Brian Reid v. Commissioner of Social Security , 769 F.3d 861 ( 2014 )

UNPUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 13-1480
BRIAN EDWARD REID,
Plaintiff - Appellant,
v.
COMMISSIONER OF SOCIAL SECURITY,
Defendant - Appellee.
Appeal from the United States District Court for the District of
South Carolina, at Greenville. Timothy M. Cain, District Judge.
(6:11-cv-02408-TMC)
Argued: May 15, 2014 Decided: July 2, 2014
Before TRAXLER, Chief Judge, and NIEMEYER and DUNCAN, Circuit
Judges.
Affirmed by unpublished opinion. Judge Niemeyer wrote the
opinion, in which Chief Judge Traxler and Judge Duncan joined.
ARGUED: Beatrice E. Whitten, Mt. Pleasant, South Carolina, for
Appellant. Sarah Van Arsdale Berry, SOCIAL SECURITY
ADMINISTRATION, Denver, Colorado, for Appellee. ON BRIEF:
William N. Nettles, United States Attorney, Barbara M. Bowens,
Assistant United States Attorney, OFFICE OF THE UNITED STATES
ATTORNEY, Columbia, South Carolina; John Jay Lee, Regional Chief
Counsel, Kirsten A. Westerland, Assistant Regional Counsel,
Dorrelyn K. Dietrich, Special Assistant United States Attorney,
SOCIAL SECURITY ADMINISTRATION, Denver, Colorado, for Appellee.
Unpublished opinions are not binding precedent in this circuit.
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NIEMEYER, Circuit Judge:
Brian Edward Reid, who suffers from degenerative disc
disease, applied for Social Security disability benefits. The
Commissioner of Social Security denied Reid’s claim, and the
district court affirmed the Commissioner’s decision.
On appeal, Reid contends (1) that the Commissioner ignored
several years of his medical history and (2) that the
Commissioner failed to consider the combined effects of his
multiple impairments. Because we find that the Commissioner’s
decision was based on all the medical evidence and that the
Commissioner did indeed consider Reid’s impairments in
combination, we affirm.
I
Reid filed for disability benefits under Title II of the
Social Security Act, 42 U.S.C. §§ 401-434, on December 7, 2006,
alleging that he became unable to work on June 4, 2004, when,
during work, he fell off of a roof.
Reid’s medical history, as documented by the record, shows
that, prior to his fall, on November 18, 2003, Reid visited Dr.
George Khoury for his chronic neck pain. Dr. Khoury diagnosed
Reid with cervical disc disease and, in December 2003, performed
a two-level anterior cervical discectomy and fusion.
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When Reid fell off the roof on June 4, 2004, he suffered
two spinal fractures. After he was discharged from the hospital
four days later, he still complained of pain and returned to the
doctor on multiple occasions in the subsequent months. Although
Dr. Khoury noted on September 9, 2004, that Reid was “feeling
better” and that he had “minimal complaints,” on January 13,
2005, he nonetheless reported that Reid had “not seen any
improvement” and decided that a posterior fusion was
appropriate. Dr. Khoury performed the procedure on February 11,
2005, and, by March 29, 2005, noted that Reid was “really
progressing well” and was cutting back on his use of pain
medication. On May 5, 2005, Dr. Todd Joye -- another doctor
Reid was seeing for pain -- found that the fusion surgery “was
very successful and ha[d] nearly resolved [Reid’s] thoracic
pain” and that steroid injections “help[ed] him tremendously in
regards to his back pain.” And on November 23, 2005, Dr. Khoury
reported that Reid’s “original thoracic pain ha[d] totally
resolved.”
Several months later, on March 24, 2006, Reid began seeing
another doctor, Dr. Kerri Kolehma, complaining of “severe
bilateral leg pain” that was aggravated by walking, difficulty
using his left ankle, and numbness in several of his toes. Dr.
Kolehma’s physical exam revealed that Reid had “[n]ormal muscle
bulk and tone,” and Reid’s tests yielded normal results, except
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for some loss of reflexes. Subsequent testing revealed that
Reid’s leg pain was related to vascular problems. Reid
underwent an iliac artery angioplasty on May 30, 2006, performed
by Dr. Kevin Beach. By July 10, 2006, Dr. Beach found that Reid
was “doing amazingly well” and “appear[ed] to be a changed man,”
noting that he had lost weight and was exercising.
On October 25, 2006, Reid again visited Dr. Khoury, whom he
had not seen since February. Dr. Khoury concluded that Reid was
“at maximum medical improvement and ha[d] essentially total
disability to the lumbar spine because of his fracture.” He
also concluded that Reid was “not able to return to any kind of
work activity at this point.” A few months later, however, on
January 17, 2007, when Reid visited Dr. Kolehma, he said that he
felt “like a million bucks” after changing drugs. He reported
that he had been cleaning his home and working out.
