“[O]ur general practice, which we see no reason to depart from here, is to take a lower tribunal at its word when it declares that it has considered a matter.”
How later courts described this case
- “[O]ur general practice, which we see no reason to depart from here, is to take a lower tribunal at its word when it declares that it has considered a matter.”
- “The ALJ was not required to obtain an expert medical opinion as to [the] RFC.”
Written by the judges who cited it.
The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA
HUNTINGTON DIVISION
PAUL J. DEAN,
Plaintiff,
vs. CIVIL ACTION NO. 3:20-CV-00566
ANDREW SAUL, COMMISSIONER OF
SOCIAL SECURITY,
Defendant.
PROPOSED FINDINGS AND RECOMMENDATION
This is an action seeking review of the final decision of the Commissioner of Social
Security denying the Plaintiff’s application for Disability Insurance Benefits (DIB) under Title II
of the Social Security Act, 42 U.S.C. §§ 401-433. By Order entered September 1, 2020 (ECF No.
3), this case was referred to the undersigned United States Magistrate Judge to consider the
pleadings and evidence, and to submit proposed findings of fact and recommendations for
disposition pursuant to 28 U.S.C. § 636(b)(1)(B). Presently pending before the Court are Plaintiff’s
Brief in Support of Motion for Judgment on the Pleadings, and Defendant’s Brief in Support of
Defendant’s Decision. (ECF Nos. 17, 19)
Having fully considered the record and the arguments of the parties, the undersigned
respectfully RECOMMENDS that the United States District Judge DENY Plaintiff’s request for
entry of an award for benefits or alternatively, remand (ECF No. 17); GRANT Defendant’s request
to affirm the decision of the Commissioner (ECF No. 19); AFFIRM the final decision of the
Commissioner; and DISMISS this matter from this Court’s docket for the reasons stated infra.
1
Procedural History
The Plaintiff, Paul J. Dean, (hereinafter referred to as “Claimant”), protectively filed his
application for benefits on or about December 14, 2017, alleging disability since May 30, 2015
due to diabetes, hearing loss, a broken back, enlarged prostate, torn tendon in the right arm, high
blood pressure, high cholesterol, and injuries to his left foot and ankle and chest as a result of a
motor vehicle accident (Tr. at 12, 267-274, 275-281, 298). His claim was initially denied on March
14, 2018 (Tr. at 167-177) and again upon reconsideration on June 25, 2018 (Tr. at 179-191).
Thereafter, Claimant filed a written request for hearing on August 10, 2018 (Tr. at 213-214).
An administrative hearing was held on November 7, 2019 before the Honorable Nathan
Brown, Administrative Law Judge (“ALJ”) (Tr. at 135-166). On December 5, 2019, the ALJ
entered an unfavorable decision. (Tr. at 9-25) On December 9, 2019, Claimant sought review by
the Appeals Council of the ALJ’s decision. (Tr. at 264-266) The ALJ’s decision became the final
decision of the Commissioner on June 29, 2020 when the Appeals Council denied Claimant’s
Request for Review. (Tr. at 1-6)
On August 27, 2020, Claimant timely brought the present action seeking judicial review of
the administrative decision pursuant to 42 U.S.C. § 405(g). (ECF No. 1) The Defendant
(hereinafter referred to as “Commissioner”) filed an Answer and a Transcript of the Administrative
Proceedings. (ECF Nos. 10, 11) Subsequently, Claimant filed a Brief in Support of Motion for
Judgment on the Pleadings (ECF No. 17), in response, the Commissioner filed a Brief in Support
of Defendant’s Decision (ECF No. 19). Consequently, this matter is fully briefed and ready for
resolution.
2
Claimant’s Background
Claimant last worked as an electrician in the petrochemical industry from 1998 through
2014 and last worked on May 30, 2015. (Tr. at 141, 154) He was 61 years old as of the alleged
onset date and considered a person closely approaching retirement age throughout the underlying
proceedings. See 20 C.F.R. § 404.1563(e). (Id.) Claimant has an associate degree in science. (Tr.
at 158, 297)
Standard
Under 42 U.S.C. § 423(d)(5) and § 1382c(a)(3)(H)(i), a claimant filing for disability
benefits has the burden of proving a disability. See Blalock v. Richardson, 483 F.2d 773, 774 (4th
Cir. 1972). A disability is defined as the “inability to engage in any substantial gainful activity by
reason of any medically determinable impairment which can be expected to last for a continuous
period of not less than 12 months . . . .” 42 U.S.C. § 423(d)(1)(A).
The Social Security Regulations establish a “sequential evaluation” for the adjudication of
disability claims, 20 C.F.R. § 404.1520. If an individual is found “not disabled” at any step, further
inquiry is unnecessary. Id. § 404.1520(a). The first inquiry under the sequence is whether a
claimant is currently engaged in substantial gainful employment. Id. § 404.1520(b). If the claimant
is not, the second inquiry is whether claimant suffers from a severe impairment. Id. § 404.1520(c).
If a severe impairment is present, the third inquiry is whether such impairment meets or equals any
of the impairments listed in Appendix 1 to Subpart P of the Administrative Regulations No. 4. Id.
§ 404.1520(d). If it does, the claimant is found disabled and awarded benefits. Id. If it does not,
the fourth inquiry is whether the claimant’s impairments prevent the performance of past relevant
3
work. Id. § 404.1520(f). By satisfying inquiry four, the claimant establishes a prima facie case of
disability. Hall v. Harris, 658 F.2d 260, 264 (4th Cir. 1981).
