United States District Court, W.D. Virginia, Danville Division
REPORT & RECOMMENDATION
C. HOPPE UNITED STATES MAGISTRATE JUDGE
Mary Ellen Yates asks this Court to review the Commissioner
of Social Security's (“Commissioner”) final
decision denying her applications for disability insurance
benefits (“DIB”) and supplemental security income
(“SSI”) under Titles II and XVI of the Social
Security Act (the “Act”), 42 U.S.C. §§
401-434, 1381-1383f. The case is before me by referral under
28 U.S.C. § 636(b)(1)(B). ECF No. 12. Having considered
the administrative record, the parties' briefs, and the
applicable law, I cannot find that substantial evidence
supports the Commissioner's final decision. Accordingly,
I recommend that the decision be reversed and the case be
remanded under the fourth sentence of 42 U.S.C. § 405(g)
to give the Commissioner another opportunity to explain her
findings and conclusions.
Standard of Review
Social Security Act authorizes this Court to review the
Commissioner's final decision that a person is not
entitled to disability benefits. 42 U.S.C. §§
405(g), 1383(c)(3); see also 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, a
court reviewing the merits of the Commissioner's final
decision asks only whether the Administrative Law Judge
(“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); see Riley v. Apfel, 88 F.Supp.2d 572,
576 (W.D. Va. 2000) (citing Melkonyan v. Sullivan,
501 U.S. 89, 98-100 (1991)).
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 Universal Camera Corp. v. NLRB, 340 U.S.
474, 487-89 (1951); Gordon v. Schweiker, 725 F.2d
231, 236 (4th Cir. 1984). 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, 594 (4th Cir. 1996)). 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).
person is “disabled” within the meaning of the
Act if he or she is unable to engage in “any
substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than 12
months.” 42 U.S.C. §§ 423(d)(1)(A),
1382c(a)(3)(A); accord 20 C.F.R. §§
404.1505(a), 416.905(a). Social Security ALJs follow a
five-step process to determine whether a claimant is
disabled. The ALJ asks, in sequence, whether the claimant (1)
is working; (2) has a severe impairment that satisfies the
Act's duration requirement; (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 Heckler
v. Campbell, 461 U.S. 458, 460-62 (1983); Lewis v.
Berryhill, 858 F.3d 858, 861 (4th Cir. 2017); 20 C.F.R.
§§ 404.1520(a)(4), 416.920(a)(4). The claimant
bears the burden of proof through step four. Lewis,
858 F.3d at 861. At step five, the burden shifts to the
agency to prove that the claimant is not disabled. See
filed for DIB and SSI on September 21, 2012, alleging
disability because of post-traumatic stress disorder
(“PTSD”), borderline split personality disorder,
anxiety, and depression. See Administrative Record
(“R.”) 71, 84, ECF No. 9-1. She alleged
disability as of December 31, 2008, at which time she was
twenty-five years old. Id. Disability Determination
Services (“DDS”), the state agency, twice
rejected Yates's applications. R. 97-98, 124-25. On
September 2, 2015, Yates appeared with counsel for an
administrative hearing before ALJ H. Munday. R. 45. Yates and
a vocational expert (“VE”) testified at the
hearing. R. 51-64, 65-69.
Munday issued an unfavorable decision on October 15, 2015. R.
16-33. She first found that Yates had not worked since
December 31, 2008, and that Yates met the Act's insured
status requirements through March 31, 2013. R. 19. At step
two, she found that Yates's fibromyalgia, PTSD, major
depressive disorder, and borderline personality disorder
qualified as “severe” medical impairments.
Id. All of Yates's other diagnosed conditions
were deemed non-severe impairments. Id. At step three,
ALJ Munday found that none of Yates's severe impairments
met or medically equaled one of the impairments listed in the
Act's regulations. R. 19-21. As part of this analysis,
she also found Yates's mental impairments caused
“mild restriction[s]” in her daily activities,
“moderate difficulties” in social functioning,
“moderate difficulties in concentration and
persistence[, ] and no significant limitation in pace.”
Munday next evaluated Yates's residual functional
capacity (“RFC”) based on all of her medical
impairments. See R. 22-31. The ALJ determined that
Yates could perform “medium work” and “simple
routine tasks involving no more than simple, short
instructions and simple work-related decisions with few
workplace changes” and “occasionally interact
with the general public and co-workers, ” but she could
not “work in close proximity to others (defined as no
teamwork or interdependence required).” R. 21. This RFC
ruled out Yates's return to her past work. R. 31-32.
Finally, based on her RFC finding and the VE's testimony,
ALJ Munday concluded that Yates was not disabled during the
relevant period because she still could perform certain
widely available “medium, unskilled” occupations
such as packer, cleaner, and inspector/grader. R. 32-33. The
Appeals Council denied Yates's request for review, R.
