Stacy Lewis v. Nancy Berryhill , 858 F.3d 858 ( 2017 )

PUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 15-2473
STACY L. LEWIS,
Plaintiff-Appellant,
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER, SOCIAL SECURITY
ADMINISTRATION,
Defendant-Appellee.
Appeal from the United States District Court for the District of Maryland, at Baltimore.
Stephanie A. Gallagher, Magistrate Judge. (1:14-cv-03694-SAG)
Argued: January 24, 2017 Decided: June 2, 2017
Before AGEE, KEENAN, and THACKER, Circuit Judges.
Vacated and remanded with instructions by published opinion. Judge Agee wrote the
opinion, in which Judge Keenan and Judge Thacker joined.
ARGUED: Gregory Dolin, UNIVERSITY OF BALTIMORE SCHOOL OF LAW,
Baltimore, Maryland, for Appellant. Jay C. Hinsley, SOCIAL SECURITY
ADMINISTRATION, Baltimore, Maryland, for Appellee. ON BRIEF: Meghan E. Ellis,
Third Year Law Student, UNIVERSITY OF BALTIMORE SCHOOL OF LAW,
Baltimore, Maryland, for Appellant. Rod J. Rosenstein, United States Attorney, OFFICE
OF THE UNITED STATES ATTORNEY, Baltimore, Maryland; Aparna V. Srinivasan,
Special Assistant United States Attorney, SOCIAL SECURITY ADMINISTRATION,
Baltimore, Maryland, for Appellee.
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AGEE, Circuit Judge:
Stacy L. Lewis appeals the district court’s decision upholding the Social Security
Administration’s denial of her application for disability insurance benefits and
supplemental security income. Because the administrative law judge (“ALJ”) did not give
appropriate weight to the opinions of Lewis’ treating physicians and failed to adequately
explain his decision to deny her benefits, we vacate the judgment of the district court and
remand for further proceedings.
I.
On October 4, 2010, Lewis filed applications for disability insurance benefits and
supplemental security income with the Acting Social Security Commissioner (the
“Commissioner”), alleging a disability beginning on March 9, 2009, due to obesity,
degenerative disc disease, degenerative joint disease/thoracic outlet syndrome, diabetes
mellitus, lupus, and depression with complaints of anxiety. Because the Commissioner
denied Lewis’ initial application and request for reconsideration, Lewis requested a hearing
before an ALJ. The hearing was granted, but the ALJ denied Lewis’ applications. Lewis
then requested review by the Appeals Council, which was denied. At that point, the ALJ’s
decision became the final decision of the Commissioner.
Subsequently, Lewis filed a complaint in district court against the Commissioner
pursuant to 42 U.S.C. § 405(g). Considering the parties’ cross-motions for summary
3
judgment, a United States magistrate judge 1 issued a letter opinion observing that “Ms.
Lewis is correct that, if the ALJ had credited her testimony, he likely would have concluded
that she is unable to work.” J.A. 15. Nevertheless, the magistrate judge ultimately denied
Lewis’ motion, granted the Commissioner’s motion, and affirmed the Commissioner’s
final decision denying benefits.
Lewis timely appealed, and this Court has jurisdiction pursuant to 28 U.S.C. § 1291and 42 U.S.C. § 405(g).
A.
To provide context for our consideration of this case, we begin with an overview of
the sequential evaluation that ALJs must follow when making disability determinations.
The relevant Social Security Administration regulations set forth a comprehensive five-
step process:
[T]he ALJ asks at step one whether the claimant has been working; at step
two, whether the claimant’s medical impairments meet the regulations’
severity and duration requirements; at step three, whether the medical
impairments meet or equal an impairment listed in the regulations; at step
four, whether the claimant can perform her past work given the limitations
caused by her medical impairments; and at step five, whether the claimant
can perform other work.
