Cox v. O'Malley

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA

CHARLESTON DIVISION

PAULA C.,

Plaintiff,

v. CIVIL ACTION NO. 2:23-cv-00659

MARTIN J. O’MALLEY

Commissioner of Social Security,1

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Defendant.

PROPOSED FINDINGS & RECOMMENDATION

Plaintiff Paula C. (“Claimant”) seeks review of the final decision of the

Commissioner of Social Security (the “Commissioner”) denying her application for

Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C.

§§ 401–33. This matter was referred by standing order 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). (ECF

No. 2). Presently pending before this Court are Claimant’s Brief in Support of Complaint

(ECF No. 5), and the Commissioner’s Brief in Support of Defendant’s Decision (ECF No.

8). Having fully considered the record and the arguments of the parties, the undersigned

1 Commissioner O’Malley was substituted in place of Acting Commissioner Kilolo Kijakazi following

O’Malley’s appointment on December 20, 2023, and is automatically substituted as a party pursuant to

Federal Rule of Civil Procedure 25(d). See 42 U.S.C. § 405(g) (stating that action survives regardless of any

change in the person occupying the office of Commissioner of Social Security).

respectfully RECOMMENDS that the presiding District Judge DENY Claimant’s

request to reverse the Commissioner’s decision, GRANT the Commissioner’s request to

affirm his decision, AFFIRM the final decision of the Commissioner, and DISMISS this

action from the Court’s active docket.

I. BACKGROUND

A. Information about Claimant and Procedural History of Claim

Claimant was 57 years old at the time of her alleged disability onset date and 60

years old on the date of the decision by the Administrative Law Judge (“ALJ”). (Tr. 223).2

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Claimant has a high school education, and her work history includes a position as an

insurance clerk. (Tr. 24-25, 243). In her application for benefits, Claimant alleges that she

became disabled on October 16, 2019, due to bipolar disorder, insomnia, depression,

anxiety, fatty liver, pre-diabetes, osteoarthritis, sciatica, edema, acid reflux, and Epstein

Barr virus. (Tr. 223, 242).

Claimant filed her application for benefits on February 15, 2021. (Tr. 11, 223-26).

The claim was denied initially on September 13, 2021, and again upon reconsideration on

February 17, 2022. (Tr. 100, 111). On March 23, 2022, Claimant submitted a written

request for an administrative hearing, which was held before an ALJ on October 20, 2022.

(Tr. 81-99). Claimant was represented by counsel at the hearing, where she and a

vocational expert each testified. (Tr. 81-99). On January 26, 2023, the ALJ entered an

unfavorable decision. (Tr. 8-25). Claimant then sought review of the ALJ’s decision by the

Appeals Council on March 8, 2023. (Tr. 213-15). The Appeals Council denied Claimant’s

2 All references to “Tr.” refer to the Transcript of Proceedings filed in this action at ECF No. 4.

request for review on August 10, 2023, and the ALJ’s decision became the final decision

of the Commissioner on that date. (Tr. 1-6).

Claimant timely brought the present action on October 6, 2023, seeking judicial

review of the ALJ’s decision pursuant to 42 U.S.C. § 405(g). (ECF No. 1). The

Commissioner filed a transcript of the administrative proceedings on November 29, 2023.

(ECF No. 4). Claimant filed her Brief in Support of Complaint (ECF No. 5) on December

22, 2023, and in response the Commissioner filed his Brief in Support of Defendant’s

Decision (ECF No. 8) on February 21, 2024. Finally, Claimant filed a Reply Brief (ECF No.

9) on March 6, 2024. Each of the parties’ filings were timely; now, having been briefed in

full, this matter is ripe for adjudication.

B. Relevant Evidence

The undersigned has considered all evidence of record, including the medical

evidence, pertaining to Claimant’s arguments and summarizes the relevant portions3 here

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for the convenience of the United States District Judge.

1. Testimony

As part of her disability application, Claimant completed an Adult Function Report

describing her subjective symptoms. (Tr. 280-87). Therein, she stated her physical

impairments prevented her from bending, kneeling, or “being on her feet all day,” and

that her mental impairments made it difficult for her to concentrate. (Tr. 280).

Additionally, Claimant reported that she is able to engage in activities such as cooking,

shopping, and driving, as well as doing chores such as light housework, laundry, and

ironing; further, Claimant stated she was able to perform her own personal care with no

3 Claimant does not dispute the accuracy of the ALJ’s recitation of the relevant medical evidence. (ECF No.

5 at 1).

difficulty, and could manage her own finances. (Tr. 281-84). Additionally, Claimant stated

that her hobbies included sewing and playing games on her phone, and she reported being

able to follow instructions and being fine with change. See id. She reported problems with

lifting, stair climbing, squatting, bending, kneeling, memory, completing tasks, and

concentration. Id.

During the administrative hearing, the claimant testified she worked as a medical

biller. She stated her depression had worsened since her application, as she could not

concentrate, she had trouble with speech and memory, and she sometimes would forget

to take her medication. (See Tr. 81-94). Further, Claimant testified she does not sleep

well and that she takes a one-to-two-hour nap four times a week but does not feel rested.

See id. She estimated that she can sit or stand for a duration of 20 to 30 minutes, can walk

a distance of approximately 600 feet, and can carry weight up to 20 pounds. Id. Claimant

testified that generally she spends her day doing light housework and laundry. Id. Finally,

Claimant testified that she cannot handwrite long because of problems with her hands.

She has problems with her left knee especially when she goes upstairs. She has problems

bending and cannot get on her knees.

Following Claimant’s testimony, Vocational Expert (“VE”) Enjouli McGoogan

testified at the administrative hearing. (Tr. 94-99). The VE categorized Claimant’s prior

insurance-clerk position as sedentary, skilled work. (Tr. 96). The ALJ then posed a

hypothetical scenario to the VE including the following limitations:

[The] individual would be capable of performing work at the sedentary

exertional level, as defined under the Regulations, with the following

limitations. The individual could occasionally climb ramps and stairs, and

never climb ladders, ropes, or scaffolds. Could occasionally balance, stoop,

kneel, crouch, and crawl. The individual would be capable of tolerating

occasional exposure to extreme cold, heat, vibration, atmospheric

conditions . . . and any workplace hazards such as moving machinery or

unprotected heights.

(Tr. 97). The VE responded that the hypothetical individual in this scenario would be

capable of performing Claimant’s past work. (Tr. 97). The ALJ then asked the VE whether

an addition to the hypothetical requiring only simple, routine tasks would affect the ability

to do Claimant’s past work, and the VE replied that such an individual would not be able

to perform Claimant’s past work. (Tr. 97). The ALJ also asked the VE what percentage of

off-task time would be tolerated by employers, and the VE replied that anything greater

than 10% would preclude full-time employment. (Tr. 98).

2. Medical Records

Claimant’s relevant medical records begin in August 2019, when an MRI of the

thoracic spine at Roane General Hospital showed a large disc protrusion or extrusion at

T9-T10 with moderate narrowing of the central canal and moderate mass effect on the

cord. (Tr. 598-926). The following month on September 17, 2019, the claimant was seen

again at Roane General Hospital for chronic left lumbar radiculopathy and edema of both

lower extremities (Tr. 598-926). Subsequently on September 30, 2019, Claimant called

her primary-care provider to report depression, feeling anxious, and panic attacks she

attributed to her job. (Tr. 491-566). She stated she put in her two weeks’ notice and now

wants a work note to cover those two weeks. Id.

On October 14, 2019, the claimant was seen at Roane General Hospital for an

earache and headache. (Tr. 598-926). Her depression screening was negative and she

presented as cooperative, alert, oriented, and in no acute distress. Id. On October 16,

2019, the claimant underwent a nuclear medicine thyroid uptake examination, and

hypothyroidism was noted on testing Id.

