United States District Court, E.D. Virginia, Richmond Division
J. Novak United States Magistrate Judge.
October 29, 2013, Teodora Elliott ("Plaintiff) applied
for Social Security Disability Benefits ("DIB")
and, on January 8, 2014, for Supplemental Security Income
("SSI") under the Social Security Act
("Act"), alleging disability from breast cancer,
chemotherapy treatment, an abdominal hernia and an aorta
aneurysm, with an alleged onset date of October 16, 2013. The
Social Security Administration ("SSA") denied
Plaintiffs claims both initially and upon reconsideration.
Thereafter, an Administrative Law Judge ("ALJ")
denied Plaintiffs claims in a written decision and the
Appeals Council denied Plaintiffs request for review,
rendering the ALJ's decision as the final decision of the
now proceeding pro se, seeks judicial review of the
ALJ's decision pursuant to 42 U.S.C § 405(g),
arguing that the ALJ erred in formulating the residual
functional capacity ("RFC"), and that additional
evidence warrants remand. (Pl.'s Mot for Summ. J. with a
Br. in Support ("Pl.'s Mem.") (ECF No. 12) at
1-2.) This matter now comes before the Court by consent of
the parties, pursuant to 28 U.S.C. § 636(c)(1), on the
parties' cross-motions for summary judgment, rendering
the matter now ripe for review. For the reasons that follow, the
Court hereby DENIES Plaintiffs Motion for Summary Judgment
(ECF No. 12), GRANTS Defendant's Motion for Summary
Judgment (ECF No. 15) and AFFIRMS the final decision of the
October 29, 2013, Plaintiff filed an application for DIB and,
on January 8, 2014, Plaintiff filed an application for SSI
with an alleged onset date of October 16, 2013. (R. at 207,
211.) The SSA denied these claims initially on June 20, 2014,
and again upon reconsideration on October 6, 2014. (R. at 80,
90.) At Plaintiffs written request, the ALJ held a hearing on
March 1, 2016. (R. at 37, 141.) On March 15, 2016, the ALJ
issued a written opinion, denying Plaintiffs claims and
concluding that Plaintiff did not qualify as disabled under
the Act, because she could make successful adjustments to
jobs that existed in significant numbers in the national
economy. (R. at 29-30.) On June 7, 2016, the Appeals Council
denied Plaintiffs request for review, rendering the ALJ's
decision as the final decision of the Commissioner subject to
review by this Court. (R. at 1-3.)
STANDARD OF REVIEW
reviewing the Commissioner's decision to deny benefits, a
court "will affirm the [SSA]'s disability
determination 'when an ALJ has applied correct legal
standards and the ALJ's factual findings are supported by
substantial evidence.'" Mascio v. Colvin,
780 F.3d 632, 634 (4th Cir. 2015) (quoting Bird v.
Comm V of Soc. Sec. Admin., 699 F.3d 337, 340
(4th Cir. 2012)). Substantial evidence requires more than a
scintilla but less than a preponderance, and includes the
kind of relevant evidence that a reasonable mind could accept
as adequate to support a conclusion. Hancock v.
Astrue, 667 F.3d 470, 472 (4th Cir. 2012); Craig v.
Chater, 76 F.3d 585, 589 (4th Cir. 1996). Indeed,
"the substantial evidence standard 'presupposes ...
a zone of choice within which the decision makers can go
either way, without interference by the courts. An
administrative decision is not subject to reversal merely
because substantial evidence would have supported an opposite
decision.'" Dunn v. Colvin, 607 F.App'x
264, 274 (4th Cir. 2015) (quoting Clarke v. Bowen,
843 F.2d 271, 272-73 (8th Cir. 1988)). To determine whether
substantial evidence exists, the court must examine the
record as a whole, but may not "undertake to re-weigh
conflicting evidence, make credibility determinations, or
substitute [its] judgment for that of the [ALJ]."
Hancock, 667 F.3d at 472 (quoting Johnson v.
Barnhart, 434 F.3d 650, 653 (4th Cir. 2005)). In
considering the decision of the Commissioner based on the
record as a whole, the court must "take into account
whatever in the record fairly detracts from its weight."
Breeden v. Weinberger, 493 F.2d 1002, 1007 (4th Cir.
1974) (quoting Universal Camera Corp. v. N.L.R.B.,
340 U.S. 474, 488 (1951)). The Commissioner's findings as
to any fact, if substantial evidence in the record supports
the findings, bind the reviewing court to affirm regardless
of whether the court disagrees with such findings.
Hancock, 667 F.3d at 477. If substantial evidence in
the record does not support the ALJ's determination or if
the ALJ has made an error of law, the court must reverse the
decision. Coffman v. Bowen, 829 F.2d 514, 517 (4th
regulations set forth a five-step process that the agency
employs to determine whether disability exists. 20 C.F.R.