The burden then shifts to the Commissioner, McLain v. Schweiker, 715 F.2d 866, 868-69
(4th Cir. 1983), and leads to the fifth and final inquiry: whether the claimant is able to perform
other forms of substantial gainful activity, considering claimant’s remaining physical and mental
capacities and claimant’s age, education and prior work experience. Id. § 404.1520(g). The
Commissioner must show two things: (1) that the claimant, considering claimant’s age, education,
work experience, skills and physical shortcomings, has the capacity to perform an alternative job,
and (2) that this specific job exists in the national economy. McLamore v. Weinberger, 538 F.2d
572, 574 (4th Cir. 1976).
Summary of ALJ’s Decision
In this particular case, the ALJ determined that Claimant meets the requirements for
insured worker status through September 30, 2019. (Tr. at 14, Finding No. 1) Next, the ALJ
determined that Claimant had not engaged in substantial gainful activity since May 30, 2015, the
alleged onset date, through his date last insured (“DLI”), September 30, 2019. (Id., Finding No. 2)
At the second inquiry, the ALJ found that Claimant had the following severe impairments:
diabetes mellitus with neuropathy; obesity; right shoulder impingement syndrome; and
degenerative disc disease. (Id., Finding No. 3)
At the third inquiry, the ALJ concluded that Claimant’s impairments or combination
thereof did not meet or equal the level of severity of any listing in 20 C.F.R. Part 404, Subpart P,
Appendix 1 through his DLI. (Tr. at 15, Finding No. 4) The ALJ then found that Claimant had the
residual functional capacity (“RFC”) to perform medium work:
4
The claimant is capable of lifting/carrying/pushing/pulling 50lbs occasionally and
25lbs frequently; sitting for six hours; and standing or walking for six hours in a
workday. He can operate foot controls with the right foot frequently and with the
left foot occasionally. For all reaching, he can reach frequently with the right upper
extremity. The claimant can climb ramps and stairs frequently, climb ladders, ropes,
or scaffolds occasionally, crouch frequently, and crawl occasionally. The claimant
can work at unprotected heights frequently, with heavy/hazardous machinery
frequently, and in vibration frequently.
(Tr. at 16, Finding No. 5)
At step four, the ALJ found Claimant was capable of performing his past relevant work as
an electrician as it is generally performed. (Tr. at 20, Finding No. 6)
Finally, the ALJ determined Claimant had not been under a disability from May 30, 2015
through September 30, 2019. (Tr. at 21, Finding No. 7)
Claimant’s Challenges to the Commissioner’s Decision
In support of his appeal, Claimant asserts that the ALJ failed in his duty to fully develop
the medical evidence regarding Claimant’s physical impairments; he “completely ignored the
claimant’s testimony and the medical documentation from his treating physicians as to his medical
impairments and the limitations they cause him.” (ECF No. 17 at 12-14) Claimant also contends
that the ALJ failed to properly consider and evaluate the combined effects of his impairments,
which is supported by the uncontradicted medical evidence from multiple treating physicians. (Id.
at 14-15) The ALJ failed to consider the medical records of longtime treating physicians and
instead substituted his own opinion for those of Claimant’s treating physicians. (Id. at 15) Claimant
also states that the ALJ erred by relying on the opinions of non-treating and partial record-
reviewing state physicians. (Id.) Claimant argues this Court should find him disabled during the
relevant period, or alternatively, to remand so that his physical impairments can be fully developed
5
and a more accurate hypothetical question be posed to the vocational expert concerning Claimant’s
RFC. (Id.)
In response, the Commissioner asserts that Claimant failed to meet his burden of proof that
he was disabled, and that the ALJ satisfied her duty to develop the evidence to assess the
appropriate RFC based upon all the relevant evidence. (ECF No. 19 at 8-17) The Commissioner
also argues that the ALJ did consider Claimant’s testimony and self-reports regarding his
limitations, but compared them with the objective medical evidence when assessing his RFC. (Id.
at 10-12) Additionally, while the ALJ alone makes an RFC finding and is not required to be based
upon a specific medical opinion, the ALJ did not ignore Claimant’s treating physicians’ opinions,
but properly evaluated same under the pertinent Regulations. (Id. at 12-17) The Commissioner
further argues that Claimant fails to not only identify any specific Listing the combination of his
impairments supposedly met, but also fails to identify any specific evidence in support of his
generalized argument for same. (Id. at 17) The Commissioner points out that at step three, the ALJ
did consider Claimant’s impairments under the pertinent Listings, as well as the combined effects
of his impairments, and proceeded to consider them in the subsequent steps in his analysis. (Id. at
18-19) Finally, the Commissioner states that the final decision is supported by substantial evidence
and asks this Court to affirm. (Id. at 20)
The Relevant Evidence of Record1
The undersigned has considered all evidence of record pertaining to Claimant’s arguments
and discusses it below.
1 The undersigned focuses on the relevant evidence of record pertaining to the issues on appeal as referenced by the
parties in their respective pleadings.
6
Primary Care Provider Records:
Claimant saw his primary care physician, Robert Turner, M.D., throughout the relevant
period for management of chronic medical conditions, such as benign prostatic hyperplasia,
hypertension, hyperlipidemia, vitamin D deficiency, and diabetes mellitus (See, e.g., Tr. at 526,
532, 535). He was prescribed metformin HCI 1000 mg twice a day for his diabetes (Tr. at 534).
Although Claimant’s hypertension was generally controlled, he repeatedly registered blood glucose
and hemoglobin A1C readings that were clinically indicative of uncontrolled diabetes mellitus (Tr.
at 514, 519, 523, 528, 597, 602). Despite these readings, there was no evidence of comorbid
conditions such as diabetic retinopathy or repeated episodes of dizziness or syncope; in addition,
these records documented that Claimant had body mass index (“BMI”) scores greater than 30
kg/m2 during the relevant period (See, e.g., Tr. at 513, 527, 536, 596). Claimant’s physical
examinations were always normal showing he was in no acute distress with no neurological
deficits and normal motor dysfunction function, balance, gait, and station (Tr. at 513, 518, 522,
527, 532, 596, 602).
