United States District Court, E.D. Virginia, Alexandria Division
CARROLL BUCHANAN, UNITED STATES MAGISTRATE JUDGE
to the Social Security Act § 205(g), 42 U.S.C. §
405(g), April Bonvillain ("Plaintiff) seeks judicial
review of the final decision of Nancy A. Berryhill
("Defendant"), the former Acting Commissioner of
Social Security,  denying Plaintiffs claim for Supplemental
Security Income ("SSI") pursuant to Title XVI of
the Social Security Act. On June 4, 2018, the certified
Administrative Record ("R.") was filed under seal,
pursuant to Local Civil Rules 5(B) and 7(C)(1). By December
4, 2018, both parties filed motions for summary judgment with
briefs in support, which are now ripe for
resolution. For the reasons set forth below, the
undersigned U.S. Magistrate Judge, pursuant to 28 U.S.C.
§ 636(c)(1), will deny Plaintiffs Motion for Summary
Judgment (Dkt. 17), grant Defendant's Motion for Summary
Judgment (Dkt. 20), and affirm the final decision of
filed the presently disputed application for SSI on September
26, 2014,  alleging disability with an alleged onset
date ("AOD") of March 25, 2014. (R. at 182-87.)
Plaintiffs claims were first denied on March 31, 2014, then
again on reconsideration on September 15, 2014. (R. at
59-92.) On July 13, 2015, Plaintiff requested a hearing in
front of an administrative law judge ("ALJ"). (R.
at 110-12.) The hearing was held in front of ALJ Francine L.
Applewhite on June 7, 2017, with Plaintiff being represented
by a non-attorney representative, and during which the
testimonies of Plaintiff and a vocational expert
("VE") were taken. (R. at 30-58.) The ALJ issued
her decision denying Plaintiffs claims on August 4, 2017. (R.
at 10-24.) On August 11, 2017, Plaintiff requested review of
the ALJ's decision to the Appeals Council for the Office
of Disability and Adjudication and Review ("Appeals
Council"). (R. at 176-81.) The Appeals Council denied
Plaintiffs request for review on June 6, 2018, making the
ALJ's decision the final decision of Defendant. (R. at
1-6.) On August 8, 2018, Plaintiff filed her Complaint for
judicial review of Defendant's decision (Dkt. 1).
Defendant filed her timely answer on October 9, 2018 (Dkt.
9). By November 2, 2018, Plaintiff filed her Motion for
Summary Judgment (Dkt. 17) and Defendant filed her Motion for
Summary Judgment (Dkt. 20).
STANDARD OF REVIEW
the Social Security Act, the Court's review of
Defendant's final decision is limited to determining
whether the ALJ's decision was supported by substantial
evidence in the record and whether the correct legal standard
was applied in evaluating the evidence. 42 U.S.C. §
405(g); Bird v. Comm'r of Soc. Sec. Admin., 699
F.3d 337, 340 (4th Cir. 2012).
evidence has long been described as "such relevant
evidence as a reasonable mind might accept as adequate to
support a conclusion." Richardson v. Perales,
402 U.S. 389, 401 (1971). Put another way, substantial
evidence is "more than a mere scintilla of evidence but
may be less than a preponderance." Pearson v.
Colvin, 810 F.3d 204, 207 (4th Cir. 2015). In reviewing
for substantial evidence, the Court must examine the record
as a whole, but it may not "undertake to re-weigh the
conflicting evidence, make credibility determinations, or
substitute [its] judgment for that of the Secretary."
Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001).
The Court must defer to Defendant's decision
"[w]here 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). The correct law to be applied includes the Social
Security Act, its implementing regulations, and controlling
case law. See Coffman v. Bowen, 829 F.2d 514, 517-18
(4th Cir. 1987).
the aforementioned standard of review is deferential, where
the ALJ's determination is not supported by substantial
evidence on the record, or where the ALJ has made an error of
law, the district court must reverse the decision. See
id. at 517. With this standard in mind, the Court
evaluates the ALJ's findings and decision.
