Opinion
No. 5:20-CV-199-M
04-19-2021
KAREN L. FAIRCLOTH, Plaintiff/Claimant, v. ANDREW SAUL, Commissioner of Social Security, Defendant.
MEMORANDUM AND RECOMMENDATION
This matter is before the court on the parties' cross-motions for judgment on the pleadings [DE-23, -26] pursuant to Fed. R. Civ. P. 12(c). Claimant Karen L. Faircloth ("Claimant") filed this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the denial of her application for a period of disability and Disability Insurance Benefits ("DIB"). The time for filing responsive briefs has expired, and the pending motions are ripe for adjudication. Having carefully reviewed the administrative record and the motions and memoranda submitted by the parties, it is recommended that Claimant's Motion for Judgment on the Pleadings be allowed, Defendant's Motion for Judgment on the Pleadings be denied, and the case be remanded to the Commissioner for further proceedings consistent with the Memorandum and Recommendation.
I. STATEMENT OF THE CASE
Claimant protectively filed an application for a period of disability and DIB on January 11, 2016, alleging disability beginning April 7, 2014. (R. 166, 328-29). Her claim was denied initially and upon reconsideration. (R. 166, 221-54). A hearing before the Administrative Law Judge ("ALJ") was held on February 25, 2019, at which Claimant, represented by counsel, and a vocational expert ("VE") appeared and testified. (R. 166, 187-220). On April 24, 2019, the ALJ issued a decision denying Claimant's request for benefits. (R. 163-86).
Claimant then requested a review of the ALJ's decision by the Appeals Council, (R. 325-27), and submitted additional evidence as part of her request, (R. 10-162). The Appeals Council did not exhibit the evidence because it found that the medical records dated October 26, 2018 did not show a reasonable probability that they would change the outcome of the decision, and the rest of the additional evidence did not relate to the period at issue. (R. 2). On April 16, 2020, the Appeals Council denied Claimant's request for review. (R. 1-7). Claimant then filed a complaint in this court seeking review of the now-final administrative decision.
II. STANDARD OF REVIEW
The scope of judicial review of a final agency decision regarding disability benefits under the Social Security Act ("Act"), 42 U.S.C. § 301 et seq., is limited to determining whether substantial evidence supports the Commissioner's factual findings and whether the decision was reached through the application of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). "The findings of the Commissioner . . . as to any fact, if supported by substantial evidence, shall be conclusive . . . ." 42 U.S.C. § 405(g). Substantial evidence is "evidence which a reasoning mind would accept as sufficient to support a particular conclusion." Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966). While substantial evidence is not a "large or considerable amount of evidence," Pierce v. Underwood, 487 U.S. 552, 565 (1988), it is "more than a mere scintilla . . . and somewhat less than a preponderance." Laws, 368 F.2d at 642. "In reviewing for substantial evidence, [the court should not] undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]." Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996), superseded by regulation on other grounds, 20 C.F.R. § 416.927(d)(2)). Rather, in conducting the "substantial evidence" inquiry, the court's review is limited to whether the ALJ analyzed the relevant evidence and sufficiently explained his or her findings and rationale in crediting the evidence. Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).
III. DISABILITY EVALUATION PROCESS
The disability determination is based on a five-step sequential evaluation process as set forth in 20 C.F.R. § 404.1520 under which the ALJ is to evaluate a claim:
The claimant (1) must not be engaged in "substantial gainful activity," i.e., currently working; and (2) must have a "severe" impairment that (3) meets or exceeds [in severity] the "listings" of specified impairments, or is otherwise incapacitating to the extent that the claimant does not possess the residual functional capacity to (4) perform . . . past work or (5) any other work.Albright v. Comm'r of the SSA, 174 F.3d 473, 475 n.2 (4th Cir. 1999). "If an applicant's claim fails at any step of the process, the ALJ need not advance to the subsequent steps." Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995) (citation omitted). The burden of proof and production during the first four steps of the inquiry rests on the claimant. Id. At the fifth step, the burden shifts to the ALJ to show that other work exists in the national economy which the claimant can perform. Id.