On November 20, 2019, the claimant presented to at Roane General Hospital

complaining of osteoarthritis in her back and knees and stated she has been seen by pain

management and orthopedics. Id. She requested a hydrotherapy referral and stated that

injections had helped her back previously. Id. Treatment notes state that Claimant was

cooperative and comfortable with no edema and grossly normal mental status exam

findings. Id. Diagnoses included left lumbar radiculopathy, generalized osteoarthritis,

and polyosteoarthritis. Id. Later that week on November 26, 2019, the claimant was

treated for a sore throat and viral upper respiratory infection. Id. On December 12, 2019,

the claimant returned with complaints of a cough with blood tinged sputum. Id. Her

depression screening remained negative, and examination findings remained normal. Id.

On February 12, 2020, the claimant was seen again at Roane General Hospital for

dizziness, ear pain, and congestion. Id. She was noted to be in no acute distress and was

diagnosed with dysfunction of both eustachian tubes. Id.

On March 4, 2020, Claimant was seen by West Virginia Medicine where she

reported doing better now that she is no longer working. (Tr. 491-566). Further, Claimant

reported she was cleaning the house and sewing and that she made two quilts. Id.

Treatment notes show that her mood was good, and she was oriented and cooperative

with good eye contact and fair insight and judgment. Id.

On June 9, 2020, claimant was seen at Clendenin Family Medicine Primary care

for back and feet pain. (Tr. 428-490). She stated her sciatic nerve was not bothering her

any further, but that it hurt to be on her feet. Id. Exam findings note she was in no acute

distress, and she had normal mood, memory, strength, and tone. Id. Her insight was

noted to be good, and diagnoses included prediabetes and gastro-intestinal-reflux

disorder (“GERD”). Id. Claimant returned on June 23, 2020, with complaints of a rash

and tick bite. Id. She stated she was bitten while working outside. Id. Exam findings

note she was ambulating normally and in no acute distress, and there was a bullseye tick

mark on her back. Id. She had normal mental status exam findings including normal

mood, affect, and memory. Id. On August 5, 2020, the claimant returned to Clendenin

reporting the new onset of right-knee and shin pain. Id. On examination, she exhibited

tenderness over the right knee and was diagnosed with patella femoral stress syndrome.

Id. Subsequently on August 10, 2020, the claimant was diagnosed with herpes zoster. Id.

On September 9, 2020, claimant presented to West Virginia Medicine, where her

mood was noted to be stable, or “euthymic.” (Tr. 491-566). Her diagnosis was major

depressive disorder. Id.

On September 10, 2020, the claimant was seen at Roane General Hospital for right

ankle pain and right leg pain. (Tr. 598-926). She had patella pain that was worse with

ambulation; however, she was able to ambulate normally. Id. Exam findings note knee

tenderness and severe obesity. Id. Diagnoses include pain in the right knee, pain in the

right ankle, prediabetes, and peripheral edema. Id. Imaging taken that day showed

minimal degenerative changes in the right knee, as well as plantar and posterior calcaneal

spurs in the feet; however, there was no acute bony abnormality and no evidence of deep

vein thrombosis in the right lower extremity despite the presence of edema. Id.

On October 29, 2020, the claimant requested to be tested for mold. (Tr. 428-490).

She reported having headaches twice a week and stated he feels bad all the time. Id. She

reported sleeping a lot and having no energy. Id. Examination notes indicated morbid

obesity and tenderness at the medial side of the tibial plateau. Id. Diagnoses included

dysuria, chronic rhinitis, chronic fatigue syndrome, and peripheral edema. Id.

On December 9, 2020, the claimant was seen by her chiropractor at McCarter

Wellness for a monthly check-up on her complaints of fatigue, malaise, weight gain,

toxicity, irritable bowel syndrome, non-alcoholic steatohepatitis, and fatty-liver disease.

(Tr. 951). Treatment notes state that the claimant “wants to go back to work.” (Tr. 951-

61). The treatment plan called for additional diagnostic testing, as well as orders for a

healthful diet and home exercise. (Tr. 952).

On January 12, 2021, Claimant presented to Charleston Area Medical Center

Gastroenterology with complaints of abdominal fullness and discomfort with mild pain

under her rib, as well as constipation and large stools. (Tr. 1345). She had normal physical

and mental exam findings and a negative depression screening. Id. Diagnoses include

colon polyps, family history of colon cancer, irritable bowel syndrome, and abdominal

pain likely related to constipation. (Tr. 1346).

On February 25, 2021, the claimant was seen for left foot and ankle pain, with

recent onset. (Tr. 428-90). She was ambulating normally and had normal tone, strength,

and mental status exam findings. Id. There was tenderness at the medial tibial plateau

with no joint effusion. Id.

On April 5, 2021, the claimant was seen at Mountain State Rheumatology for an

evaluation of rheumatoid arthritis. (Tr. 1018-38). She reported morning stiffness and

pain in the right knee and lumbar spine joints; however, she is independent in her

activities of daily living. Id. Imaging showed osteoarthritic changes in her knee and

lumbar region. Id. Exam findings note she was in no acute distress with normal range of

motion and gait and tenderness in the right knee. Id. Diagnoses included doubtful

rheumatoid arthritis involving multiple sites with positive rheumatoid factor,

osteoarthritis in the lumbar spine, and chronic pain of the right knee. Id.

On March 10, 2021, claimant presented to West Virginia Medicine, where

treatment records note she reported sleeping more than she would like and being unable

to sit for a long duration. (Tr. 491-566). She stated her mood was okay and she thinks the

medications are working. Id. Mental status exam findings were normal. Id.

On May 6, 2021, the claimant returned to her chiropractor at McCarter Wellness,

where she reported intermittent bilateral lower lumbar pain and exhibited guarding,

spasm, and tenderness in the hip and pelvis (Tr. 951-61). She had full range of motion. Id.

On June 2, 2021, the claimant was seen for osteoarthritis in the lumbar spine

without radiation. (Tr. 598-926). She exhibited pain with range of motion in the neck and

lumbar and had negative straight leg raise testing. Id. Diagnoses included a Vitamin D

deficiency, spondylosis without myelopathy, and rotator cuff tendinitis. Id. On August 3,

2021, MRI imaging showed L3-L4 bilateral facet arthropathy and shallow broad based

disc displacement, L4-L5 non-compressive disc protrusion, and L5-S1 left paracentral

preforaminal disc protrusion. Id. On June 17, 2021, the claimant was seen at Mountain

State Rheumatology where she reported right knee pain and back pain. (Tr. 1018-38). She

continued to report being independent in her activities of daily living and had normal gait

and range of motion. Id.

On July 1, 2021, the claimant presented to her primary-care physician at Clendenin

Family Medicine with complaints of back pain and diarrhea. (Tr. 962-94). Treatment

records indicate morbid obesity and note that Claimant was ambulating normally, with

normal tone and strength. Id. Mental status exam findings remained normal and

diagnoses include GERD, prediabetes, allergies, postmenopausal state, chronic back pain,

and hypothyroidism. Id.

On July 27, 2021, Claimant was seen at Charleston Area Medical Center

Gastroenterology for a six-month follow-up appointment regarding her irritable bowel

syndrome and fatty liver. (Tr. 1157-61). She reported no concerns and explained that the

diarrhea stopped when she stopped taking Metformin. (Tr. 1162).

On August 3, 2021, an MRI of the lumbar spine showed L3-L4 bilateral facet

arthropathy and shallow broad based disc displacement, L4-L5 noncompressive disc

protrusion, and L5-S1 left paracentral preforaminal disc protrusion. (Tr. 260, 261).