THE ALJ'S DECISION
is required to employ a five-step sequential evaluation in
every Social Security disability claim analysis to determine
a claimant's eligibility. The Court examines this
five-step process on appeal to determine whether the correct
legal standards were applied in this case, and whether
Defendant's resulting decision is supported by
substantial evidence in the record. 20 C.F.R. §§
404.1520, 416.920. In accordance with the five-step
sequential analysis, the ALJ made the following findings of
fact and conclusions of law.
one of the sequential evaluation, the ALJ found that
Plaintiff had not engaged in substantial gainful activity
since Plaintiffs AOD of March 25, 2014. (R. at 15.) At step
two of the sequential evaluation, the ALJ found Plaintiffs
lumbar radiculopathy, bursitis of the left hip, carpal tunnel
syndrome, and obesity to be severe medically determinable
impairments. (R. at 15.) The ALJ determined that Plaintiffs
other impairments-hypertension, anxiety, and
fibromyalgia-were not severe as they were treatable without
significant complication or stable with monitoring, and
because the medical evidence did not support a finding of
severe limitation. (R. at 15-17.) At step three of the
sequential evaluation, the ALJ found Plaintiff did not have
an impairment or combination of impairments that met or
medically equaled the severity of one of the listed
impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R.
at 17.) In between steps three and four of the sequential
evaluation, the ALJ found that Plaintiff had the residual
functional capacity ("RFC") to perform light work
as defined in 20 C.F.R. § 416.967(b), except Plaintiff
could never climb ladders, ropes, or scaffolds; occasionally
climb ramps and stairs, balance, stoop, kneel, crouch, and
crawl; and frequent bilateral handling, grasping or
fingering. (R. at 18.) At step four of the sequential
evaluation, the ALJ found Plaintiffs RFC did not preclude her
from performing any of her past work. (R. at 22.)
Nonetheless, the ALJ still made a step five determination and
found that Plaintiff was able to perform jobs that existed in
significant numbers in the national economy. (R. at 23-24.)
Therefore, the ALJ concluded that Plaintiff was not under a
disability, as defined by the Social Security Act, since
September 26, 2014, the date the application was filed. (R.
essentially raises three issues on appeal in support of her
contention that Defendant's final decision is unsupported
by substantial evidence and erroneous as a matter of law.
First, Plaintiff argues that the ALJ failed to properly
evaluate the medical opinion evidence and did not afford
appropriate weight to Plaintiffs treating and examining
physicians. (Pl's Br. Supp. at 5-11.) Next, Plaintiff
contends that the ALJ erred in finding that Plaintiffs
impairments did not meet or equal Listing 1.04A.
(Id. at 12-14.) Finally, Plaintiff argues that the
ALJ failed to consider several of Plaintiff s medical
impairments. (Id. at 14-16.) Each argument by
Plaintiff is addressed in turn below.
Weight Given to Medical Opinion Evidence
contends that the ALJ improperly evaluated the findings of
Dr. Lagatutta, Dr. Siekerkotte, and the state medical
examiners. (Pl's Br. Supp. at 5-11.) Specifically,
Plaintiff argues that the ALJ disregarded a great deal of
evidence contained in those medical opinions and did not
provide a proper explanation for why those opinions were
being discredited. (Id.) In response, Defendant
argues that substantial evidence supports the ALJ's
decision to give the opinions of Dr. Siekerkotte, Dr.
Lagutta, and state medical examiners partial or little
weight. (Def.'s Mem. Supp. & Opp'n at 7.)
Plaintiff recognizes, the question over the weight to be
assigned to the medical opinions at issue speaks to the
ultimate determination of Plaintiffs RFC. After step three of
an ALJ's 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), 416.902(e)-(f),
416.945(a)(1). Opinions by medical professionals, whether
"acceptable medical sources" or "other
sources," are one type of evidence that an ALJ is to
consider in determining a claimant's RFC. Id.
§ 404.1527(b); SSR 06-03p, 2006 WL 2329939, at *4 (Aug.
the opinions by medical professionals are inconsistent with
each other or with other evidence, the ALJ must evaluate the
opinions and assign them respective weight to properly
analyze the evidence involved. 20 C.F.R. §§
404.1527(c)(2)-(6), (d), 416.927(c)(2)-(6), (d); SSR 06-03p,
2006 WL 2329939, at *5. Only opinions from treating
physicians may be given controlling weight. See 20 C.F.R.
