ROBERT T. NUMBERS, II, Magistrate Judge.
Plaintiff Kellisha Maria Davis instituted this action in May 2017 to challenge the denial of her application for social security income. Davis claims that Administrative Law Judge ("ALJ") Larry A. Miller erred in (1) determining that she had a residual functional capacity ("RFC") to perform sedentary work with limitations and (2) evaluating Davis's credibility. Both Davis and Defendant Nancy A. Berryhill, Acting Commissioner of Social Security, have filed motions seeking a judgment on the pleadings in their favor. D.E. 17, 22.
After reviewing the parties' arguments, the court has determined that ALJ Miller reached the appropriate decision. ALJ Miller properly analyzed Davis's abilities and accurately determined her RFC. Moreover, there was no error with his evaluation of Davis's credibility. Therefore, the undersigned magistrate judge recommends that the court deny Davis's motion, grant the Commissioner's motion, and affirm the Commissioner's decision.
In April 2014, Davis protectively filed an application for disability benefits, alleging a disability that began on March 8, 2014. After her claim was denied at the initial level and upon reconsideration, Davis appeared before ALJ Miller for a hearing to determine whether she was entitled to benefits. ALJ Miller determined Davis was not entitled to benefits because she was not disabled. Tr. at 11-23.
ALJ Miller found that Davis had several severe impairments: hypertension, diabetes mellitus, obesity, obstructive sleep apnea ("OSA"), asthma, lumbar degenerative disc disease, and gastroesophageal reflux disease ("GERD"). Tr. at 13. ALJ Miller found that Davis's impairments, either alone or in combination, did not meet or equal a Listing impairment. Tr. at 14.
ALJ Miller then determined that Davis had the residual functional capacity to perform a range of sedentary work with additional limitations. Id. She can occasionally lift, carry, push, or pull up to ten pounds. Id. Davis can frequently finger and handle. She cannot climb or balance on narrow, slippery, or moving surfaces. Id. Davis can occasionally stoop, crouch, crawl, or kneel. Id. And Davis cannot work at heights, around dangerous machinery, or in environments with concentrated respiratory irritants. Id.
ALJ Miller concluded that Davis could not perform her past relevant work as a nurse assistant. Tr. at 21. But ALJ Miller determined that, considering her age, education, work experience, and RFC, there were other jobs existing in significant numbers in the national economy that Davis could perform. Tr. at 22-23. These include: charge accounts clerk, referral clerk, or addresser. Id. Thus, ALJ Miller found that Davis was not disabled. Tr. at 23.
After unsuccessfully seeking review by the Appeals Council, Davis began this action in May 2017. D.E. 6.
When a social security claimant appeals a final decision of the Commissioner, the district court's review is limited to determining whether, based on the entire administrative record, there is substantial evidence to support the Commissioner's findings. 42 U.S.C. § 405(g); Richardson v. Perales, 402 U.S. 389, 401 (1971). Substantial evidence is defined as "evidence which a reasoning mind would accept as sufficient to support a particular conclusion." Shively v. Heckler, 739 F.2d 987, 989 (4th Cir. 1984) (quoting Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966)). The court must affirm the Commissioner's decision if it is supported by substantial evidence. Smith v. Chater, 99 F.3d 635, 638 (4th Cir. 1996).
In making a disability determination, the ALJ engages in a five-step evaluation process. 20 C.F.R. § 404.1520; see Johnson v. Barnhart, 434 F.3d 650 (4th Cir. 2005). The ALJ must consider the factors in order. At step one, if the claimant is engaged in substantial gainful activity, the claim is denied. At step two, the claim is denied if the claimant does not have a severe impairment or combination of impairments significantly limiting him or her from performing basic work activities. At step three, the claimant's impairment is compared to those in the Listing of Impairments. See 20 C.F.R. Part 404, Subpart P, App. 1. If the impairment is listed in the Listing of Impairments or if it is equivalent to a listed impairment, disability is conclusively presumed. However, if the claimant's impairment does not meet or equal a listed impairment, the ALJ assesses the claimant's RFC to determine, at step four, whether he can perform his past work despite his impairments. If the claimant cannot perform past relevant work, the analysis moves on to step five: establishing whether the claimant, based on his age, work experience, and RFC can perform other substantial gainful work. The burden of proof is on the claimant for the first four steps of this inquiry, but shifts to the Commissioner at the fifth step. Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995).