When assessing the severity of mental impairments, the ALJ must do so in accordance with the "special technique" described in 20 C.F.R. § 404.1520a(b)-(c). This regulatory scheme identifies four broad functional areas in which the ALJ rates the degree of functional limitation resulting from a claimant's mental impairment(s): understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing oneself. Id. § 404.1520a(c)(3). The ALJ is required to incorporate into his written decision pertinent findings and conclusions based on the "special technique." Id. § 404.1520a(e)(3).
In this case, Claimant alleges that the ALJ erred in weighing a 2012 functional assessment and the medical opinions. Pl.'s Mem. [DE-24] at 8-17.
IV. ALJ'S FINDINGS
Applying the above-described sequential evaluation process, the ALJ found Claimant "not disabled" as defined in the Act. At step one, the ALJ found Claimant had not engaged in substantial gainful employment from her alleged onset date of April 7, 2014 through her date last insured of September 30, 2018. (R. 168). Next, the ALJ determined Claimant had the following severe impairments: complex regional pain syndrome ("CRPS"), cervical spondylosis, and bilateral carpal tunnel syndrome. Id. The ALJ also found Claimant had nonsevere impairments of hypothyroidism, obesity, an anxiety disorder, and depression as well as a non-medically determinable impairment of bowling ball syndrome. (R. 169-70). However, at step three, the ALJ concluded these impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 170-71). Applying the technique prescribed by the regulations, the ALJ found that Claimant's mental impairments have resulted in no limitations in understanding, remembering, or applying information and interacting with others and mild limitations in concentrating, persisting, or maintaining pace and adapting or managing oneself. (R. 170).
Prior to proceeding to step four, the ALJ assessed Claimant's RFC, finding Claimant had the ability to perform light work requiring the following limitations:
Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, you must have the ability to do substantially all of these activities. If an individual can perform light work, he or she can also perform sedentary work, unless there are additional limiting factors such as the loss of fine dexterity or the inability to sit for long periods of time. 20 C.F.R. § 404.1567(b).
[T]he claimant can occasionally push and pull with her upper extremities. The claimant can never reach overhead with her left upper extremity. The claimant can frequently handle, finger, and feel with her bilateral upper extremities. The claimant can occasionally climb ramps and stairs, but never climb ladders, ropes, or scaffolds. The claimant can occasionally balance, stoop, kneel, crouch, and crawl. In addition, the claimant can never perform work at unprotected heights or with/around moving mechanical parts.(R. 171-79). In making this assessment, the ALJ found Claimant's statements about her limitations not entirely consistent with the medical and other evidence. (R. 173). At step four, the ALJ concluded Claimant had the RFC to perform the requirements of her past relevant work as a medical processing assistant. (R. 179-80). Alternatively, at step five, upon considering Claimant's age, education, work experience, and RFC, the ALJ determined Claimant is capable of adjusting to the demands of other employment opportunities that exist in significant numbers in the national economy. (R. 180-81).
V. DISCUSSION
A. The ALJ did not sufficiently explain why little weight was given to Claimant's 2012 functional assessment.
Claimant contends that substantial evidence does not support the RFC because the ALJ did not properly consider a September 12, 2012 comprehensive functional assessment. Pl.'s Mem. [DE-24] at 10-13.
An individual's RFC is the capacity she possesses despite the limitations caused by physical or mental impairments. 20 C.F.R. § 404.1545(a)(1); see also S.S.R. 96-8p, 1996 WL 374184, at *1 (July 2, 1996). "[T]he residual functional capacity 'assessment must first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions' listed in the regulations." Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting S.S.R. 96-8p). The RFC is based on all relevant medical and other evidence in the record and may include a claimant's own description of limitations arising from alleged symptoms. 20 C.F.R. § 404.1545(a)(3); see also S.S.R. 96-8p, 1996 WL 374184, at *5.
