Opinion
No. 5:19-CV-546-D
03-12-2021
TODD RUGGIERO, Plaintiff, v. ANDREW SAUL, Commissioner of Social Security, Defendant.
MEMORANDUM AND RECOMMENDATION
In this action, Plaintiff Todd Ruggiero ("Plaintiff" or, in context, "Claimant") challenges the final decision of defendant Commissioner of Social Security ("Commissioner") determining that he was no longer entitled to Disability Insurance Benefits ("DIB"). The case is before the court on the parties' respective motions for judgment on the pleadings [DE-16, -20] pursuant to Fed. R. Civ. P. 12(c). Both parties submitted memoranda in support of their respective motions [DE-16-1, -21]. The motions were referred to the undersigned Magistrate Judge for a memorandum and recommendation pursuant to 28 U.S.C. § 636(b)(1). For the reasons set forth below, it is recommended that Plaintiff'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
Plaintiff was initially awarded DIB on May 30, 2013, with a disability onset date of November 2, 2012. Transcript of Proceedings ("Tr.") at 82. On May 8, 2017, it was determined that Plaintiff was no longer disabled as of May 5, 2017. Tr. 110, 128.
Plaintiff filed a request for reconsideration on May 26, 2017 (Tr. 131-34), and a disability hearing was held by a State Agency Disability Hearing Officer on January 9, 2018 (Tr. 145-56). On January 11, 2018, the cessation determination was upheld, finding that the Plaintiff's health had improved and that he was able to work. Tr. 112, 113-27, 157-58. Thereafter, Plaintiff filed a request for a hearing before an Administrative Law Judge ("ALJ") (Tr. 159), and a hearing was held on June 27, 2018, at which Plaintiff, represented by counsel, and a vocational expert ("VE") appeared and testified (Tr. 32-66). In a written decision dated October 30, 2018, the ALJ found that Plaintiff's disability ended on May 5, 2017, as initially determined, and that he was therefore not entitled to DIB. Tr. 12-31.
On December 17, 2018, Plaintiff requested review of the ALJ's decision by the Appeals Council (Tr. 207-10) and submitted additional evidence as part of his request (Tr. 5). The Appeals Council received the additional evidence, consisting of Plaintiff's request for review (Tr. 207-10) and written argument submitted by Plaintiff's counsel (Tr. 372-73), and incorporated this evidence into the record (Tr. 5). On October 2, 2019, the Appeals Council denied Plaintiff's request for review of the ALJ's decision. Tr. 1-6. Plaintiff then filed a complaint in this court seeking review of the now-final administrative decision.
II. STANDARD OF REVIEW
The standard of review under 42 U.S.C. § 405(g) applies to review of disability cessation determinations. See Marker v. Finch, 322 F. Supp. 905, 909 (D.C. Del. 1971) (holding that "the standards to be applied by the Court in reviewing a termination of benefits do not differ materially from those applied in reviewing a denial of benefits"); see also Goodwater, 579 F. Supp. 2d at 761 (applying 42 U.S.C. § 405(g) to review of Commissioner's termination of individual's SSI benefits and DIB). Under that provision, judicial review of a final decision of the Commissioner is limited to considering whether the Commissioner's decision is supported by substantial evidence in the record and whether the appropriate legal standards were applied. See Richardson v. Perales, 402 U.S. 389, 390, 401 (1971); Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990). Unless the court finds that the Commissioner's decision is not supported by substantial evidence or that the wrong legal standard was applied, the Commissioner's decision must be upheld. See, e.g., Smith v. Schweiker, 795 F.2d 343, 345 (4th Cir. 1986); Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).
Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Perales, 402 U.S. at 401 (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)). It is more than a scintilla of evidence, but somewhat less than a preponderance. Perales, 402 U.S. at 401.