On August 11, 2021, the claimant underwent an MRI and consultative examination

(Tr. 927-30; 931-36). MRI imaging showed mild degenerative disc changes at L3-L4, L4-

L5, and L5-S1, with trace grade 1 anterolisthesis at L3-L4. (Tr. 927-30). The consultative

examiner’s report notes the claimant’s chief complaints were low back pain, osteoarthritis

everywhere, and prediabetes. Id. Exam findings note her posture was straight and her gait

was normal. Id. Further exam findings indicated that the claimant was morbidly obese

with no atrophy, and that she had normal sensation and reflexes, normal gait, and normal

gait, grip strength, and fine manipulation. (Tr. 931-36). She also had normal range of

motion with the exception of lumbar flexion, and was noted to be able to get on and off

the table independently. Id.

On August 16, 2021, the claimant was seen at West Virginia Neurology for low back

pain that radiated into her buttocks bilaterally. (Tr. 937-50). Records note her symptoms

were consistent with claudication; however, her vascular study was normal. Id. Her gait

and station were antalgic, but her range of motion, strength, and sensation were normal.

Id. Further, her cranial nerves were grossly intact. Id. Diagnoses included low back pain

and degeneration of the lumbar intervertebral disc. Id.

On August 30, 2021, the claimant was seen at Mountain State Rheumatology;

treatment notes state that claimant reported taking Tylenol for her pain. (Tr. 102). She

was in no acute distress with normal mood and affect, intact judgement and insight,

normal range of motion, and tenderness in her right hand. (Tr. 103-04). Imaging from

the same date reflected mild degenerative changes with some mild joint space narrowing

and subchondral sclerosis. (Tr. 105).

On October 6. 2021, the claimant was seen at West Virginia Medicine for a

medication check. (Tr. 995-1001). She reported dizzy spells and having an appointment

to see her primary care provider in December 2021. Id. Her mood was euthymic and she

had good eye contact and fair insight and judgment. Id. Subsequently on October 26,

2021, the claimant was seen at Mountain State Rheumatology; she reported taking

Tylenol and Aleve, but her pain was not adequately controlled. (Tr. 1760). Further,

Claimant reported mild morning stiffness; however, she also reported that she remained

independent in her activities of daily living. Id. Exam findings noted bilateral wrist and

finger tenderness, intact sensation, right knee tenderness, and pain on axial compression

bilaterally; however, gait remained normal. (Tr. 1762). Diagnoses included inflammatory

arthritis, osteoarthritis in both hands, and osteoarthritis in the lumbar spine. (Tr. 1762-

63). The claimant was given an injection in her right knee. (Tr. 1764).

On December 7, 2021, Claimant was seen at Charleston Area Medical Center

Gastroenterology for a six-month follow up on her fatty-liver diagnosis. (Tr. 1142-1143).

She reported a chief complaint of black stools and indigestion. (Tr. 1142). The treatment

plan was to prescribe an antibiotic and order lab work; Claimant was directed to call in

with any increase in symptoms. Id. On December 20, 2021, the claimant followed up at

Mountain State Rheumatology; treatment notes show claimant had normal mood, range

of motion, and sensation. (Tr. 1018-38). Her gait remained normal despite pain on axial

compression. (Tr. 1727). On December 22, 2021, the claimant was seen in follow up for

reflux, GERD, fatigue, and morbid obesity (Tr. 962-94). Exam findings continue to show

normal strength and tone, no contractures, malalignment, or tenderness, and normal

movement of all extremities. Id. Diagnoses included persistent insomnia, GERD, and

prediabetes. Id.

On January 19, 2022, the claimant was seen for low back pain and covid-19 testing.

(Tr. 1390-1415). The following week on January 28, 2022, the claimant reported her

covid-19 symptoms improved except for a lingering cough. Id.

On March 23, 2022, the claimant was seen at Mountain State Rheumatology; she

reported her medication helps with osteoarthritis and that her disease was reasonably

controlled. (Tr. 1715). She continued to remain independent in her activities of daily

living. Id. Mood, range of motion, sensation, and gait were all noted to be normal (Tr.

1717-18).

Subsequently on March 29, 2022, the claimant was diagnosed with a pancreatic

cyst seen on imaging; ultimately, however, the biopsy results were negative. (Tr. 1807,

1812, 1814).

On April 13, 2022, the claimant was seen at West Virginia Medicine; she reported

struggles with sleep and racing thoughts. (Tr. 491-566). She stated she has no energy, but

her mood is not depressed. Id. Treatment notes state that Claimant’s mood was apathetic,

but that her exam findings were otherwise normal. Id.

On April 21, 2022, the claimant was seen at Foot & Ankle Center; there, she was

diagnosed with capsulitis of the toe and neuroma of the foot. (Tr. 1360-64). Claimant had

pain at the second metatarsal head and interspace pain at the second digit, and was given

an injection to help relieve her symptoms. Id.

On June 7, 2022, treatment notes show Claimant’s reported symptoms were worse,

but she remained independent in her activities of daily living. (Tr. 1367-87). She reported

increased pain and swelling in the second, third, and fourth digits. Id. On examination,

Claimant showed tenderness and swelling in the right hand and bilateral hips; however,

strength was noted to be 5/5, with a normal gait. Id. Diagnoses included inflammatory

arthritis, osteoarthritis in both hands, spondylosis in the lumbar spine, calcaneal spurs in

the bilateral feet, right leg pain, trochanteric bursitis in both hips, primary osteoarthritis

in both knees, and sprain of the right hand. Id.

Finally, on September 7, 2022, the claimant reported low back pain to her primary-

care provider at Clendenin Health Center. (Tr. 1390-1415). Additionally, Claimant

reported that her right-leg pain had resolved, and she was taking muscle relaxers and

steroids. Id. On examination, she was noted to be ambulating normally and had normal

strength, tone, and movement of all extremities. Id.

3. Prior Administrative Findings

In September 2021, Isidro Amigo, M.D., a State-agency medical consultant, found

from a review of the medial records that Claimant had a number of severe physical

impairments, including chronic-fatigue syndrome. (Tr. 105). Dr. Amigo found that

Claimant would be able to occasionally lift up to twenty pounds and frequently lift up to

ten pounds; could stand and/or walk for six hours in an eight-hour workday; could sit for

six hours in an eight-hour workday; could never climb ladders/ropes/scaffolds, and could

occasionally engage in all other postural activities; should avoid concentrated exposure to

most hazards; and had no manipulative limitations. (Tr. 107-08). On reconsideration,

State agency physician Lisa Venkataraman, M.D., affirmed Dr. Amigo’s findings as

written. (Tr. 117-18).

Regarding Claimant’s mental-health impairments, State-agency psychological

consultant Karl G. Hursey, Ph.D., found that Claimant had no limitations in all four

“paragraph B” criteria; Dr. Hursey concluded that—because Claimant reported that her

medications were working well, that her mood and anxiety were well-controlled, and that

she expected to go back to work in the next year—the medical record “does not indicate

severe functional limitations” related to Claimant’s mental impairments. (Tr. 105-06). On

reconsideration, State-agency psychological consultant James Capage, Ph.D., noted that

Claimant reported an increase in her symptoms of depression since Dr. Hursey’s initial-

level evaluation. However, Dr. Capage found this new information was “not significant

enough to change the initial determination,” and thus adopted Dr. Hursey’s findings as

written. (Tr. 115).