§ 416.920(a)(4); see Mascio, 780 F.3d 634-35
(describing the ALJ's five-step sequential evaluation).
To summarize, at step one, the ALJ looks at the
claimant's current work activity. §
416.920(a)(4)(i). At step two, the ALJ asks whether the
claimant's medical impairments meet the regulations'
severity and duration requirements. § 416.920(a)(4)(ii).
Step three requires the ALJ to determine whether the medical
impairments meet or equal an impairment listed in the
regulations. § 416.920(a)(4)(iii). Between steps three
and four, the ALJ must assess the claimant's RFC,
accounting for the most that the claimant can do despite her
physical and mental limitations. § 416.945(a). At step
four, the ALJ assesses whether the claimant can perform her
past work given her RFC. § 416.920(a)(4)(iv). Finally,
at step five, the ALJ determines whether the claimant can
perform any work existing in the national economy. §
THE ALJ'S DECISION
March 1, 2016, the ALJ held a hearing during which Plaintiff
(then-represented by counsel) and a vocational expert
testified. (R. at 37-69.) On March 15, 2016, the ALJ issued a
written opinion, finding that Plaintiff did not qualify as
disabled under the Act. (R. at 29-30.)
followed the five-step evaluation process established by the
Act in analyzing Plaintiffs disability claim. (R. at 20-29.)
At step one, he found that Plaintiff had not engaged in
substantial gainful activity since her alleged onset date.
(R. at 21.) At step two, he determined that Plaintiff had the
following severe impairments: breast cancer, depressive
disorder and anxiety disorder. (R. at 21.) The ALJ concluded
at step three that none of these impairments or combination
of impairments met or medically equaled the severity of one
of the listings. (R. at 22.)
assessing Plaintiffs RFC, the ALJ determined that Plaintiff
could perform light work with additional limitations. (R. at
23-24.) She could lift and carry ten pounds frequently and
twenty pounds occasionally. (R. at 23.) She could sit, stand
or walk for six hours in an eight-hour workday. (R. at 23.)
Plaintiff could constantly push or pull at the light
exertional level. (R. at 23.) Although she could frequently
climb stairs and ramps, she could never climb ladders, ropes
or scaffolds. (R. at 23-24.) She could frequently balance,
stoop, kneel, crouch or crawl. (R. at 24.) Plaintiff could
never tolerate exposure to unprotected heights. (R. at 24.)
As for her mental RFC, the ALJ limited Plaintiff to
understanding, remembering and carrying out short, simple
instructions consistent with the performance of unskilled
work. (R. at 24.) Plaintiff could tolerate frequent
interaction with supervisors and co-workers, but only
occasional interaction with the public. (R. at 24.)
four, the ALJ found that Plaintiff could not perform any of
her past relevant work. (R. at 28.) Then, at step five, the
ALJ determined that Plaintiff could perform jobs that existed
in significant numbers in the national economy. (R. at 28.)
Therefore, she did not qualify as disabled under the Act. (R.
forty-eight years old at the time of this Opinion, previously
worked as an insurance representative and a sales assistant.
(R. at 227, 231.) On September 19, 2013, a biopsy revealed
that Plaintiff had stage II left breast cancer. (R. at 339.)
She applied for Social Security Benefits, alleging disability
from stage II breast cancer, chemotherapy treatment,
abdominal hernia and aorta aneurysm, with an alleged onset
date of October 16, 2013. (R. at 230.) Plaintiffs appeal to
this Court challenges the ALJ's RFC
assessment. (Pl.'s Mem. at 1-2.) Specifically, she
alleges that the ALJ erred in the weight that he assigned
Plaintiffs two treating physicians. (Pl.'s Mem. at 1.)
Additionally, Plaintiff asks the Court to remand based on new
evidence submitted with her motion for summary judgment.
(Pl.'s Mem. at 1-2.)
The ALJ Did Not Err in Assigning Weight to Plaintiffs
alleges that the ALJ erroneously weighed the opinions of her
treating physicians, resulting in a faulty RFC. (Pl.'s
Mem. at 1.) The ALJ gave great weight to the opinion of
Attique Samdani, M.D., but little weight to the opinion of
Vivian Fernandez, M.D. (R. at 27-28.) Defendant responds that
the ALJ properly weighed the medical opinion evidence.
