United States District Court, E.D. North Carolina, Southern Division
TERRENCE W. BOYLE, UNITED STATES DISTRICT JUDGE
cause comes before the Court on cross-motions for judgment on
the pleadings. A hearing was held on these matters before the
undersigned on February 24, 2016, in Raleigh, North Carolina.
For the reasons discussed below, this matter is remanded to
the Acting Commissioner for further proceedings.
brought this action under 42 U.S.C. §§ 405(g) and
1383(c)(3) for review of the final decision of the
Commissioner denying his claim for disability and disability
insurance benefits ("DIB") pursuant to Title II of
the Social Security Act. Plaintiff protectively filed his
application on March 5, 2012, alleging disability beginning
August 1, 2012. After initial denial, a hearing was held
before an Administrative Law Judge (ALJ) who issued an
unfavorable ruling. The decision of the ALJ became the final
decision of the Commissioner when the Appeals Council denied
plaintiffs request for review. Plaintiff then timely sought
review of the Commissioner's decision in this Court.
the Social Security Act, 42 U.S.C. §§ 405(g), and
1383(c)(3), this Court's review of the Commissioner's
decision is limited to determining whether the decision, as a
whole, is supported by substantial evidence and whether the
Commissioner employed the correct legal standard.
Richardson v. Perales, 402 U.S. 389, 401 (1971).
Substantial evidence is "such relevant evidence as a
reasonable mind might accept as adequate to support a
conclusion." Johnson v. Barnhart, 434 F.3d 650,
653 (4th Cir. 2005) (per curiam) (internal quotation and
individual is considered disabled if he 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
[twelve] months." 42 U.S.C. § 1382c(a)(3)(A). The
Act further provides that an individual "shall be
determined to be under a disability only if his physical or
mental impairment or impairments are of such severity that he
is not only unable to do his previous work but cannot,
considering his age, education, and work experience, engage
in any other line of substantial gainful work which exists in
the national economy." 42 U.S.C. § 1382c(a)(3)(B).
issued by the Commissioner establish a five-step sequential
evaluation process to be followed in a disability case. 20
C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The
claimant bears the burden of proof at steps one through four,
but the burden shifts to the Commissioner at step five.
See Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987).
If a decision regarding disability can be made at any step of
the process, however, the inquiry ceases. See 20
C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).
one, if the Social Security Administration determines that
the claimant is currently engaged in substantial gainful
activity, the claim is denied. If not, then step two asks
whether the claimant has a severe impairment or combination
of impairments. If the claimant has a severe impairment, it
is compared at step three to those in the Listing of
Impairments ("Listing") in 20 C.F.R. Pt. 404,
Subpt. P, App. 1. If the claimant's impairment meets or
medically equals a Listing, disability is conclusively
presumed. If not, at step four, the claimant's residual
functional capacity ("RFC") is assessed to
determine if the claimant can perform his past relevant work.
If so, the claim is denied. If the claimant cannot perform
past relevant work, then the burden shifts to the
Commissioner at step five to show that the claimant, based on
his age, education, work experience, and RFC, can perform
other substantial gainful work. If the claimant cannot
perform other work, then he is found to be disabled. See 20
C.F.R. § 416.920(a)(4).
one, the ALJ determined that plaintiff met the insured status
requirements and had not engaged in substantial gainful
activity since his alleged onset date. Plaintiffs
degenerative disk disease of the lumbar spine, history of
aortic dissection with aortic valve replacement, and
hypertension were considered severe impairments at step two,
but were not found alone or in combination to meet or equal a
listing at step three. Plaintiffs subclavian steel syndrome,
nephropathy, GERD, temporary blindness in one eye, and
migraines, anxiety, and depression were considered non-severe
by the ALJ. The ALJ concluded that plaintiff had the RFC to
perform light work with additional exertional limitations.