The court may not substitute its judgment for that of the Commissioner as long as the decision is supported by substantial evidence. Hunter v. Sullivan, 993 F.2d 31, 34 (4th Cir. 1992) (per curiam). In addition, the court may not make findings of fact, revisit inconsistent evidence, or make determinations of credibility. See Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996); King v. Califano, 599 F.2d 597, 599 (4th Cir. 1979). A Commissioner's decision based on substantial evidence must be affirmed, even if the reviewing court would have reached a different conclusion. Blalock, 483 F.2d at 775.
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). "Judicial review of an administrative decision is impossible without an adequate explanation of that decision by the administrator." DeLoatche v. Heckler, 715 F.2d 148, 150 (4th Cir. 1983).
III. STANDARDS FOR DETERMINATION OF DISABILITY CESSATION
The Social Security Act ("Act") defines disability as the "inability to engage in any substantial gainful activity ("SGA") 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." 42 U.S.C. § 423(d)(1)(A); Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995). "An individual shall be determined to be under a disability only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." 42 U.S.C. § 423(d)(2)(A). The Act defines a physical or mental impairment as "an impairment that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques." Id. (d)(3).
Following a determination that an individual is disabled and therefore entitled to DIB, his continued entitlement is subject to periodic review. See 20 C.F.R. § 404.1594(a). Such entitlement ends if the disability is determined to have ended - that is, if there is a finding supported by substantial evidence that "the physical or mental impairment on the basis of which such benefits are provided has ceased, does not exist, or is not disabling." 42 U.S.C. § 423(f).
The regulations specify a number of factors that must be considered in determining whether a disability has either ended or continues, including the key factor of medical improvement. See 20 C.F.R. § 404.1594(a). Medical improvement is defined as "any decrease in the medical severity of [an individual's] impairment(s) which was present at the time of the most recent favorable medical decision that [an individual was] disabled or continued to be disabled." Id. (b)(1). As this definition implies, to determine whether there has been medical improvement a comparison is made between the individual's current condition and his condition at the time of the most recent favorable medical decision that the individual was disabled or continued to be disabled, the so-called comparison point date or CPD. Id. (b)(7). A determination that there has been medical improvement must be based on improvement in the symptoms, signs, or laboratory findings associated with the impairments underlying the disability. Id. (b)(1).
Medical improvement in an individual's impairments alone does not merit a determination that he is no longer disabled. Rather, the medical improvement must be related to the individual's ability to work and there usually must also be a showing that the individual is currently able to engage in substantial gainful activity. Id. (a), (b)(3). In addition, the regulations provide two groups of exceptions to medical improvement whereby an individual's disability can be found to have ended even though medical improvement has not occurred. Id. (d), (e).
The regulations set out an eight-step sequential analysis for evaluating medical improvement and the other specified factors to determine whether an individual's disability continues. See id. (f)(1)-(8). It provides, in relevant part, as follows:
(1) Are you engaging in substantial gainful activity? If you are . . . , we will find disability to have ended . . . .
(2) If you are not, do you have an impairment or combination of impairments which meets or equals the severity of an impairment listed in [20 C.F.R. Part 404, Subpart P, Appendix 1] ["listings"]? If you do, your disability will be found to continue.
(3) If you do not, has there been medical improvement . . . ? If there has been medical improvement as shown by a decrease in medical severity, see step (4). If there has been no decrease in medical severity, there has been no medical improvement. (See step (5).)
(4) If there has been medical improvement, we must determine whether it is related to your ability to do work . . . ; i.e., whether or not there has been an increase in the residual functional capacity ["RFC"] based on the impairment(s) that was present at the time of the most recent favorable medical determination. If medical improvement is not related to your ability to do work, see step (5). If medical improvement is related to your ability to do work, see step (6).
(5) If we found at step (3) that there has been no medical improvement or if we found at step (4) that the medical improvement is not related to your ability to work, we consider whether any of the exceptions in . . . [the two groups of exceptions to medical improvement] apply. If none of them apply, your disability will be found to continue. If one of the first group of exceptions to medical improvement applies, see step (6). If an exception from the second group of exceptions to medical improvement applies, your disability will be found to have ended. The second group of exceptions to medical improvement may be considered at any point in this process.