The medical record shows that Davis has a history of hypertension, diabetes, sleep apnea, asthma, reflux disease, and degenerative disc disease. In June 2012, Davis sought treatment at Boice Willis Clinic for back pain, shortness of breath, and chest pain with left arm tingling. Tr. at 291-92. Providers prescribed her medications. Id. An electrocardiogram later that month showed an overall ejection fraction of 65%, with trace mitral and tricuspid regurgitation, and a left ventricular relaxation abnormality. Tr. at 323.
One year later, Davis complained of worsening back pain, and providers administered a Toradol injection. Tr. at 261-62. An MRI of her lumbar spine showed degenerative disc disease and facet arthropathy. Tr. at 344-45.
In July 2013, Davis was seen by Dr. Raymond Baule of Atlantic Neurosurgery Consultants for back pain that radiated into her left lower extremity, along with numbness and tingling. Tr. at 337-39. Davis also reported increased symptoms with standing, walking, and sitting. Id. An EMG and nerve conduction study showed diminished left peroneal motor amplitude. Tr. at 342. An MRI of her lumbar spine revealed mild degenerative disc disease at L5-S1. Tr. at 341. At a follow-up visit with Dr. Baule, Davis again reported lower back pain, which he assessed as spondylosis. Tr. at 304-05. He administered an epidural steroid injection and repeated the treatment one week later. Tr. at 333-36.
Davis returned to Boice Willis Clinic the next month reporting a recent incident of passing out. Tr. at 253-58. Davis's blood pressure was low but she had an elevated her blood sugar level. Id. Dr. Paul Bondy continued her medication regimen. Id.
In October 2013, Davis visited Eastern North Carolina Medical Group for heartburn and abdominal symptoms. Tr. at 362-69. Providers prescribed medications for her blood pressure. At a follow-up visit, Davis reported sweating and heart racing. Id. The next month, Davis returned complaining of low back pain, and providers recommended she undergo an MRI. Tr. at 331-32.
Two months later, Davis returned complaining of fatigue and back pain radiating into her lower left extremity. Tr. at 357-60. Providers prescribed medications. Id. Davis was next seen in March for fatigue, back pain, and chest pain. Tr. at 353-56. Providers adjusted her medications. Id. Later that month, Davis returned claiming shortness of breath and feeling like she would pass out. Tr. at 349-52. She reported that a stress test three days earlier disclosed a defect that may be ischemia. Id. She was advised to follow-up with her cardiology appointment. Id.
At a cardiology consultation at East Carolina Heart Institute later that month, Davis reported chest discomfort for the last four years, along with left upper extremity heaviness and weakness. Tr. at 378-82. She also asserted exertional intolerance, an inability to walk extended distances, and left side weakness with handgrip. Id. Providers prescribed medication and ordered tests. Id.
Davis returned one week later with reports of chest pain, heart racing, leg pain, hypertension, and left-sided body pain and weakness. Tr. at 387-95, 404-13. Dr. Mariavittoria Pitzalis prescribed medication and recommended that Davis undergo a sleep study. Id.
Davis returned to Dr. Pitzalis in May 2014 for chest pain and worsening left-sided body weakness. Tr. at 417-38. Dr. Pitzalis again prescribed medications and instructed Davis to use an Albuterol inhaler. Id. Davis reported shortness of breath and chest pain with numbness in the left side of her body the next month, which Dr. Pitzalis again treated with medications. Id.
At this same time, Davis returned to Eastern North Carolina Medical Group with complaints of left-sided weakness, headaches, and blurred vision. Tr. at 441-47. She noted her left leg sometimes gave way when walking. Id. Providers referred Davis for a neurological evaluation. Id. The next month, Davis reported lower back and abdominal pain, for which providers prescribed medications and ordered more testing. Id.
In October 2014, Davis presented at the emergency department for chest pain and epigastric tenderness. Tr. at 486-94. Providers assessed GERD and prescribed medications for this condition. Id.
Providers at Eastern North Carolina Medical Group next examined Davis in November 2015. Tr. at 502-06. Davis complained of headaches, light-headedness, and a racing heartbeat. Id. She also reported fatigue, poor sleep, and left hand numbness. Id. Providers adjusted Davis's medication regimen. Id. Davis returned several days later for headaches with dizziness and left hand numbness. Tr. at 509-12. Providers again adjusted her medication and referred Davis for a nerve conduction study. Id. A nerve conduction study showed right median neuropathy at or near the wrist. Tr. at 516-18.
