LAKENISHA DOWLING, Plaintiff - Appellant, v. COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant - Appellee.
No. 19-2141
UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT
January 21, 2021
PUBLISHED. Argued: December 9, 2020. Reversed and remanded by published opinion. Judge Thacker wrote the opinion, in which Judge King and Judge Floyd concurred.
On February 10, 2011, the Social Security Administration (“SSA“) Office of Disability Adjudication and Review determined that Lakenisha Dowling (“Appellant“) had been disabled since April 15, 2009. However, on November 3, 2016, an administrative law judge (“ALJ“) found that Appellant‘s disability had ceased as of March 31, 2013. Appellant challenged the ALJ‘s decision in the United States District Court for the District of South Carolina pursuant to
The ALJ committed two legal errors. First, the ALJ erred by failing to consider each of the factors listed in
A.
Appellant is 42 years old and resides in South Carolina with her mother and 18 year old daughter. She suffers from a multitude of health problems, the most serious of which relate to her gastrointestinal system. She has lived with inflammatory bowel disease (“IBD“) since 1998 and has been diagnosed with both ulcerative colitis and Crohn‘s disease.2 Appellant‘s IBD causes her to experience diarrhea, abdominal pain, fatigue, body aches, and cramping. In addition, Appellant has a small hole in the skin near her anus, which has been diagnosed as an anal fissure, a perianal fistula, and a pilonidal sinus.3 The fissure routinely leaks and bleeds, and it causes Appellant discomfort when sitting. Appellant also suffers from numerous non-gastrointestinal health problems, including thyroid cancer, obesity, anxiety, anemia, arthritis of the right ankle, and migraine headaches.
Appellant graduated from high school and attended a technical college in Orangeburg, South Carolina, where she became a certified nursing assistant. After receiving this education, Appellant began working full-time in the healthcare sector. She spent six months as a nursing assistant in 2003, followed by nearly seven years as a dialysis
B.
On May 6, 2009, shortly after leaving her job as a monitor technician, Appellant filed an application for disability insurance benefits pursuant to Title II of the Social Security Act,
Appellant challenged the SSA‘s decision to discontinue her disability benefits and requested a hearing before an ALJ. At that hearing, which took place on February 2, 2016, Appellant testified about the activities and tasks she was physically capable of completing, which included driving and riding in a car, cleaning her house, going to the grocery store, putting on clothes, using the bathroom, preparing meals, and doing dishes. She also testified about her job as a home health aide, her medical problems and how they impacted her life, and the medications she took and how they affected her. A vocational expert also appeared at the hearing and testified about the nature of Appellant‘s past jobs and the amount of physical exertion required to adequately perform them.
On November 3, 2016, the ALJ agreed with the initial SSA decision that Appellant‘s disability had ended on March 31, 2013. The ALJ first noted that while Appellant continued to suffer from severe medical impairments, her overall medical condition had significantly improved between February 10, 2011, the day that she was originally determined to be disabled, and March 31, 2013. The ALJ found that, because of her medical improvement, Appellant possessed the RFC to perform sedentary work,5 but not
Per Appellant‘s request, the SSA Office of Disability Adjudication and Review reviewed the ALJ‘s decision on December 7, 2017, but found no basis for changing it. At that point, the ALJ‘s decision became “the final decision of the Commissioner of Social Security in [this] case.” A.R. 1. Appellant then challenged the ALJ‘s decision in the United States District Court for the District of South Carolina, which affirmed, finding the ALJ‘s decision to be supported by substantial evidence. The ALJ‘s decision is now before this court. We hold that it must be reversed.
We review the ALJ‘s Social Security disability determination pursuant to the standard set out in
III.
A.
Regulatory Procedure
SSA regulations establish an eight-step procedure for determining whether a recipient of disability insurance benefits continues to be disabled. See
In this case, Appellant‘s continuing eligibility for disability benefits boiled down to steps seven and eight: the assessment of whether, despite her severe impairments, she possessed the RFC to perform work she had done in the past. The ALJ found that, as of March 31, 2013, Appellant possessed an RFC “to perform sedentary work,” J.A. 11, which rendered her “capable of performing past relevant work,” id. at 18. Accordingly, the ALJ determined that Appellant ceased to be disabled as of that date.