C. Sequential Evaluation Process

An individual unable “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” is considered to be disabled and thus eligible for benefits. 42 U.S.C. §

423(d)(1)(A). The Social Security Administration has established a five-step sequential

evaluation process to aid in this determination. 20 C.F.R. §§ 404.1520(a)(4),

416.920(a)(4); Lewis v. Berryhill, 858 F.3d 858, 861 (4th Cir. 2017). The ALJ proceeds

through each step until making a finding of either “disabled” or “not disabled”—in other

words, if no finding is made at a certain step, the ALJ’s analysis advances on to the next

step. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). “The ultimate burden to prove disability

lies on the claimant.” Preston v. Heckler, 769 F.2d 988, 990 n.* (4th Cir. 1985); see Bird

v. Comm’r, 699 F.3d 337, 340 (4th Cir. 2012) (“To establish eligibility for . . . benefits, a

claimant must show that he became disabled before his [date last insured].”).

At the first step in the sequential evaluation process, the ALJ determines whether

the claimant is engaged in “substantial gainful activity.” 20 C.F.R. §§ 404.1520(a)(4)(i),

416.920(a)(4)(i). If the claimant is not engaged in substantial gainful activity, the ALJ

moves on to the second step. At the second step, the ALJ considers the combined severity

of the claimant’s medically determinable physical and mental impairments. Id.

§§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). The ALJ gleans this information from the

available medical evidence. See Mastro v. Apfel, 270 F.3d 171, 177 (4th Cir. 2001). An

individual impairment or combination of impairments that is not classified as “severe”

and does not satisfy the durational requirements will result in a finding of “not disabled.”

20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii); Mascio v. Colvin, 780 F.3d 632, 634–

35 (4th Cir. 2015). Similarly, at the third step, the ALJ determines whether the claimant’s

impairment or combination of impairments meets or is medically equal to the criteria of

an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. See 20 C.F.R.

§§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii). “A claimant is entitled to a conclusive

presumption that he is impaired if he can show that his condition ‘meets or equals the

listed impairments.’” Radford v. Colvin, 734 F.3d 288, 291 (4th Cir. 2013) (quoting

Bowen v. City of New York, 476 U.S. 467, 471 (1986)).

“If the first three steps do not lead to a conclusive determination, the ALJ then

assesses the claimant’s residual functional capacity” (“RFC”) before proceeding to the

fourth step. Mascio, 780 F.3d at 635; see 20 C.F.R. §§ 404.1520(e), 416.920(e). The

claimant’s RFC reflects “her ability to perform work despite her limitations.” Patterson v.

Comm’r, 846 F.3d 656, 659 (4th Cir. 2017); Monroe v. Colvin, 826 F.3d 176, 179 (4th Cir.

2016) (defining claimant’s RFC as “the most the claimant can still do despite physical and

mental limitations that affect his ability to work” (alterations and internal quotation

marks omitted)); see 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1). The ALJ “first

identif[ies] the individual’s functional limitations or restrictions and assess[es] his or her

work-related abilities on a function-by-function basis,” then “define[s] the claimant’s RFC

in terms of the exertional levels of work.” Lewis, 858 F.3d at 862. “In determining a

claimant’s RFC, the ALJ must consider all of the claimant’s medically determinable

impairments . . . including those not labeled severe” as well as “all the claimant’s

symptoms, including pain, and the extent to which his symptoms can reasonably be

accepted as consistent with the objective medical evidence and other evidence.” Monroe,

826 F.3d at 179 (alterations and internal quotation marks omitted); see 20 C.F.R.

§§ 404.1545(a), 416.945(a).

When the claimant alleges a mental impairment, the first three steps of the

sequential evaluation process and the RFC assessment are conducted using a “special

technique” to “evaluate the severity of [the] mental impairment[].” 20 C.F.R.

§§ 404.1520a(a), 416.920a(a); see Patterson, 846 F.3d at 659. Considering the claimant’s

“pertinent symptoms, signs, and laboratory findings,” the ALJ determines whether the

claimant has “a medically determinable mental impairment(s)” and “rate[s] the degree of

functional limitation resulting from the impairment(s)” according to certain criteria. 20

C.F.R. §§ 404.1520a(b), 416.920a(b); see id. §§ 404.1520a(c), 416.920a(c). “Next, the ALJ

must determine if the mental impairment is severe, and if so, whether it qualifies as a

listed impairment.” Patterson, 846 F.3d at 659; see 20 C.F.R. §§ 404.1520a(d),

416.920a(d). “If the mental impairment is severe but is not a listed impairment, the ALJ

must assess the claimant’s RFC in light of how the impairment constrains the claimant’s

work abilities.” Patterson, 846 F.3d at 659. After assessing the claimant’s RFC, the ALJ

at the fourth step determines whether the claimant has the RFC to perform the

requirements of her past relevant work. 20 C.F.R. §§ 404.1520(a)(4)(iv),

416.920(a)(4)(iv); Monroe, 826 F.3d at 180. If she does not, then “the ALJ proceeds to

step five.” Lewis, 858 F.3d at 862.

The fifth and final step requires the ALJ to consider the claimant’s RFC, age,

education, and work experience in order to determine whether she can make an

adjustment to other work. 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). At this point,

“the burden shifts to the Commissioner to prove, by a preponderance of the evidence, that

the claimant can perform other work that ‘exists in significant numbers in the national

economy.’” Lewis, 858 F.3d at 862 (quoting Mascio, 780 F.3d at 635). “The

Commissioner typically offers this evidence through the testimony of a vocational expert

responding to a hypothetical that incorporates the claimant’s limitations.” Id. (quoting

Mascio, 780 F.3d at 635). If the claimant can perform other work, the ALJ will find her

“not disabled.” 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). If she cannot perform

other work, the ALJ will find her “disabled.” Id.

Applying the sequential evaluation process in this case, the ALJ concluded that

Claimant satisfied the insured status requirements and was insured through September

30, 2024—the date last insured—and thus qualified to apply for DIB benefits. (Tr. 13).

Turning to the first step of the sequential evaluation process, the ALJ determined that

Claimant had not engaged in substantial gainful activity since the alleged onset of her

disability. Id. Next, at step two, the ALJ determined that the following of Claimant’s

conditions constituted “severe” impairments: osteoarthritis; bursitis; degenerative-disc

disease of the lumbar spine; radiculopathy; spondylosis; chronic-liver disease; obesity;

capsulitis of the toe; neuroma of the foot; and calcaneal spurs. Id. However, the ALJ found

at step three that those impairments, or a combination thereof, failed to meet or medically

equal any of the impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 15).

Next, upon assessing Claimant’s RFC, the ALJ determined that Claimant is able “to

perform sedentary work,” subject to the following limitations:

[C]laimant can occasionally climb ramps and stairs but never climb ladders,

ropes, and scaffolds. She can occasionally balance, stoop, kneel, crouch, and

crawl. She is capable of tolerating occasional exposure to extreme cold, heat,

vibration, atmospheric conditions . . . and any workplace hazards such as

moving machinery or unprotected heights.

(Tr. 18).

Finally, at the last step of the sequential evaluation process, the ALJ enlisted a

Vocational Expert (“VE”) to aid in her findings. (Tr. 24). The ALJ found that Claimant “is

able to perform . . . [and] can return to . . . her past relevant work” as an insurance clerk—

a sedentary, skilled position—because it “does not require the performance of work-

related activities precluded by the claimant’s residual functional capacity.” (Tr. 24-25).

Based upon this finding, the ALJ determined that Claimant “has not been under a

disability” during the relevant time period. (Tr. 25).

II. LEGAL STANDARD

This Court has a narrow role in reviewing the Commissioner’s final decision to

deny benefits: it “must uphold the factual findings of the [ALJ] if they are supported by

substantial evidence and were reached through application of the correct legal standard.”

Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012) (quoting Johnson v. Barnhart, 434

F.3d 650, 653 (4th Cir. 2005) (per curiam)). “Substantial evidence” is “such relevant

evidence as a reasonable mind might accept as adequate to support a conclusion,” and it

must be “more than a mere scintilla.” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019). In

other words, this Court “looks to [the] administrative record and asks whether it contains

‘sufficient evidence’ to support the agency’s factual determinations.” Id. (alteration

omitted). “[T]he threshold for such evidentiary sufficiency is not high.” Id. “In reviewing

for substantial evidence, [this Court] do[es] not undertake to reweigh conflicting

evidence, make credibility determinations, or substitute [its] judgment for that of the

[ALJ].” Johnson, 434 F.3d at 653 (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir.

1996)). Even if “reasonable minds [could] differ as to whether a claimant is disabled,” this

Court upholds the ALJ’s decision if it is supported by substantial evidence. Id. (quoting

Craig, 76 F.3d at 589).

III. ANALYSIS

In support of this § 405(g) action, Claimant makes three assertions of error. First,

Claimant argues that the ALJ’s written determination regarding Claimant’s Residual

Functional Capacity (“RFC”) is deficient as a matter of law because “the ALJ failed to

accommodate [Claimant’s] proven mild mental limitations or explain why they were

omitted from the ALJ’s RFC assessment.” (ECF No. 5 at 2). As to Claimant’s second and

third assertions of error, she argues that remand is required because the ALJ’s RFC

determination failed to properly consider the impact caused by Claimant’s fatigue and

bilateral-hand arthritis, respectively. Id.

In response, the Commissioner argues that the ALJ did not err and that her

decision is supported by substantial evidence. He points out that the ALJ’s decision in

this case is thorough and well-supported, particularly considering the volume of medical

evidence in the record—which spans more than 1,000 pages in total. (See ECF Nos. 4; 4-

1). The Commissioner further argues that the Claimant’s arguments lack merit because

they each ignore the ALJ’s extensive discussion of each of these conditions and the basis

for her determination that Claimant’s fatigue and bilateral-hand arthritis did not impact

Claimant’s RFC. (See ECF No. 8).

In her reply brief, the Claimant reiterates her first argument that the ALJ

specifically found the Claimant had “mild” limitations in all four broad areas of mental

functioning, but failed to explain why she did not incorporate these mild limitations into

Claimant’s RFC. (ECF No. 9 at 1-3). Second, Claimant argues that the ALJ relied

improperly upon her own lay judgment and ignored medical opinions and other evidence

that Claimant’s fatigue would significantly impact her ability to perform her past skilled

work. Id. at 3-4. Lastly, Claimant reiterates that the ALJ made no actual finding regarding

the severity or non-severity of Claimant’s bilateral-hand impairment, leaving it unclear

whether she considered any work-related limitations. (ECF No. 9 at 4).

Having reviewed the parties’ submissions as well as the transcript of

administrative proceedings (the “record”), herein the undersigned takes up each of

Claimant’s three assertions of error in turn.

A. Impact of Claimant’s Mild Mental-Health Limitations on Her RFC

In support of her first assertion of error, Claimant points to the ALJ’s finding that

the medically-determinable impairment of depression caused mild limitations in all four

domains of mental functioning (i.e., understanding, remembering, or applying

information; interacting with others; concentrating, persisting, or maintaining pace; and

adapting or managing oneself). (ECF No. 5 at 4 (citing Tr. 14-15)). Claimant highlights

that the ALJ’s finding is more favorable to her than the opinions of the state-agency

physicians, who found Claimant had no mental-function limitations. (ECF No. 5 at 4

(citing Tr. 14-15, 105, 115)). Claimant does not challenge the ALJ’s determination that her

mental-function limitations were mild; as she explains in her brief, her assertion of error

“has nothing to do with how the ALJ weighed the medical evidence or what medical

opinions and other facts were considered.” (ECF No. 5 at 4 n.2). Instead, according to

Claimant, “the issue is solely whether it was legal error for the ALJ to omit Claimant’s

proven mental functional limitations from the RFC finding without explanation.” Id.

Specifically, Claimant argues that “the ALJ here included precisely zero mental functional

limitations in her RFC finding and dispositive hypothetical question to the VE (Tr. 18,

97),” despite the ALJ’s prior finding of credible mild limitations at steps two and three of

the sequential evaluation process. (ECF No. 5 at 5-6).

Claimant concedes that, “[w]ith respect to the ability to perform unskilled work,

any omission of mild mental functional limitations may likely constitute harmless error.”

Id. at 6-11. However, Claimant distinguishes the circumstances sub judice based upon the

ALJ’s determination that the Claimant can perform prior skilled work. Id. at 11 (citing Tr.

18-23). Based upon these factors, Claimant concludes that the ALJ’s written decision is

“facially defective” because the ALJ fails therein to explain why the mild mental

limitations were omitted from the discussion of her RFC determination, and fails to

otherwise identify how Claimant’s mild mental-function limitations impact her ability to

perform her skilled prior work. Id. According to Claimant, this “facial deficiency” violates

Agency policy and warrants remand. Id. at 11-13 (citing SSR 96-8p, 1996 WL 374184, *4).

In response, the Commissioner argues that the ALJ did not err because she

thoroughly explained why Claimant’s mild mental impairments did not require any work-

related limitations. (ECF No. 8 at 8). Unlike the cases Claimant cites, the ALJ here

discussed Claimant’s mental impairments many times throughout her decision—not only

at step two of the sequential evaluation process, but also during her RFC assessment. See

id. According to the Commissioner, the ALJ’s extensive discussion demonstrates her

adequate consideration of Claimant’s mild mental impairments and her reasoning for not

adding limitations related to those impairments in her RFC. Id.

In support, the Commissioner highlights the ALJ’s explanation that, although

Claimant sometimes reported feelings of anxiety and depression and trouble

concentrating, Claimant’s mental-status examinations consistently showed normal

memory, cooperative attitude, good eye contact, normal attention, normal thought

content, and “fair if not better” insight and judgment. Id. (citing Tr. 14-15, 462, 495, 819,

967, 974, 998-99, 1120-21). Furthermore, the ALJ points to Claimant’s own statements

that she engaged in a number of daily-living activities requiring relatively-unimpaired

mental functioning and concentration, such as playing games on her phone, sewing,

preparing meals, shopping, doing chores, handling her own finances, managing personal

care, and spending time with others. Id. (citing Tr. 14-15, 281-84). The Commissioner

further points out that the ALJ expressly stated in her written decision that her RFC

assessment “reflects the degree of limitation . . . found in the ‘paragraph B’ mental

function analysis.” (Tr. 19). More significant, the Commissioner explained that—unlike

the caselaw relied upon by Claimant’s brief—the ALJ did not merely confine her analysis

of Claimant’s mental-function limitations to step two of the sequential-evaluation

process. (ECF No. 8 at 9-10).

On review, the undersigned FINDS that—contrary to Claimant’s assertions—the

ALJ expressly explained the logical and evidentiary basis for her finding that Claimant’s

mild mental-function limitations did not impact her ability to perform her skilled prior

work, and that the ALJ included this explanation in the portion of the written decision

where she discusses her RFC analysis. The ALJ specifically included a detailed

explanation demonstrating the evidentiary basis and rationale she employed in her

evaluation of “the intensity, persistence, and limiting effects of the claimant’s symptoms

to determine the extent to which they limit the claimant’s work-related activities.” Id. The

ALJ expressly acknowledged Claimant’s own reports of memory and concentration

problems, and explained the basis for her determination that those limitations did not

“limit the [Claimant’s] ability to do work-related activities.” (Tr. 18). She expressly

evaluated the Claimant’s allegations and testimony—including Claimant’s allegations of

disability based upon “bipolar disorder, insomnia, depression, [and] anxiety,” and

pointed to specific evidence she weighed against these statements to support her finding

that “the claimant’s statements concerning the intensity, persistence and limiting effects

of these symptoms are not entirely consistent with the medical evidence and other

evidence in the record.” (Tr. 18-19). For instance, the ALJ noted that the Claimant

reported memory and concentration problems, but she explained that the medical records

demonstrate that, overall, Claimant had consistently normal mental-status-exam

findings. (Tr. 19-23 (citing 462, 495, 819, 967, 974, 998-99, 1120-21)).