In January 2016, Davis began treatment with Wilson Community Family Practice. Tr. at 521-24. She reported headaches, blurry vision, cardiovascular symptoms, asthma, GERD, and left-sided weakness. Id. Providers prescribed medication and ordered pulmonary and cardiology evaluations. Id.
At a follow-up visit the next month, Davis reported worsening headaches and pain radiating to the left side. Tr. at 525-29. She also stated she had fallen and now had left arm pain with tingling into her fingers. Id. Providers refilled her medications. Id.
In March 2016, Davis again noted headaches that radiated to her left side, worsening vision with blurriness, and left-sided weakness. Tr. at 540-45. An examination showed muscle spasms and tenderness to palpitation along the lumbar spine. Id. Providers refilled her medications. Id.
Later that month, Dr. Rosario Guarino at Wilson Neurology examined Davis. Tr. at 548-50. She reported left-sided weakness and that her leg gave out when standing and walking. Id. Dr. Guarino recommended Davis have a repeat an MRI and he prescribed medications. Id.
Davis also saw Dr. Malay Agrawal at North Carolina Heart & Vascular. Tr. at 553-55. Dr. Agrawal ordered an echocardiogram stress test to assess Davis's complaints of chest pain with activity, racing heartbeat, and shortness of breath. Id.
Davis contends that ALJ Miller erred in finding that she could perform a reduced range of sedentary work. She argues that her inability to sit for six hours a day because of low back pain, coupled with her limited he ability to handle and finger, precludes sedentary work. The Commissioner asserts that ALJ Miller properly considered all of Davis's impairments. The undersigned finds that substantial evidence supports ALJ Miller's finding that Davis can perform the exertional demands of sedentary work with additional limitations.
The RFC is a determination, based on all the relevant medical and non-medical evidence, of what a claimant can still do despite her impairments; the assessment of a claimant's RFC is the responsibility of the ALJ. See 20 C.F.R. §§ 404.1520, 404.1545, 404.1546; SSR 96-8p, 1996 WL 374184, at *2. If more than one impairment is present, the ALJ must consider all medically determinable impairments, including medically determinable impairments that are not "severe," when determining the claimant's RFC. Id. §§ 404.1545(a), 416.945(a). The ALJ must also consider the combined effect of all impairments without regard to whether any such impairment, if considered separately, would be of sufficient severity. Id. § 404.1523; see Walker v. Bowen, 889 F.2d 47, 50 (4th Cir. 1989) ("[I]n evaluating the effect[] of various impairments upon a disability benefit claimant, the [Commissioner] must consider the combined effect of a claimant's impairments and not fragmentize them.").
The ALJ must provide "findings and determinations sufficiently articulated to permit meaningful judicial review." DeLoatche v. Heckler, 715 F.2d 148, 150 (4th Cir. 1983); see also Wyatt v. Bowen, 887 F.2d 1082, 1989 WL 117940, at *4 (4th Cir. 1989) (per curiam). The ALJ's RFC determination "must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g. daily activities, observations)." Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting Social Security Ruling ("SSR") 96-8p). Furthermore, "[t]he record should include a discussion of which evidence the ALJ found credible and why, and specific application of the pertinent legal requirements to the record evidence." Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013). Fourth Circuit precedent "makes it clear that it is not [the court's] role to speculate as to how the ALJ applied the law to [her] findings or to hypothesize the ALJ's justifications that would perhaps find support in the record. Fox v. Colvin, 632 F. App'x 750, 755 (4th Cir. 2015).
Social Security Ruling 96-8p explains how adjudicators should assess residual functional capacity. The Ruling instructs that the residual functional capacity "assessment must first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions" listed in the regulations. "Only after that may [residual functional capacity] be expressed in terms of the exertional levels of work, sedentary, light, medium, heavy, and very heavy." SSR 96-8p. The Ruling further explains that the residual functional capacity "assessment must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations)." Id.
There is no "per se rule requiring remand when the ALJ does not perform an explicit function-by-function analysis[.]" Mascio, 780 F.3d at 636. However, "[r]emand may be appropriate . . . where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite contradictory evidence in the record, or where other inadequacies in the ALJ's analysis frustrate meaningful review." Id. (quoting Cichocki v. Astrue, 729 F.3d 172, 177 (2d Cir. 2013)).