(6) If medical improvement is shown to be related to your ability to do work or if one of the first group of exceptions to medical improvement applies, we will determine whether all your current impairments in combination are severe . . . . This determination will consider all your current impairments and the impact of the combination of those impairments on your ability to function. If the [RFC] assessment in step (4) above shows significant limitation of your ability to do basic work activities, see step (7). When the evidence shows that all your current impairments in combination do not significantly limit your physical or mental abilities to do basic work activities, these impairments will not be considered severe in nature. If so, you will no longer be considered to be disabled.
(7) If your impairment(s) is severe, we will assess your current ability to do substantial gainful activity . . . . That is, we will assess your [RFC] based on all
your current impairments and consider whether you can still do work you have done in the past. If you can do such work, disability will be found to have ended.Id.
(8) If you are not able to do work you have done in the past, we will consider whether you can do other work given the [RFC] assessment made under paragraph (f)(7) of this section and your age, education, and past work experience . . . . If you can, we will find that your disability has ended. If you cannot, we will find that your disability continues.
RFC is the most an individual can still do despite his physical and mental limitations. See 20 C.F.R. § 404.1545(a)(1).
The exceptions are set out in 20 C.F.R. § 404.1594(d) and (e). The exceptions are not relevant to this case.
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)(4).
Steps 1, 2, 6, 7, and 8 in this analysis correspond to varying degrees to steps 1, 3, 2, 4, and 5, respectively, in the five-step sequential analysis used to make initial determinations on disability. See 20 C.F.R. § 404.1520(a)(4).
At step eight, the Medical-Vocational Guidelines or so-called grid rules are used. 20 C.F.R. Part 404, Subpart P, Appendix 1. They indicate whether an individual is "disabled" or "not disabled" based on the exertional level of work the individual is found to be able to perform as part of his RFC and his vocational profile, comprised of his age, education, and past work experience. Id. § 200.00(a). The decision of "disabled" or "not disabled" specified in the grid rules reflects an administrative determination as to whether sufficient jobs exist in the national economy for the individual given his exertional level and vocational profile. Id. § 200.00(b). If an individual can perform all or substantially all of the exertional demands at a given exertional level, the grid rule directs the conclusion on disability - that is, the conclusion of "disabled" or "not disabled" indicated by the rule has controlling effect. Soc. Sec. Ruling 83-11, 1983 WL 31252, at *1 (1983). If the individual cannot perform all or substantially all the exertional demands or has non-exertional limitations, the grid rules are used as a framework for decision making, subject to certain exceptions. See Soc. Sec. Ruling 83-12, 1983 WL 31253, at *1 (1983); Soc. Sec. Ruling 83-14, 1983 WL 31254, at *1 (1983).
Rulings are interpretations of the Act by the Social Security Administration that, while lacking the force of law, are entitled to deference unless they are clearly erroneous or inconsistent with the law. Pass, 65 F.3d at 1204 n.3 (citing Quang Van Han v. Bowen, 882 F.2d 1453, 1457 (9th Cir.1989)).
The Act requires that a disability cessation determination be made on "the weight of the evidence and on a neutral basis with regard to the individual's condition, without any initial inference as to the presence or absence of disability being drawn from the fact that the individual has previously been determined to be disabled." 42 U.S.C. § 423(f). The determination must also be based on "all the evidence available in the individual's case file, including new evidence concerning the individual's prior or current condition which is presented by the individual or secured by the Commissioner of Social Security." Id.
IV. ALJ'S FINDINGS
The ALJ first found that the most recent favorable medical decision finding Plaintiff disabled was the determination on May 30, 2013, also known as the "comparison point decision" ("CPD"). Tr. 16. The ALJ found that at the time of the CPD, Plaintiff had the medically determinable impairments of: osteoarthrosis, joint dysfunction, hypertension ("HTN"), liver cirrhosis, gastrointestinal hemorrhage, diabetes mellitus ("DM"), a depressive disorder, and alcohol abuse—and that these impairments were found to result in the RFC to perform less than a full range of sedentary work. Tr. 17.
