United States District Court, E.D. Virginia, Richmond Division
CAROL S. WILLIAMS, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
J. NOVAK UNITED STATES MAGISTRATE JUDGE.
September 1, 2015, Carol S. Williams ("Plaintiff")
applied for Social Security Disability Benefits
("DIB"), alleging disability from arthritis, high
blood pressure, high cholesterol, left hip pain, carpel
tunnel syndrome and right knee pain, with an alleged onset
date of June 1, 2015. 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 Commissioner.
now seeks judicial review of the ALJ's decision pursuant
to 42 U.S.C. § 405(g), arguing that the ALJ erred in:
(1) affording little weight to the opinion of Plaintiff s
treating physician, Malalai Azmi, M.D.; (2) assessing the
opinions of the state agency physicians; and, (3) failing to
account for Plaintiffs need for an assistive walking device
in the ALJ's residual functional capacity
("RFC") assessment. (Mem. in Support of Pl.'s
Mot. For Summ. J. ("Pl.'s Mem.") (ECF No. 17)
at 9-16.) This matter now comes before the Court for a Report
and Recommendation pursuant to 28 U.S.C. § 636(b)(1)(B)
on the parties' cross-motions for summary judgment,
rendering the matter ripe for review. For the reasons that follow,
the Court recommends that Plaintiffs Motion for Summary
Judgment (ECF No. 16) be GRANTED, that Defendant's Motion
for Summary Judgment (ECF No. 18) be DENIED and that the
final decision of the Commissioner be REVERSED and REMANDED.
September 1, 2015, Plaintiff filed an application for DIB.
(R. at 193-96.) The SSA denied these claims initially on
October 15, 2015, and again upon reconsideration on January
7, 2016. (R. at 98-109.) At Plaintiffs written request, the
ALJ held a hearing on April 6, 2017. (R. at 35-84, 133-34.)
On October 16, 2017, the ALJ issued a written opinion,
denying Plaintiffs claims and concluding that Plaintiff did
not qualify as disabled under the Act, because she could
perform work existing in significant numbers in the national
economy. (R. at 20-30.) On July 31, 2018, 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 Social Security
Administration'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'r 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 Fed.Appx. 264, 274 (4th Cir. 2015) (quoting
Clarke v. Bowen, 843 F.2d 271, 272-73 (8th Cir.
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)); see also Biestek v. Berryhill, 139 S.Ct.
1148, 1157 (2019) (holding that the substantial-evidence
inquiry requires case-by-case consideration, with deference
to the presiding ALJ's credibility determinations). 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
Social Security Administration regulations set forth a
five-step process that the agency employs to determine
whether disability exists. 20 C.F.R. § 404.1520(a)(4);
see Mascio, 780 F.3d at 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. § 404.1520(a)(4)(i). At step two, the ALJ asks
whether the claimant's medical impairments meet the
regulations' severity and duration requirements. §
404.1520(a)(4)(ii). Step three requires the ALJ to determine
whether the medical impairments meet or equal an impairment
listed in the regulations. § 404.1520(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. §
404.1545(a). At step four, the ALJ assesses whether the
claimant can perform her past work given her RFC. §
404.1520(a)(4)(iv). Finally, at step five, the ALJ determines
whether the claimant can perform any work existing in the
national economy. § 404.1520(a)(4)(v).
THE ALJ'S DECISION
April 6, 2017, the ALJ held a hearing during which Plaintiff
(represented by counsel) and a vocational expert
("VE") testified. (R. at 35-84.) On October 16,
2017, the ALJ issued a written opinion, finding that
Plaintiff did not qualify as disabled under the Act. (R. at
followed the five-step evaluation process established by the
Social Security Act in analyzing Plaintiffs disability claim.
(R. at 22-30.) At step one, the ALJ found that Plaintiff had
not engaged in substantial gainful activity since July 1,
2015 - the amended alleged onset date. (R. at 22.) At step
two, the ALJ found that Plaintiff had the following severe
impairments: osteoarthritis and obesity. (R. at 22.) At step
three, the ALJ found that 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. Subpart P, Appendix 1. (R. at
assessing Plaintiffs RFC, the AIJ found that Plaintiff could
perform light work with additional limitations. Specifically,
Plaintiff could lift and carry twenty pounds occasionally and
ten pounds frequently. (R. at 23.) Plaintiff could stand and
walk for six hours and sit for six hours during an eight-hour
workday, and she could periodically alternate between sitting
and standing at will while remaining on task. (R. at 23.)
Plaintiff could push and pull as much as she could lift and
carry, but she could never operate foot controls with either
foot. (R. at 23.) Plaintiff could occasionally climb ramps
and stairs, but she could never climb ladders, ropes or
scaffolds. (R. at 23.) Plaintiff could occasionally stoop,
but she could never kneel crouch or crawl, and she could
never work at unprotected heights. (R. at 23.) Plaintiff
could occasionally work with moving mechanical parts and in
vibration. (R. at 23.) Lastly, the ALJ limited Plaintiff to
unskilled work due to pain. (R. at 23.) At step four, the ALJ
found that Plaintiff could not perform any past relevant
work. (R. at 29.) At step five, the ALJ determined that
Plaintiff could perform jobs existing in significant numbers
in the national economy. (R. at 29-30.) Therefore, Plaintiff
did not qualify as disabled under the Act. (R. at 30.)
age fifty-four at the time of this Report and Recommendation,
previously worked as a correctional officer. (R. at 193,
209.) She applied for Social Security Benefits, alleging
disability from arthritis, high blood pressure, high
cholesterol, left hip pain, carpel tunnel syndrome and right
knee pain with an alleged onset date of June 1, 2015. (R. at
207-08.) Plaintiffs appeal to this Court alleges that the ALJ
erred in: (1) affording little weight to the opinion of
Plaintiff s treating physician, Dr. Azmi; (2) assessing the
opinions of the state agency physicians; and, (3) failing to
account for Plaintiffs need for an assistive walking device
in the ALJ's RFC assessment. (Pl.'s Mem. at 9-15.)