Here, ALJ Miller did not conduct a function-by-function analysis of Davis's abilities. This alone is not sufficient to require remand. Mascio, 780 F.3d 636. Without an explicit function-by-function analysis, the reviewing court "must assess whether the ALJ's RFC analysis considered the relevant functions, whether his decision provides a sufficient basis to review his conclusions, and, ultimately, whether substantial evidence in the record supports that decision." Ashby v. Colvin, No. 2:14-674, 2015 WL 1481625, *3 (S.D.W. Va. Mar. 31, 2015) (holding that ALJ did not conduct explicit function-by-function analysis of claimant's physical abilities, but sufficient evidence existed showing that ALJ analyzed the relevant function).
Davis asserts that the record supports her claims that she cannot sit for six hours a day or perform more than occasional fingering and handling. Because most sedentary work involves repetitive handling or fingering and it generally requires sitting for six hours in an eight-hour workday, Davis maintains that she cannot meet the exertional demands of the RFC.
Despite her arguments, substantial evidence supports the RFC determination that Davis is capable of a reduced range of sedentary work. A review of ALJ Miller's decision reflects that he considered all of Davis's symptoms, whether severe or nonsevere, in formulating the RFC. Tr. at 14-21. ALJ Miller considered the relevant functions and provided sufficient detail about how evidence from the record supported his conclusions on Davis's RFC. He thoroughly discussed the medical evidence including Davis's subjective complaints, examination finings, test results, and providers' assessment. Id.
ALJ Miller noted, for example, that an MRI showed that Davis had mild degenerative disc disease and an EMG and nerve conduction study showed mild right median neuropathy at the wrist. Tr. at 17, 19. ALJ Miller also noted Davis's reports of radiating back pain that she claimed reduced her abilities to sit, stand, and walk. Tr. at 18. He also addressed Davis's alleged diminished upper extremity muscle strength, poor grip strength, and hand pain and weakness. Tr. at 17-19.
ALJ Miller pointed out, however, that several treatment records between 2013 and 2016 addressing Davis's back condition reflect that she had a normal gait, unimpaired range of motions, normal strength. The evidence also demonstrated that providers found Davis to have normal coordination, no tenderness in her back, and negative straight leg tests. Although imaging showed positive findings, providers characterized her degenerative disc disease as mild, and no providers reported any moderate or marked limitations that resulted from this impairment.
As to Davis's ability to handle and manipulate, the record shows her upper left extremity had reduced muscle strength in January, February, and March 2016, but later examinations established normal strength and reflexes. Additionally, testing on Davis's upper extremities showed only mild findings on the right. No providers assessed concomitant limitations.
Finally, ALJ Miller remarked that Davis's treatment for these conditions had been routine and conservative, consisting of medications. Tr. at 17-18. Although some evidence may support Davis's argument, the undersigned finds that ALJ Miller properly considered the all of Davis's symptoms and noted where the record supported or failed to confirm them. Davis has failed to carry her burden of establishing any error in the RFC determination, which is supported by substantial evidence. For this reason, the court should deny relief to her on this issue.
Davis argues that ALJ Miller erred in failing to credit Davis's statements of her symptoms and their limiting effects. The Commissions contends, and the undersigned agrees, that the credibility evaluation was proper and has the support of substantial evidence.
In evaluating a claimant's subjective symptoms, an ALJ must follow a two-step analysis. 20 C.F.R. §§ 404.1529(a), 416.929(a); SSR 16-3p, 2016 WL 1119029, at *2. The first step requires an ALJ to determine the existence of an underlying medically determinable impairment that could reasonably produce the claimant's complaints, such as pain. 20 C.F.R. §§ 404.1529(b), 416.929(b); SSR 16-3p, 2016 WL 1119029, at *2-3. When the underlying impairment reasonably could produce the claimant's complaints, the ALJ moves to the second part of the analysis, which involves the evaluation of subjective symptoms. 20 C.F.R. §§ 404.1529(c), 416.929(c); SSR 16-3p, 2016 WL 1119029, at *2, 4.
An ALJ must evaluate the intensity and persistence of a claimant's subjective symptoms, such as pain, and determine the extent to which the symptoms limit the claimant's capacity for work. 20 C.F.R. §§ 404.1529(c), 416.929(c), SSR 16-3p, 2016 WL 1119029, at *4. The ALJ must consider all of the available evidence of symptoms from both objective medical evidence (i.e., medical signs and laboratory findings), medical history, a claimant's daily activities, the location, duration, frequency and intensity of symptoms, precipitating and aggravating factors, type, dosage, effectiveness and adverse side effects of any pain medication, treatment, other than medication, for relief of pain or other symptoms and functional restrictions. 20 C.F.R. §§ 404.1529(c) (1)-(3), 416.929 (c) (1)-(3), SSR 16-3p, 2016 WL 1119029, at *8.