On April 11, 2007, Reid visited Dr. William Kee, a clinical
psychologist, for help with his anxiety and pain management.
Reid told Dr. Kee that he cooked on a daily basis and cared for
his 12-year-old daughter.
In September 2007, Reid began seeing Drs. Marc Dubick and
Tony Azzolino, who noted that Reid had severe pain below the
fusion site and weakness in the lower lumbar area. Dr. Dubick
administered an epidural injection and Reid experienced “total
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pain relief.” Dr. Dubick reported on December 17, 2007, that
Reid’s “functional level ha[d] increased dramatically.”
Reid continued to go to Dr. Dubick from January 2008 to
July 2009 for injection therapy and pain medication, and during
this period, Dr. Dubick reported that Reid was “doing very
well,” “gardening and doing his normal activities,” “leading a
normal lifestyle,” and “showing some improvement,” although Reid
sometimes complained of “significant pain” and experienced
“quite a bit of discomfort.” In July 2009, Reid suffered a fall
that exacerbated his back pain, but the next month, on August
19, 2009, Dr. Dubick noted that Reid’s “injuries [were] markedly
improved from his fall” and that his back discomfort was
“minor.”
Finally, several times in 2008, Reid visited Summerville
Behavioral Health, complaining of obsessive-compulsive disorder
symptoms and panic attacks.
Reid filed his claim for disability benefits on December 7,
2006, which was denied. Following his request, a hearing was
conducted before an administrative law judge (“ALJ”) on
September 11, 2009. While the ALJ did find that Reid suffered
from several medical impairments, he did not find credible
Reid’s statements about the intensity, persistence, and effects
of his pain and other symptoms in light of the objective
evidence of his residual functionality and positive response to
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treatment. Accordingly, the ALJ found that because Reid could
engage in sedentary work, he “ha[d] not been under a disability
. . . from June 4, 2004 through the date of this decision.”
On review of the ALJ’s decision, the Appeals Council
remanded the case, ordering the ALJ to consider the evidence
from June 4, 2004, forward, which the ALJ had not done because
he thought that res judicata applied to the 2004-2006 period.
The Appeals Council also instructed the ALJ to consider the
effect of Reid’s mental impairments and obesity on his
disability claim.
The ALJ conducted a second hearing on January 18, 2011,
after which he again denied Reid benefits. The ALJ found that
Reid’s severe impairments included adjustment disorder and a
history of obesity, in addition to degenerative disc disease.
Nonetheless, the ALJ found that Reid “did not have an impairment
or combination of impairments that met or medically equaled one
of the listed impairments in 20 CFR Part 404, Subpart P,
Appendix 1.” In making that finding, the ALJ explained that he
“ha[d] considered the combined effects of the claimant’s
impairments, both severe and non-severe, and ha[d] determined
that the findings related to them [were] not at least equal in
severity to” a listed impairment. After recounting Reid’s
medical history in substantial detail, the ALJ found that Reid
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had the residual functional capacity to perform unskilled
sedentary work and thus was not disabled.
Reid again appealed to the Appeals Council, which largely
adopted the ALJ’s findings and conclusions, including the
findings that Reid’s impairments did not meet or medically equal
in severity a listed impairment and that Reid’s subjective
complaints were not credible in light of his residual functional
capacity. Differing from the ALJ, however, the Appeals Council
found that Reid’s adjustment disorder was not severe, and,
therefore, that Reid retained the ability to perform “the full
range of sedentary work.” The Appeals Council’s decision was
the final decision of the Commissioner.
Reid commenced this action, seeking review of the
Commissioner’s decision. He argued, among other things, that
(1) the decision was not based on substantial evidence because
the ALJ failed to consider the evidence between 2004 and 2006
and (2) the ALJ had not evaluated the combined effects of Reid’s
multiple impairments. With respect to the substantial evidence
argument, a magistrate judge found that Reid had failed to show
how he was harmed by any failure on the part of the ALJ to
specifically cite evidence from the 2004-2006 period and that,
in any event, the record indicated that the ALJ and Appeals
Council had indeed considered all the evidence before them. The
magistrate judge also found that the ALJ had explicitly
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considered and discussed Reid’s combination of impairments.
Thus, the magistrate judge recommended affirming the
Commissioner.
The district court followed the magistrate judge’s
recommendation and affirmed, adopting the magistrate judge’s
report and providing additional explanation for its decision.
Reid v. Astrue, No. 6:11-2408-TMC, 2013 U.S. Dist. LEXIS 17815(D.S.C. Feb. 11, 2013).