Emergency Room Records:
On October 12, 2015, Kanawha County Emergency Medical Services team of Brigit
Holloway, Paramedic, and Donald Ennis, EMT, attended to Claimant at the sight of a collision
and delivered him to Cabell Huntington Hospital Emergency Department; Claimant had an
abrasion on his head and was suffering a headache from the impact (Tr. at 426). When Claimant
presented to the emergency room, he was complaining of chest and forehead pain (Tr. at 433). A
physical examination was unremarkable showing a full range of motion throughout, normal muscle
strength, no signs of musculoskeletal tenderness or swelling, normal extremity fine motor function,
7
no focal deficits, and normal sensation (Tr. at 458). Given Claimant’s complaints, medical
providers ordered x-rays and CAT scans of his head, chest, pelvis, and abdomen; diagnostic
imaging of the cervical, thoracic, and lumbar spine showed generally mild signs of degenerative
disc disease with no acute findings (Tr. at 463, 464, 465) and diagnostic imaging of the chest,
abdomen and pelvis were also negative (Tr. at 465, 466). Physicians determined that Claimant did
not have a serious injury and discharged him in stable condition with instructions to follow up with
his primary care physician (Tr. at 442, 445). In November 2015 and May 2016, Claimant saw his
primary care physician following the motor vehicle accident but did not complain of any
musculoskeletal issues; he reported that he had been retired about a year, “feels fine”, and had
gone “camping twice already.” (Tr. at 521, 526).
Chiropractic Treatment:
On September 16, 2016, Claimant reported to Alan Wild, DC for treatment of pain in his
left foot and ankle connected to the October 2015 motor vehicle collision. (Tr. at 470) Dr. Wild
noted that Claimant’s Lateral and Medial Stability tests were positive with mild pain, and Tinel’s
foot sign, Simmond’s Test, and Achilles Tap Test were negative. (Id.) Following several weeks
of therapy, on October 28, 2016, Dr. Wild released Claimant from care, noting Claimant had
normal range of motion in his ankle; no pain with walking, standing, or bending; and no positive
orthopedic or neurological findings (Tr. at 473). Dr. Wild concluded by finding that Claimant
was back to his pre- accident status and had no residual symptoms (Id.).
On October 25, 2019, Dr. Wild completed a “Residual Physical Functional Capacity
Evaluation” indicating that Claimant: could stand, walk, or sit no more than two hours in an eight-
hour workday; alternate sitting and standing every thirty minutes; frequently and/or occasionally
8
lift/carry less than ten pounds; limited in both upper and lower extremities with respect to pushing
and/or pulling; should never climb ramps, stairs, ladders, ropes or scaffolds and never crawl; could
occasionally balance, stoop, and crouch; and should avoid all exposure to temperature extremes
and hazards (Tr. at 607). Dr. Wild opined that after reviewing Claimant’s “medicals for Social
Security Disability . . . [Claimant] has been disabled since May 2015.” (Id.)
State Agency Medical Consultant Opinions:
In March 2018, Narenda Parikshak, M.D., reviewed Claimant’s medical records and
concluded that his impairments did not satisfy the criteria in Listing 1.02 (Tr. at 172). Dr. Parikshak
further opined that Claimant retained the functional capacity to lift and carry fifty pounds
occasionally and twenty-five pounds frequently; stand for up to six hours a day and sit for up to
six hours; occasionally crawl and climb; frequently balance, stoop, kneel, and crouch; frequently
reach in all directions with his right arm; and should avoid concentrated exposure to extreme cold,
wetness, noise, and hazards (Tr. at 174-175).
In June 2018, Rabah Boukhemis, M.D., reviewed the updated record of evidence and
affirmed Dr. Parikshak’s assessment of Claimant’s residual functional capacity (Tr. at 187-189).
Consultative Physical Examination:
In May 2018, Claimant saw Stephen Nutter, M.D., for a consultative physical examination
at the behest of the state agency (Tr. at 559-564). Claimant reported a seven or eight-year history
of right arm problems due to a torn bicep, but he did not have surgery on it (Tr. at 559). He also
reported left ankle and foot pain, diabetes mellitus, hypertension, and asthma (Id.). On
examination, he had a normal gait and appeared stable in the supine and sitting positions (Tr. at
560). He had slight crepitus in both shoulders and some right biceps pain but no shoulder or left
9
arm tenderness; normal (5/5) grip strength; and normal shoulder, elbow, wrist, and finger range of
motion (Tr. at 561, 563). Examination of his lower extremities and cervical spine was normal
except for mildly reduced knee flexion (Id.). Dr. Nutter noted reduced range of motion in his
dorsolumbar spine, but no muscle spasm or tenderness and negative straight leg-raising test (Tr. at
561). An x-ray of Claimant’s left ankle revealed a calcaneal heel spur, but was otherwise normal
(Tr. at 564). Dr. Nutter assessed Claimant with a torn right biceps and chronic dorsolumbar strain
(Tr. at 562).
Scott Orthopedic Center – Jack Steel, M.D.:
On September 11, 2018, Claimant saw Dr. Jack Steel, an orthopedist, for evaluation of
right shoulder pain (Tr. at 572-573). Right shoulder x-rays showed no degenerative changes (Tr.
at 573), and Dr. Steel assessed Claimant with right shoulder impingement syndrome and right
proximal biceps tendon rupture (Tr. at 572). Dr. Steel referred Claimant to physical therapy and
advised him to use aspirin as an anti-inflammatory (Tr. at 573). Claimant subsequently participated
in a physical therapy program between September 17 and October 19, 2018 (Tr. at 609-630). When
Claimant returned to Dr. Steel on October 23, 2018, he endorsed improvement in his symptoms
(Tr. at 570). A physical examination documented mild infraspinatus atrophy in the right shoulder
and tenderness along the bicep groove, but Claimant had full (5/5) muscle strength throughout
both shoulders, intact extremity sensation, normal coordination, and normal walking gait (Id.). Dr.
