United States District Court, W.D. Virginia, Danville Division
CHRISTOPHER S. SMALLWOOD, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner, Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
JOEL C. HOPPE, Magistrate Judge.
Plaintiff Christopher Smallwood asks this Court to review the Commissioner of Social Security's ("Commissioner") final decision denying his applications for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-422, 1381-1383f. This Court has authority to decide Smallwood's case under 42 U.S.C. §§ 405(g) and 1383(c)(3), and his case is before me by referral under 28 U.S.C. § 636(b)(1)(B). On appeal, Smallwood objects to the Commissioner's evaluation of his severe mental impairment and resulting functional limitations. See generally Pl. Br. 3-7, ECF No. 17. Having considered the administrative record, the parties' briefs and oral arguments, and the applicable law, I find that substantial evidence supports the Commissioner's final decision that Smallwood is not disabled.
I. Standard of Review
The Social Security Act authorizes this Court to review the Commissioner's final decision that a person is not entitled to disability benefits. See 42 U.S.C. § 405(g); Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). The Court's role, however, is limited-it may not "reweigh conflicting evidence, make credibility determinations, or substitute [its] judgment" for that of agency officials. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Instead, the Court asks only whether the ALJ applied the correct legal standards and whether substantial evidence supports the ALJ's factual findings. Meyer v. Astrue, 662 F.3d 700, 704 (4th Cir. 2011).
"Substantial evidence" means "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). It is "more than a mere scintilla" of evidence, id., but not necessarily "a large or considerable amount of evidence, " Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence review takes into account the entire record, and not just the evidence cited by the ALJ. See Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984); Universal Camera Corp. v. NLRB, 340 U.S. 474, 487-89 (1951). Ultimately, this Court must affirm the ALJ's factual findings if "conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled.'" Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (per curiam) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996) (internal quotation marks omitted)). However, "[a] factual finding by the ALJ is not binding if it was reached by means of an improper standard or misapplication of the law." Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).
A person is "disabled" if he or she is unable 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." 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a) (governing claims for DIB), 416.905(a) (governing adult claims for SSI). Social Security ALJs follow a five-step process to determine whether an applicant is disabled. The ALJ asks, in sequence, whether the applicant: (1) is working; (2) has a severe impairment; (3) has an impairment that meets or equals an impairment listed in the Act's regulations; (4) can return to his or her past relevant work based on his or her residual functional capacity; and, if not (5) whether he or she can perform other work. See 20 C.F.R. §§ 404.1520(a), 416.920(a)(4); Heckler v. Campbell, 461 U.S. 458, 460-62 (1983). The applicant bears the burden of proof at steps one through four. Hancock, 667 F.3d at 472. At step five, the burden shifts to the agency to prove that the applicant is not disabled. See id.
II. Procedural History
Smallwood filed for DIB and SSI on June 15, 2010. See Administrative Record ("R.") 62, 70. He was 35 years old, id., and had worked for many years in the construction industry, R. 90. Smallwood said that he stopped working on November 30, 2009, because of "back problems, " hernias, and depression. R. 215. The state agency denied his applications initially in October 2010, R. 68, 78, and upon reconsideration in July 2011, R. 91, 103.
Smallwood appeared with counsel at a hearing before an Administrative Law Judge ("ALJ") on May 9, 2012. R. 32. He testified as to his alleged impairments and to the limitations those impairments caused in his daily activities. R. 37-52. A vocational expert ("VE") also testified as to Smallwood's past work and ability to perform other work existing in the national and regional economies. R. 52-57.
In a written decision dated July 9, 2012, the ALJ concluded that Smallwood was not entitled to disability benefits. R. 25. He found that Smallwood suffered from three "severe impairments: back difficulty, asthma, and mood disorder." R. 16. None of Smallwood's severe impairments, alone or combined, met or medically equaled an impairment listed in the Act's regulations. R. 17-18.
The ALJ next determined that Smallwood had the residual functional capacity ("RFC") to perform a limited range of light work. R. 18, 24-25. As to Smallwood's mental capacity, the ALJ found that Smallwood could "handle simple and repetitive tasks, " maintain concentration "within customary work tolerances, with breaks, " "interact with co-workers and supervisors as needed for task completion, " and "respond appropriately to change[s] in a routine work setting, " but "should have minimal public contact." R. 18. The ALJ noted that this RFC ruled out Smallwood's return to his past work as a construction laborer and dump-truck driver because the VE testified that these were at least "medium" exertion jobs. R. 23-24.
Finally, relying on the VE's testimony, the ALJ concluded that Smallwood was not disabled because he still could perform certain unskilled occupations that existed in significant numbers nationally and in Virginia, such as merchandise marker, silver wrapper, and routing clerk. R. 24. The Appeals Council declined to review the ALJ's decision, R. 1, and this appeal followed.