1-5, and this appeal followed.
makes two overarching arguments on appeal. First, she argues
that ALJ Munday ignored evidence of her diagnosed migraine
headaches and joint hypermobility syndrome when evaluating
the severity of her medical impairments at step two and
“failed to consider” those conditions when
assessing her physical RFC. See Pl.'s Br. 11-13,
17. This argument merits only a brief discussion because, as
the Commissioner correctly points out, Yates does not suggest
ALJ Munday overlooked any impairment-related functional
limitations that might have changed the outcome in this case.
See Id. at 11-13; Def.'s Br. 12-13, ECF No. 19.
Yates argues that ALJ Munday did not explain how her mental
RFC determination-i.e., that Yates was limited to
“simple routine tasks involving no more than simple,
short instructions and simple work-related decisions with few
workplace changes, ” occasional interaction with the
general public and coworkers, and no jobs requiring teamwork
or “interdependence”-reflected her step-three
finding that Yates had moderate difficulties maintaining
concentration and persistence. Pl.'s Br. 13, 15. The
Commissioner responds that ALJ Munday explained how
“she arrived at the specific concentration,
persistence, or pace limitations constituting her RFC”
determination, Def.'s Br. 18, and reasonably relied on
medical opinions that Yates could perform simple, routine
tasks despite her mental impairments. See Id. at
15-17, 18-19. Yates has the better position on this issue.
“Given the depth and ambivalence of the [current]
record, ” however, I find that the Commissioner should
have another opportunity to explain her findings and
conclusions. Radford v. Colvin, 734 F.3d 288,
296 (4th Cir. 2013).
two, the ALJ determines whether the claimant has a
“severe” medically determinable physical or
mental impairment or combination of impairments. 20 C.F.R.
§§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). An
impairment or combination of impairments “is considered
‘severe' if it significantly limits an
individual's physical or mental abilities to do basic
work activities.” SSR 96-3p, 1996 WL 374181, at *1
(July 2, 1996). Conversely, an impairment or combination of
impairments is “considered . . . ‘not severe'
only if it is a slight abnormality which has such a minimal
effect on the individual, ” Evans v. Heckler,
734 F.2d 1012, 1014 (4th Cir. 1984) (emphasis omitted), that
it does not meaningfully impair his or her functional ability
to perform basic work activities, SSR 96-3p, 1996 WL 374181,
at *2. See also Felton-Miller v. Astrue, 459
Fed.Appx. 226, 229-30 (4th Cir. 2011) (per curiam)
(“[M]edical conditions alone do not entitle a claimant
to disability benefits; ‘[t]here must be a showing of
related functional loss.'” (quoting Gross v.
Heckler, 785 F.2d 1163, 1166 (4th Cir. 1986))).
“Basic work activities” are the “abilities
and aptitudes necessary to do most jobs, ” such as
standing, walking, and lifting, or responding to other
people, exercising judgment, and dealing with normal
workplace situations. 20 C.F.R. §§ 404.1521(b),
asserts that ALJ Munday committed reversible error by
“fail[ing] to assess” her joint hypermobility
syndrome and by never “mention[ing] the word
‘migraine'” when evaluating her physical
impairments. Pl.'s Br. 12, 13. Critically, however, Yates
does not identify any specific error in ALJ Munday's
finding that, with the exception of fibromyalgia, PTSD, major
depressive disorder, and borderline personality disorder,
all of Yates's other diagnosed conditions,
“considered singly and in combination, ” were
non-severe impairments at least in part because they
“did not result in any continuous . . . functional
limitations” affecting her ability to do basic work
activities. See R. 19. For example, although Yates
faults ALJ Munday for not mentioning a July 30, 2015 comment
by Jeffrey Potter, M.D., that Yates exhibited hypermobility
at the elbows, two finger joints, knees, and ankles,
Pl.'s Br. 12 (citing R. 1095-99), she does not identify
any “related functional loss” that ALJ Munday
supposedly overlooked, Felton-Miller, 459 Fed.Appx.
at 230; Gross, 785 F.2d at 1166. Nor does she
identify any functional limitations associated with the
“complaints of migraines” that appear in the
medical record. Pl.'s Br. 12-13.
is no rigid requirement that the ALJ specifically refer to
every piece of evidence in [her] decision” so long as
it is clear the “decision was based on the entire
record” and the ALJ's factual findings are
supported by substantial evidence. Reid v. Comm'r of
Soc. Sec., 769 F.3d 861, 865 (4th Cir. 2014) (quoting
Dyer v. Barnhart, 395 F.3d 1205, 1211 (11th Cir.
2005) (per curiam)). ALJ Munday's discussion of
Yates's physical impairments satisfied these standards.