Where a claimant has numerous impairments, including non-severe impairments, the ALJ must consider their cumulative effect in making a disability determination. 42 U.S.C. § 423(d)(2)(B); see Hines v. Brown, 872 F.2d 56, 59 (4th Cir. 1989) ("[I]n determining whether an individual's impairments are of sufficient severity to prohibit basic work related activities, an ALJ must consider the combined effect of a claimant's impairments.") (citations omitted). The ALJ has sufficiently considered the combined effects of a claimant's impairments when each is separately discussed by the ALJ and the ALJ also discusses a claimant's complaints and activities. Baldwin v. Barnhart, 444 F. Supp. 2d 457, 465 (E.D.N.C. 2005) (citations omitted). The RFC assessment "must include a discussion of why reported symptom-related functional limitations and restrictions can or cannot reasonably be accepted as consistent with the medical and other evidence" and also "must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations)." S.S.R. 96-8p, 1996 WL 374184, at *7; see also Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000) (observing that the ALJ "must build an accurate and logical bridge from the evidence to his conclusion").
The functional capacity evaluation performed by Dr. Keisha Christian on September 12, 2012 concluded that Claimant can perform light work. (R. 970). Dr. Christian noted that Claimant was then working four hours a day, and she recommended that Claimant increase her daily work time tolerance by thirty minutes every two weeks "to gradually increase her work tolerance." Id. Claimant could not reach with her left upper extremity greater than fifty-six inches above the floor because of stiffness in her left shoulder joint, and while her job at the time required her to lift up to thirty pounds, she was restricted to lifting twenty pounds. Id. The ALJ quoted the conclusions of the evaluation and explained that it was given little weight because "[t]he findings in this assessment provide little insight into the claimant's functioning during the relevant period for the purposes of this decision, April 7, 2014 through September 30, 2018." (R. 179).
The ALJ was required to consider the evaluation even though it predated the alleged onset date. See Cotton v. Colvin, No. 5:14-CV-425-FL, 2015 WL 5714912, at *3 (E.D.N.C. Sept. 29, 2015) ("Where evidence predating the alleged date of disability is made part of the record, the regulations require the Commissioner to consider that evidence."); Lewis v. Saul, No. 5:19-CV-02298-DCN, 2021 WL 1040512, at *3 (D.S.C. Mar. 18, 2021) ("An ALJ's failure to consider pre-disability onset date evidence is contrary to the clear instruction of the Social Security regulations and the relevant case law. The Social Security regulations provide that an ALJ 'will consider all evidence in [a claimant's] case record when [making] a determination or decision whether [the claimant is] disabled.' 20 C.F.R. § 404.1520(a)(3). District courts in the Fourth Circuit have held that 'all evidence' under § 404.1520(a)(3) includes medical records predating a claimant's alleged onset date." (citing Cotton, 2015 WL 5714912, at *3)); Cunningham v. Berryhill, No. 5:17-CV-301-FL, 2018 WL 6731380, at *4 (E.D.N.C. Nov. 19, 2018) ("the fact that Dr. Purcell's opinion was issued some six months prior to Claimant's alleged onset date does not excuse the ALJ's failure to consider and weigh it."), adopted by 2018 WL 6729784 (E.D.N.C. Dec. 21, 2018). The ALJ here found that the assessment provided little insight into the claimant's functioning during the relevant period, so it was given little weight. (R. 179). However, the ALJ did not explain why the assessment provided little insight into the relevant period. The evaluation addressed Claimant's diagnoses of complex regional pain syndrome ("CRPS") and neck pain. (R. 970). The ALJ found that CRPS and cervical spondylosis were severe impairments during the relevant period. (R. 168). Accordingly, the court cannot trace the ALJ's reasoning in finding that the assessment provided little insight into the claimant's functioning during the relevant period. On remand, the ALJ should more thoroughly explain the weight given to the September 2012 evaluation.