Steel determined that Claimant had improved significantly and had no symptoms (Tr. at 571).
Body-Mind-Spirit Podiatric Center Records:
In August 2019, Claimant saw Brian Bailey, DPM, a podiatrist, for a chronic bilateral foot
pain as well as chronic ingrown toenail of his left great toe (Tr. at 632-634). On examination, Dr.
10
Bailey observed Claimant to be in good health who could heel to toe walk with ease and had full
(5/5) strength and full range of motion in the lower leg, ankle, and foot, though he did have pain
at the ingrown toenail (Tr. at 633). Dr. Bailey noted Claimant is a type 2 diabetic and started
paperwork for a custom diabetic insole shoe insert which would also help with the ankle pain (Tr.
at 634). Repeat physical examinations were unchanged (Tr. at 636, 639).
On October 30, 2019, Dr. Bailey completed a “Residual Physical Functional Capacity”
form noting Claimant’s diagnoses included diabetes, type II, right torn bicep, chronic dorsolumbar
sprain, “broke back”, hearing loss, enlarged prostate, high blood pressure, high chol[esterol],
injured left foot/ankle/chest, and asthma (Tr. at 644). Dr. Bailey opined that Claimant could lift
and carry no more than ten pounds, stand and walk less than two hours in an eight-hour workday,
and sit less than two hours in an eight-hour workday (Tr. at 644). Dr. Bailey stated that Claimant
would need to alternate positions all day, and he had limited ability to push and or pull with both
his upper and lower extremities (Id.). Dr. Bailey did not indicate any postural, manipulative,
communicative, or environmental limitations (Id.).
The Administrative Hearing
Claimant Testimony:
Claimant described his past work as an electrician, for which he wore a toolbelt that
weighed at least 25 pounds, and involved lifting, carrying, and pulling from 50 to 100 pounds
every day. (Tr. at 141-143) Claimant stated that he had upper and lower back pain everyday as
well as foot pain and shoulder pain; when walking, his foot bothers him more than his back. (Tr.
at 143-144) He testified that he takes medicine for his pain, which does help. (Tr. at 145) Claimant
testified that he is right hand dominant, and that he is unable to lift anything with his right arm due
11
to pain, and it will turn black and blue where the muscle had torn. (Tr. at 145-147) He stated he
can lift anything with his left hand, though. (Tr. at 147)
Claimant stated that if he walks too much, his feet hurt and throb at nighttime. (Tr. at 148)
He estimated that he could walk about four blocks, but he walked a block the other day and his
foot was hurting (Tr. at 149). He testified that he cannot sit long, but can sit through an hour for
church services, but his back hurts (Tr. at 148). Claimant testified that he gets dizzy a lot, and was
unsure if it was his blood pressure or when he gets hot; he has ringing in his ears, and although
hearing aids were not recommended, he was told that he has severe hearing loss (Tr. at 149).
Vocational Expert (“VE”) Testimony:
After listening to Claimant’s testimony, the VE determined that Claimant’s past work as
an electrician is classified as medium and skilled as generally performed, but heavy as Claimant
performed it. (Tr. at 159) After having considered a hypothetical question posed by the ALJ with
regard to an individual with Claimant’s functional profile (Tr. at 160-162), the VE testified that an
individual of Claimant’s age, education, and vocational background who had Claimant’s
limitations as described in the RFC, supra, would be able to perform Claimant’s past relevant work
as an electrician, but not as performed by Claimant (Tr. at 162). The VE further testified that there
were no transferable skills to light or sedentary work (Id.).
In response to questioning by Claimant’s attorney, the VE testified that a hypothetical
including the limitation endorsed by Drs. Bailey and Wild, Claimant’s treating providers, all jobs
would be eliminated (Tr. at 163). The VE further explained that in medium-type jobs, the lifting
maximum is 50 pounds occasionally with either arm; light-type jobs involve lifting up to 20 pounds
occasionally (Tr. at 163-164).
12
Scope of Review
The sole issue before this Court is whether the final decision of the Commissioner denying
the claim is supported by substantial evidence. In Blalock v. Richardson, substantial evidence was
defined as:
evidence which a reasoning mind would accept as sufficient to support a particular
conclusion. It consists of more than a mere scintilla of evidence but may be
somewhat less than a preponderance. If there is evidence to justify a refusal to direct
a verdict were the case before a jury, then there is ‘substantial evidence.’
Blalock v. Richardson, 483 F.2d 773, 776 (4th Cir. 1972) (quoting Laws v. Celebrezze, 368 F.2d
640, 642 (4th Cir. 1966)). Additionally, the Commissioner, not the Court, is charged with resolving
conflicts in the evidence, however, the Court determines if the final decision of the Commissioner
is based upon an appropriate application of the law. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th
Cir. 1990). Further, the Courts “must not abdicate their traditional functions; they cannot escape
their duty to scrutinize the record as a whole to determine whether the conclusions reached are
rational.” Oppenheim v. Finch, 495 F.2d 396, 397 (4th Cir. 1974). If substantial evidence exists,
the Court must affirm the Commissioner’s decision “even should the court disagree with such
decision.” Blalock, 483 F.2d at 775.