Mascio v. Colvin, 780 F.3d 632, 634 (4th Cir. 2015); see also 20 C.F.R. §§ 404.1520(a)(4),
416.920(a)(4). The claimant bears the burden to make the requisite showing during the
first four steps. Monroe v. Colvin, 826 F.3d 176, 179–80. (4th Cir. 2016). If the claimant
1
The parties consented to trial by a magistrate judge. See generally Fed. R. Civ. P.
73.
4
fails to carry that burden at any step, she is determined not to be disabled. If the claimant
does meet her burden of proof, the burden then shifts to the Commissioner at step five. Id.
at 180. The Commissioner does not contest that Lewis met her burden as to steps one and
two, so we focus on steps three through five as those are most relevant to the issues before
us.
If the claimant fails to demonstrate she has a disability that meets or medically
equals a listed impairment at step three, the ALJ must assess the claimant’s residual
functional capacity (“RFC”) before proceeding to step four, which is “the most [the
claimant] can still do despite [her physical and mental] limitations [that affect h[er] ability
to work].” 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1). That determination requires the
ALJ to “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, 780 F.3d at 636 (internal quotations omitted); see also SSR
96-8p, 1996 WL 374184, at *1 (July 2, 1996). Once the function-by-function analysis is
complete, an ALJ may define the claimant’s RFC “in terms of the exertional levels of work,
sedentary, light, medium, heavy, and very heavy.” SSR 96-8p, 1996 WL 374184, at *1.
See generally 20 C.F.R. §§ 404.1567, 416.967 (defining “sedentary, light, medium, heavy,
and very heavy” exertional requirements of work).
When assessing the claimant’s RFC, the ALJ must examine “all of [the claimant’s]
medically determinable impairments of which [the ALJ is] aware,” 20 C.F.R. §§
404.1525(a)(2), 416.925(a)(2), “including those not labeled severe at step two.” Mascio,
780 F.3d at 635. In addition, he must “consider all [the claimant’s] symptoms, including
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pain, and the extent to which [her] symptoms can reasonably be accepted as consistent with
the objective medical evidence and other evidence,” 20 C.F.R. §§ 404.1529(a), 416.929(a).
“When the medical signs or laboratory findings show that [the claimant has] a medically
determinable impairment(s) that could reasonably be expected to produce [her] symptoms,
such as pain, [the ALJ] must then evaluate the intensity and persistence of [the claimant’s]
symptoms so that [the ALJ] can determine how [her] symptoms limit [her] capacity for
work.” 20 C.F.R. §§ 404.1529(c)(1), 416.929(c)(1).
After assessing the claimant’s RFC, the ALJ continues with the fourth step, where
the claimant must establish she is unable to perform past work. Mascio, 780 F.3d at 635.
If she meets her burden as to past work, the ALJ proceeds to step five.
“At step five, the burden shifts to the Commissioner to prove, by a preponderance
of the evidence, that the claimant can perform other work that ‘exists in significant numbers
in the national economy,’ considering the claimant’s residual functional capacity, age,
education, and work experience.” Id. (quoting 20 C.F.R. §§ 416.920(a)(4)(v),
416.960(c)(2), 416.1429). “The Commissioner typically offers this evidence through the
testimony of a vocational expert responding to a hypothetical that incorporates the
claimant's limitations.” Id. If the Commissioner meets this burden, the claimant is deemed
not disabled and her benefits application is denied. Id.B.
Following this regulatory assignment of the burden of proof and evidentiary
standards, we summarize the evidence before the ALJ as it relates to this appeal, including
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testimony and medical records, and then describe the ALJ’s reasoning in denying Lewis
benefits.
At the time of the ALJ hearing on August 22, 2013, Lewis was 38 years old. She
testified that she has a B.S. in criminal justice and an employment history that included
residential counselor at Maryland Sherriff’s Youth Ranch, deli worker, and store clerk.
She reported that she stopped working as a residential counselor on March 9, 2009, when
she was slated to be switched to an afternoon shift that would have exacerbated her
diabetes. She claims she has been unable to work since then because of her combined
medical impairments.