B. The ALJ erred in weighing the medical opinions.
Claimant contends the ALJ failed to discuss Dr. Sameer Mathur's October 2011, March 2012, and June 2012 opinions and Dr. Shehzad Choudry's April 2015 opinion. (R. 930, 924-25, 1075). Pl.'s Mem. [DE-24] at 12-13. Claimant also contends that the ALJ improperly weighed the opinions of Dr. Rodolfo Reyes and Dr. Deltra Williams-Tonne. Id. at 13-16. (R. 589-669, 704-17).
When assessing a claimant's RFC, the ALJ must consider the opinion evidence. 20 C.F.R. § 404.1545(a)(3). Regardless of the source, the ALJ must evaluate every medical opinion received. Id. § 404.1527(c). In general, the ALJ should give more weight to the opinion of an examining medical source than to the opinion of a non-examining source. Id. § 404.1527(c)(1). Additionally, more weight is generally given to opinions of treating sources, who usually are most able to provide "a detailed, longitudinal picture" of a claimant's alleged disability, than non-treating sources such as consultative examiners. Id. § 404.1527(c)(2). When the opinion of a treating source regarding the nature and severity of a claimant's impairments is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence," it is given controlling weight. Id. However, "[i]f a physician's opinion is not supported by clinical evidence or if it is inconsistent with other substantial evidence, it should be accorded significantly less weight." Craig, 76 F.3d at 590.
If the ALJ determines that a treating physician's opinion should not be considered controlling, the ALJ must then analyze and weigh all of the medical opinions in the record, taking into account the following non-exclusive list: (1) whether the physician has examined the applicant, (2) the treatment relationship between the physician and the applicant, (3) the supportability of the physician's opinion, (4) the consistency of the opinion with the record, and (5) whether the physician is a specialist. Johnson v. Barnhart, 434 F.3d 650, 654 (4th Cir. 2005) (citing 20 C.F.R. § 404.1527). An ALJ may not reject medical evidence for the wrong reason or no reason. See Wireman v. Barnhart, No. 2:05-CV-46, 2006 WL 2565245, at *8 (W.D. Va. Sept. 5, 2006). "In most cases, the ALJ's failure to consider a physician's opinion (particularly a treating physician) or to discuss the weight given to that opinion will require remand." Love-Moore v. Colvin, No. 7:12-CV-104-D, 2013 WL 5350870, at *2 (E.D.N.C. Sept. 24, 2013) (citations omitted). However, "[a]n ALJ's determination as to the weight to be assigned to a medical opinion generally will not be disturbed absent some indication that the ALJ has dredged up 'specious inconsistencies,' or has failed to give a sufficient reason for the weight afforded a particular opinion." Dunn v. Colvin, 607 F. App'x 264, 267 (4th Cir. 2015) (quoting Scivally v. Sullivan, 966 F.2d 1070, 1077 (7th Cir. 1992)).
1. Dr. Mathur
Claimant contends that the ALJ failed to discuss three medical opinions issued by Dr. Mathur. Pl.'s Mem. [DE-24] at 12-15. The ALJ is required to evaluate every medical opinion received. 20 C.F.R. § 404.1527(c). "Medical opinions are statements from acceptable medical sources that reflect judgments about the nature and severity of your impairment(s), including your symptoms, diagnosis and prognosis, what you can still do despite impairment(s), and your physical or mental restrictions." 20 C.F.R. § 404.1527(a)(1).