§ 404.1527(c)(2). Generally, opinions from treating
sources are given more weight than other opinions, and if it
is found that a treating source's opinion on the nature
and severity of a claimant's impairment is
"well-supported by medically acceptable clinical and
laboratory diagnostic techniques and is not inconsistent with
the other substantial evidence in [the] case record," it
will be given "controlling weight." 20 C.F.R.
§§ 404.1527(c)(2), 416.927(c)(2). Four requirements
essentially exist for an opinion to be given controlling
weight: (1) the opinion must come from a "treating
source;" (2) the opinion must be a "medical
opinion," defined as an opinion about the nature and
severity of the claimant's impairments; (3) the opinion
must be well-supported by medically acceptable clinical and
laboratory diagnostic techniques; and (4) the opinion must
not be inconsistent with the other substantial evidence in
the record. S.S.R. 96-2p, 1996 WL 324188, at *2.
opinion does not meet the aforementioned four requirements,
it cannot be given controlling weight. Id. If an
opinion is not given controlling weight as a treating
source's opinion, the Social Security regulations require
that certain factors be considered to determine the weight
given to the medical opinion. Those factors include: (1)
examining relationship, (2) treatment relationship, (3)
supportability, (4) consistency, (5) specialization, and (6)
any other factors that tend to support or contradict the
medical opinion. 20 C.F.R. §§ 404.1527(c)(1)-(6),
416.927(c)(1)-(6); S.S.R. 96-2p, 1996 WL 324188, at *4. An
ALJ is not required to explicitly analyze each of the
aforementioned factors so long as the ALJ is clear as to
which factor justified his or her conclusion. Bishop v.
Comm'r of Soc. Sec. 583 Fed.Appx. 65, 67 (4th Cir.
2014) (per curiam) ("While the ALJ did not explicitly
analyze each of the ... factors on the record, the ALJ was
clear that he concluded that the doctor's opinion was not
consistent with the record or supported by the medical
evidence, which are appropriate reasons."). Under the
substantial evidence standard, "[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 Fed.Appx. 264, 267 (4th Cir. 2015)
(citations and quotations omitted).
the ALJ gave Dr. Lagattuta's and Dr. Siekerkotte's
opinions little weight. (R. at 21-22.) Additionally, the ALJ
gave the state medical examiners' opinions only some
weight. (R. at 22.) The Court addresses each evaluation in
Lagutta, Plaintiffs treating physician, completed an RFC
questionnaire on August 4, 2015. (R. at 431-34.) He noted
that he had been treating Plaintiff on a monthly basis since
May 4, 2015. (R. at 431.) Dr. Lagutta reported Plaintiff
suffered from headaches, feeling light headed, night sweats,
sleep disturbances and fatigue, and that she had constant
pain, including pins and needles, which radiated to her legs
and arms. (R. at 431.) He stated his objective findings were
supported by conducting an EMG, x-ray, and MRI on Plaintiff.
(R. at 431.)
on his observations, Dr. Lagutta opined that the severity of
Plaintiff s pain and other symptoms would frequently
interfere with the attention and concentration necessary to
sustain simple, repetitive work tasks. (R. at 432.) Dr.
Lagutta also determined that Plaintiff could not tolerate
"low stress" work, though he did not explain the
basis for such an extreme restriction. (R. at 432.) Dr.
Lagutta then opined that Plaintiff could sit as well as stand
for only one (1) hour at a time and thus was limited to less
than two (2) hours of sitting, standing, walking in an eight
(8) hour workday and would need one unscheduled break every
two hours. (R. at 432-33.) He also opined that Plaintiff
could lift no more than ten (10) pounds and had limitations
in doing repetitive reaching, handling or fingering. (R. at
433.) However, he did not explain whether the reaching,
handling, or fingering limitations were mild, moderate, or
severe but instead explained the limitations were due to
Plaintiffs carpal tunnel syndrome. (R. at 433.) Finally, Dr.
Lagutta explained that Plaintiffs limitations would result in
good and bad days and would also cause Plaintiff to miss more
than four (4) days of work per month. (R. at 434.)
gave little weight to Dr. Lagutta's opinions. (R. at 22.)
Although recognizing that Dr. Lagutta was Plaintiffs treating
physician, the ALJ nonetheless chose to disregard Dr.