For the reasons set forth below, the ALJ erred in her
The ALJ Provided an Insufficient Explanation for Affording
Little Weight to Dr. Azmi's Opinion.
argues that the ALJ erred in assigning little weight to Dr.
Azmi's opinion and provided insufficient reasoning for
doing so. (Pl.'s Mem. at 9.) Defendant asserts that the
ALJ provided legally sufficient reasoning for assigning Dr.
Azmi's opinion little weight and that substantial
evidence supports the ALJ's opinion. (Def.'s Mot. for
Summ. J. and Br. in Supp. (ECF No. 18) ("Def.'s
Mem.") at 15-22.)
the sequential analysis, when the ALJ determines whether the
claimant has a medically-determinable severe impairment, or
combination of impairments, that would significantly limit
the claimant's physical or mental ability to do basic
work activities, the ALJ must analyze the claimant's
medical records that are provided and any medical evidence
resulting from consultative examinations or medical expert
evaluations that have been ordered. 20 C.F.R. §§
404.1512, 404.1527. When the record contains a number of
different medical opinions, including those from Plaintiffs
treating sources, consultative examiners or other sources
that are consistent with each other, then the ALJ makes a
determination based on that evidence. § 404.1527(c). If,
however, the medical opinions are inconsistent internally
with each other or other evidence, the ALJ must evaluate the
opinions and assign them respective weight to properly
analyze the evidence involved. §§
the regulations, only an "acceptable medical
source" may be considered a treating source that offers
an opinion entitled to controlling weight. SSR
06-03p. Acceptable medical sources include
licensed physicians, licensed or certified psychologists and
certain other specialists, depending on the claimed
disability. SSR 06-03p. The regulations also provide for the
consideration of opinions from "other sources,"
including nurse-practitioners, physician's assistants or
therapists. SSR 06-03p; § 404.1527(f).
treating source's opinion must be given controlling
weight if it is well-supported by medically acceptable
clinical and laboratory diagnostic techniques and is not
inconsistent with other substantial evidence in the record.
Lewis v. Berryhill, 858 F.3d 858, 867 (4th Cir.
2017); Craig, 76 F.3d at 590; § 404.1527(c)(2);
SSR 96-2p. Further, the regulations do not require that the
ALJ accept opinions from a treating source in every
situation, e.g., when the source opines on the issue
of whether the claimant is disabled for purposes of
employment (an issue reserved for the Commissioner), or when
the treating source's opinion is inconsistent with other
evidence or when it is not otherwise well-supported. §
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 v. Colvin, 607
Fed.Appx. 264, 267 (4th Cir. 2015) (citing Scivally v.
Sullivan, 966 F.2d 1070, 1077 (7th Cir. 1992)). Indeed,
an ALJ's decision regarding weight afforded a medical
opinion should be left untouched unless the ALJ failed to
give a sufficient reason for the weight afforded.
must consider the following when evaluating a treating
source's opinion: (1) the length of the treating source
relationship and frequency of examination; (2) the nature and
extent of the treatment relationship; (3) supportability
based upon the medical record; (4) consistency between the
opinion and the medical record; (5) any specialization on the
part of the treating source; and, (6) any other relevant
factors. § 404.1527(c). However, those same regulations
specifically vest the ALJ - not the treating source - with
the authority to determine whether a claimant is disabled as
that term is defined under the Act. § 404.1527(d)(1).
Although the regulations explicitly apply these enumerated
factors only to treating sources, those same factors may be
applied in evaluating opinion evidence from "other
sources." SSR 06-03p.
Azmi treated Plaintiff multiple times between 2015 and 2017.
(R. at 293, 296, 299, 447, 661-78). On February 14, 2017, Dr.
Azmi completed a medical source statement for Plaintiff. (R.
at 549-50.) Dr. Azmi listed chronic lower back pain with
radiculopathy as Plaintiffs primary ailments. (R. at 549.)
Utilizing a check-the-box format, Dr. Azmi further indicated
that Plaintiff could occasionally sit, stand and walk, never
stoop, and infrequently climb with assistance. (R. at 549.)
Dr. Azmi opined that Plaintiff could infrequently carry one
to five pounds, occasionally carry six to ten pounds and
never carry more than ten pounds. (R. at 549.) However, Dr.
Azmi believed that Plaintiff could frequently use her hands
for fine and gross manipulation and frequently raise both
arms over her shoulders. (R. at 549.) Dr. Azmi checked a box
describing Plaintiffs pain as severe and he opined that
Plaintiff would be off task 70 percent of the time during an
eight-hour workday due to pain. (R. at 550.) Further, Dr.
Azmi believed that Plaintiff would need to elevate her legs
over her waist for approximately three to four hours per day.
(R. at 550.) Lastly, Dr. Azmi opined that Plaintiff would
need to take unscheduled break periods during an eight-hour
workday and required an assistive device to ambulate. (R. at
assigned little weight to Dr. Azmi's opinion because it
lacked consistency with the record evidence as a whole, and
because Dr. Azmi used a check-the-box form to complete his
opinion. (R. at 27.) Plaintiff argues that the ALJ provided
legally insufficient reasoning for ...