On October 21, 2011, Dr. Mathur completed a form indicating that Claimant was seen for a consultation and treatment and was "not able to return to work until further notice." (R. 930). The form does not indicate Claimant's impairments, symptoms, diagnoses, prognosis, or what she can still do despite her impairments; it only indicates, without explanation, that she is restricted from returning to work until further notice. Id. A check-box form indicating only that a person is unable to work is not a medical opinion within the meaning of the regulations. See Matheny v. Saul, No. 3:20-CV-00203, 2020 WL 7635970, at *12 (S.D.W. Va. Dec. 7, 2020) (holding that a letter from a doctor "which stated simply: 'Patient is completely and permanently disabled' . . . fails to conform with the definition of a 'medical opinion' in accordance with SSA Regulations"), adopted by 2020 WL 7634163 (S.D.W. Va. Dec. 22, 2020); Byrd v. Saul, No. CV 6:18-495-DCC-KFM, 2019 WL 8953204, at *10 (D.S.C. Aug. 22, 2019) ("This letter contains no description of any functional limitations; accordingly, the letter is not an 'opinion' and does not provide evidence of any functional limitations that could have been incorporated into the RFC assessment. . . . [A] statement from a physician that a claimant is 'unable to work' is not a medical opinion."), adopted by 2020 WL 1501942 (D.S.C. Mar. 30, 2020). Accordingly, the ALJ was not required to weigh the October 2011 form.
In March and June 2012, Dr. Mathur completed forms in which he indicated that Claimant "will be able to return to work immediately." (R. 924-25). In contrast to the October 2011 form, Dr. Mathur added commentary to the March and June 2012 forms, writing that Claimant "may not lift more than 20 pounds" with "occasional bending, twisting, crawling, [and] climbing" and "may sit with frequent position changes." Id. Dr. Mathur also wrote, "Additional restrictions: 1/2 work." Id. Unlike the October 2011 form, the March and June 2012 documents contain judgment about Claimant's impairments and what she can still do despite her impairments, including functional limitations that could have been incorporated into the RFC. See 20 C.F.R. § 404.1527(a)(1); Byrd, 2019 WL 8953204, at *10. Dr. Mathur opined on Claimant's ability to lift, bend, twist, crawl, climb, and sit. (R. 924). Accordingly, the March and June 2012 documents are medical opinions within the meaning of the regulations, and the ALJ erred in failing to consider them, even though they were issued prior to Claimant's alleged onset date. See Cunningham, 2018 WL 6731380, at *4 ("the fact that Dr. Purcell's opinion was issued some six months prior to Claimant's alleged onset date does not excuse the ALJ's failure to consider and weigh it.").
2. The April 16, 2015 Treatment Note
On April 16, 2015, Claimant was seen at Rex Pain Management, and the treatment note was signed by Nathalie J. Grippon, PA and Dr. Deltra Williams-Toone. (R. 1072-76). Ms. Grippon noted that Claimant was upset and wanted to talk with Dr. Choudry about a misunderstanding regarding her work restrictions. (R. 1072). Ms. Grippon explained that Dr. Choudry gave Claimant work limitations but determined that she was able to work an eight-hour day. Id. Claimant responded that "she tried to do her best and pushed herself to perform" the functional capacity evaluation, "so it made her appear to be more capable than she actually was," and she was "no good for three days after." Id. Claimant stated that she could only work for three hours a day, which includes getting ready for work. Id. Claimant's physical exam during that visit indicated "5/5 strength throughout the right upper extremity—slightly decreased appearing on left (affected) from right UE," tenderness that improved with palpation, and decreased sensation in her left upper arm. (R. 1074-75). Ms. Grippon noted: "It appears that the work restrictions based on the FCE ha[ve] not been transferred appropriately from the paper charts to the electronic record. Therefore, Dr. Choudry will review the FCE again and rewrite these recommendations and we will forward them on to vocational rehabilitation." (R. 1075). The work restrictions were as follows:
Left arm no use at all permitted. Right arm in accordance with the FCE will allow occastional upper extremity lifting/carrying with 20 pounds (lift 10 pounds shoulder to 56 inches above the floor) pushing and pulling up to 20 pounds with both hands together (20 pounds unilateral pushing with right arm permitted but not with left arm). Computer keying and filing limited to a frequent level throughout the work day (34-66% of the day). These restrictions are in accordance with a 4 hour work day. She may be permitted to increase her daily work time tolerance by 30 minute increments every 2 weeks to gradually increase her up to tolerance of 4 hours max per day. These will be permanent restrictions.Id.