Following her discussion of this medical evidence the ALJ summarized that the

“[m]ental health treatment records note the claimant reports her medication is effective

and that she denies symptoms of depression or anxiety when compliant . . . [and]

[f]urther, the claimant had multiple depression screenings when seen by her providers

and her mental status exam findings are normal.” (Tr. 23). The ALJ concluded that,

“[o]verall, the evidence of record does not support the alleged loss of functioning[,] [but

rather] shows that the claimant’s allegations of disabling impairments, which are found

in the claimant’s disability reports and hearing testimony, are inconsistent with objective

findings and subjective findings on examinations as well as her activities of daily living.”

(Tr. 23).

Next, the ALJ’s RFC assessment discussed the opinions of the psychological

consultants and explained why she found those opinions to be persuasive. (Tr. 23-24). As

the ALJ explained, “[t]he consultants opined the claimant has only non-severe mental

impairments and no functional limitations.” (Tr. 24). She found that the opinions were

“consistent with the evidence of record that notes normal mental status exam findings

including normal memory, attention, and behavior, a generally euthymic mood, and fair

insight and judgment.” Id. The ALJ also found it significant that Claimant “has

consistently reported she is independent in her activities of daily living.” Likewise, the

ALJ specifically discussed mental-health-treatment records from West Virginia

University Medicine where Claimant reported that her depression and anxiety improved

after she quit her job; in fact, Claimant reported that her mood was good and her

medications were working. (Tr. 22-23, 495, 497-98). Based upon this evidence, the ALJ

concluded that the record evidence “does not support [Claimant’s] alleged loss of

functioning,” because the “[m]ental health treatment records note [Claimant] reports her

medication is effective and that she denies symptoms of depression or anxiety when

compliant” with her prescribed course of medication. (Tr. 23) (emphasis added).

The undersigned agrees with the Commissioner’s characterization that the instant

action “is not a case where the ALJ failed to discuss Claimant’s mental impairments

beyond step two,” because the ALJ’s analysis “very clearly allows for meaningful review

of the ALJ’s determination that Claimant did not have any mental RFC restrictions.” (ECF

No. 8 at 10). The RFC analysis set forth in the ALJ’s written decision thoroughly explained

why she did not include a limitation for Claimant's mild mental-function impairments.

Consequently, the ALJ’s RFC analysis is distinguishable from the caselaw cited by

Claimant, all of which involved an ALJ’s omission of a claimant’s mental impairments

from the RFC discussion entirely. See Shank v. Saul, 3:20-cv-00444, 2021 WL 2767063,

at *8 (S.D. W. Va. June 11, 2021), adopted, 2021 WL 2744550, at *1 (July 1, 2021); Jones

v. Kijakazi, 5:21-cv-00634, ECF No. 18 at 19 (S.D. W. Va. Sept. 22, 2022) (“[T]he ALJ did

not discuss, or even mention, [c]laimant’s mental limitations at any subsequent steps of

the sequential evaluation.”), adopted, ECF No. 19 (Nov. 28, 2022).

In her reply brief, the Claimant reiterates her assertion of error on the grounds that

“the ALJ did not accept the state agency finding that [Claimant] had ‘no’ mental limitation

in the four broad areas of mental functioning (Tr. 24, 105, 115) . . . and instead specifically

found . . . ‘mild’ limitations in all four broad areas.” (ECF No. 9 at 2 (citing Tr. 14-15)).

Claimant asserts that “[t]his inconsistency and lack of explanation alone preclude any

meaningful judicial review, requiring remand.” Id. at 3. Claimant is correct in that the

ALJ stated that “[t]he evidence of record supports finding the claimant has no more than

mild limitations in any area of mental function and no severe mental impairments.” (Tr.

24). Claimant’s position, however, relies upon an overly-literal construction of the ALJ’s

statement and ignores the central theme of the RFC analysis, that—while finding no more

than mild mental-health limitations—the ALJ did not include any work-related mental-

function limitations in the RFC because the medical and state-agency opinion evidence

demonstrated that Claimant’s symptoms are resolved when she is compliant with her

regimen of medication. Simply put, a fair reading of the written decision demonstrates

that the ALJ provided an accurate and logical bridge between the evidence and her

conclusions—quite distinct from the line of improper decisions which frustrated judicial

review by leaving the reader “to guess about how the ALJ arrived at [her] conclusions.”

Mascio, 780 F.3d at 637.

Based upon the foregoing, the undersigned FINDS that the ALJ’s decision is

supported by substantial evidence, and Claimant has failed to demonstrate error on this

basis. Accordingly, the undersigned respectfully recommends that Claimant’s request for

remand be DENIED.

B. Impact of Claimant’s Condition of Fatigue on Her RFC

In her second assertion of error, Claimant argues the ALJ “committed legal error

in considering [Claimant’s] fatigue.” (ECF No. 5 at 13-14). Specifically, Claimant argues

that the ALJ—in finding that Claimant’s chronic-fatigue syndrome is non-severe—

improperly substituted her own lay judgment over the opinions of state-agency physicians

Isidro Amigo, M.D., and Lisa Venkataraman, M.D., who found that Claimant has severe

chronic-fatigue syndrome. (ECF No. 5 at 13-14). Claimant also argues that the ALJ

“completely ignored [the] fatigue symptoms” after determining that Claimant’s chronic-

fatigue syndrome was non-severe. (ECF Nos. 5 at 13-14; 9 at 3; Tr. 105, 116). Claimant

argues that the ALJ’s failure to consider her fatigue is not harmless in light of the ALJ’s

finding that Claimant was able to return to her past skilled work. See id.

In response, the Commissioner argues that the ALJ appropriately evaluated the

persuasiveness of the state-agency physicians’ opinions under the express provisions of

20 C.F.R. § 404.1520c. (ECF No. 8 at 12-13) (citing 20 C.F.R. § 404.1520c(a). The ALJ

determined that the physicians’ opinions as to the severity of Claimant’s chronic-fatigue

syndrome were inconsistent with the record evidence as a whole, and she explained the

evidentiary basis for this determination. (ECF No. 8 at 13-14) (citing Tr. 24, 105, 116)).

The Commissioner concludes that, because the ALJ’s written decision properly discusses

her evaluation of “the most important [persuasiveness] factors” of supportability and

consistency, the decision complies with the requirements of § 104.1520c(a) and is

therefore free of error. See id.

In reply, Claimant does not address the Commissioner’s arguments; instead, she

merely restates her argument that the ALJ improperly substituted her lay opinion to find

that Claimant’s chronic-fatigue syndrome was not severe, and then “completely ignored”

Claimant’s fatigue symptoms. (ECF No. 9 at 3-4).

Simply put, Claimant’s argument lacks merit and fails to demonstrate error. First,

it is plain that the ALJ’s severity determination did not trespass into the territory of a

medical opinion. It is undisputed that Claimant’s chronic-fatigue syndrome was a

medically-determinable impairment; in fact, the ALJ specifically found that the

impairments at issue “could reasonably be expected to cause the alleged symptoms[.]”

(Tr. 19). Rather than replacing the physicians’ diagnosis with her own lay opinion, the

ALJ appropriately considered the persuasiveness of the physicians’ opinions regarding

the severity of Claimant’s impairment in light of the evidence from other medical sources,

the objective medical evidence, and nonmedical sources in the claim. (See Tr. 19-20). In

accordance with § 404.1520c(c)(1)-(2), the ALJ assessed the factors of supportability and

consistency and explained the logical and evidentiary basis for her conclusion. (See Tr.