"Sedentary work involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met." 20 C.F.R. § 404.1567(a); S.S.R. 96-9p, 1996 WL 374185, at *3 (July 2, 1996). "Occasionally" generally totals no more than about 2 hours of an 8-hour workday. "Sitting" generally totals about 6 hours of an 8-hour workday. S.S.R. 96-9p, 1996 WL 374185, at *3. A full range of sedentary work includes all or substantially all of the approximately 200 unskilled sedentary occupations administratively noticed in 20 C.F.R. Part 404, Subpart P, Appendix 2, Table 1. Id.
Applying the above-described eight-step sequential evaluation process, the ALJ found Plaintiff "not disabled" as defined in the Act. At step one, the ALJ found Plaintiff had not engaged in SGA through the date of the ALJ's decision, October 30, 2018. Tr. 17, 25. Next, the ALJ determined that Plaintiff had the following severe impairments after the CPD through the date of the ALJ's decision: degenerative knee joint disease ("DJD") of the bilateral knees, back disorder with lower back pain, portal pulmonary HTN, HTN, liver cirrhosis, esophageal varices, DM, obesity, a bipolar disorder, an anxiety disorder, a learning disability, and alcohol abuse. Tr. 17.
At step two, the ALJ concluded that these impairments, both physical and mental, were not severe enough, either individually or in combination, to meet or medically equal one the severity of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. Tr. 17. Applying the special technique prescribed by the regulations, the ALJ found that Plaintiff's mental impairments resulted in moderate limitation in understanding, remembering, or applying information; moderate limitation in interacting with others; moderate limitation in concentrating, persisting, or maintaining pace; and, moderate limitation in adapting or managing oneself. Tr. 18-19.
At step three, the ALJ determined medical improvement occurred by May 5, 2017. Tr. 19. In making this finding, the ALJ stated, "The medical evidence supports a finding that by May 5, 2017, there had been a decrease in medical severity of the impairments. The claimant's medical records showed that the claimant's HTN and DM became controlled or stable with treatment. The claimant testified his cirrhosis was stable, and that his therapist helped his mental issues." Tr. 19.
At step four, the ALJ determined that since May 5, 2017, the Plaintiff has had the RFC to perform light work with 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).
[O]ccasionally climb ramps or stairs; never climb ladders, ropes or scaffolds; occasionally balance, stoop, kneel, crouch, and crawl; occasional exposure to
extreme heat and loud noise; no exposure to very loud noise; occasional exposure to pulmonary irritants such as dust, odors, fumes, and gases and to poorly ventilated areas; and occasional exposure to unprotected heights, hazardous machinery or hazardous moving mechanical parts. The claimant's work is limited to simple, routine and repetitive tasks, not at a production rate pace; simple work-related decisions; and occasional interaction with the public, co-workers and supervisors. The claimant would be off-task no more than 10% of the time in an eight-hour workday, in addition to normal breaks (with normal breaks defined as a fifteen minute morning and afternoon break and a thirty to sixty minute lunch break).Tr. 19. In making this assessment, the ALJ found "claimant's medically determinable impairments could have reasonably been expected to produce the alleged symptoms; however, the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the objective medical and other evidence . . . ." Tr. 20. The ALJ additionally found at step four that Plaintiff's medical improvement was related to ability to work because it resulted in an increase in Plaintiff's RFC since May 5, 2017. Tr. 23. Because the ALJ determined that Plaintiff's medical improvement was related to his ability to do work, the ALJ skipped step five pursuant to 20 C.F.R. § 404.1594(f)(4) and proceeded to step six.
At step six, the ALJ concluded that the Plaintiff continued to have a severe impairment or combination of impairments, that being "knee DJD, back disorder with lower back pain, portal pulmonary HTN, HTN, liver cirrhosis, esophageal varices, diabetes mellitus, obesity, a bipolar disorder, an anxiety disorder, a learning disability, and alcohol abuse." Tr. 19, 23. The ALJ also found Plaintiff had the non-severe impairments of asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, esophagitis, bums, bronchitis, migraines, and attention-deficit hyperactivity disorder. Tr. 23-24.