This appeal followed.
II
Reid raises two issues on appeal. First, he argues that
“[t]he Commissioner’s decision to deny [his] benefits was not
based on the entire record.” Specifically, he criticizes the
ALJ’s discussion of his medical history in the period from 2004
to 2006, noting that “[t]he ALJ referenced evidence from the
period 2004 to 2006 just a few times; and he never mentioned
objective findings which supported Mr. Reid’s claims.” He
contends that this “[f]ailure to consider all relevant evidence
precludes a proper substantial evidence test analysis.” Second,
Reid argues that “the Commissioner failed to provide any
meaningful analysis of the combined effect of his multiple
impairments.”
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We review the district court’s judgment de novo, applying
the same standard of review applied by the district court, and
thus we review the Commissioner’s decision for substantial
evidence. See Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir.
2005) (per curiam). While the Commissioner’s decision must
“contain a statement of the case, in understandable language,
setting forth a discussion of the evidence, and stating the
Commissioner’s determination and the reason or reasons upon
which it is based,” 42 U.S.C. § 405(b)(1), “there is no rigid
requirement that the ALJ specifically refer to every piece of
evidence in his decision,” Dyer v. Barnhart, 395 F.3d 1206, 1211
(11th Cir. 2005) (per curiam); accord Russell v. Chater, No. 94-
2371, 1995 U.S. App. LEXIS 17254, at *8 (4th Cir. July 7, 1995)
(per curiam) (explaining that this Court has not “establish[ed]
an inflexible rule requiring an exhaustive point-by-point
discussion in all cases”).
After carefully reviewing the record in the present case,
we conclude that the Commissioner’s decision satisfied the
statutory requirements. The Commissioner, through the ALJ and
Appeals Council, stated that the whole record was considered,
and, absent evidence to the contrary, we take her at her word.
See Hackett v. Barnhart, 395 F.3d 1168, 1173 (10th Cir. 2005)
(“[O]ur general practice, which we see no reason to depart from
here, is to take a lower tribunal at its word when it declares
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that it has considered a matter”). Moreover, the record shows
that the ALJ’s decision, on which the Commissioner’s decision
was based, specifically referenced Reid’s “history of thoracic
and lumbar fusion,” noting that “treatment notes from the
relevant period document that the claimant was responding well
to treatment with minimal complaints.” This finding -- which
relates to the time period that Reid claims the Commissioner
ignored -- is amply supported by the record. Indeed, Reid has
failed to point to any specific piece of evidence not considered
by the Commissioner that might have changed the outcome of his
disability claim. As such, we conclude that the Commissioner’s
decision was based on the entire record and supported by
substantial evidence.
Reid’s other argument -- that the Commissioner failed to
consider his impairments in combination -- is similarly without
merit. To be sure, an ALJ must “adequately explain his or her
evaluation of the combined effects of [a claimant’s]
impairments.” Walker v. Bowen, 889 F.2d 47, 50 (4th Cir. 1989).
But in the present case, the ALJ did consider Reid’s impairments
in combination. After meticulously describing why Reid’s three
severe impairments -- his degenerative disc disease, adjustment
disorder, and obesity -- did not, individually, qualify as
disabling, the ALJ then considered whether these three
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impairments, cumulatively, would “equal in severity” a listed
impairment:
[T]he undersigned has considered the combined effects
of the claimant’s impairments, both severe and non-
severe, and has determined that the findings related
to them are not at least equal in severity to those
described in Listings 1.00, 4.00, 11.00, and 12.00.
In this consideration, the undersigned has
specifically considered the cumulative effects of the
impairments on the claimant’s ability to work. See
also Walker v. Bowen, 889 F.2d 47 (4th Cir. 1989). The
undersigned notes that the claimant’s heart condition
was asymptomatic despite his history of obesity. Even
with consideration of the combined effects of the
claimant’s obesity, treatment records fail to indicate
that the claimant’s degenerative disc disease status
post fusion resulted in an inability to ambulate or
perform fine or gross motor movements effectively.
The claimant’s physical impairments obviously affected
his mental health condition. Nevertheless, when
considered in conjunction, no further limitation in
the claimant’s mental health condition, other than
those discussed above, are warranted.
(Emphasis added). Relying on this analysis, the ALJ concluded
that Reid “did not have an impairment or combination of
impairments that met or medically equaled one of the listed
impairments.” (Emphasis added). It is thus readily apparent
that the Commissioner specifically contemplated the
combinatorial effects of Reid’s various impairments and, in
doing so, more than satisfied the statutory requirements and our
guidance set forth in Walker.
AFFIRMED
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