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Exum v. Saul

United States District Court, E.D. North Carolina, Western Division

September 13, 2019

CARSTON EXUM, Plaintiff/Claimant,
ANDREW M. SAUL, Commissioner of Social Security, Defendant.


          Robert B. Jones, Jr., United States Magistrate Judge.

         This matter is before the court on the parties' cross-motions for judgment on the pleadings [DE-17, -20] pursuant to Fed.R.Civ.P. 12(c). Claimant Carston Exum ("Claimant"), proceeding pro se, filed this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the denial of his application for Supplemental Security Income ("SSI") payments. Accordingly, the pending motions are ripe for adjudication. Having carefully reviewed the administrative record and the motions and memoranda submitted by the parties, it is recommended that Claimant's Motion for Judgment on the Pleadings be denied, Defendant's Motion for Judgment on the Pleadings be allowed, and the final decision of the Commissioner be upheld.


         Claimant protectively filed an application for SSI on February 18, 2016, alleging disability beginning the same date. (R. 31, 166-75). His claim was denied initially and upon reconsideration. (R. 31, 69-104). A hearing before the Administrative Law Judge ("ALJ") was held on March 27, 2018, at which Claimant, represented by counsel, and a vocational expert ("VE") appeared and testified. (R. 55-68). On June 11, 2018, the ALJ issued a decision denying Claimant's request for benefits. (R. 28-49). Claimant then requested a review of the ALJ's decision by the Appeals Council (R. 163-64), and he submitted additional evidence as part of his request (R. 50-54). The Appeals Council found that the evidence did not show a reasonable probability that it would change the outcome of the decision, so it did not consider and exhibit the evidence. (R. 6). The Appeals Council denied Claimant's request for review on December 13, 2018. (R. 5-10). Claimant then filed a complaint in this court seeking review of the now-final administrative decision.


         The scope of judicial review of a final agency decision regarding disability benefits under the Social Security Act ("Act"), 42 U.S.C. § 301 et seq., is limited to determining whether substantial evidence supports the Commissioner's factual findings and whether the decision was reached through the application of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). "The findings of the Commissioner ... as to any fact, if supported by substantial evidence, shall be conclusive . . . ." 42 U.S.C. § 405(g). Substantial evidence is "evidence which a reasoning mind would accept as sufficient to support a particular conclusion." Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966). While substantial evidence is not a "large or considerable amount of evidence," Pierce v. Underwood, 487 U.S. 552, 565 (1988), it is "more than a mere scintilla . . . and somewhat less than a preponderance." Laws, 368 F.2d at 642. "In reviewing for substantial evidence, [the court should not] undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]." Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (quoting Craig v. Chater, 16 F.3d 585, 589 (4th Cir. 1996), superseded by regulation on other grounds, 20 C.F.R. § 416.927(d)(2)). Rather, in conducting the "substantial evidence" inquiry, the court's review is limited to whether the ALJ analyzed the relevant evidence and sufficiently explained his or her findings and rationale in crediting the evidence. Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).


         The disability determination is based on a five-step sequential evaluation process as set forth in 20 C.F.R. § 416.920 under which the ALJ is to evaluate a claim:

The claimant (1) must not be engaged in "substantial gainful activity," i.e., currently working; and (2) must have a "severe" impairment that (3) meets or exceeds [in severity] the "listings" of specified impairments, or is otherwise incapacitating to the extent that the claimant does not possess the residual functional capacity to (4) perform ... past work or (5) any other work.

Albright v. Comm'r of the SSA, 174 F.3d 473, 475 n.2 (4th Cir. 1999). "If an applicant's claim fails at any step of the process, the ALJ need not advance to the subsequent steps." Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995) (citation omitted). The burden of proof and production during the first four steps of the inquiry rests on the claimant. Id. At the fifth step, the burden shifts to the ALJ to show that other work exists in the national economy which the claimant can perform. Id.

         When assessing the severity of mental impairments, the ALJ must do so in accordance with the "special technique" described in 20 C.F.R. § 416.920a(b)-(c). This regulatory scheme identifies four broad functional areas in which the ALJ rates the degree of functional limitation resulting from a claimant's mental impairments): understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing oneself. Id. § 416.920a(c)(3). The ALJ is required to incorporate into her written decision pertinent findings and conclusions based on the "special technique." Id. § 416.920a(e)(3).