The ALJ then determines the extent to which the subjective symptoms are consistent or inconsistent with the available evidence. 20 C.F.R. §§ 404.1529(c)(4), 416.929(c)(4); SSR 16-3p, 2016 WL 1119029, at *8. In explaining a subjective symptom evaluation, an ALJ must articulate which of a claimant's subjective symptoms are supported by the evidence, and an ALJ cannot make a blanket statement addressing all subjective symptoms. See Radford, 734 F.3d at 295; SSR 16-3p, 2016 WL 1119029, at *9. This includes stating which subjective symptoms are consistent or inconsistent with the available evidence. SSR 16-3p, 2016 WL 1119029, at *8. When subjective symptoms are consistent with the available evidence, an ALJ must determine that the subjective symptoms are more likely to cause the claimant limitations. Id. at *7. On the other hand, when subjective symptoms are inconsistent with the available evidence, the ALJ must determine that the subjective symptoms are less likely to cause the claimant limitations. Id.
Here, ALJ Miller determined that Davis's medically determinable impairments could reasonably have caused her symptoms. Tr. at 17. But he concluded that her statements about the intensity, persistence, and limiting effects of her symptoms were not entirely credible. Id.
In support of her argument, Davis points to her statements about her symptoms. These include her allegations that she experienced dizziness and headaches almost daily, she had a sensitivity to light, she had pain and tingling on her left side, her hands were weak, and she had lower back pain. Davis asserts that she continues to have pain despite medication. Because of these symptoms, Davis claims that she cannot sit for long periods and must lie down for most of the day. She maintains that her testimony is consistent with the medical evidence.
As the Commissioner aptly points out, Davis reiterates her subjective statements about symptoms but does not identify specific errors in ALJ Miller's decision, other than to argue he did not credit them. In evaluating her credibility, ALJ Miller considered Davis activities of daily living, which included caring for her personal needs. Additionally, although Davis asserted that her medications caused her to "doz[e] in and out" for much of the day, ALJ Miller observed that she appeared alert and able to respond coherently at the hearing. Tr. a 20, 45.
ALJ Miller noted that the extent of her physical limitations stemming from her various impairments was not generally consistent with the diagnostic imaging or treatment records. Tr. at 17. ALJ Miller then commented on the evidence, pointing out how Davis's allegations were not fully supported by the findings on examination and testing. Tr. at 17-20. For instance, Davis complained of back pain but testing revealed only mild findings and examinations showed normal gait, full strength and range of motion, and normal reflexes and coordination. Tr. at 18. Davis reported that her hypertension caused dizziness, blackouts, sharp chest pains, and migraine headaches. Yet evidence related to this condition established only mild findings upon testing, her cardiovascular examinations were consistently normal, and she required treatment only with medication. Tr. at 19. And despite asthma and shortness of breath, the record showed normal lung examinations. Tr. at 20.
This evidence supports ALJ Miller's finding that Davis's statements about her symptoms were not fully credible. As Davis has only shown disagreement, nor error, with ALJ Miller's evaluation of this evidence, her argument on this issue lacks merit. See Johnson, 434 F.3d at 653 (reviewing court should not undertake to reweigh conflicting evidence, make credibility determinations, or substitute its judgment for that of the ALJ).
For the forgoing reasons, the undersigned recommends that the court deny Davis's Motion for Judgment on the Pleadings (D.E. 17), grant the Commissioner's Motion for Judgment on the Pleadings (D.E. 22), and affirm the Commissioner's decision.
The court directs that the Clerk of Court serve a copy of this Memorandum and Recommendation on each of the parties or, if represented, their counsel. Each party shall have until 14 days after service of the Memorandum and Recommendation on the party to file written objections to the Memorandum and Recommendation. The presiding district judge must conduct his or her own review (that is, make a de novo determination) of those portions of the Memorandum and Recommendation to which objection is properly made and may accept, reject, or modify the determinations in the Memorandum and Recommendation, receive further evidence, or return the matter to the magistrate judge with instructions. See, e.g., 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b)(3); Local Civ. R. 1.1 (permitting modification of deadlines specified in local rules), 72.4(b), E.D.N.C.