Indeed, she cited Dr. Potter's essentially normal
findings on the July 30 physical exam, as well as his
recommendation that Yates manage her pain with medications
and “regular physical activity, ” to help support
her finding that Yates's muscle and joint pain was not as
debilitating as alleged. R. 28 (citing R. 1094-95, 1097,
1099). She also mentioned that Dr. Potter's exam
“findings were consistent with hypermobility syndrome
and associated fibromyalgia, ” id., and she
explained why Yates's complaints of back and knee pain,
combined with “limited” and “mild”
abnormal findings on physical exams and X-rays, supported her
finding that fibromyalgia reduced Yates's physical
capacity to work even though a DDS physician opined she had
“no severe physical impairment, ” R. 30 (citing
R. 103, 115-16, 632, 668, 673). Thus, Yates has not shown
that ALJ Munday either “ignored” her joint
hypermobility syndrome, Pl.'s Br. 12, or overlooked
evidence showing the impairment caused specific functional
limitations that might have changed the outcome of her
disability claim. Reid, 769 F.3d at 865; see
also Vitrano v. Colvin, No. 6:14cv51, 2016 WL 1032888,
at *2 (W.D. Va. Mar. 14, 2016) (“[A]ny error by the ALJ
at step two is harmless if the ALJ considers the effects of
all of [the claimant's] impairments in the subsequent
ALJ Munday did not mention that Yates sometimes reported
migraine headaches or that her family physician Larry Smith,
M.D., occasionally prescribed a “migraine prophylaxis,
” see, e.g., R. 54, 622-24, 627-29, 643, she
acknowledged that Yates reported having headaches, R. 23, and
stated that she considered “the entire record”
before making her factual findings, R. 18. See also
R. 22-23, 25 (citing R. 53-54, 358-60, 622-24, 627-29, 643).
There is no indication that Yates ever attributed specific
functional limitations to migraine headaches. R. 54, 622,
627, 643. On March 18, 2013, for example, she told Dr. Smith
that she was “currently able to do activities of daily
living without limitation” even though she suffered
“intense” migraines marked by “some
nausea” and “increased sensitivity to light and
sound” two or three times a week. R. 622. She also said
her migraines were “less frequent” on topiramate,
id., but Dr. Smith told her to stop taking that
medication because she was pregnant, R. 624. Yates repeatedly
denied suffering from headaches and visual disturbances after
this date. R. 653 (Aug. 2013), 1074 (Feb. 2015), 1066 (Mar.
2015), 1057 (Apr. 2015), 1053 (May 2015), 1038 (June 2015).
Considering Yates's infrequent report of migraines and
the absence of evidence showing any related functional
limitations, ALJ Munday's failure to specifically discuss
this medical condition almost certainly would not have
changed the outcome of her disability claim. Cf.
Felton-Miller, 459 Fed.Appx. at 229
(“Felton-Miller's sarcoidosis diagnosis, without
more, does not establish that she suffers from any particular
symptoms or limitations.”). Nonetheless, should the
case be remanded for further proceedings, as I recommend, the
next ALJ's decision must make clear that he or she
considered all of Yates's medically determinable
impairments reflected in the record. See 20 C.F.R.
§§ 404.1523, 404.1545, 416.923, 416.945; 96-3p,
1996 WL 374181, at *1-2.
Mental RFC Assessment
next challenges ALJ Munday's assessment of her RFC,
particularly as it relates to her ability to pay attention
and stay on task in the workplace. See Pl.'s Br.
13-17. A claimant's RFC represents her “maximum
remaining ability to do sustained work activities in an
ordinary work setting on a regular and continuing
basis” despite her medical impairments. SSR
96-8p, 1996 WL 374184, at *2 (emphasis omitted) (July 2,
1996); see 20 C.F.R. §§ 404.1545, 416.945.
It is a factual finding “made by the Commissioner based
on all the relevant evidence in the [claimant's] record,
” Felton-Miller, 459 Fed.Appx. at 230-31, and
it must reflect the combined functionally limiting effects of
impairments that are supported by the medical evidence or the
claimant's credible symptoms, see Mascio, 780
F.3d at 640. The ALJ's RFC assessment must “include
a narrative discussion describing” how medical facts
and nonmedical evidence “support each conclusion,
” Mascio, 780 F.3d at 636, and explaining why
she discounted any “obviously probative”
conflicting evidence, Arnold v. Sec'y of Health,
Educ. & Welfare, 567 F.2d 258, 259 (4th Cir. 1977).
The ALJ must also “build an accurate and logical bridge
from the evidence to [her] conclusion, ” Monroe v.
Colvin, 826 F.3d 176, 189 (4th Cir. 2016) (quoting
Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir.