Paula Felton-Miller v. Michael Astrue , 459 F. App'x 226 ( 2011 )


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  •                             UNPUBLISHED
    UNITED STATES COURT OF APPEALS
    FOR THE FOURTH CIRCUIT
    No. 11-1500
    PAULA FELTON-MILLER,
    Plaintiff - Appellant,
    v.
    MICHAEL J. ASTRUE, Commissioner of Social Security,
    Defendant - Appellee.
    Appeal from the United States District Court for the Eastern
    District of North Carolina, at New Bern.  Louise W. Flanagan,
    Chief District Judge. (2:10-cv-00005-FL)
    Submitted:   December 1, 2011             Decided:   December 21, 2011
    Before GREGORY, DAVIS, and DIAZ, Circuit Judges.
    Affirmed by unpublished per curiam opinion.
    David J. Cortes, ROBERTI, WITTENBERG, LAUFFER AND WICKER,
    Durham, North Carolina, for Appellant. Thomas G. Walker, United
    States Attorney, Amy C. Rigney, Special Assistant United States
    Attorney, Baltimore, Maryland, for Appellee.
    Unpublished opinions are not binding precedent in this circuit.
    PER CURIAM:
    Paula Felton-Miller appeals the district court’s order
    affirming the Commissioner of Social Security’s denial of her
    application for disability insurance benefits and supplemental
    security income.          We must uphold the decision to deny benefits
    if the decision is supported by substantial evidence and the
    correct law was applied.                 
    42 U.S.C. § 405
    (g) (2006); Johnson v.
    Barnhart,      
    434 F.3d 650
    ,    653       (4th Cir. 2005)              (per        curiam).
    “Substantial evidence is such relevant evidence as a reasonable
    mind   might       accept      as     adequate        to       support       a     conclusion.”
    Johnson, 
    434 F.3d at 653
     (internal quotation marks omitted).
    This   court     does       not      reweigh        evidence      or     make       credibility
    determinations in evaluating whether a decision is supported by
    substantial        evidence;         “[w]here        conflicting         evidence             allows
    reasonable      minds     to    differ,”        we    defer      to    the       Commissioner’s
    decision.    
    Id.
    Felton-Miller “bears the burden of proving that [s]he
    is   disabled      within      the    meaning        of   the    Social      Security          Act.”
    English v. Shalala, 
    10 F.3d 1080
    , 1082 (4th Cir. 1993) (citing
    
    42 U.S.C. § 423
    (d)(5) (2006)).                       The Commissioner uses a five-
    step   process       to     evaluate       a    disability            claim.            
    20 C.F.R. §§ 404.1520
    (a)(4),          416.920(a)(4)             (2011).           Pursuant         to     this
    process,     the     Commissioner          asks,          in    sequence,         whether        the
    claimant:       (1) worked during the alleged period of disability;
    2
    (2) had a severe impairment; (3) had an impairment that met or
    equaled the severity of a listed impairment; (4) could return to
    her    past    relevant      work;      and     (5) if         not,    whether   she     could
    perform      any   other    work     in    the       national     economy.         
    Id.
          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).
    Felton-Miller contends that the ALJ did not properly
    analyze      her   subjective       complaints            of   pain.        Relying    on   our
    decision in Craig v. Chater, 
    76 F.3d 585
     (4th Cir. 1996), she
    argues that a claimant’s statements regarding the severity and
    limiting      effects      of    pain     are       entitled      to    a   presumption      of
    credibility        once    the     claimant         has    produced      medical      evidence
    demonstrating        the     existence          of    an       impairment      which     could
    reasonably be expected to produce the pain alleged.
    “[T]he determination of whether a person is disabled
    by pain or other symptoms is a two-step process.”                                  Craig, 
    76 F.3d at 594
    .        First,    the    claimant            must    produce   “objective
    medical evidence showing the existence of a medical impairment[]
    . . . which could reasonably be expected to produce the pain
    . . .     alleged.”         Id.;     
    20 C.F.R. §§ 404.1529
    (a),        416.929(a)
    3
    (2011).       Second,        “the    intensity     and     persistence       of       the
    claimant’s pain, and the extent to which it affects her ability
    to work, must be evaluated.”              Craig, 
    76 F.3d at 595
    .         The second
    step is analyzed using statements from treating and nontreating
    sources   and   from    the        claimant.      
    20 C.F.R. §§ 404.1529
    (a),
    416.929(a).      Factors       in   evaluating     the    claimant’s      statements
    include     consistency       in    the    claimant’s       statements,      medical
    evidence,     medical       treatment      history,      and   the     adjudicator’s
    observations    of     the    claimant.        See     Social     Security     Ruling
    (“SSR”) 96-7p, 
    1996 WL 374186
    , at *5-*8.
    Craig lends no support to Felton-Miller’s position. 1
    Craig notes that step one of the pain analysis is focused solely
    “on   establishing      a     determinable       underlying       impairment      —     a
    statutory requirement for entitlement to benefits.”                       Craig, 
    76 F.3d at 594
    .      Craig explains that, after the claimant crosses
    this threshold, “the intensity and persistence of the claimant’s
    pain, and the extent to which it affects her ability to work,
    1
    Felton-Miller identifies a host of other cases that she
    contends support the existence of a “great weight rule.” These
    cases recognize that subjective evidence may be entitled to
    great weight, but the cases do not rely on the finding at step
    one of the pain analysis.    Rather, great weight is afforded to
    subjective evidence when it is either uncontradicted or
    supported by substantial evidence.        See, e.g., Combs v.
    Weinberger, 
    501 F.2d 1361
    , 1362-63 (4th Cir. 1974) (“[W]e have
    held that subjective evidence is entitled to great weight,
    especially where such evidence is uncontradicted in the
    record.”) (internal quotation marks omitted).
    4
    must be evaluated.”            Id. at 595.          The claimant’s own statements
    regarding her pain are not afforded any presumption; rather,
    “[u]nder the regulations, . . . evaluation [of the claimant’s
    pain] must take into account not only the claimant’s statements
    about her pain, but also all the available evidence, including
    the claimant’s medical history, medical signs, and laboratory
    findings.”        Id. (internal quotation marks omitted).
    Felton-Miller            contends        the     ALJ’s        reasons      for
    discrediting her subjective complaints at step two of the pain
    analysis     were    inaccurate        and    insubstantial.           First,     the   ALJ
    found that Felton-Miller’s sarcoidosis has been well controlled
    with various medication regimens.                        Felton-Miller asserts that
    this    statement        is   at    odds     with    a    treatment       note   that   her
    symptoms were not well controlled with prednisone and subsequent
    notes    that      she    stopped         taking    Plaquenil       and    methotrexate.
    However,     we    conclude        that    substantial       evidence      supports     the
    ALJ’s conclusion because the record shows that, although Felton-
    Miller’s     medication            occasionally          required     adjustment,       her
    symptoms were successfully controlled at various times.
    Second, Felton-Miller contends that the ALJ’s reliance
    on     the   absence          of    clinical        signs    of     persistent       joint
    inflammation, joint deformity, or limitation of joint motion is
    erroneous.        She argues that sarcoidosis is a disease that, by
    definition, primarily involves a kind of inflammation, that she
    5
    at times presented and was assessed with joint problems, and
    that she was treated with anti-inflammatory drugs.                               However,
    medical conditions alone do not entitle a claimant to disability
    benefits;     “[t]here     must    be   a       showing      of    related    functional
    loss.”      Gross v. Heckler, 
    785 F.2d 1163
    , 1166 (4th Cir. 1986).
    Accordingly,      Felton-Miller’s           sarcoidosis            diagnosis,     without
    more, does not establish that she suffers from any particular
    symptoms or limitations.            Here, the ALJ acknowledged Felton-
    Miller’s      treatment     for    joint,        back,       and     muscle     problems.
    However, the ALJ also determined that these problems were not
    persistent.      Our review of the record leads us to conclude that
    the ALJ’s finding is supported by substantial evidence.
    Third, Felton-Miller asserts that the ALJ erroneously
    relied on an irrelevant finding that her carpal tunnel syndrome
    was   mild.      We     conclude   that         no    such    error    occurred.        In
    evaluating symptoms, including pain, an ALJ is to “consider all
    of    the   evidence      presented.”            
    20 C.F.R. §§ 404.1529
    (c)(3),
    416.929(c)(3) (2011).           Consideration of the limiting effects of
    Felton-Miller’s carpal tunnel syndrome led the ALJ to a residual
    functional      capacity    (“RFC”)         assessment        precluding        her   from
    performing tasks requiring the constant use of her hands.
    Fourth,     the     ALJ   concluded            that      Felton-Miller’s
    degenerative disc disease was mild.                    Felton-Miller asserts that
    this finding is not supported by substantial evidence because
    6
    treatment      notes     indicate        that       she   has    a     history         of    severe
    degenerative disc and joint disease.                      However, the ALJ reviewed
    the records Felton-Miller cites in addition to evidence that
    Felton-Miller        enjoyed        full    strength,            had        no     neurological
    deficits indicating nerve root compression, and had normal motor
    nerve       function       with     no     evidence         of       cervical           myopathy.
    Additionally, contrary to Felton-Miller’s assertions, the ALJ’s
    finding that Felton-Miller’s degenerative disc disorder was a
    severe impairment at step two of the sequential evaluation does
    not contradict the ALJ’s conclusion that the disorder’s impact
    on    her    functioning      was    mild.           Step    two       of    the       sequential
    evaluation is a threshold question with a de minimis severity
    requirement.        See Bowen, 
    482 U.S. at 153-54
    ; SSR 88-3c, 
    1988 WL 236022
    .
    Fifth, Felton-Miller argues that the ALJ erroneously
    rejected     her    pain    testimony       on      the   ground       that       she       has    not
    required aggressive measures for pain relief such as ongoing use
    of steroid medication.              Felton-Miller has waived review of this
    issue by failing to raise it below.                       See Pleasant Valley Hosp.
    v.    Shalala,      
    32 F.3d 67
    ,     70       (4th Cir. 1994)              (finding         that
    appellant’s failure to raise issue during administrative hearing
    and    before      district       court    operates         as   waiver           of    appellate
    review).
    7
    Turning to Felton-Miller’s argument that the ALJ’s RFC
    finding is not supported by substantial evidence because the ALJ
    is a layman and did not obtain an expert medical opinion, we
    conclude this argument is without merit. 2   “[R]esidual functional
    capacity is the most [a claimant] can still do despite [her]
    limitations.”   
    20 C.F.R. §§ 404.1545
    (a), 416.945(a) (2011).     It
    is an administrative assessment made by the Commissioner based
    on all the relevant evidence in the case record.     See 
    20 C.F.R. §§ 404.1546
    (c), 416.946(c) (2011) (assigning responsibility of
    RFC assessment at hearing level to ALJ); SSR 96-8p (identifying
    RFC finding as administrative assessment and outlining criteria
    to be used).    The ALJ was not required to obtain an expert
    medical opinion as to Felton-Miller’s RFC.       The ALJ properly
    based his RFC finding on Felton-Miller’s subjective complaints,
    the objective medical evidence, and the opinions of treating,
    examining, and nonexamining physicians.
    2
    Felton-Miller asserts that, because “bare medical findings
    are unintelligible to a lay person in terms of residual
    functional capacity, the ALJ is not qualified to assess residual
    functional capacity based on a bare medical record.” Gordils v.
    Sec. of Health & Human Servs., 
    921 F.2d 327
    , 329 (1st Cir.
    1990).   Here, however, the nerve conduction test Felton-Miller
    identifies as too technical for a layman to interpret was
    interpreted in functional terms by the examining physician.
    Based on the test results, the doctor concluded that Felton-
    Miller had evidence of mild carpal tunnel syndrome but no other
    disorders.
    8
    Felton-Miller also argues that the ALJ did not make a
    valid mental RFC assessment because he did not apply the proper
    standards.          In evaluating mental impairments, the ALJ employs a
    specific       technique        that     considers        four     functional       areas
    essential to the ability to work:                     activities of daily living;
    ability        to      maintain        social        functioning;      concentration,
    persistence,           and      pace     in       performing       activities;        and
    deterioration or decompensation in work or work-like settings
    (Psychiatric          Review    Technique         “PRT”   findings).        
    20 C.F.R. §§ 404
    .1520a, 416.920a (2011).                The ALJ’s decision must show the
    significant         history     and    medical     findings    considered     and    must
    include a specific finding as to the degree of limitation in
    each      of         the     four      functional         areas.         
    20 C.F.R. §§ 404
    .1520a(e)(4), 416.920a(e)(4) (2011).
    The     ALJ     concluded      that    Felton-Miller’s       depressive
    disorder was a severe impairment at step two of the sequential
    process without discussion of the special technique.                             At step
    three, the ALJ listed the four functional areas and analyzed the
    impact of Felton-Miller’s depressive disorder on these areas.
    The decision discusses the medical records relevant to Felton-
    Miller’s treatment for depression in assessing her mental RFC.
    We conclude that the ALJ assessed Felton-Miller’s mental RFC in
    accordance with regulations.
    9
    Based   on   the   foregoing,       we   find    that   substantial
    evidence   supports     the   agency    decision,     and    we    affirm   the
    judgment of the district court.             We dispense with oral argument
    because the facts and legal contentions are adequately presented
    in the materials before the court and argument would not aid the
    decisional process.
    AFFIRMED
    10