(Def.'s Mot. for Summ. J. and Br. in Support
("Def.'s Mem.") (ECF No. 15) at 18.)
step three of the sequential analysis, but before deciding
whether a claimant can perform past relevant work at step
four, the ALJ must determine the claimant's RFC. 20
C.F.R. §§ 404.1520(e)-(f), 404.1545(a)(1),
416.920(e)-(f), 416.945(a)(1). In analyzing claimant's
abilities, an ALJ must first assess the nature and extent of
the claimant's physical and mental limitations and then
determine the claimant's RFC for work activity on a
regular and continuing basis. §§ 404.1545(b),
416.945(b). The RFC must incorporate impairments supported by
the objective medical evidence in the record, as well as
those impairments that have basis in the claimant's
credible complaints. Carter v. Astrue, 2011 WL
2688975, at *3 (E.D. Va. June 23, 2011); accord
§§ 404.1545(e), 416.945(e).
determine which impairments to incorporate, the ALJ must
analyze the claimant's provided medical records and any
medical evidence resulting from consultative examinations and
ordered medical expert evaluations. §§
404.1512(a)-(e), 404.1527, 416.912(a)-(e), 416.927. When the
record contains a number of different medical opinions,
including those from Plaintiffs treating sources,
consultative examiners, or other sources that show
consistency with each other, then the ALJ makes a
determination based on that evidence. §§
404.1520b(a), 416.920b(a). If, however, the medical opinions
conflict internally with each other or other evidence, the
ALJ must evaluate the opinions and assign them respective
weight to properly analyze the evidence involved.
§§ 404.1520b(b), 404.1527(c)(2)-(6), (e),
416.920(b), 416.927(c)(2)-(6), (e).
must evaluate and assign weight to every medical opinion,
regardless of its source. §§ 404.1527(c),
416.927(c). In doing so, he considers the following factors:
(1) examining relationship; (2) treatment relationship; (3)
supportability from objective medical evidence; (4)
consistency; and, (5) specialization. §§
404.1527(c)(1)-(5), 416.927(c)(1)-(5). Courts generally
should not disturb an ALJ's decision as to the weight
afforded a medical opinion absent some indication that the
ALJ "dredged up specious inconsistences."
Dunn, 607 F.App'x at 267 (citing Scivally v.
Sullivan, 966 F.2d 1070, 1077 (7th Cir. 1992)). Indeed,
a reviewing court should leave untouched an ALJ's
decision regarding weight afforded a medical opinion unless
the ALJ failed to give a sufficient reason for the weight
The ALJ Did Not Err by Giving Great Weight to Dr.
first takes issue with the ALJ's assignment of great
weight to Dr. Samdani's opinion. (Pl.'s Mem. at 1.)
Dr. Samdani opined that Plaintiff could not perform strenuous
activity, but that she could carry out light or sedentary
work. (R. at 371, 423, 495.) The ALJ gave this opinion great
weight, because it comported with the evidence in the record,
including examination findings. (R. at 27.) Substantial
evidence in the form of Dr. Samdani's examination
findings, the other objective medical evidence and Plaintiffs
daily activities supports the ALJ's decision.
Samdani's opinion comports with his own examination
findings, supporting the ALJ's decision. On November 26,
2013, Plaintiff presented to Dr. Samdani at Virginia Cancer
Institute following her breast cancer diagnosis. (R. at 378.)
Plaintiff had no specific symptoms and denied any
abnormalities on review. (R. at 378-79.) For example, she
denied headaches, blurred vision, nausea, joint pain and
excessive fatigue. (R. at 379.) She also denied insomnia,
depression and mood swings. (R. at 379.) Dr. Samdani noted
that the evidence did not demonstrate any metastatic disease.
(R. at 378.) On examination, Plaintiff exhibited a normal
range of motion with no tenderness, swelling or obvious
weakness. (R. at 380.) Plaintiff displayed a normal gait
without any sensory or motor deficits. (R. at 380.)
January 8, 2014, Plaintiff again presented to Dr. Samdani.
(R. at 370.) Dr. Samdani noted that Plaintiff looked
clinically stable and that she had responded well to
chemotherapy. (R. at 373.) On examination, Plaintiff had
normal findings, including no joint pain, swelling, redness,
decreased range of motion or obvious weakness. (R. at 372.)
Additionally, Plaintiff exhibited a normal gait and no
sensory or motor deficits. (R. at 372.) Plaintiff denied any
headaches, blurred vision, insomnia, depression or mood
swings. (R. at 371.)
each of Plaintiff s visits through March 19, 2014, Dr.
Samdani made similarly unremarkable findings. She looked
clinically stable and responded well to chemotherapy. (R. at
373, 374, 381, 496, 499.) On exam, Plaintiff had normal
findings, including no joint pain, swelling, redness,
decreased range of motion or obvious weakness. (R. at 371,
375, 379, 494, 498, 504.) Plaintiff exhibited a normal gait
with no sensory or motor deficits. (R. at 372, ...