Lewis reports a myriad of severe medical impairments, which include insulin-
dependent diabetes, with no neuropathy or end-organ failure, as well as lupus for which
she takes prednisone as she experiences symptom flares, though it has been in remission
since August 2012. She has a bulge on one of her lumbar disks, which causes her to walk
with a limp at times and to experience tingling and numbing down the back of her left leg.
In addition, Lewis has autoimmune anemia, which is generally under control. She further
experiences non-exertional pain in her left arm from thoracic outlet syndrome that causes
her left hand to have tremors and to go numb. Lewis describes the pain as “stabbing,
burning, tingling pain” and “throbbing pain” in her back, as well as pain that is “constant
in [her] arm,” and prevents her from sleeping at night. A.R. 56. She also has mental
impairments, including depression and anxiety, for which she takes medication.
These severe medical impairments significantly limit her ability to do basic work
activities. Lewis stated she can lift approximately five pounds with her left hand and fifteen
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to twenty pounds with her right, but can sit for no more than thirty minutes before
experiencing pain in her shoulder and the back of her neck. She has a driver’s license and
her own car, which she “can drive short distances, about five to 10 miles” at least five times
per week, but she can only go grocery shopping with assistance. A.R. 52.
In addition to Lewis’ testimony, the ALJ called a vocational expert (“VE”) to testify
at the administrative hearing. In questioning the VE, the ALJ described a hypothetical
individual possessing the same limitations as Lewis. The VE testified that such a
hypothetical person could not perform any of Lewis’ past relevant work. However, the VE
testified that there were jobs in the national economy that such a person could perform and
specifically identified jobs of call-out operator, surveillance monitor, and charge account
clerk.
When questioned by Lewis’ attorney, the VE testified that if the hypothetical person
needed to walk away from her work station and be off task for more than ten percent of the
time then she would not be able to maintain employment. The ALJ then inquired as to
whether a hypothetical person could maintain employment if they had Lewis’ ailments and
must rest ten minutes every two hours. The VE stated that under those circumstances the
hypothetical individual would not be able to maintain employment.
C.
In addition to the testimonial evidence, the administrative record contains medical
records from several of Lewis’ treating physicians, including Dr. Shahid Mahmood, who
has treated Lewis since 2009. Dr. Mahmood’s medical opinion noted that Lewis could sit
for up to two hours and stand/walk for three hours in a normal competitive work
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environment. He further opined that she can rarely lift ten pounds, that her condition
impairs her ability to keep her neck in a constant position, that she cannot push/pull, can
tolerate only low stress work, and would need to be absent from work three times per
month. Dr. Mahmood further stated that the diagnosis and prognosis of Lewis’ pain is
unknown, that she reports her pain as ten out of ten, and that she is not a malingerer. Dr.
Mahmood also noted that she was taking medications that included Lidoderm Patches,
Fentanyl Patches, and Oxycodone. 2
Evidence from Lewis’ treating rheumatologist, Dr. Ashok Jacob, is also in the
administrative record. Dr. Jacob noted Lewis has bilateral arthritis in her hands, wrists,
and shoulders; pericarditis; pleuritic, hemolytic anemia/leukopenia; and systemic lupus.
He noted she can sit for two hours and stand/walk for up to one hour in a competitive work
environment, and she can occasionally lift or carry up to five pounds, but she experiences
constant pain that interferes with her attention and concentration. He further stated that
she is incapable of performing even low stress jobs, as “stress increases frequency of
flares.” A.R. 924. Dr. Jacob noted Lewis would need to be absent from work more than
three times per month, but is not a malingerer, and she “will experience severe pain,
swelling, stiffness and fatigue throughout her body making daily functions very difficult
for the rest of her lifetime.” A.R. 925.
2
Lewis also underwent numerous tests including X-Rays, MRIs, EMGs in an
attempt to identify the cause of her pain. Although these diagnostic procedures did not
conclusively establish the cause of her upper extremity pain, none of those tests proved to
be normal.