At step seven, the ALJ found that Plaintiff had been unable to perform past relevant work since May 5, 2017. Tr. 24. This finding was based upon the vocational expert's testimony that the Plaintiff's past relevant work was all skilled or semi-skilled. Tr. 24. Nonetheless, at step eight, upon consideration of Plaintiff's age, education, work experience, and RFC, the ALJ determined Plaintiff is capable of adjusting to the demands of other employment opportunities that exist in significant numbers in the national economy, such as marker, photocopy machine operator, and router. Tr. 24-25.
V. OVERVIEW OF PLAINTIFF'S CONTENTIONS
Plaintiff alleges the following errors by the ALJ: (1) failure to follow the eight-step sequential evaluation, specifically a failure to identify the medical records supporting the ALJ's statement that "there had been a decrease in medical severity"; and (2) failure to properly consider additional impairments from which Plaintiff suffered at the time of the ALJ's decision relative to the CPD in the ALJ's RFC assessment, specifically noting Plaintiff's mental health impairments. Pl.'s Mem. [DE-16-1] at 6.
The Commissioner argues that substantial evidence supports the ALJ's decision and that the ALJ properly considered the treating source medical opinion and properly considered Plaintiff's mental health impairments in the RFC assessment. Def.'s Mem. [DE-21] at 7-15. For the reasons discussed below, the undersigned disagrees with the Commissioner and recommends this case be remanded for further proceedings.
VI. DISCUSSION
A. Eight-Step Sequential Evaluation
Plaintiff first contends that the ALJ erred "because he failed to follow the eight-step sequential evaluation applicable to claims of this nature" and specifically, "failed to identify medical records supporting his blanket statement that 'there had been a decrease in medical severity' of Mr. Ruggiero's symptoms." Pl.'s Mem. [DE-16-1] at 6. The court disagrees with Plaintiff with regard to the overall eight-step evaluation process—the ALJ followed each of the required steps. As the court described in Section IV above, and as the ALJ documented in his decision (Tr. 15-25), the ALJ followed each of the eight steps of the sequential evaluation process as required by 20 C.F.R. §§ 404.1594(f)(1)-(8).
Plaintiff alleges that the ALJ "was supposed to make a finding as to whether any of the prescribed exceptions applied to the 'medical improvement rule' but his decision is devoid of any such analysis or findings." Pl.'s Mem. [DE-16-1] at 4. This was not an error. Pursuant to 20 C.F.R. § 404.1594(f)(4), the ALJ appropriately skipped step five and proceeded to step six because the ALJ determined that Plaintiff's medical improvement was related to his ability to do work.
Plaintiff alleges that the ALJ committed an error at step seven by failing to determine whether Plaintiff could perform his past relevant work and failing to identify Plaintiff's past relevant work. Pl.'s Mem. [DE-16-1] at 5. As also described in Section IV above, the ALJ determined that Plaintiff could not perform past relevant work, pursuant to 20 C.F.R. § 404.1565. The ALJ appropriately cited to the testimony of the vocational expert in support of this finding. Tr. 24. The vocational expert specifically defined Plaintiff's past relevant work during her testimony at the disability hearing. Tr. 61-65. The ALJ did not err at step seven as Plaintiff alleges.
B. Medical Improvement
Plaintiff's specific substantive allegation concerning the eight-step sequential evaluation is that the ALJ failed to identify medical records supporting his determination at step three that there had been medical improvement in Plaintiff's severe impairments. Step three requires the ALJ to determine if there has been medical improvement in a claimant's impairment or impairments. 20 C.F.R. § 404.1594(f)(3). Medical improvement is any decrease in medical severity of the impairment, or impairments, as established by improvement in symptoms, signs, and/or laboratory findings. Id. (b)(1). The ALJ found there had been medical improvement by May 5, 2017, and provided this explanation:
The medical evidence supports a finding that by May 5, 2017, there had been a decrease in medical severity of the impairments. The claimant's medical records showed that the claimant's HTN and DM became controlled or stable with treatment. The claimant testified his cirrhosis was stable, and that his therapist helped his mental issues.Tr. 19.