First, Claimant contends that the ALJ did not discuss those limitations included in the April 16, 2015 treatment note and that the opinion was written by Dr. Choudry. Pl.'s Mem. [DE-24] at 12. It is not clear from the treatment note whether the limitations were from Dr. Choudry's FCE, which was referenced in the note, or whether the limitations were authored by either Ms. Grippon or Dr. Williams-Toone, who signed the note. (R. 1075-76). Regardless of who authored the opinion and despite Claimant's contention otherwise, the ALJ did discuss the limitations contained in the April 16, 2015 treatment note. (R. 178). The ALJ directly quoted the treatment note and inferred that the restrictions were written by Dr. Williams-Toone, not Dr. Choudry. (R. 178). The ALJ explained that the opinion was given little weight because Dr. Williams-Toone did not have a treating relationship with Claimant; the assessment provided no basis for the restrictions; Claimant's treatment notes before and after the assessment did not objectively support the conclusion that Claimant is unable to use her left upper extremity or work for more than four hours per day; and it was "conducted in connection with a workers compensation claim, which has different standards and rules for determining disability, and it is unclear whether the terms used are vocationally relevant for the purposes of determining disability under the Social Security Act." (R. 178). Accordingly, Claimant's argument that the ALJ failed to discuss the opinion is without merit.
Next, Claimant contends that the ALJ erred in giving little weight to the treatment note, and Claimant references it as an opinion of Dr. Williams-Toone. Pl.'s Mem. [DE-24] at 15. Claimant contends that her abnormal EMGs, physical examination, abnormal neurological examinations, abnormal MRIs, and other treating doctors' opinions undermine the ALJ's conclusion that Dr. Williams-Toone's opinion is not supported by Claimant's treatment notes before and after the assessment. Id. However, the ALJ sufficiently explained why little weight was assigned to the opinion. First, the ALJ noted that Dr. Williams-Toone did not have a treating relationship with Claimant. (R. 178). This rationale may serve as a reason for discounting an opinion, for more weight is generally given to treating sources than non-treating sources. See 20 C.F.R. § 404.1527(c)(2) (explaining that more weight is generally given to opinions of treating sources, who usually are most able to provide "a detailed, longitudinal picture" of a claimant's alleged disability, than non-treating sources such as consultative examiners).
Defendant contends that Claimant "appears to have found two opinions where only one exists" and that Claimant alternatively argues that the ALJ failed to consider the opinion and erred in giving it little weight. Def.'s Mem. [DE-27] at 11. The court agrees; Claimant references the same treatment note when she discusses Dr. Choudry's and Dr. Williams-Toone's opinions.
Second, the ALJ found that the assessment provides no explanation for the restrictions. (R. 178). The restrictions are noted to be in accordance with a four hour work day, which is to be increased by thirty minutes every two weeks, and they are noted to be permanent, but there is no explanation as to why the restrictions were imposed. See Vanderpool v. Berryhill, No. 5:18-CV-44-RJ, 2019 WL 118414, at *5 (E.D.N.C. Jan. 7, 2019) (holding that an ALJ did not err in giving a medical opinion partial weight because the limitations in the opinion were vague and the doctor failed to provide a function-by-function assessment).
Third, the ALJ found that the treatment notes do not support the conclusion that Claimant cannot use her left upper extremity for any activities. (R. 178). The treatment note indicates that Claimant had 5/5 strength in her right upper extremity and "slightly decreased appearing on left (affected) from right UE." (R. 630). The note also states that Claimant had tenderness over her cervical trap muscles "but felt better with [] palpation," and she had decreased sensation in her left upper arm. Id. The court can trace the ALJ's reasoning in concluding that the treatment note does not support the conclusion that Claimant is unable to use her left upper extremity for any activities.
