor that she had a problem of methamphetamine abuse and was seeking “help to
get into rehab for methamphetamine abuse.” (Tr. at 2073.)
11
ot other medical sources opined that Plaintiffs headaches caused any limitations at all during
the time period in question.
Asa final matter, Plaintiff cites the Fourth Circuit’s recent decision in Oakes v. Kijakazi,
70 F.4th 207, 215 (4th Cir. 2023), for the proposition that “a claimant is entitled to rely
exclusively on subjective evidence to prove the severity of their symptoms.” (Pl.’s Br. at 10-
11 (quoting Hines, 453 F.3d at 565 and citing Oakes, 70 F.4th at 215).) Plaintiff stresses that
the Fourth Circuit remanded in Oakes “because the ALJ ‘never addressed the fact that
disability benefits can be awarded on the sole basis of an objective impairment and derivative
subjective pain[,]’ and further explanation was needed.” (Pl.’s Br. at 11 (quoting Oakes, 70
F.4th at 215-16).) However, in the present case, the AL] did not rely upon the absence of
objective evidence alone to discount Plaintiffs symptoms. Rather, the ALJ cited Plaintiffs
conservative treatment, her symptomatic improvement when compliant with treatment, and
her continuing ability to perform a variety of daily activities. (Tt. at 29, 31, 33, 35.) As set out
above, the ALJ specifically noted Plaintiffs conservative treatment history with good control
with medications when she complied with the CPAP usage, as well as her physical
examinations and treatment record, including the lack of follow-up with the neurologist. (See
also Tr. at 29, 31, 33.) Accordingly, this is not a scenario in which the AL] failed “to assess
[the] claimant’s capacity to perform relevant functions, despite contradictory evidence in the
record, ot where other inadequacies in the ALJ’s analysis frustrate meaningful review.” Mascio
v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting Cichocki v. Astrue, 729 F.3d 172, 177
(2d Cir. 2013) (per curiam)). Here, the AL] included Plaintiffs migraines among her severe
impairments, crafted the RFC to account for her credibly established limitations, and explained
12
the omission of additional limitations in accordance with the regulations and relevant case law,
including Arakas. Substantial evidence therefore supports this AL}’s determination.
B. Handling and Fingering
Plaintiff next contends that the ALJ erred by failing to perform a function-by-function
evaluation of evidence relating to Plaintiffs ability to handle and finger with her left hand,
despite evidence suggesting greater limitations. As Social Security Ruling (“SSR”) 96-8p
instructs, “[t]he RFC assessment must first identify the individual’s functional limitations ot
restrictions and assess his or her work-related abilities on a function-by-function basis,”
including the functions listed in the regulations. Social Security Ruling 96-8p: Policy
Interpretation Ruling Titles I] and XVI: Assessing Residual Functional Capacity in Initial
Claims, 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, 187 (4th Cir. 2016) Gnternal quotations and citations 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, 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)
(emphasis omitted).
The Fourth Circuit has noted that a per se rule requiring remand when the AL] 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 ot
13
uncontested.”” Mascio, 780 F.3d at 636 (quoting Cichocki, 729 F.3d at 177). Rather, remand
may be appropriate “where an ALJ fails to assess a claimant’s capacity to perform relevant
functions, despite contradictory evidence in the record, or where other inadequacies in the
ALJ’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 arrived at his conclusions on [the claimant’s] ability to perform
relevant functions” because the ALJ 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 AL]
did not address. Mascio, 780 F.3d at 637.
Hete, as set out above, Plaintiff challenges the ALJ’s analysis of evidence relating to
Plaintiffs ability to handle and finger with her left upper extremity. At the administrative
hearing, the following interchange took place between the ALJ and Plaintiff:
Q What symptoms ate you having with your left arm
A I have sharp pains in my left arm. It goes down to my shoulder blades
down to my left arm and my fingertips.
Q Does it affect your hands?
A Yes, it does.
Q How—can you button a blouse?
A Yeah, I can button a blouse, but sometimes it will grab my hand. It’s
like a cramp and it twisted by hands back.
Q It twists your hands back?
A And I get bad cramps. When I get the cramps, it kind of, you know,
turns it the other way and it grabs my hands.