Medical Opinion Evidence
On May 4, 2015, Dr. Gross, Appellant‘s treating physician from 2011 through 2016,7 submitted a treating source statement (the “Statement“) concerning Appellant‘s medical impairments and ability to perform certain physical functions. In the Statement, Dr. Gross diagnosed Appellant with, inter alia, IBD, migraines, anxiety, depression, and thyroid cancer. She also explained that these conditions caused Appellant to experience fatigue, joint pain, abdominal pain, dizziness, and headaches. Dr. Gross then expressed her medical opinion as to Appellant‘s ability to engage in certain activities. The prognosis was bleak. According to Dr. Gross, Appellant had the ability to sit for only 15 to 30 minutes at one time, and could not sit for even two hours “total in an 8-hour working day (with normal breaks).” A.R. 774. Dr. Gross opined that Appellant “frequently” experienced “pain severe enough to interfere with attention and concentration.” Id.
In his November 3, 2016 decision, although the ALJ acknowledged Dr. Gross‘s Statement, the ALJ stated that he gave the medical opinion contained therein only “negligible weight.” J.A. 16. We conclude that the ALJ erred in his treatment of Dr. Gross‘s medical opinion. The ALJ was required to do more than simply acknowledge the existence of Dr. Gross‘s opinion.
When determining Appellant‘s Social Security disability status, the ALJ was required to consider the medical opinions of Appellant‘s treating physicians. See
Section 404.1527(c)(2) sets out two rules an ALJ must follow when evaluating a medical opinion from a treating physician. First, it establishes the “treating physician rule,” under which the medical opinion of a treating physician is entitled to “controlling weight” if it is “well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record.”
2.
Here, substantial evidence supports the ALJ‘s decision to not give controlling weight to the medical opinion contained in Dr. Gross‘s Statement. This is because while there is no indication that Dr. Gross‘s opinion was not “well-supported by medically acceptable clinical and laboratory diagnostic techniques,”
Although we accept the ALJ‘s conclusion that Dr. Gross‘s medical opinion was not entitled to controlling weight, it does not follow that the ALJ had free reign to attach whatever weight to that opinion that he deemed fit. The ALJ was required to consider each
3.
The ALJ explained that he afforded only negligible weight to Dr. Gross‘s medical opinion because he found the opinion to be inconsistent with other evidence in the record, and the basis for the opinion was “not adequately explained” by Dr. Gross. J.A. 16. This explanation by the ALJ touches on two of the Section 404.1527(c) factors -- consistency and supportability. However, there is no indication that the ALJ actually undertook the required analysis of Dr. Gross‘s opinion. Indeed, the ALJ never so much as acknowledged the existence of the Section 404.1527(c) factors. Moreover, the ALJ was completely silent as to the remaining four Section 404.1527(c) factors; for instance, the ALJ considered neither the “[l]ength of the treatment relationship and the frequency of examination,” nor the “[n]ature and extent of the treatment relationship.”
The ALJ‘s failure to consider each of the Section 404.1527(c) factors was error. While an ALJ is not required to set forth a detailed factor-by-factor analysis in order to discount a medical opinion from a treating physician, it must nonetheless be apparent from the ALJ‘s decision that he meaningfully considered each of the factors before deciding how much weight to give the opinion. See Arakas, 983 F.3d at 107 n.16 (”
4.
This error necessitates a remand in this case. Two of the factors ignored by the ALJ -- those which relate to the length, frequency, nature, and extent of Appellant‘s treatment relationship with Dr. Gross -- appear to cut in Appellant‘s favor. Dr. Gross was Appellant‘s family physician. The record demonstrates that from as early as 2011 through at least 2016, Dr. Gross treated her regularly, with appointments occurring at least every three months. Through these frequent appointments, Dr. Gross surely “obtained a longitudinal picture of [Appellant‘s] impairment[s].”