Fourth, the ALJ found that the treatment note provided no objective or clinical basis, other than Claimant's assertions, for the restriction that she is unable to work more than four hours per day. (R. 178). If the ALJ had discounted the opinion because it was based on subjective reports when it was in fact based on clinical observations, that reasoning would have been in error. See Ryan v. Comm'r of Soc. Sec., 528 F.3d 1194, 1200 (9th Cir. 2008) (holding that an ALJ erred in finding that an opinion was based too heavily on subjective complaints because "[t]here is nothing in the record to suggest that Dr. Randhawa disbelieved Ryan's description of her symptoms, or that Dr. Randhawa relied on those descriptions more heavily than his own clinical observations"); c.f. Harmon v. Berryhill, No. 1:17-CV-417, 2018 WL 1936478, at *6 (M.D.N.C. Apr. 24, 2018) (distinguishing Ryan because the physician relied more on subjective complaints than on clinical observations). However, the ALJ specified here that one particular restriction appeared to be based only on Claimant's subjective complaints: the restriction to no more than four hours of work per day. (R. 178); see Jeffries v. Berryhill, No. 1:18-CV-51, 2019 WL 1005501, at *11 (M.D.N.C. Mar. 1, 2019) (holding that Ryan "actually supports the ALJ's decision" to discount an opinion where the opinion is based more on subjective complaints than on clinical observations), adopted by 2019 WL 2468241 (M.D.N.C. Mar. 29, 2019); Schaller v. Colvin, No. 5:13-CV-334-D, 2014 WL 4537184, at *14 (E.D.N.C. Sept. 11, 2014) (noting that the ALJ properly assigned little weight to a medical opinion "because it was largely reliant on Claimant's subjective complaints"). Accordingly, the ALJ offered a valid reason for discounting the opinion in concluding that the four-hour workday restriction had no objective or clinical basis other than Claimant's assertions.
Fifth, the ALJ stated that because the evaluation was conducted in connection with a workers' compensation claim, it is unclear whether the terms used are vocationally relevant. (R. 178). This rationale for discounting the opinion is the only one that is not supported. A vocationally relevant term "provides functional limitations arising from [the claimant's] impairments." Gillis v. Colvin, No. 1:14CV426, 2015 WL 4644777, at *6 (M.D.N.C. Aug. 4, 2015). Here, the author of the restrictions assessed Claimant's ability to lift, carry, type, and file. (R. 631). Those terms appear to be vocationally relevant because they provide functional limitations regarding Claimant's ability to work. See Jones v. Saul, No. 5:18-CV-177-BO, 2019 WL 2884279, at *2 (E.D.N.C. July 3, 2019) (finding that an ALJ erred in concluding that an opinion was not expressed in vocationally relevant terms because "Dr. Coplin's opinions are in regard to plaintiffs ability to sit, stand, lift and carry, and push and pull, which are directly relevant to the inquiry into whether a claimant can perform substantial gainful activity."). Accordingly, the court cannot trace the ALJ's reasoning with respect to the fifth rationale for discounting the opinion.
Nonetheless, the ALJ provided four other reasons for giving little weight to the work restrictions contained in the April 16, 2015 treatment note. Accordingly, the ALJ sufficiently explained the rationale and did not err in weighing the opinion.
3. Dr. Reyes
Lastly, Claimant contends that the ALJ erred in giving little weight to Dr. Reyes's letter dated February 27, 2017. Pl.'s Mem. [DE-24] at 15-16. Dr. Reyes wrote a note stating: "This letter is in reference to patient, Karen Faircloth, [] and her obligation to jury duty. Please excuse or exempt her from this obligation due to severe chronic shoulder pain and Bowling Ball Syndrome which is aggravated by prolonged sitting for more than four hours." (R. 718). The ALJ gave the letter little weight because "[t]he limitations and alleged conditions cited are verbatim what the claimant subjectively reported during the appointment with Dr. Reyes" and "the only references to Bowling Ball Syndrome [in] the record are the claimant's reports to Dr. Reyes that she was diagnosed with this condition (Ex. 5F/15, 5F/19). The record does not contain an actual medical treatment note in which an acceptable medical source actually diagnoses the claimant with this condition, based on any clinical or diagnostic findings." (R. 178).