14
Q Are you able to hold one of those small, plastic water bottles in your left
hand?
A No, but sometimes I can and sometimes I don’t. Tl have a like a sharp
pain in my left arm and it—I will give out on my hands. My hands will let it
drop.
(Tr. at 122.)
By way of background, Plaintiff underwent two cervical surgeries prior to her alleged
onset date: a C3-C6 anterior cervical discectomy and fusion in 2014 and a revision of that
procedure in May 2019. (Tr. at 30, 721, 1172.) She reported improvement following her
sutgeties, including improvement in pain radiating down her left arm. (I'r. at 1013, 1109,
1142.) Nevertheless, as Plaintiff correctly notes, treatment notes ftom the relevant time period
reflect that, at times, she continued to exhibit mildly reduced grip strength upon examination,
estimated as 4 or 4+ out of 5. (T'r. at 1013, 1109, 1142, 1703.) At other examinations, Plaintiff
was noted to have full (5/5) grip strength. (Tr. at 1428, 1516, 1560.) Plaintiff also consistently
demonstrated intact sensation during her examinations, despite subjective reports of tingling
and loss of sensation. (Ir. at 977, 1013, 1109, 1142, 1516, 1560, 1703, 2092.) The ALJ
specifically considered Plaintiff's cervical spine issues and related imaging as it related to her
“chronic neck pain with paresthesias in both arms” (Tr. at 31), and noted that an MRI in
November 2020
tevealed no new abnormality compared to previous cervical MRI scans, with
[Plaintiff] being status post C3-6 discectomy and fusion, with widely patent
central canal at each level but uncovertebral spurring causing mild left foraminal
narrowing at C4-5. Adjacent segment disease at the C6-7 level demonstrated a
shallow bulge and uncovertebral disease on the left causing mild central canal
and mild-to-moderate left foraminal narrowing.
(Ir. at 31.) Thus, the ALJ also relied on imaging reflecting that Plaintiffs cervical MRI and
CT results generally remained consistent over time.
15
The ALJ further noted that, although Plaintiff was referred to the UNC OT Hand
Center in August 2019 due to complaints of bilateral, radial-sided wrist pain, x-rays
demonstrated only minimal arthritic changes. (I't. at 30, 1069, 1075.) Plaintiffs provider
tecommended occupational therapy for thenar strengthening and supportive CMC splints for
comfort. (Tr. at 30, 1069.) However, Plaintiff attended only two occupational therapy
appointments. (Tr. at 1068, 1075.) As noted above in subsection A, Plaintiff also described
doing well in April 2021 even after she stopped all treatment, including all medications. (Tr.
at 32.)/
The AL] also considered and found persuasive the opinions of the State agency medical
consultants, who found that Plaintiff was capable of performing work at the light exertional
level with additional postural limitations. (Tr. at 33.) In this regard, the State agency medical
consultants at the initial and reconsideration levels, Drs. Celeste Williams and Stephanie
Green, considered the entire record, including Plaintiffs surgical history, imaging results, and
intermittent, mildly decreased etip strength, when rendering their medical opinions. (See Tr.
at 219-26, 268-74.) Although Dr. Williams found that Plaintiff required limitations to light
work and limitations in bilateral overhead teaching as a result of her cervical impairment,
neither she nor Dr. Green opined that Plaintiff required any limitations in handling, fingering,
7 As with Plaintiffs headache impairment, the ALJ sufficiently explained his reasons for deviating from
Plaintiff's statements regarding the impact of her symptoms on her ability to work. As set out above, the AL]
teviewed the medical evidence, the opinion evidence, Plaintiffs testimony, and the record, and explained the
analysis of Plaintiff's subjective complaints. The ALJ specifically noted that Plaintiff managed her cervical
symptoms conservatively, with pain management including Tylenol, Flexeril, and gabapentin (Tr. at 30), that
her physical examinations showed no significant neurological deficits, and that she showed good control of
symptoms when using her medications as prescribed (Ir. at 33). The AL] also relied upon the opinions of the
State agency medical consultants, as further discussed herein.