In his Memorandum, Plaintiff unambiguously concedes "that his hypertension and diabetes symptoms improved over time with treatment." Pl.'s Mem. [DE-16-1] at 7. The remaining severe impairments mentioned in the ALJ's medical improvement finding are Plaintiff's liver cirrhosis and mental health impairments. Tr. 19. Plaintiff argues that his mental health impairments have not improved, but instead have deteriorated over time—a statement Plaintiff alleges is supported by the opinions of his treating mental health provider, Dr. Ramaswamy Sriraman of the Monarch mental health clinic. Pl.'s Mem. [DE-16-1] at 7.
In finding medical improvement occurred, the ALJ made the conclusory statement that "medical evidence supports a finding . . . [that] there had been a decrease in medical severity of the impairments." Tr. 19. The ALJ did not address whether this medical improvement finding applied to Plaintiff's mental health impairments other than to state that Plaintiff testified at the disability hearing "that his therapist helped his mental issues." Tr. 19. With no further explanation provided, the court is left to guess to which severe mental health impairment(s) this may apply.
In his decision, the ALJ summarizes medical records, treatment notes, and opinion evidence, some of which relate to Plaintiff's mental health impairments. As will be discussed further below in Section VI(C), these summaries are followed by conclusory statements that are not sufficient to enable meaningful judicial review regarding whether substantial evidence exists to support the ALJ's decision. For example, the ALJ provided the below collective summary of the medical opinions offered by Disability Determination Services ("DDS") consultants which discussed medical improvement, however it does not address or explain the underlying inconsistencies regarding the mental health impairments:
In March, May and August of 2017, Disability Determination Services (DDS) consultants opined, overall, that medical improvement had occurred, and the claimant was able to perform light work, with postural and environmental restrictions, and simple, routine and repetitive tasks, in a stable, undemanding work environment, without intensive interpersonal relating. (Exhibits 3A, l0F, 11F, 12F, 13F, and 14F). The undersigned [ALJ] gives substantial weight to these opinions. The opinions are consistent with the evidence at the time and supported by explanations. These consultants are experts in the evaluation of SSA disability claims, and they thoroughly reviewed the available record. However, given the complete record, to include the claimant's testimony, the undersigned found the claimant more limited.Tr. 23 (emphasis added).
In this description, the ALJ stated that the "consultants opined, overall, that medical improvement had occurred . . ." and cites to Exhibits 3A (Tr. 83-109), 10F (Tr. 624-31), 11F (Tr. 632-35), 12F (Tr. 636-37), 13F (Tr. 638-53), and 14F (Tr. 654-57). The referenced records clearly state that the consultants found medical improvement in Plaintiff's physical impairments (Tr. 96-97, 631-635). Yet, the records also clearly state that the consultants found no medical improvement, or no significant medical improvement, in Plaintiff's mental impairments (Tr. 95-96, 98-99, 637).
The Commissioner argues that "the ALJ indicated Mr. Ruggiero had significant mental limitations and those were not considered medically improved (see, e.g., Tr. 96, 98, 637). That is, in his original disability finding, Mr. Ruggiero was limited to simple, routine, repetitive tasks, and it was noted in these evaluations that anxiety and depression, and learning disability, were always the main diagnosis behind these limitations (Tr. 95-96, 636-637)." Def.'s Mem. [DE-21] at 12. The Commissioner provides details that may indeed reconcile the inconsistencies upon review, however the ALJ does not state this in his decision. It is not the reviewing court's role to reconcile inconsistencies.
"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). The court finds that the ALJ did not provide sufficient explanation in his administrative decision so as to permit meaningful judicial review here. Accordingly, the court recommends this case be remanded for further proceedings.