         In this case, Claimant alleges the ALJ improperly weighed the medical evidence, the opinion evidence, the VE's testimony, and the Claimant's testimony; the ALJ failed to consider the reasons why Claimant stopped taking his antidepressant medication; the ALJ failed to account for Claimant's limitations in interacting with others, concentrating, and maintaining pace; and the ALJ failed to use a medical expert ("ME") at the hearing. Pl.'s Mem. [DE-15] at 1-6.


         Applying the above-described sequential evaluation process, the ALJ found Claimant "not disabled" as defined in the Act. At step one, the ALJ found Claimant had not engaged in substantial gainful employment since February 18, 2016, the application date. (R. 33). Next, the ALJ determined Claimant had the severe impairments of hernia, osteoarthritis, adjustment disorder with depressed mood, major depressive disorder, and unspecified anxiety disorder and the non-severe impairments of pre-diabetes, vision loss, history of buttock abscess, hematuria, mild obesity, tachycardia, dental caries, rhinitis, and a history of polysubstance abuse. (R. 33-34). At step three, the ALJ concluded Claimant's impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 34-3 5). Applying the technique prescribed by the regulations, the ALJ found that Claimant's mental impairments have resulted in mild limitations in understanding, remembering, or applying information and adapting or managing oneself and in moderate limitations in interacting with others and concentrating, persisting, or maintaining pace. Id.

         Prior to proceeding to step four, the ALJ assessed Claimant's RFC, finding Claimant could perform medium work[1] with the ability to understand, remember, and carry out simple instructions, which is defined to mean activity that is consistent with a reasoning level of 2 or 3 as defined in the Dictionary of Occupational Titles; sustain attention and concentration sufficient to carry out simple instructions over two-hour periods of time in an eight-hour workday; interact occasionally with the general public and coworkers; and work in a low stress setting, which is specifically defined to mean no fast paced production, only simple work related decisions, and few or no changes in the work setting. (R. 35-43). In making this assessment, the ALJ found Claimant's statements about the intensity, persistence, and limiting effects of his symptoms not entirely consistent with the medical and other evidence in the record. (R. 41). At step four, the ALJ concluded Claimant was unable to perform any past relevant work. (R. 43). At step five, upon considering Claimant's age, education, work experience, and RFC, the ALJ determined Claimant is capable of adjusting to the demands of other employment opportunities that exist in significant numbers in the national economy. (R. 43-44).

         V. DISCUSSION

         A. The ALJ's RFC Determination

         An individual's RFC is the capacity he possesses despite the limitations caused by physical or mental impairments. 20 C.F.R. § 416.945(a)(1); see also S.S.R. 96-8p, 1996 WL 374184, at *l (July 2, 1996). The RFC is based on all relevant medical and other evidence in the record, which may include a claimant's own description of limitations arising from alleged symptoms. 20 C.F.R. § 416.945(a)(3); see also S.S.R. 96-8p, 1996 WL 374184, at *5. Where a claimant has numerous impairments, including non-severe impairments, the ALJ must consider their cumulative effect in making a disability determination. 42 U.S.C. § 423(d)(2)(B); see Hines v. Brown, 872 F.2d 56, 59 (4th Cir. 1989) ("[I]n determining whether an individual's impairments are of sufficient severity to prohibit basic work related activities, an ALJ must consider the combined effect of a claimant's impairments.") (citations omitted).

         "[T]he 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." Mascio v. Colvin,780 F.3d 632, 636 (4th Cir. 2015) (quoting S.S.R. 96-8p). The ALJ must provide "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. (quoting S.S.R. 96-8p). "Only after such a function-by-function analysis may an ALJ express RFC 'in terms of the exertional levels of work.'" Monroe v. Colvin,826 F.3d 176, 179 (4th Cir. 2016) (quoting Mascio, 780 F.3d at 636); see also Clifford v. Apfel,227 F.3d 863, 872 (7th Cir. 2000) (observing that the ALJ "must build an accurate and logical bridge from the evidence to his conclusion"). The Fourth Circuit has rejected "a per se rule requiring remand when the ALJ does not perform an explicit function-by-function analysis." Mascio, 780 F.3d at 636. Rather, the court explained that "[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 ...

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