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Lewis underwent additional examinations with State agency medical and
psychological consultants, who concluded that she was limited to light work activity with
postural, manipulative, environmental, and mental restrictions.
D.
The ALJ’s decision was issued in August 2013 and determined that Lewis was not
disabled during the relevant period. The ALJ found that Lewis met her burden at step one
to show she had not been working since the onset of the disability. At step two, he found
that Lewis had the following severe, medically determinable impairments: obesity,
degenerative disc disease, degenerative joint disease/thoracic outlet syndrome, diabetes
mellitus, lupus, and depression with complaints of anxiety.
At step three, the ALJ determined that none of Lewis’ impairments, alone or in
combination, met or medically equaled any of the listed impairments. The ALJ then
assessed Lewis’ RFC and determined she could perform “light work,” except that—
[T]he claimant can lift 10 pounds frequently and 20 occasionally with her
dominant right upper extremity, but she can lift five pounds frequently and
10 occasionally with her non-dominant left upper extremity. The claimant
can push and pull with her bilateral upper extremities five pounds frequently
and 10 occasionally. The claimant is limited to jobs with no overhead work
with her left arm, and her reaching ability with left arm, both laterally and in
front, is limited to occasionally. Furthermore, she is limited to no more than
occasional fine and gross dexterity with the left arm and hand. Ms. Lewis is
limited to work in an inside environment without excessive heat, cold, or
humidity. She requires jobs that allow her to change positions once per hour.
Finally, Ms. Lewis is limited to simple routine tasks, with positions that allow
her to be off task about 5% of the time, rest for 10 minutes every two hours,
and miss eight days of work per year.
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A.R. 23. This assessment conflicted with Lewis’ testimony regarding her symptoms and
resulting functional limitations. While the ALJ found Lewis’ claimed symptoms
reasonably could be expected to be caused by her impairments, the ALJ nevertheless
determined that Lewis’ “statements concerning the intensity, persistence and limiting
effects of these symptoms are not entirely credible” because “[the] objective findings of
the claimant’s treating and examining sources do not support the severity of assessed
restrictions that Ms. Lewis has alleged.” A.R. 25, 28.
The ALJ’s analysis regarding Lewis’ chronic pain in her upper left extremity bears
particular relevance to the issues on appeal. As to that impairment, the ALJ stated:
[T]he medical evidence documents the claimant’s long history of shoulder
and upper extremity pain. Ms. Lewis has undergone several surgical
procedures in the course of her treatment regimen including a carpal tunnel
release, left de Quervain tenosynovitis release, and decompression of the left
ulnar nerve at the cubital tunnel. In late 2011, the claimant underwent several
procedures to treat thoracic outlet syndrome, including a left first rib
resection. In early 2012, she was diagnosed with lupus and prescribed anti-
inflammatory medications to control the acute symptoms. However, the
record reflects that the claimant recovered from her procedures without
incident or acute complication. The claimant testified that her lupus has been
in remission since August of 2012. Follow-up physical examinations noted
ongoing complaints of pain; however, there was 5/5 muscle strength in all
major muscle groups, normal sensation and reflexes, and no evidence of
acute range of motion irregularities.
***
The State agency consultants concluded that the claimant is limited to light
work activity with postural, manipulative, environmental, and mental
restrictions. The undersigned gives these opinions limited weight, because
the longitudinal record supports additional exertional and non-exertional
restrictions.
***
[The ALJ then summarized the findings of Dr. Mahmood and Dr. Jacob
described above.] The undersigned gives these opinions partial weight,
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because the severity of assessed exertional and non-exertional limitations is
not entirely consistent with the longitudinal conservative treatment record,
the documented clinical and examination findings, and Ms. Lewis’ stated
ongoing capabilities.
A.R. 28–29. With regard to the functional limits resulting from Lewis’ obesity,
degenerative disc disease, diabetes mellitus, lupus, and depression/anxiety, the ALJ found
that they were consistent with her RFC.