19-24). In particular, the ALJ explained that the opinions of Dr. Amigo and Dr. Venkataraman

were inconsistent with the record evidence as a whole. See id. For instance, the ALJ noted that, in

contrast to the physicians’ opinions and Claimant’s subjective complaints regarding the severity of

her symptoms, a diagnosis of chronic-fatigue syndrome appears only once in a sea of

medical records spanning more than a thousand pages. (Tr. 20, 438). The ALJ noted that

this finding is equivocal, because the same record states that additional testing may be

required to identify other potential etiologies for Claimant’s symptoms—including a

medication or obstructive sleep apnea. Id. Furthermore, the ALJ points extensively to

treatment records consistently indicating that Claimant’s mental-status and physical

examinations were normal and that Claimant reported being fully independent in her

activities of daily living—including activities requiring sustained concentration like

sewing, gaming, and cooking. (Tr. 20-24). Based upon this evidence, the ALJ

appropriately determined that “the claimant’s statements concerning the intensity,

persistence and limiting effects of these symptoms are not entirely consistent with the

medical evidence and other evidence in the record.” (Tr. 19).

Furthermore, Claimant’s assertion that the ALJ ignored Claimant’s other

symptoms of fatigue “once she concluded that [Claimant’s] chronic-fatigue syndrome did

not rise to the level of a severe impairment,” (see ECF No. 5 at 14), is inaccurate. It is

undisputed that Claimant reported other fatigue-related symptoms, as recognized by the

ALJ. (Tr. 23-24). The ALJ’s extensive discussion of the medical records as well as her RFC

discussion expressly acknowledge Claimant’s reported struggles with sleep, racing

thoughts, and lack of energy. (Tr. 20, 23). The ALJ explains that these reported symptoms

are simply incongruous with the record as a whole; nonetheless, the ALJ accounted for

Claimant’s non-severe fatigue-related impairments in part by adding limitations

consistent with a restriction to sedentary work into the RFC. (Tr. 23-24, 1416-1425). The

ALJ’s extensive discussion of the medical records demonstrates a traceable tether of logic

between the evidence and the ALJ’s conclusions, and the ALJ reasonably found, based on

Claimant’s generally normal exam findings and independent activities of daily living,

that the record did not support Claimant’s allegations. This is supported by substantial

evidence.

Tellingly, Claimant’s assertion of error is unsupported by any Fourth-Circuit

authority, or other persuasive caselaw setting forth circumstances similar to the instant

action; nor does Claimant’s reply brief refute any of the Commissioner’s

counterarguments and supporting authority. Instead, Claimant merely states that “the

record is replete with evidence of [Claimant’s] fatigue (Tr. 103, 114, 641-42, 653-54, 899-

900, 951, 955, 967, 1308).” (ECF No. 5 at 14; see also ECF No. 9 at 3 (repeating the same)).

Claimant fails to offer any meaningful discussion of the dozen or so listed numbers pulled

from a record spanning 1,425 pages. (See ECF Nos. 4; 4-1). The only record addressed by

Claimant’s brief is a single treatment note from a May 6, 2021 chiropractic examination.

(ECF Nos. 5 at 14; 9 at 3-4 (each citing Tr. 955)). According to the Claimant, therein her

chiropractor “characterized [Claimant’s] fatigue as ‘daily debilitating fatigue.’” Id.

Notably, the treatment note at issue does not contain a medical opinion that the

claimant has “daily debilitating fatigue,” as Claimant’s brief suggests. (ECF No. 5 at 14).

Instead, the quoted language is pulled from the patient-history section of the

chiropractor’s treatment note, summarizing Claimant’s report that she suffers from daily

debilitating fatigue in addition to her reported symptoms of joint pain, malaise,

depression, and progressive obesity, in addition to summarizing the list of the Claimant’s

current medications. (Tr. 955). In the treatment plan, the chiropractor recommends that

Claimant seek a medical evaluation and additional diagnostic testing through her

primary-care physician. (Tr. 956). The only reference to Claimant’s fatigue in this section

is the chiropractor’s addition in the Comments section of the treatment plan to “Update

exercise once fatigue is stabilized.” Id. In short, Claimant failed to demonstrate that any

of the medical records she cites in her brief support a finding that the ALJ’s determination

improperly contravenes the medical evidence or that the ALJ otherwise committed legal

error in considering Claimant’s symptoms of fatigue.

Furthermore, Claimant’s mere citation to record “evidence of [her] fatigue” fails to

demonstrate error. By simply pointing to other evidence on the record that may support

a different finding, Claimant is essentially asking the Court to re-weigh the evidence. This

is improper because it is the province of the ALJ, and not this Court, to resolve conflicts

in the evidence. See, e.g., Keene v. Berryhill, 732 Fed. App’x 174, 177 (4th Cir. 2018)

(“This court’s function is not to substitute its own judgment for that of the ALJ, but to

determine whether the ALJ’s decision is supported as a matter of fact and law. There

were a number of conflicts in the evidence here, and we do not second guess the ALJ

in resolving those conflicts.”). As set forth supra, the Court’s only role on review pursuant

to 42 U.S.C. § 405(g) is to ensure the ALJ’s decision is supported by substantial evidence,

and free of legal error.

Ultimately, Claimant may disagree with the ALJ’s determination that the record

evidence does not support the extent of fatigue-related impairments alleged by the

Claimant, but it is well-established that a claimant’s mere disagreement with the

inferences the ALJ made from the evidence, standing alone, is patently insufficient to

demonstrate error. See id. The ALJ clearly explained why she did not find the State agency

physicians’ opinions regarding the severity of Claimant’s impairments of chronic-fatigue

syndrome and other fatigue-related symptoms were persuasive in light of the record evidence

as a whole; the ALJ then grounded her explanation in support from the medical record, in a

manner that is more than sufficient to trace the path of her reasoning. The undersigned

FINDS that the ALJ appropriately considered Claimant’s subjective complaints and the

state-agency physicians’ opinions under the appropriate regulatory framework, and

substantial evidence—more than a scintilla—supports the ALJ’s fact-finding. While

Claimant, and even the Court, may have reached a different determination, the ALJ’s

decision plainly met this standard. Accordingly, the undersigned respectfully

recommends that Claimant’s request for remand be DENIED.

C. Impact of Claimant’s Bilateral-Hand Osteoarthritis on Her RFC

Finally, Claimant argues that remand is required because the ALJ failed to

appropriately consider Claimant’s impairment of bilateral osteoarthritis of the hands and

its impact upon the RFC. (ECF No. 5 at 15). Claimant highlights that x-ray images from

August 2021 “confirm bilateral degenerative changes of the hands,” and treatment

records indicate that she has been diagnosed with osteoarthritis of both hands on at least

three occasions. Id. (citing Tr. 1035, 1045, 1122, 1385). Claimant concedes that “the ALJ

recognized this evidence in the narrative portion of the decision,” but objects that the ALJ

did not make an express finding specifically as to severity. Id. (citing Tr. 22). Claimant

concludes that “[t]he ALJ’s failure to articulate her reasons for omitting . . . hand

limitations from her RFC renders this decision beyond judicial review . . . [because] it is

impossible to know, on this record, how, or even if, the ALJ considered [Claimant’s] work-

related limitations related to her bilateral osteoarthritis of the hands[.]” Id. at 15-16.