Further, it is an elemental principle of administrative law that agency determinations must “be made in accordance with certain procedures which facilitate judicial review.” Patterson v. Comm‘r of SSA, 846 F.3d 656, 662 (4th Cir. 2017). One such procedure is Section 404.1527(c)‘s requirement that ALJs consider each of the enumerated factors before assigning less than controlling weight to a medical opinion from a treating physician. Here, the ALJ neglected to even acknowledge the existence of those factors, much less engage in a meaningful discussion of them, so as to facilitate judicial review. Therefore, remand is necessary to allow the ALJ to consider Dr. Gross‘s medical opinion in light of each of the Section 404.1527(c) factors. See id. at 662-63 (remanding and noting that “because we cannot gauge the propriety of the ALJ‘s [] assessment, we cannot say that substantial evidence supports the ALJ‘s denial of benefits“); Cook v. Heckler, 783 F.2d 1168, 1173 (4th Cir. 1986) (remanding where the ALJ‘s failure to comply with certain Social Security procedures made it “simply impossible to tell whether there was substantial evidence to support [his] determination“).
C.
Residual Functional Capacity Assessment
The failure to consider each of the
1.
A Social Security claimant‘s RFC represents “the most [she] can still do despite [her] limitations.”
2.
Here, the ALJ relied on an incorrect regulatory framework when he assessed Appellant‘s RFC. He did not cite to
The ALJ‘s reliance on an incorrect regulatory framework led to an erroneous RFC assessment that, like the ALJ‘s failure to consider each of the
a.
First, the ALJ expressed Appellant‘s RFC “in terms of [] exertional levels of work” without first engaging in “a function-by-function analysis.” Monroe, 826 F.3d at 179. “[A] proper RFC analysis” proceeds in the following order: “(1) evidence, (2) logical explanation, and (3) conclusion.” Thomas, 916 F.3d at 311. But here, the ALJ began with step three, noting at the outset of his RFC evaluation that Appellant only “had the residual functional capacity to perform sedentary work.” J.A. 11. Only then did the ALJ identify evidence and attempt to explain how that evidence logically supported his predetermined conclusion. In this way, the ALJ assessed Appellant‘s RFC in a manner that this court
b.
Second, the ALJ did not properly assess the extent to which Appellant‘s sitting problems impacted her ability to work. Appellant has argued throughout her administrative and judicial proceedings that her IBD and anal fissure cause her to experience discomfort when she sits for a prolonged period of time. But the ALJ apparently concluded that Appellant was not restricted in her ability to sit, as he did not indicate that her RFC was limited because of those problems. This conclusion should have been the result of an analysis that was separate from the ALJ‘s appraisal of Appellant‘s ability to perform other functions, and should have been accompanied by “a narrative discussion describing” the evidence supporting it. Thomas, 916 F.3d at 311. The ALJ‘s evaluation of Appellant‘s ability to sit was lacking in both respects. The ALJ never specifically discussed the extent to which Appellant‘s alleged sitting problems impacted her ability to perform sedentary work. The ALJ could not have supported a conclusion in this regard through a narrative discussion concerning the relevant evidence because he reached no such express conclusion in the first instance. In fact, the ALJ barely mentioned Appellant‘s sitting problems in his decision, and discussed them only when rattling off a laundry list of her many impairments and functional restrictions. This grouping of Appellant‘s sitting limitations with her other impairments and restrictions is a far cry from the “function-by-function analysis” the ALJ was required to conduct.
c.
Third, the ALJ failed to analyze whether Appellant‘s RFC was impacted by her need to work near a restroom and take frequent bathroom breaks. There is considerable evidence in the record demonstrating that Appellant regularly experienced diarrhea and incontinence, as well as drainage from her anal fissure. Appellant argues that these problems caused her to require bathroom breaks at a frequent, and often unpredictable,
IV.
For the reasons set forth herein, we reverse the district court‘s order affirming the decision of the ALJ. The case is remanded to the district court with instructions to remand to the Commissioner for further administrative proceedings consistent with this opinion.
REVERSED AND REMANDED