At step four, taking into account Lewis’ RFC, the ALJ determined she was unable
to perform her past work. However, relying on the testimony of the VE, the ALJ found
that jobs did exist in the national economy for a person with Lewis’ age, education, work
experience, and RFC. Accordingly, the ALJ concluded that Lewis was not disabled and
denied her application for benefits.
II.
Section 405(g) of Title 42 of the United States Code provides judicial review of the
Social Security Commissioner’s denial of social security benefits. When examining a
disability determination, a reviewing court is required to uphold the determination when
an ALJ has applied correct legal standards and the ALJ’s factual findings are supported by
substantial evidence. 42 U.S.C. § 405(g); Bird v. Comm'r of Soc. Sec. Admin., 699 F.3d
337, 340 (4th Cir. 2012).
On appeal, Lewis contends the ALJ failed to satisfactorily explain his decision not
to credit her subjective complaints of chronic, non-exertional pain in her upper left
extremity. Disputes over the role of subjective evidence in proving pain are nothing new.
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“This circuit has battled the [Commissioner] for many years over how to evaluate a
disability claimant's subjective complaints of pain.” Mickles v. Shalala, 29 F.3d 918, 919
(4th Cir. 1994) (Hall, J., concurring). Under the regulations implementing the Social
Security Act, an ALJ follows a two-step analysis when considering a claimant’s subjective
statements about impairments and symptoms. 20 C.F.R. §§ 404.1529(b)–(c), 416.929(b)–
(c). First, the ALJ looks for objective medical evidence showing a condition that could
reasonably produce the alleged symptoms. Id. §§ 404.1529(b), 416.929(b). Second, the
ALJ must evaluate the intensity, persistence, and limiting effects of the claimant’s
symptoms to determine the extent to which they limit the claimant’s ability to perform
basic work activities. Id. §§ 404.1529(c), 416.929(c). The second determination requires
the ALJ to assess the credibility of the claimant’s statements about symptoms and their
functional effects. Id. §§ 404.1529(c)(4), 416.929(c)(4).
The parties agree that the ALJ properly found that Lewis met the requirements of
the first step in the analysis, i.e. that Lewis’ medically determinable impairments “could
reasonably be expected to produce the pain or other symptoms alleged.” Id.
§§ 404.1529(b), 416.929(b). They diverge, however, as to the second step of the analysis.
Lewis contends the ALJ erred at the second step when it concluded her “statements
concerning the intensity, persistence, and limiting effects of these symptoms [we]re not
entirely credible.” A.R. 25. Lewis urges us to find the ALJ’s conclusion on the second
prong of the analysis was error because it misapprehended the objective medical evidence,
failed to give appropriate weight to the medical opinions of her treating physicians,
improperly concluded that her course of treatment was “conservative,” and improperly
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assessed her ability to perform limited household chores as evidence of non-impairment.
We address these arguments in turn.
A.
First, Lewis contends the ALJ improperly discounted her subjective evidence of
pain based solely on the lack of objective evidence of pain intensity. According to the
regulations, the ALJ “will not reject your statements about the intensity and persistence of
your pain or other symptoms or about the effect your symptoms have on your ability to
work solely because the available objective medical evidence does not substantiate your
statements.” 20 C.F.R. §§ 404.1529(c)(2), 416.929(c)(2). Thus, Lewis’ subjective
evidence of pain intensity cannot be discounted solely based on objective medical findings.
See id. §§ 404.1529(c)(2), 416.929(c)(2).
Moreover, the ALJ failed to explain in his decision what statements by Lewis
undercut her subjective evidence of pain intensity as limiting her functional capacity. See
Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013) (“A necessary predicate to engaging
in substantial evidence review is a record of the basis for the ALJ’s ruling,” including “a
discussion of which evidence the ALJ found credible and why, and specific application of
the pertinent legal requirements to the record evidence.”); see also SSR 96-8p, 1996 WL
374184, at *7 (explaining that the residual functional capacity “assessment must include 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).”). Accordingly, we find the ALJ’s determination that objective medical
14
evidence was required to support Lewis’ evidence of pain intensity improperly increased
her burden of proof. See 20 C.F.R. §§ 404.1529(c)(2), 416.929(c)(2).
B.
We turn next to Lewis’ argument that the ALJ improperly discredited the opinions
of her treating physicians, which Lewis maintains corroborate her subjective complaints of
pain.
Pursuant to the regulations:
Because symptoms, such as pain, are subjective and difficult to quantify, any
symptom-related functional limitations and restrictions that your medical
sources or nonmedical sources report, which can reasonably be accepted as
consistent with the objective medical evidence and other evidence, will be
taken into account as explained in [20 C.F.R. § 404.1529(c)(4) and §
416.929(c)(4)] in reaching a conclusion as to whether you are disabled.
Id. §§ 404.1529(c)(3), 916.929(c)(3). And treating physicians are given “more
weight . . . since these sources are likely to be the medical professionals most able to
provide a detailed, longitudinal picture of your medical impairment(s) and may bring a
unique perspective to the medical evidence that cannot be obtained from the objective
medical findings alone[.]” Id. §§ 404.1527(c)(2), 416.927(c)(2). “When the treating
source has seen you a number of times and long enough to have obtained a longitudinal
picture of your impairment, we will give the medical source’s medical opinion more weight
than we would give it if it were from a nontreating source.” Id. §§ 404.1527(c)(2)(i),
416.927(c)(2)(i). Accordingly, the ALJ is required to give “controlling weight” to opinions
proffered by a claimant’s treating physicians so long as the opinion is “well-supported by
medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent
15
with the other substantial evidence in [the claimant’s] case record[.]” Id.
§§ 404.1527(c)(2), 416.927(c)(2).
Lewis provided medical records containing opinions from two of her treating
physicians, including her treating rheumatologist, Dr. Jacob. He opined that Lewis’ pain
constantly interfered with attention and concentration, she was precluded from lifting more
than five pounds of weight and was incapable of even low stress jobs. Indeed, Dr. Jacob
noted in Lewis’ medical chart that she “will experience severe pain, swelling, stiffness, and
fatigue throughout her entire body making daily functions very difficult for the rest of her
lifetime.” A.R. 925. The ALJ gave short shrift to Dr. Jacob’s opinion, but also discounted
the opinion of Lewis’ primary treating physician, Dr. Mahmood, who treated Lewis for
four years essentially on a bi-weekly basis. Dr. Mahmood opined that Lewis cannot sit for
more than two hours, stand/walk for more than three hours, and has significant limitations
in tasks such as handling, reaching, fingering, lifting, and keeping her neck in a constant
position. He marked her pain as seven of ten on a ten point scale.
The ALJ failed to adequately explain why he failed to give the opinions of Lewis’
treating physicians “controlling weight” under 20 C.F.R. § 404.1527(c)(2) and
§ 416.927(c)(2). In contrast to Lewis’ well-documented medical history, the ALJ’s
rejection of Lewis’ treating physician sources is perfunctory. The ALJ points to nothing
in the record indicating that any non-treating sources disputed that the medical opinions of
Drs. Jacob and Mahmood were not “well-supported by medically acceptable clinical and
laboratory diagnostic techniques.” 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2). Indeed,
the ALJ’s analysis spans only four lines and overlooks critical aspects of Lewis’ medical
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treatment history. For instance, the ALJ fails to note that neither of Lewis’ treating
physicians suspected her of exaggerating her symptoms and that she endured various
adjustments to her medications as they lost effectiveness over time (without any evidence
of drug-seeking behavior). The ALJ’s cursory analysis overlooks Dr. Jacob’s and Dr.
Mahmood’s consistent medical conclusions about Lewis’ limited abilities to stand, sit, lift,
grip, or perform other manual tasks. Accordingly, the ALJ’s analysis has impermissible
gaps when describing the opinions of Lewis’ treating physician and her overarching
medical history.