Claimant does not contest the ALJ's finding that Bowling Ball Syndrome is not a medically determinable impairment; rather, Claimant contends that the ALJ's analysis of Dr. Reyes's opinion "is perfunctory, only spans one sentence, and makes this conclusory statement while giving no examples to support her finding." Pl.'s Mem. [DE-24] at 16. However, the ALJ does explain her analysis of the opinion, and she does so in more than one sentence. (R. 178). The ALJ offers two reasons for discounting the opinion. First, the ALJ explains that the limitations in the opinion are taken verbatim from Claimant's subjective reports to Dr. Reyes. See Schaller, 2014 WL 4537184, at *14 (noting that the ALJ properly assigned little weight to a medical opinion "because it was largely reliant on Claimant's subjective complaints"). Second, the ALJ discounted the opinion because the record does not contain a diagnosis of Bowling Ball Syndrome based on clinical or diagnostic findings. See Chapman v. Comm'r of Soc. Sec., 709 F. App'x 992, 995 (11th Cir. 2017) (holding that a letter excusing the claimant from jury service was a medical opinion that must be considered by the ALJ, but failure to weigh the letter was harmless error because "the ALJ had good cause to disregard the letter, to the effect that it was not supported by [the] medical findings"); Dean v. Berryhill, No. 1:15CV1095, 2017 WL 684196, at *6 (M.D.N.C. Feb. 21, 2017) (finding no error when the ALJ gave little weight to a similar letter excusing the claimant from jury service because it was vague, it did not specify the length of time the claimant could sit, and the objective evidence did not support the letter's conclusion that the claimant could not sit for long periods of time); Graham v. Colvin, No. 5:12-CV-174, 2015 WL 114277, at *6 (W.D.N.C. Jan. 8, 2015) (finding no error when the ALJ discounted a letter excusing the claimant from jury duty because it was inconsistent with the record as a whole and unsupported by treatment records). The ALJ sufficiently explained why she gave little weight to Dr. Reyes's letter, and she did not err in weighing the opinion. Nonetheless, the ALJ's failure to sufficiently explain the weight given to the September 12, 2012 comprehensive functional assessment and failure to weigh Dr. Mathur's March and June 2012 opinions warrant remand.
VI. CONCLUSION
For the reasons stated above, it is RECOMMENDED that Claimant's Motion for Judgment on the Pleadings [DE-23] be ALLOWED, Defendant's Motion for Judgment on the Pleadings [DE-26] be DENIED, and the case be REMANDED to the Commissioner for further proceedings consistent with the Memorandum and Recommendation.
IT IS DIRECTED that a copy of this Memorandum and Recommendation be served on each of the parties or, if represented, their counsel. Each party shall have until May 3, 2021 to file written objections to the Memorandum and Recommendation. The presiding district judge must conduct his or her own review (that is, make a de novo determination) of those portions of the Memorandum and Recommendation to which objection is properly made and may accept, reject, or modify the determinations in the Memorandum and Recommendation; receive further evidence; or return the matter to the magistrate judge with instructions. See, e.g., 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b)(3); Local Civ. R. 1.1 (permitting modification of deadlines specified in local rules), 72.4(b), E.D.N.C. Any response to objections shall be filed by within 14 days of the filing of the objections.
If a party does not file written objections to the Memorandum and Recommendation by the foregoing deadline, the party will be giving up the right to review of the Memorandum and Recommendation by the presiding district judge as described above, and the presiding district judge may enter an order or judgment based on the Memorandum and Recommendation without such review. In addition, the party's failure to file written objections by the foregoing deadline will bar the party from appealing to the Court of Appeals from an order or judgment of the presiding district judge based on the Memorandum and Recommendation. See Wright v. Collins , 766 F.2d 841, 846-47 (4th Cir. 1985).
Submitted, this the 19th day of April 2021.
/s/_________
Robert B. Jones, Jr.
United States Magistrate Judge