Smallwood's overarching objection is that the ALJ impermissibly crafted his own mental RFC that conflicted with each relevant medical-source opinion in the record. See Pl. Br. 6. He argues that the ALJ's rejection of these opinions triggered the Commissioner's duty to obtain a consultative mental examination before denying his claim. See id. at 3-4, 6-7. He also argues that the ALJ erred in giving "little weight" to the opinions of Richard Patterson, M.A., Smallwood's former mental health counselor. Id. at 5-6. Smallwood asks the Court to reverse the Commissioner's decision and award benefits, or to remand his case for further administrative proceedings. Id. at 7.
A. Consultative Mental Exam
The Commissioner must purchase a consultative examination "when the evidence as a whole, both medical and nonmedical, is not sufficient to support a decision on the [applicant's] claim." Kersey v. Astrue, 614 F.Supp.2d 679, 695 (W.D. Va. 2009) (quoting 20 C.F.R. §§ 404.1519a(b), 416.919a(b)). Although the Commissioner has a duty to develop the record, the regulations require only that the "evidence be complete' enough to make a determination regarding the nature and severity of the claimed disability, the duration of the disability[, ] and the claimant's residual functional capacity." Id. (citing Cooke v. Heckler, 783 F.2d 1168, 1173 (4th Cir. 1986)). Thus, a "reviewing court must defer to the [Commissioner's] decision not to purchase a consultative exam when the record contains sufficient information" to make these administrative findings. Johnson v. Astrue, No. 6:11cv9, 2012 WL 2046939, at *3 (W.D. Va. June 5, 2012).
Smallwood argues that the Commissioner was required to order a consultative mental exam because the ALJ's RFC determination conflicts with each of the medical-source opinions about his mental impairment. See Pl. Br. 4. This argument confuses the agency's duty to obtain evidence "sufficient" to resolve Smallwood's claim with the ALJ's authority to weigh and resolve conflicting evidence, including medical evidence, in the record. See Kersey, 614 F.Supp.2d at 693; Nye v. Colvin, No. 3:13-12115, 2014 WL 2893199, at *20 (S.D. W.Va. June 24, 2014). When the record contains sufficient evidence to determine whether a claimant is disabled under the Act, the fact that the ALJ discredited the available medical-source opinions "does not mean that [the agency] had a duty to seek additional information...." Coleman v. Astrue, No. 2:06cv66, 2007 WL 3088074, at *7 (W.D. Va. Oct. 22, 2007).
Smallwood's administrative record contained medical opinions from two state-agency psychologists, a mental RFC assessment from Smallwood's former counselor, medical records documenting Smallwood's mental health treatment throughout the relevant period, observations of Smallwood's mental state from three examining physicians and one examining nurse practitioner, and statements from Smallwood and a close friend describing Smallwood's activities and limitations. See R. 67, 75, 86-88, 99-100 (state-agency psychologists' opinions); R. 37-51, 236-41, 245, 290, 300 (claimant's and friend's statements); R. 346-47, 365-70, 418, 421-23, 424-25, 471, 473-75, 491-93, 494-96, 497-98, 500-01, 513 (treatment notes); R. 514-16 (counselor's opinion); R. 377-81, 401, 445 (examining sources' observations). This evidence, as described more fully below, is sufficient to support an informed decision on Smallwood's disability claim. Compare Bishop v. Barnhart, 78 F.App'x 265, 268 (4th Cir. 2003) (per curiam) (finding no error where the ALJ had opinions from the claimant's "treating physician, a licensed clinical psychologist, state agency psychologist, and notes from" a mental health provider), with Huddleston v. Astrue, 826 F.Supp.2d 942, 959 (S.D. W.Va. 2011) (reversing and remanding where "the ALJ had no medical records, consultative examinations, or medical source statements" from the relevant period and "circumstances point[ed] to the probable existence of probative and necessary evidence" not provided by the claimant). Accordingly, I find that the Commissioner was not required to obtain a consultative mental exam in Smallwood's case.
B. Medical-Source Opinions
ALJs must weigh each "medical opinion" in the applicant's record. 20 C.F.R. §§ 404.1527(c), 416.927(c). Medical opinions are statements from "acceptable medical sources, " such as physicians and psychologists, that reflect judgments about the nature and severity of the applicant's impairment, including his symptoms, diagnosis and prognosis, what he can still do despite his impairment, and his functional limitations. 20 C.F.R. §§ 404.1527(a)(2), 416.927(a)(2). The regulations classify medical opinions by their source: those from treating sources and those from non-treating sources, such as examining physicians and state-agency psychologists. See 20 C.F.R. §§ 404.1527(c), 416.927(c).
Opinions from non-treating sources are not entitled to any particular weight. See id. Rather, the ALJ must consider certain factors in determining what weight to give such opinions, including the source's familiarity with the applicant, the weight of the evidence supporting the opinion, the source's medical specialty, and the opinion's consistency with other evidence in the record. See id. The ALJ also must explain the weight given to all medical opinions and the reasons for such weight. See Radford v. Colvin, 734 F.3d 288, 295-96 (4th Cir. 2013); 20 C.F.R. §§ 404.1527(e)(2), 416.927(e)(2). Finally, if the ALJ's RFC assessment conflicts with a medical opinion, he must explain why that ...