Furthermore, the opinions of outside physicians hired to evaluate Lewis’ medical
records bolster the opinions of the treating physicians, yet the ALJ ignored their
conclusions. Those non-treating sources concluded that Lewis’ “statements about the
intensity, persistence, and functionally limiting effects of [the] symptoms” were
“substantiated by the objective medical evidence alone.” A.R. 74. Indeed, all of the
medical professionals who examined Lewis provided opinions consistent with her treating
physicians that Lewis suffers from “significant, persistent, and very debilitating pain in her
neck and upper extremity.” E.g., A.R. 604.
To the extent the ALJ suggests Lewis is malingering, that conclusion is directly
contradicted by the record. Both of Lewis’ treating physicians (Dr. Mahmood and Dr.
Jacobs) opined that there was no suggestion of malingering or exaggeration of pain.
Further, the Commissioner’s own medical expert specifically noted that Lewis’
“[c]redibility is full.” A.R. 90. And Lewis’ subjective reports of pain are consistent
throughout the record—she reports on numerous medical reports severe pain at a ten out
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of ten level that is disabling. In short, the ALJ inappropriately substituted a subjective
decision for that of the overwhelming medical evidence in this case by opining that Lewis
over-reported her pain. The ALJ offered no record evidence supporting that conclusion.
Our examination of the record makes clear that the ALJ’s conclusions do not fully account
for the characteristics of Lewis’ ailments and symptoms regarding pain. 3
In sum, the ALJ erred by failing to appreciate the consistent prognosis of Lewis’
treating physicians in contravention of the mandate that “controlling weight” be accorded
to such opinions. See 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2). The ALJ’s failure to
“build an accurate and logical bridge from the evidence to his conclusion” constitutes
reversible error. Monroe, 826 F.3d at 189; accord id. at 191 (rejecting cursory analysis of
the ALJ as to whether there existed objective evidence of medical impairment that
precluded “meaningful substantial-evidence review”).
C.
Turning to Lewis’ third argument, she maintains the ALJ mischaracterized her
treatment record as “conservative.” We agree the ALJ’s determination in this regard is
difficult to reconcile with the record. Lewis has a documented and exhaustive medical
history, which includes degenerative changes in her spine, a sclerotic lesion centered in the
3
The ALJ points to Lewis’ ability to perform incremental activities interrupted by periods
of rest, such as “driv[ing] short distances of up to 30 miles, shop for groceries with the
assistance of her mother or roommate, handle her finances, and watch television.” A.R.
24–25. The ALJ’s conclusion that Lewis’ activities demonstrate she is capable of work is
unsupported by the record. See Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998)
(“[D]isability claimants should not be penalized for attempting to lead normal lives in the
face of their limitations.”).
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left humeral metadiaphysis, lupus with corresponding symptoms, spinal stenosis, and
injury to her brachial plexus and corresponding nerve damage. Dr. Jacob’s assessment of
Lewis’ functional impairment, along with Lewis’ subjective complaints of pain, are
consistent with Lewis’ numerous ailments.
Lewis’ multiple medical conditions require her to take powerful analgesics,
including Fentanyl and Oxycodone. Furthermore, Lewis endured multiple surgeries, one
of which required removal of her first left rib to alleviate pain. Before those surgeries,
Lewis underwent a lumbar epidural injection, two supraspinatus nerve blocks, and a
radiofrequency ablation of her supraspinatus nerve. In light of the extensive treatment
Lewis received for her various conditions, the ALJ’s designation of Lewis’ course of
treatment as “conservative” amounts to improperly “playing doctor” in contravention of
the requirements of applicable regulations. 20 C.F.R. §§ 404.1529, 416.929; Hill v. Colvin,
807 F.3d 862, 868 (7th Cir. 2015) (“The ALJ’s conclusion is not supported by any medical
evidence in the record; it amounts to the ALJ improperly ‘playing doctor.”).
D.