Analysis
As noted supra, Claimant argues that the ALJ failed in his duty to develop the record with
respect to several alleged impairments2, and that he “completely ignored” Claimant’s testimony
and the medical documentation concerning the limitations his impairments caused. (ECF No 17 at
2 Later in his brief, Claimant specified that the following impairments preclude his ability to engage in substantial
gainful activity: hearing loss; diabetes type II; a broken back; enlarged prostate; left ankle; foot; torn right biceps
tendon; hypertension; asthma; heel spur; hammer toe; high blood pressure; high cholesterol; and bursitis of right
shoulder. (ECF No. 17 at 14)
13
11-14) As an initial matter, with respect to Claimant’s contention that the ALJ “completely
ignored” his testimony and the medical documentation from his treating physicians as to his
limitations, the undersigned FINDS this argument lacks merit:
In his written decision, the ALJ specifically recalls not only Claimant’s statements in his
application for disability benefits (Tr. at 16-17), but also Claimant’s testimony concerning his
alleged chronic musculoskeletal pain that impaired his ability to function and that it affected his
sleep through the night (Tr. at 17). He also recognized that Claimant had alleged uncontrolled
diabetes mellitus and that he was unable to lift anything because of his arm and back spasms and
that he testified he could stand no more than 15 minutes and sit for no more than one hour at a
time. (Id.) Further, in addition to discussing the relevant medical evidence of record (Tr. at 15-16,
17-19, discussed further, infra), the ALJ explicitly considered the opinion evidence of not just the
state agency medical consultants and examiners, but also Claimant’s treating providers, namely,
Drs. Wild and Bailey (Tr. at 19-20).
The Duty to Develop the Evidence:
In Cook v. Heckler, the Fourth Circuit noted that an ALJ has a “responsibility to help
develop the evidence.” Cook v. Heckler, 783 F.2d 1168, 1173 (4th Cir. 1986). The Court stated
that “[t]his circuit has held that the ALJ has a duty to explore all relevant facts and inquire into the
issues necessary for adequate development of the record, and cannot rely on evidence submitted
by the claimant when that evidence is inadequate.” Id. The court explained that the ALJ’s failure
to ask further questions and to demand the production of further evidence about the claimant’s
arthritis claim in order to determine if it met the requirements in the listings of impairments
amounted to a neglect of his duty to develop the evidence. Id.
14
Nevertheless, it is Claimant’s responsibility to prove to the Commissioner that he is
disabled. 20 C.F.R. § 404.1512(a) (“In general, you have to prove to us that you are blind or
disabled. You must inform us about or submit all evidence known to you that relates to whether
or not you are blind or disabled.” Thus, Claimant is responsible for providing medical evidence to
the Commissioner showing that he has an impairment, further, the Regulations are clear that this
responsibility is ongoing at each level of the administrative review process. Id. The Supreme Court
noted:
The severity regulation does not change the settled allocation of burdens of proof
in disability proceedings. It is true . . . that the Secretary bears the burden of proof
at step five . . . [b]ut the Secretary is required to bear this burden only if the
sequential evaluation process proceeds to the fifth step. The claimant first must
bear the burden . . . of showing that . . . he has a medically severe impairment or
combination of impairments . . . . If the process ends at step two, the burden of
proof never shifts to the Secretary. . . . It is not unreasonable to require the
claimant, who is in a better position to provide information about his own medical
condition, to do so.
Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987).
Although the ALJ has a duty to fully and fairly develop the record, he is not required to act
as Claimant’s counsel. Clark v. Shalala, 28 F.3d 828, 830-831 (8th Cir. 1994). In this case, Claimant
was represented by counsel and the ALJ has the right to assume that Claimant’s counsel was
presenting the strongest case for benefits. See Laney v. Astrue, 2011 WL 11889, at *11 (S.D.W.Va.
Jan. 4, 2011) (Eifert, M.J.) (citing Nichols v. Astrue, 2009 WL 2512417, at *4 (7th Cir. 2009). An
ALJ’s duty to develop the record does not require him to make specific inquiries into Claimant’s
treatment modalities or search for cumulative evidence; his duty is to obtain sufficient evidence
upon which he can render an informed decision. Id. (internal citations omitted).
Claimant bears the burden of establishing a prima facie entitlement to benefits. See Hall v.
15
Harris, 658 F.2d 260, 264-65 (4th Cir. 1981); 42 U.S.C. § 423(d)(5)(A) (“An individual shall not
be considered to be under a disability unless he furnishes such medical and other evidence of the
existence thereof as the Commissioner of Social Security may require.”) Similarly, Claimant
“bears the risk of non-persuasion.” Seacrist v. Weinberger, 538 F.2d 1054, 1056 (4th Cir. 1976).
With respect to Claimant’s assertion that the ALJ failed to develop the evidence of his
numerous physical impairments (See footnote 2, supra), it is noted that Claimant neither specifies
what evidence was not adequately fleshed out by the ALJ, nor what evidence specifically supports
his argument that he is disabled. For starters, it is important to recognize that this Circuit has
recognized that “there is no rigid requirement that the ALJ specifically refer to every piece of
evidence in his decision” Reid v. Comm’r of Soc. Sec., 769 F.3d 861, 865 (4th Cir. 2014) (quoting
Dyer v. Barnhart, 395 F.3d 1206, 1211 (11th Cir. 2005) (per curiam)); see also Call v. Berryhill,
Civil Action No. 2:17- CV-02292, 2018 WL 4659342, *4 (S.D.W. Va. Sept. 28, 2018). While the
ALJ may not have specifically mentioned each of Claimant’s alleged impairments3, he stated that
he considered all the evidence of record. (See Tr. at 12 (“After careful consideration of all the
evidence. . .”); Tr. at 16 (“After careful consideration of the entire record. . .”; and Tr. at 17 (“After
careful consideration of the evidence . . .”). Having so stated, this court should “take [him] at [his]
word.” Reid, 769 F.3d at 865 (“The Commissioner, through the ALJ and Appeals Council, stated
3 The ALJ did not expressly mention the “broke back”, asthma, hammer toe, or high cholesterol as mentioned supra,
and Claimant does not explain how each of these impairments, let alone in combination, disabled him. It is significant
to recognize however, that despite Claimant’s assertion that he suffered from a “broke back”, and despite the reference
to a “fracture” in the history section listed in the radiology reports concerning imaging of Claimant’s skull and cervical,
thoracic, and lumbar spine (Tr. at 463-465), there is simply no evidence whatsoever of any fracture of any area of
Claimant’s vertebrae in the record. Thus, the ALJ’s failure to mention any fracture or “broke back” appears justified.