C. RFC Assessment
"RFC is an assessment of an individual's ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis" despite impairments and related symptoms. SSR 96-8p, 1996 SSR LEXIS 5, *1, 1996 WL 374184, at *1 (July 2, 1996); see also 20 C.F.R. § 404.1545(a)(1). In assessing an individual's RFC, an ALJ considers that person's "ability to meet the physical, mental, sensory, and other requirements of work." 20 C.F.R. § 404.1545(a)(4). It must based upon all relevant evidence in the case record, and this may include the claimant's own description of limitations from alleged symptoms. SSR 96-8p, 1996 SSR LEXIS 5, *13, 1996 WL 374184, at *5; 20 C.F.R. § 404.1545(a)(3). If necessary, the ALJ must "explain how any material inconsistences or ambiguities in the evidence were considered and resolved." SSR 96-8p, 1996 SSR LEXIS 5, *19, 1996 WL 374184, at *7.
An ALJ must "include a narrative discussion describing how the evidence supports each conclusion" in the RFC. Monroe v. Colvin, 826 F.3d 176, 189 (4th Cir. 2016) (quoting Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015)). The ALJ must specifically explain how certain pieces of evidence support particular conclusions and "discuss[ ] . . . which evidence the ALJ found credible and why." Monroe, 826 F.3d at 189 (quoting Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013)). The Fourth Circuit has interpreted this to require an ALJ to "build an accurate and logical bridge from the evidence to his conclusion." Monroe, 826 F.3d at 189 (quoting Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000)).
"[A] proper RFC analysis has three components: (1) evidence, (2) logical explanation, and (3) conclusion . . . . [M]eaningful review is frustrated when an ALJ goes straight from listing evidence to stating a conclusion." Thomas v. Berryhill, 916 F.3d 307, 311 (4th Cir. 2019) (citing Woods v. Berryhill, 888 F.3d 686, 694 (4th Cir. 2018)). An ALJ must "[s]how [their] work." Patterson v. Comm'r of Soc. Sec. Admin., 846 F.3d 656, 663 (4th Cir. 2017). Such analysis—"[h]armonizing conflicting evidence and bolstering inconclusive findings," Patterson, 846 F.3d at 662—is a "necessary predicate" to determining whether substantial evidence supports the Commissioner's findings, Monroe, 826 F.3d at 189 (quoting Radford, 734 F.3d at 295). "An ALJ has a duty to explain the administrative decision so as to enable meaningful judicial review." Parker v. Colvin, No. 4:13-CV-38-FL, 2014 U.S. Dist. LEXIS 79467, 2014 WL 2604282, at *3 (E.D.N.C. June 11, 2014). Where a court is "left to guess about how the ALJ arrived at his conclusions on [a claimant's] ability to perform relevant functions . . ., remand is necessary." Mascio, 780 F.3d at 637.
Plaintiff's primary contention throughout his Memorandum is that the ALJ's decision is not supported by substantial evidence because the ALJ did not properly weigh the evidence of Plaintiff's mental health impairments, including the opinion evidence of Dr. Sriraman, and did not properly consider these mental health impairments in assessing Plaintiff's RFC. Pl.'s Mem. [DE-16-1] at 7-8. As described below, the court cannot trace the ALJ's reasoning for concluding that "claimant's statements concerning the intensity, persistence and limiting effects of his symptoms are not supported by the overall evidence of record to the extent they purport to limit him more than that provided for in the residual functional capacity herein." Tr. 23.
On May 22, 2018, Dr. Sriraman completed a Mental Residual Function Capacity Statement form and it was made part of the record. Tr. 704-711. In the form, Dr. Sriraman noted that Plaintiff was bipolar and that his response to treatment was "guarded." Tr. 704. He identified Plaintiff's symptoms by completing the "check box" list in the form indicating that Plaintiff had "pressured speech" and "decreased need for sleep." Tr. 707-708. Dr. Sriraman indicated that Plaintiff had marked limitations in each of the four functional areas under 20 C.F.R. § 404.1520a(c)(3) resulting from Plaintiff's mental impairments, that being: understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and, adapting or managing oneself. Tr. 710. Dr. Sriraman anticipated that Plaintiff's impairments would cause him to be absent from work four or more days per month, and that Plaintiff could be expected to perform a job, 8 hours per day, 5 days per week on a sustained basis with less than 80 percent efficiency of an average worker. Tr. 710.