In response, the Commissioner asserts that Claimant’s argument is “demonstrably

inaccurate.” (ECF No. 8 at 15). The Commissioner points out that the ALJ’s written

decision specifically included osteoarthritis as one of Claimant’s severe impairments,

and specifically addresses Claimant’s osteoarthritis in both hands in the RFC

determination. Id. at 15-16 (citing Tr. 13). The Commissioner concludes that the ALJ’s

decision rests on application of proper legal standards and is supported by substantial

evidence. Id. at 17. In her reply brief, Claimant challenges the Commissioner’s argument

that the ALJ’s finding of severe osteoarthritis encompassed a consideration of Claimant’s

“hand limitations.” (ECF No. 9 at 4). Claimant acknowledges that the ALJ “mentioned

[the] hand impairment in the narrative portion of the decision,” but argues that, without

a finding of severity, “[i]t is impossible to know, on this record, how, or even if, the ALJ

considered [Claimant’s] work-related limitations related to her bilateral osteoarthritis of

the hands, requiring remand.” Id.4

3F

Upon review of the ALJ’s thorough and well-supported written decision,

Claimant’s assertion of error is simply not borne out by the record. At step two of the

sequential evaluation process, the ALJ expressly found “[t]he medical evidence of record

reflects that the claimant has medical signs and objective findings establishing the

diagnoses [of] osteoarthritis, and that Claimant’s osteoarthritis constituted a “severe

impairment[.]” (Tr. 13). Further, throughout the opinion, the ALJ expressly discusses the

evidence regarding to Claimant’s hand function in the context of her bilateral

osteoarthritis. In the ALJ’s narrative discussion, she describes how the medical evidence,

including results from imaging and physical examinations reflected in Claimant’s

treatment records, do not support “finding the claimant . . . is unable to independently

initiate, sustain, and complete work-related activities involving fine and gross

movements.” (Tr. 16). Specifically, in her assessment of the listed impairments under 20

C.F.R. Part 404, Subpart P, Appendix 1, the ALJ explained that, in order to qualify for

abnormality of a major joint in any extremity in accordance with Listing 1.18, Claimant

must demonstrate the following:

4 Claimant also argues in her initial and reply briefs that the Commissioner may not rely upon post-hoc

rationalization to rehabilitate the ALJ’s failure to explain her findings, and that the ALJ’s purported error

is not harmless because manipulation of the hands and fingers would be necessary to perform her past

skilled work as an insurance clerk. (See ECF No. 5). Because the undersigned finds herein that the ALJ did

not err, however, Claimant’s arguments on these points are not relevant.

documented chronic joint pain or stiffness AND abnormal motion,

instability, or immobility of the affected joint AND anatomical abnormality

of the affected joint noted on physical examination or imaging AND

impairment-related physical limitation of musculoskeletal functioning that

has lasted, or is expected to last, for a continuous period of at least 12

months, and medical documentation of at least one of the following: . . . an

inability to use both upper extremities to the extent that neither can be

used to independently initiate, sustain, and complete work-related

activities involving fine and gross movements.

(Tr. 17).

Applying this standard to the record evidence, the ALJ pointed to medical

records—with specific record citations—showing that medical examination findings and

x-ray imaging revealed “mild degenerative changes in [Claimant’s] hands bilaterally,”

but normal strength, sensation, and range of motion—with “no evidence [Claimant] is

unable to independently initiate, sustain, and complete work-related activities involving

fine and gross movements.” Id. Further, the ALJ specifically noted in her discussion of

the Claimant’s RFC that Claimant reported “increased pain in her . . . hand” in the

disability report, and testified that “[s]he cannot write long because of problems with her

hands.” (Tr. 19). The ALJ contrasted this evidence with the extensive activities of daily

living in Claimant’s function report. Id. Specifically, the Claimant “stated in her function

report that she plays games on her phone, cooks, does chores, sews, prepares meals,

drives, shops, and handles her finances . . . [and] reported no difficulty with personal

care.” Id. (citing Tr. 280-87). Finally, the ALJ further discussed Claimant’s hand-related

symptoms in medical records from her rheumatologist, as well as the opinions of the state-

agency physicians. (Tr. 21-24).

Based upon the ALJ’s extensive consideration of the evidence, she found that

Claimant’s impairments—including Claimant’s osteoarthritic impairments—could

reasonably be expected to cause the alleged symptoms; however, the claimant’s

statements concerning the intensity, persistence and limiting effects of these symptoms

are not entirely consistent with the medical evidence and other evidence in the record[.]”

Id. The ALJ provided for this finding in her RFC, stating that Claimant’s combination of

impairments, including osteoarthritis, “results in additional limitations consistent with

the finding the claimant capable of sedentary exertion with postural and environmental

limitations.” (Tr. 24). This thorough, extensive discussion throughout the ALJ’s written

decision explains the evidentiary and logical basis for the ALJ’s determination, and is

well-supported by specific record citations. As such, Claimant’s argument that “it is

impossible to know, on this record, how, or even if, the ALJ considered [Claimant’s]

work-related limitations related to her bilateral osteoarthritis of the hands,” (ECF No. 5

at 15-16), is simply not borne out by the record.

Moreover, Claimant does not highlight any specific findings from the medical

records, or point to any inaccuracies in the ALJ’s decision. In fact, she cites to only three

pages of her medical records in support of her assertion that she was “diagnosed with

osteoarthritis of both hands.” (ECF No. 5 at 15 (citing Tr. 1035, 1045, 1385)). However,

Claimant acknowledges that “the ALJ recognized this evidence.” Id. Tellingly, Claimant

fails both in her initial brief and in her reply brief to set forth any relevant authority,

either within or without the Fourth Circuit, in support of her position that the ALJ erred

under the circumstances. In fact, the sole basis for Claimant’s challenge to the

Commissioner’s argument is her own stated disagreement that the ALJ’s finding of

severe osteoarthritis “did not” encompass a finding of severity with respect to Claimant’s

bilateral osteoarthritis of the hands. (ECF No. 9 at 4 (“It did not.”)). Without any factual

or legal support, Claimant’s argument is patently insufficient to demonstrate error

pursuant to the highly deferential standard of § 405(g) review.

The undersigned FINDS that the ALJ appropriately considered Claimant’s

bilateral osteoarthritis of the hands pursuant to the appropriate regulatory framework,

and substantial evidence—more than a scintilla—supports the ALJ’s determination.

Again, while Claimant, and even the Court, may have reached a different determination,

the ALJ’s decision is supported by substantial evidence and Claimant has demonstrated

no error. Accordingly, the undersigned respectfully recommends that Claimant’s request

for remand be DENIED.

IV. CONCLUSION

For the foregoing reasons, the undersigned respectfully RECOMMENDS that the

presiding District Judge DENY Claimant’s request to reverse the Commissioner’s

decision (ECF No. 5), GRANT the Commissioner’s request to affirm his decision (ECF

No. 8), AFFIRM the final decision of the Commissioner, and DISMISS this action from

the Court’s active docket.

The parties are notified that this Proposed Findings and Recommendation is

hereby FILED and a copy will be submitted to the Honorable John T. Copenhaver, Jr.,

Senior United States District Judge. Pursuant to the provisions of 28 U.S.C.

§ 636(b)(1)(B) and Federal Rule of Civil Procedure 72(b), the parties shall have fourteen

(14) days from the date of the filing of this Proposed Findings and Recommendation 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. Copies of

any objections shall be served on opposing parties and provided to Judge Copenhaver.

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 Fourth Circuit

Court of Appeals. 28 U.S.C. § 636(b)(1); see Thomas v. Arn, 474 U.S. 140, 155 (1985);

Snyder v. Ridenour, 889 F.2d 1363, 1366 (4th Cir. 1989); Wright v. Collins, 766 F.2d 841,

846 (4th Cir. 1985); United States v. Schronce, 727 F.2d 91, 94 (4th Cir. 1984).

The Clerk is DIRECTED to file this Proposed Findings and Recommendation and

to transmit a copy of the same to counsel of record.

ENTERED: August 22, 2024

ae

Dwane L. Tinsley

_._ United States Magistrate Judge

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