As for the Commissioner’s arguments, she hones in on two “objective” findings that
purportedly support the ALJ’s conclusion. First, she focuses on the MRI and EMG studies
that, although not “normal,” did not show substantial abnormalities. Second, the
Commissioner cites to several examinations which “demonstrated normal muscle tone,
normal gait with no deviation or assistive devices; and 5/5 muscle strength testing in all
major muscle groups of upper and lower extremities[.]” Resp. Br. 35. These medical
19
records “reflect[] the breadth of evidence considered and discussed by the ALJ,” according
to the Commissioner. Resp. Br. 35. We are not persuaded.
“An ALJ has the obligation to consider all relevant medical evidence and cannot
simply cherrypick facts that support a finding of nondisability while ignoring evidence that
points to a disability finding.” Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010). In the
same medical records containing the “normal” findings relied upon by the ALJ, the
physician also noted that Lewis presented with “stabbing, burning throbbing and tingling,
constant pain that increases with elevating the hand above the shoulder and decreases by
rest. . . . [n]eck pain is really bothering her today,” A.R. 936; that a left shoulder MRI
“showed scelerotic [sic] lesion,” A.R. 939; and that Lewis indicated “left shoulder pain
with marked discomfort on [range of motion] . . . with pain on shoulder abduction and
extension of arm,” A.R. 939. And Lewis was given a steroid injection into her shoulder
at the conclusion of the appointment.
Furthermore, the ALJ did not indicate how the results he cited were relevant to the
functional limitations Lewis suffered as a result of her chronic, non-exertional pain in her
left shoulder. See Monroe, 826 F.3d at 190 (“In citing ‘normal’ results from pulmonary
and respiratory tests and an EEG, the ALJ did not explain why he believed these results
had any relevance to the question of what symptoms Monroe suffered from narcolepsy.”).
The ALJ does not explain, for instance, how Lewis’ normal gait bears any nexus to her
complaint of chronic shoulder pain.
Lastly, the Commissioner relies on our decision in Gross v. Heckler, 785 F.2d 1163(4th Cir. 1986), in which we stated “subjective evidence of pain cannot take precedence
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over objective medical evidence or the lack thereof.” Id. at 1166. In that case, however,
the claimant complained of chest pain without any medically acceptable evidence
demonstrating an “anatomical, physiological, or psychological abnormalit[y]” that could
cause such pain. Id. Lewis’ circumstances are quite different from those of the claimant
in Gross. In contrast to the claimant in Gross, the ALJ here did find that Lewis’ pain does
“result from anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” Id.Lewis does not argue her subjective claims of the existence of pain take precedence over
objective medical evidence, but rather that she not be required to meet an additional burden
of proffering objective evidence of the intensity of her pain. See Hines v. Barnhart, 453
F.3d 559, 565 (4th Cir. 2006) (“Having met his threshold obligation of showing by
objective medical evidence a condition reasonably likely to cause the pain claimed, [the
claimant] was entitled to rely exclusively on subjective evidence to prove the second part
of the test, i.e., that his pain is so continuous and/or so severe that it prevents him from
working a full eight hour day.” (footnote omitted)).
***
In conclusion, we do not reflexively rubber-stamp an ALJ’s findings. See id. at 566(“The deference accorded an ALJ’s findings of fact does not mean that we credit even those
findings contradicted by undisputed evidence.”). The ALJ’s decision applied an improper
legal standard to discredit Lewis’ evidence of pain intensity and the opinions of her treating
physicians. Further, the ALJ failed to adequately explain the reasons for denying Lewis
benefits given her extensive medical history, thus precluding our ability to undertake the
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“meaningful review” with which we are tasked on appeal. Radford, 734 F.3d at 296. Given
the complexity of the record, we decline to apply these principles in the first instance and
remand accordingly. See id.
III.
For the reasons set forth, the judgment is vacated and this case is remanded with
instructions that the district court remand the case for further proceedings before the
agency.
VACATED AND REMANDED
WITH INSTRUCTIONS
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