The ALJ then found that plaintiff was unable to return to his
past relevant work, but that, considering plaintiffs age,
education, work experience, RFC, and testimony from the
vocational expert ("VE"), there were other jobs
that existed in significant numbers in the national economy
that plaintiff could perform. Thus, the ALJ determined that
plaintiff was not disabled within the meaning of the Act.
ALJ's decision in this instance is not supported by
substantial evidence. An ALJ makes an RFC assessment based on
all of the relevant medical and other evidence. 20 C.F.R.
§ 404.1545(a). An RFC should reflect the most that a
claimant can do, despite the claimant's limitations.
Id. An RFC finding should also reflect the
claimant's ability to perform sustained work-related
activities in a work setting on regular and continuing basis,
meaning eight-hours per day, five days per week. SSR 96-8p;
Hines v. Barnhart, 453 F.3d 559, 562 (4th Cir.
2006). The ALJ found plaintiff capable of light exertional
work with no mental limitations. Tr. 16. At the hearing, the
ALJ asked the VE to assume a hypothetical person of the
plaintiffs age, education and past relevant work experience
and who was limited to light work except never to climb
ladders, ropes or scaffolding, and to avoid concentrated
exposure to hazards and extreme temperature. Tr. 51. The VE
testified that given all of these factors the individual
would be able to perform the requirements of representative
light occupations such as return goods sorter, checker, and
merchandise marker and sedentary jobs such as alarm adjuster,
lens sorter, and telephone information clerk. Tr. 52. The VE
was not asked by the ALJ to consider any mental limitations
in his answer.
Fourth Circuit has found that in Social Security disability
cases, "[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) (citing Hines v. Bowen, 872 F.2d 56,
59 (4th Cir. 1989)). "If the reviewing court has no way
of evaluating the basis for the ALJ's decision, then
'the proper course, except in rare circumstances, is to
remand to the agency for additional investigation or
explanation.'" Radford at 295 (citing
Florida Power & Light Co. v. Lorion, 470 U.S.
729, 744 (1985)).
case, the ALJ committed error by failing to mention or weigh
several treating physician opinions on plaintiffs mental
conditions in making a determination whether such conditions
are severe and whether those conditions constituted
non-exertional limitations. If an opinion from a treating
source is well-supported by and consistent with the objective
medical evidence in the record, it may be entitled to
controlling weight. 20 C.F.R. §§ 404.1527(c),
416.927(c). Where an opinion is inconsistent with other
evidence in the record, the ALJ need not give that opinion
any significant weight. Id.; see also Craig v.
Chater, 76 F.3d at 585, 590 (4th Cir. 1996) ("[I]f
a physician's opinion is not supported by clinical
evidence or if it is inconsistent with other substantial
evidence, it should be accorded significantly less
weight."). However, ALJ's decision to do so must be
accompanied by "a narrative discussion" that
discusses "how the evidence supports each conclusion,
" such that the ALJ's decision is sufficiently
specific to make it clear to a reviewing district court
"why the opinion was not adopted." See SSR
began seeing John Parkinson, MD, a psychiatrist, on August
11, 2010, upon referral by his primary care doctor, for
depression and anxiety. Tr. 257. Dr. Parkinson diagnosed
major depressive disorder, recurrent, in partial remission,
with melancholic features, and anxiety, and assessed him with
a global assessment of functioning score of 55. Tr. 258.
Plaintiff also underwent psychotherapy with Jenifer Phelps,
MSN, PMHNP-BC, beginning March 30, 2011, for depression. Tr.
344-363. On November 15, 2012, plaintiff reported that his
anxiety symptoms had worsened, that feelings of apprehensive
expectations have worsened or increased, and that difficulty
concentrating was occurring more frequently. Tr. 691. On
March 19, 2013, Mr. Watkins reported that his anxiety had
increased and that his avoidance of certain situations that
evoke anxiety has increased, with worsening sleep
difficulties, and he was diagnosed with Post Traumatic Stress
Disorder ("PTSD"). Tr. 703. He also reported
continued depression symptoms and even less energy and the