In any event, the ALJ does discuss how Claimant’s impairments and symptoms related thereto affected his overall
functioning in his review of the medical and other evidence of record in the RFC assessment (Tr. at 16-20).
16
that the whole record was considered, and, absent evidence to the contrary, we take her at her
word.”); see also Hackett v. Barnhart, 395 F.3d 1168, 1173 (10th Cir. 2005) (“[O]ur general
practice, which we see no reason to depart from here, is to take a lower tribunal at its word when
it declares that it has considered a matter.”); Christina W. v. Saul, No. 4:19-cv-00028-PK, 2019
WL 6344269, *4 (D. Utah Nov. 27, 2019) (“Plaintiff further argues that the ALJ erred in not
explicitly discussing various pieces of evidence, particularly the fact that she is participating in a
structured treatment program. While the ALJ must consider all the evidence, she need not recite
each piece of evidence she has considered. The ALJ stated that she carefully considered the entire
record and the Court can take her at her word.”). Moreover, despite Claimant’s listing the various
diagnoses and symptoms related thereto in his brief, this is not the litmus test for disability, as it is
also well known that diagnoses alone do not establish disability, because there must be a showing
of related functional loss. See Gross v. Heckler, 785 F.2d 1163, 1166 (4th Cir. 1986) (per curiam)
(internal citations omitted).
Nevertheless, despite Claimant’s assertion otherwise, the ALJ expressly considered the
medical evidence from the treating sources of record, including medical evidence that predated his
alleged onset date, since April 2015 (Tr. at 17, 19, 20, 532). In addition to the opinion evidence
(Tr. at 18, 19-20), which included the opinions provided by state agency consultative examiners,
state agency medical consultants, as well as Claimant’s own treating providers, the ALJ also
expressly considered Claimant’s and the vocational expert’s testimonies (Tr. at 16-17, 20-21)
Indeed, when asked by the ALJ at the beginning of the hearing if there was a complete record in
this case, Claimant’s attorney responded in the affirmative. (Tr. at 139) In short, Claimant has
failed to demonstrate any paucity in the evidence that would have warranted further development
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of the record.
Accordingly, the undersigned FINDS that Claimant’s contention that the ALJ erred by
failing to develop the record is without merit.
Consideration of the Combined Effect of Impairments:
In a conclusory fashion, Claimant asserts that the medical evidence confirms that the
combined effect of his severe physical and mental impairments rendered him totally disabled and
meet or exceed Listing requirements. (ECF No. 17 at 14) Claimant does not specify which
impairment specifically meets or equals any Listing, he again emphasizes that the ALJ failed to
consider the medical evidence from his treating physicians. (Id.)
The Regulations provide:
In determining whether your physical or mental impairment or impairments are of
a sufficient medical severity that such impairment or impairments could be the basis
of eligibility under the law, we will consider the combined effect of all of your
impairments without regard to whether any such impairment, if considered
separately, would be of sufficient severity.
See 20 C.F.R. § 404.1523(c). When confronted with a combination of impairments, an adjudicator
must not only acknowledge “the existence of the problems, but also the degree of their severity,
and whether, together, they impaired the claimant’s ability to engage in substantial gainful
activity.” Oppenheim v. Finch, 495 F.2d 396, 398 (4th Cir. 1974). The Fourth Circuit has held that
the ailments should not be fractionalized and considered in isolation, but considered in
combination to determine the impact on the ability of the claimant to engage in substantial gainful
activity. Id. In short, the ALJ must analyze the cumulative or synergistic effect that the various
impairments have on Claimant’s ability to work. DeLoatche v. Heckler, 715 F.2d 148, 150 (4th
Cir. 1983).
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“The Listing of Impairments . . . describes for each of the major body systems impairments
that we consider to be severe enough to prevent an individual from doing any gainful activity,
regardless of his or her age, education, or work experience.” See 20 C.F.R. § 404.1525(a); Sullivan
v. Zebley, 493 U.S. 521, 532 (1990). To qualify for benefits, Claimant must show that his
combination of impairments is “equivalent” to a listed impairment, and he “must present medical
findings equal in severity to all the criteria for the one most similar listed impairment.” See Id. at
531. A claimant must meet all, not just some, of the criteria for a listing to apply. Id. at 530.
It is important to note that at the second step in the sequential evaluation process, the ALJ
found numerous impairments that were not severe enough to have significantly limited Claimant’s
ability to perform basic work activities: benign hypertension; benign prostatic hyperplasia;
keratosis; left heel spur; hearing loss; and an ingrown toenail. (Tr. at 14-15, 489-538, 539-556,
577-605, 631-642) The ALJ specifically noted that the longitudinal objective evidence supported
the conclusion that none of these conditions, either singly or in combination, resulted in more than
a minimal impact on Claimant’s ability to engage in work activities (Tr. at 15, 458, 518, 522, 527,
532, 560-563, 572, 590, 633).