Lagutta's medical opinions as his restrictive RFC was not
supported by the longitudinal medical record. (R. at 22.) In
the weight determination paragraph, the ALJ specifically
found that (1) Dr. Lagutta's medical notes revealed no
problems or complaints regarding Plaintiffs gait, (2)
Plaintiff exhibited consistent strength in her back and hips,
and (3) Plaintiffs pain could be managed through injections
and prescriptions. (R. at 22.) In that same paragraph, the
ALJ also noted that Plaintiff testified during the hearing
that she managed her pain with Aleve (R. at 22, 41), and
could perform daily activities such as driving and laundry
(R. at 22, 37, 41-42). Finally, the ALJ found that Plaintiffs
grip strength of "4" was inconsistent with Dr.
Lagutta's opinion that Plaintiff could rarely carry ten
(10) pounds and occasionally less than ten pounds. (R. at 22,
addition to those specific findings in the weight
determination paragraph, the ALJ devoted several pages to
discussing the objective medical evidence in the record. (R.
at 19-21.) In this section of the decision, the ALJ found
that Plaintiffs alleged difficulties arising from her lumbar
radiculopathy were inconsistent with the objective medical
evidence. The ALJ acknowledged that Plaintiff possessed nerve
root inflammation and an injured disc in her lumbar region,
but determined that Plaintiff nonetheless demonstrated
relative stability. (R. at 20, 458, 466.) In support of her
findings, the ALJ directly cited to several portions of
Plaintiff s medical records. (R. at 20.) For example, the ALJ
pointed to Plaintiff's examination with Dr. Siekerkotte
in which Dr. Siekerkotte reported that while Plaintiff could
not stand on her toes, she could still stand on her heels.
(R. at 411.) The ALJ also noted that in that same
examination, Plaintiffs (1) range of motion for her lumbar
region was 0-90 degrees for her flexion, 0-25 degrees for her
extension, and 0-25 degrees for her lateral flexion
bilaterally and (2) straight-leg test was negative
bilaterally in a seated position. (R. at 411-12.) Further,
the ALJ found that Plaintiffs multiple epidural injections,
received in February 2016, provided Plaintiff with some
manner of relief. (R. at 454.) While Plaintiff continued to
feel pain, she nonetheless could continue to move. (R. at
441, 446, 451.) Moreover, Plaintiffs gait was described as
"smooth" with an upright posture in March 2017, (R.
at 498), and Plaintiff previously denied any problems walking
(R. at 441). Furthermore, an independent review by the Court
of Plaintiff s medical records establishes Plaintiff
consistently denied any musculoskeletal weakness or instances
of falling. (R. at 442, 446-47, 451-52, 457-58, 461-62,
also found that Plaintiffs alleged difficulties caused by her
left hip bursitis were inconsistent with the objective
medical evidence. (R. at 20-21.) Plaintiff was definitely
diagnosed with "trochanteric bursitis of the left
hip" in May 2017. (R. at 506.) This matches the
consultative examiner's notation that Plaintiff could not
tolerate any range of motion testing on her left side during
the examination. (R. at 411.) However, Plaintiffs past
examinations "revealed consistent right and left hip
flexion strength at 5/5, hip extension at 5/5, and hip
abduction at 5/5 with a slightly reduced left hip abduction
at 4/5." (R. at 20, 442, 446, 451.) Again, as previously
noted, Plaintiff previously denied any difficulties with her
gait and exhibited an upright posture. (R. at 441, 498.)
addition to inconsistencies with the objective medical
evidence, the ALJ noted inconsistencies with Plaintiffs
subjective evidence. (R. at 19-20.) Plaintiff stated in
January 2015 that she went grocery shopping, performed
household chores, drove her kids to school, and went to
physical therapy. (R. at 239, 240-42.) But in that same
statement, Plaintiff claimed to no longer be able to sit,
stand, or walk for extend periods of time. (R. at 238.) At
the hearing before the ALJ, Plaintiff testified that she
possessed a driver's license, drove around town, and
continued to go to physical therapy. (R. at 37, 40.)
Plaintiffs testimony also established that her pain
medication relieved some of the pain. (R. at 41.) Finally,
Plaintiff stated she could not, or at least struggled to,
perform household chores such as laundry. (R. at 41-42, 46,
240.) However, when describing why she struggled to do the
laundry, Plaintiff specifically ...