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ot feeling with either upper extremity. (I'r. at 225, 269, 274.) The ALJ included the limitation
to light work and Dr. Williams’ recommended limitation to no more than frequent reaching
overhead bilaterally to address Plaintiff's arm and neck impairment. (Tr. at 28, 225.) Plaintiff
does not contest the ALJ’s reliance on these findings, which represent the only medical
opinions of record.
Moreover, the ALJ also explicitly relied on the prior ALJ decision, decided just one day
prior to Plaintiffs alleged onset date. Specifically, on June 27, 2019, a different ALJ also
considered Plaintiff's similar claims and determined that Plaintiff remained capable of a limited
range of light work. (See Tr. at 161-73.) In that decision, the prior AL] considered Plaintiff's
“left hand numbness and tingling,” and particularly treatment records reflecting on some
occasions Plaintiffs reduced strength of “4/5”, but with other records reflecting “5 /5
strength”, “suggesting that [Plaintiff's] strength ranged from slightly diminished at 4/5 to
grossly intact at 5/5.” (Tr. at 162.) The prior ALJ concluded that “there are a few episodes
of atm or etip strength weakness, but these reports ate offset by other reports of intact
strength, and also reports of [Plaintiffs] activities of daily living that include dressing,
housework, and cooking.” (Tr. at 162.) The prior AL] did not include any handling, fingering,
ot teaching limitations in the RFC.
Plaintiff's present claims allege an onset date beginning the day after that prior decision,
on June 28, 2019, and in light of the prior decision, the AL] in the present case therefore
considered Albright v. Commissioner of Social Security Administration, 174 F.3d 473 (4th Cir.
1999) and Acquiescence Ruling (“AR”) 00-1(4) when evaluating the prior determination. The
ALJ found that:
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In connection with Albright, the undersigned gives the June 27, 2019 prior
decision from AL] Greenberg great weight. [Plaintiffs] alleged onset date is
June 28, 2019, the day after ALJ Greenberg’s decision, thus the previously
adjudicated period is very close in time to the period being adjudicated in this
claim. The AL]J’s finding of a residual functional capacity limiting [Plaintiff] to
light work activity with additional postural, environmental, and mental
limitations is consistent with the overall conservative treatment record during
the petiod at issue as described above, along with the claimant’s reported
extensive activities of daily living.
(Tr. at 34.) Plaintiff has not attempted to show any worsening or aggravation of this
impaitment since June 27, 2019, and as noted by the ALJ, the imaging of Plaintiffs cervical
spine did not reveal any new abnormalities (Tr. at 31), and the records reflect conservative
treatment since that time (Tr. at 29, 34). As noted above, Plaintiff elected not to complete
occupational therapy or other treatment and was discharged by her neurologist due to “several
no-shows and last minute cancellations.” (Tr. at 32-33.)
In the circumstances, the Court can sufficiently trace the ALJ’s reasoning regarding
Plaintiffs cervical impairment, including objective testing, medical opinion evidence, the prior
ALJ decision, and the treatment record, all of which provide substantial evidence to support
his finding that Plaintiff did not require specific handling, fingering, or feeling limitations.
Woods, 888 F.3d at 694. It is not the function of this Court to re-weigh the evidence or
reconsider the AL]’s determinations if they ate supported by substantial evidence. As noted
above, “[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.” Hancock, 667 F.3d at 472
(internal brackets and quotation omitted). Thus, the issue before the Court is not whether a
different fact-finder could have drawn a different conclusion, or even “whether [Plaintiff] is
disabled,” but rather, “whether the ALJ's finding that [Plaintiff] is not disabled is supported
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by substantial evidence and was reached based upon a correct application of the relevant law.”
Craig, 76 F.3d at 589. Here, the ALJ reviewed the evidence and explained the reasons for his
determination. Plaintiff has not identified any errors that require remand, and Plaintiffs
Motion to Reverse the Decision of the Commissioner will therefore be denied.
IT IS THEREFORE ORDERED that the Commissioner’s decision finding no
disability is AFFIRMED, that Plaintiffs Dispositive Brief [Doc. #12] is DENIED, that
Defendant’s Dispositive Brief [Doc. #13] is GRANTED, and that this action is DISMISSED
with prejudice.
This, the 30% day of September, 2024.
Dada
United Stites Magistrate Judge
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