Next, at the third step of the sequential evaluation process, the ALJ first evaluated
Claimant’s impairments under Section 1.00 which pertains to the musculoskeletal system. (Tr. at
15) With regard to Claimant’s right shoulder impingement syndrome under Listing 1.02, which
concerns major dysfunction of a joint, he noted that the records did not show that this condition
did not result in an inability to ambulate effectively or an inability to perform fine and gross
movements effectively. The ALJ further noted that Claimant’s severe impairment also did not meet
criteria under Listing 1.04, which concerns disorders of the spine, as there was no evidence of
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nerve root compression, spinal arachnoiditis, or lumbar spinal stenosis resulting
pseudoclaudication.
With regard to Claimant’s obesity pursuant to Social Security Ruling (SSR) 19-2p, the ALJ
acknowledged that while obesity is not a listed impairment, he recognized that any impairment to
Claimant’s functioning as a result of this condition must be considered when assessing his claim
at other steps in the sequential evaluation process, including the RFC. (Id.)
With regard to Claimant’s diabetes mellitus, the ALJ acknowledged this impairment may
cause symptoms or complications with regard to treatment similar to other impairments under the
Listings, and that SSR 14-2p and Listing 9.00B5 require him to consider Listing requirements
under Sections 1.00, 2.00, 4.00, 5.00, 6.00, 8.00, 11.00, and 12.00. (Id.) The ALJ determined that
Claimant has not exhibited any symptoms or suffered from complications resulting from his
diabetes mellitus that medically equaled any of these Listings’ requirements, specifically with
respect to Listing 11.14, because the evidence did not demonstrate disorganization of motor
function in two extremities, resulting in an extreme limitation in the ability to stand up from a
seated position, balance while standing or walking, or use the upper extremities or demonstrate
marked limitation in physical functioning. (Tr. at 15-16)
To the extent that Claimant takes issue with the ALJ’s evaluation of his subjective
complaints, it is noted that recently the Fourth Circuit held that “an ALJ has the obligation to
consider all relevant medical evidence and cannot simply cherrypick facts that support a finding
of nondisability while ignoring evidence that points to a disability finding.” See Arakas v. Comm’r,
Soc. Sec. Admin., 983 F.3d 83, 98 (4th Cir. 2020) (internal citations omitted). The Fourth Circuit
“reiterate[d] the long-standing law in our circuit that disability claimants are entitled to rely
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exclusively on subjective evidence to prove the severity, persistence, and limiting effects of their
symptoms.” Id. It is important to recognize that in Arakas, the Court concluded that substantial
evidence did not support the ALJ’s finding that the claimant’s subjective complaints were
inconsistent with her daily activities because the overall record actually supported her subjective
complaints and demonstrated she would be unable to engage in substantial gainful activity. Id.
Another significant, if not critical, aspect of the Arakas holding is that the Court found the ALJ’s
analysis included misrepresentations or overinflation of the claimant’s abilities, to the exclusion
of that evidence which did not support such a conclusion. Id. Essentially, the Fourth Circuit has
once again cautioned against an ALJ’s analysis must not primarily rely upon the lack of objective
medical evidence as the reason for discounting a claimant’s complaints. As demonstrated by the
foregoing, this did not occur here, the ALJ herein did not select only those portions from the
objective medical evidence that failed to support Claimant’s allegations of disabling impairments,
the ALJ also examined both aggravating and mitigating factors with respect to Claimant’s
subjective complaints which included his testimony, his reports to providers, the objective medical
evidence, as well as the opinion evidence. The law does not require one to be pain-free of
experience no discomfort in order to be found not disabled. Hays v. Sullivan, 907 F.2d 1453, 1458
(4th Cir. 1996). In this case, the ALJ provided a thorough and adequate analysis of Claimant’s
subjective complaints that complied with the pertinent Regulations and case law.
Clearly, the ALJ considered the medical evidence as well as Claimant’s reported
symptomology from the relevant time period. As discussed supra, the ALJ did consider this
evidence in making his third step determination, thus, to the extent that Claimant argues that the
ALJ failed to consider and evaluate the combined effects of his impairments, the undersigned
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FINDS this argument lacks merit. Additionally, to the extent that Claimant contends the ALJ failed
to consider the medical records provided by his treating physicians, the undersigned FINDS this
contention also lacks merit. Finally, to the extent that Claimant asserts the ALJ failed to consider
his subjective complaints, the undersigned FINDS that the ALJ’s subjective symptoms analysis
complied with the pertinent Regulations and controlling case law and is based upon substantial
evidence. The undersigned further FINDS the ALJ’s discussion of the objective and other
evidence of record in his evaluation of Claimant’s statements regarding the intensity, persistence,
and limiting effects of his symptoms, and that the ALJ’s conclusion that Claimant’s statements
were inconsistent with the evidence of record complied with the applicable law and is supported
by substantial evidence.
Evaluation of Opinion Evidence:
Claimant argues that the ALJ “substituted” his own opinion with those provided by
Claimant’s treating providers, Drs. Wild and Bailey, ostensibly because the ALJ did not adopt
their opinion that Claimant was disabled or at least incapable of performing work greater than
sedentary level (ECF No. 17 at 14-15). Here, the ALJ explicitly applied the regulatory framework
pursuant to Section 404.1520c to claims filed after March 27, 2017: “[a]s for medical opinion(s)
and prior administrative medical finding(s), we will not defer or give any specific evidentiary
weight, including controlling weight, to any administrative medical finding(s) or medical
opinion(s), including those from your medical sources.” (Tr. at 19) (emphasis added) Here, the
ALJ properly applied Section 404.1520c, which emphasizes the supportability and consistency
factors when assessing the persuasiveness of the medical opinions of record. Instead of assigning
weight to medical opinions, the ALJ now just considers the persuasiveness of a medical opinion
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(or a prior administrative medical finding). Id. 404.1520c(b)(2). Critically, the source of the
opinion is not the most important factor in evaluating its persuasive value, instead, the most
important factors are supportability and consistency. Id. When discussing her finding about
whether an opinion is persuasive, the ALJ need only explain how she considered the “the most
important factors” of supportability and consistency. Id. § 416.1520c(c). The ALJ “may” comment
on the other factors, including the source’s relationship with the claimant, but generally has no
obligation to do so. Id. § 404.1520c(b)(2)-(3).
