Paula Felton-Miller v. Michael Astrue

UNPUBLISHED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Affirmed by unpublished per curiam opinion.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Unpublished opinions are not binding precedent in this circuit.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;
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(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)
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(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).
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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
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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
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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).
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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.
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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.
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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
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