The ALJ gave limited weight to Dr. Sriraman's opinion and explained his reasoning as follows:
In May of 2018, Dr. Sriraman found the claimant had mostly marked mental functional limitations, had marked restrictions in the four functional areas of the "B" criteria, would be less than 80% efficient on the job, and would miss work four or more days per month (Exhibit 16F). Limited weight is given to Dr. Sriraman's opinion. The severity of his limitations is not supported by the medical and other evidence of record, as described above, or his own treatment notes. For example, Dr. Sriraman's mental status examination of the claimant in April 2018 was essentially normal, to include alert and oriented, appropriate affect, normal thought content, and intact insight and judgment (page 5 of Exhibit l5F). In addition, Dr. Sriraman provided no explanation for his limitations.Tr. 23. In his written decision, the ALJ summarized and assessed Plaintiff's mental health treatment records from Monarch. In the below, the ALJ referenced the same treatment records, Exhibit 15F (Tr. 658-703), as he cited in the discussion of Dr. Sriraman's opinion:
The claimant was treated at Monarch from February of 2017 to April of 2018, for a bipolar I disorder with depressed episode and psychotic features, for which the claimant was provided therapy and medications. In February of 2017, it was observed the claimant was intelligent (see page 14 of Exhibit 8F). In the most recent reports dated June and August of 2017 and April of 2018, the claimant's mental status exams revealed an appropriate appearance, normal motor activity, normal alertness, intact orientation, normal speech, an appropriate affect, goal-directed logical thought processes, normal thought content, unimpaired memory functions, and intact insight and judgment. The claimant denied having hallucinations, delusions, suicidal thoughts, or homicidal ideations (see pages 6, 21, and 29 of Exhibit 15F). (Exhibits 8F and 15F).Tr. 21.
The only medical opinions to which the ALJ assigned substantial weight were those of the DDS consultants, as discussed above. This weight was assigned collectively, without a discussion of the individual DDS consultants' opinions. Therefore, it is unknown how the ALJ credited each opinion. Despite the substantial weight assigned to the consultant's opinions as a whole, the ALJ states that "given the complete record, to include the claimant's testimony, the undersigned [ALJ] found the claimant more limited." Tr. 23. With this statement, it appears that the ALJ gave Plaintiff's statements concerning the limiting effects of his symptoms, or perhaps another record, enough weight to discount the DDS consultants' opinions to some degree. The ALJ does not provide any explanation for this conclusion, and it is difficult to understand how the ALJ arrived at the RFC based upon the weight he assigned to the opinions in the record.
Following the summaries of the medical records, treatment notes, and opinion evidence, the ALJ concludes that "the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the objective medical and other evidence" (Tr. 20) and "claimant's statements concerning the intensity, persistence and limiting effects of his symptoms are not supported by the overall evidence of record to the extent they purport to limit him more than that provided for in the residual functional capacity herein." Tr. 23. Here again, the ALJ does not explain the inconsistencies to which he is referring.
The ALJ's lack of explanation and analysis frustrates meaningful review by the court. Based on the descriptions by ALJ, it is impossible to know how he weighed the evidence. See Monroe, 826 F.3d at 190-91 (explaining how an ALJ's general and conclusory assignments of weight precluded meaningful review). Accordingly, the undersigned recommends this case be remanded to the Commissioner for further proceedings. On remand, the Commissioner should make findings that sufficiently explain the probative evidence, and that would permit meaningful judicial review, if necessary.
VII. CONCLUSION
For the reasons stated above, it is RECOMMENDED that Plaintiff's Motion for Judgment on the Pleadings [DE-16] be ALLOWED, Defendant's Motion for Judgment on the Pleadings [DE-20] 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 March 19, 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 March 25, 2021.
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 12th day of March, 202
/s/_________
Brian S. Meyers
United States Magistrate Judge