In this case, the ALJ appropriately recognized that pursuant to 20 C.F.R. § 404.1527(d), he
found the opinions provided by Drs. Wild and Bailey “unpersuasive”, specifically noting their
opinions that Claimant “was limited to a sedentary range of activity, with standing or walking no
more than two hours in a workday, and lifting no more than 10 pounds in weight”, in addition to
Dr. Wild’s opinion that Claimant “should never climb or crawl, no more than occasionally perform
all remaining postural activities, and avoid all exposure to temperature extremes.” (Tr. at 19, 607,
644) The ALJ correctly observed that “neither doctor cited to any objective evidence or findings
to support their opinions” and further, “their opinions are not consistent with the objective
evidence.” (Id.) The ALJ explained:
Despite the claimant’s impairments, objective examinations documented grossly
normal muscle strength and motion throughout the claimant’s musculoskeletal
system, as well as normal find motor coordination and balance, intact extremity
sensation, and a normal and independent walking gait.
(Tr. at 19-20, 458, 518, 522, 527, 532, 560-563, 572, 590, 633). Accordingly, the ALJ concluded
that these findings were inconsistent with the opinions that Claimant could stand and walk for only
two hours in a workday or limited to lifting or carrying no more than 10 pounds, thus, the ALJ did
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not adopt the restrictions endorsed by Drs. Wild and Bailey in the RFC assessment. (Tr. at 20) The
Regulations and pertinent case law support the ALJ’s observation, because an RFC assessment
lies squarely with the ALJ, not with any medical provider/examiner. 20 C.F.R. § 404.1546(c); see
Felton-Miller v. Astrue, 459 F. App’x 226, 230-31 (4th Cir. 2011) (“The ALJ was not required to
obtain an expert medical opinion as to [the] RFC.”).
Although Claimant advocates for an alternate decision, such are matters that involve
resolving the conflicting evidence of record, which is an evidentiary finding within the purview of
the ALJ. In short, though Claimant may disagree with the ALJ’s determination that he is not
disabled, this Court cannot re-weigh this conflicting evidence or substitute its judgment for the
Commissioner’s. Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996); see also, SSR 96-8p, 1996 WL
3741784, at *7. The ALJ’s narrative of the record included the objective medical evidence,
including imaging, and examination findings, as well as the other evidence of record, including
but not limited to Claimant’s own statements and testimony; the ALJ’s thorough discussion of all
this evidence, and his ultimate determination that Claimant remained capable of medium work
during the relevant period despite his subjective complaints, provided sufficient explanation
allowing for meaningful judicial review. Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015). This
Court is not “left to guess about how the ALJ arrived at his conclusions” therefore remand is not
necessary. Mascio, 780 F.3d at 637. Accordingly, the undersigned FINDS the ALJ’s evaluation of
the opinion evidence is supported by substantial evidence.
Finally, the undersigned FINDS that the Commissioner’s final decision determining that
Claimant was not disabled from May 30, 2015 through September 30, 2019 is supported by
substantial evidence.
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Recommendations for Disposition
For the reasons set forth above, it is hereby respectfully PROPOSED that the District
Court confirm and accept the foregoing findings and RECOMMENDED that the District Court
DENY the Claimant’s request for reversal or remand (ECF No. 17), GRANT the Defendant’s
request to affirm the decision below (ECF No. 19), AFFIRM the final decision of the
Commissioner, and DISMISS this matter from this Court’s docket.
The parties are notified that this Proposed Findings and Recommendation is hereby
FILED, and a copy will be submitted to the Honorable Robert C. Chambers, United States District
Judge. Pursuant to the provisions of Title 28, United States Code, Section 636(b)(1)(B), and Rules
6(d) and 72(b), Federal Rules of Civil Procedure, the parties shall have fourteen days (filing of
objections) and then three days (mailing/service) from the date of filing this Proposed Findings
and Recommendation within which to file with the Clerk of this Court, specific written objections,
identifying the portions of the Proposed Findings and Recommendation to which objection is
made, and the basis of such objection. Extension of this time period may be granted for good cause
shown.
Failure to file written objections as set forth above shall constitute a waiver of de novo
review by the District Court and a waiver of appellate review by the Circuit Court of Appeals.
Snyder v. Ridenour, 889 F.2d 1363, 1366 (4th Cir. 1989); Thomas v. Arn, 474 U.S. 140, 155 106
S.Ct. 466, 475, 88 L.E.2d 435 (1985), reh’g denied, 474 U.S. 1111, 106 S.Ct. 899, 88 L.E.2d 933
(1986); Wright v. Collins, 766 F.2d 841 846 (4th Cir. 1985); United States v. Schronce, 727 F.2d
91, 94 (4th Cir.), cert. denied, 467 U.S. 1208, 104 S.Ct. 2395, 81 L.E.2d 352 (1984). Copies of
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such objections shall be served on opposing parties, District Judge Chambers, and this Magistrate
Judge.
The Clerk of this Court is directed to file this Proposed Findings and Recommendation and
to send a copy of same to counsel of record.
ENTER: May 19, 2021.
©) al Aoton
QE Oars. Aboulhosn
——"—Ssé«niitted States Magistrate Judge
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