Wills v. Kijakazi

Case: 22-20609 Document: 00516786292 Page: 1 Date Filed: 06/14/2023
United States Court of Appeals
for the Fifth Circuit United States Court of Appeals
Fifth Circuit
____________ FILED
June 14, 2023
No. 22-20609 Lyle W. Cayce
____________ Clerk
Linda Jeanette Wills,
Plaintiff—Appellant,
versus
Kilolo Kijakazi, Acting Commissioner of Social Security,
Defendant—Appellee.
______________________________
Appeal from the United States District Court
for the Southern District of Texas
USDC No. 4:21-CV-1391
______________________________
Before Wiener, Southwick, and Duncan, Circuit Judges.
Per Curiam: *
The district court affirmed the Social Security Commissioner’s
decision denying disability benefits to Linda Wills. Wills contends the
Administrative Law Judge failed to develop the record in assessing her
Residual Functional Capacity and, therefore, the denial of benefits is not
supported by substantial evidence. We disagree. AFFIRMED.
_____________________
*
This opinion is not designated for publication. See 5th Cir. R. 47.5.
Case: 22-20609 Document: 00516786292 Page: 2 Date Filed: 06/14/2023
No. 22-20609
FACTUAL AND PROCEDURAL BACKGROUND
On December 28, 2018, Linda Jeanette Wills applied for Title II Social
Security disability benefits. She alleged her disability began December 16,
2017, due to physical impairments, vision problems, depression, asthma, and
migraines.
On initial review, a State Agency Medical Consultant (“SAMC”)
determined on March 5, 2019, that Wills had no exertional limitations and
was not disabled. The SAMC nonetheless recommended she avoid
concentrated exposure to extreme temperatures, wetness, humidity, and
pulmonary irritants, and avoid all exposure to hazards.
Wills asked for reconsideration. In a decision of May 28, 2019, a
different SAMC assessed Wills as having limited left near and far acuity,
limited depth perception, and limited field of vision. The SAMC
recommended she avoid concentrated exposure to hazards and working with
moving objects, scaffolds, and heights. She was again, though, found not to
be disabled.
In the reconsideration decision, Wills was informed she could request
a hearing before an Administrative Law Judge (“ALJ”). She made that
request, and a telephonic hearing was conducted on August 13, 2020. Wills
was represented by counsel.
Wills and a vocational expert testified at the hearing. Wills stated that,
prior to surgery in November 2019, she “was crawling around [her] house,
[because she] couldn’t stand or walk.” Since the surgery, her condition had
improved. Still, she had been experiencing pain and stiffness in her back and
neck. Additionally, looking down caused headaches and numbness in her
face and neck. All of this, she claimed, made walking and sitting painful. She
explained that she could walk to her mailbox — though with pain — before
having to rest, and that on her “good days” she could walk to the corner of
2
Case: 22-20609 Document: 00516786292 Page: 3 Date Filed: 06/14/2023
No. 22-20609
her street. Moreover, she could sit for approximately 15 to 20 minutes before
having to change positions, and she could stand for approximately 20
minutes, provided she was able to move around. She further stated that she
could not reach upward without becoming dizzy.
The ALJ determined Wills had not engaged in substantial gainful
activity since her alleged disability date and was significantly limited by her
physical, but not her mental, impairments. Additionally, her impairments
did not meet the severity of any of the enumerated conditions in the
applicable regulation. Further, the ALJ found that although Wills’s
“impairments could reasonably be expected to cause the alleged symptoms,”
she was not as limited as she claimed.
The ALJ determined Wills had the Residual Functional Capacity
(“RFC”) to perform “sedentary work with an option to alternate sitting and
standing.” 1 In addition, the ALJ provided that Wills’s ability to work would
be further restricted by a host of physical limitations due to her cervical
degenerative disc disease, vertigo, arthritis, impaired vision, and asthma.
The ALJ also found, based on the vocational expert’s testimony, that
even though Wills’s RFC made her unable to perform any past relevant work,
she had acquired skills from her work experience which were transferable to
other occupations existing in significant numbers without vocational
adjustment. Therefore, the ALJ concluded she was not disabled during the
alleged disability period and denied her application.
_____________________
1
“Sedentary work involves lifting no more than 10 pounds at a time and
occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although
a sedentary job is defined as one which involves sitting, a certain amount of walking and
standing is often necessary in carrying out job duties.” 20 C.F.R. § 404.1567(a).
3
Case: 22-20609 Document: 00516786292 Page: 4 Date Filed: 06/14/2023
No. 22-20609
The Appeals Council denied Wills’s request for review, making the
ALJ’s opinion the Commissioner’s final decision. See Sims v. Apfel, 530 U.S.
103, 106–07 (2000).
Wills petitioned for review in district court as permitted by 42 U.S.C.
§ 405(g). The parties consented to proceed before a magistrate judge.
Summary judgment was granted in favor of the Commissioner, and Wills
timely appealed.
DISCUSSION
Our review “is exceedingly deferential and limited to two inquiries:
whether substantial evidence supports the ALJ’s decision, and whether the
ALJ applied the proper legal standards when evaluating the evidence.”
Taylor v. Astrue, 706 F.3d 600, 602 (5th Cir. 2012). “Substantial evidence is
such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” Perez v. Barnhart, 415 F.3d 457, 461 (5th Cir. 2005)
(quotation marks and citation omitted). “A finding of no substantial
evidence is appropriate only if no credible evidentiary choices or medical
findings support the decision.” Whitehead v. Colvin, 820 F.3d 776, 779 (5th
Cir. 2016) (emphasis added) (quotation marks and citation omitted). We
must “not reweigh the evidence or substitute [our] judgment for the
Commissioner’s.” Perez, 415 F.3d at 461.
In making a disability determination, the Commissioner follows a five-
step approach and considers:
(1) whether the claimant is engaged in substantial gainful
activity, (2) the severity and duration of the claimant’s
impairments, (3) whether the claimant’s impairment meets or
equals one of the listings in the relevant regulations, (4)
whether the claimant can still do his past relevant work, and (5)
whether the impairment prevents the claimant from doing any
relevant work.
4
Case: 22-20609 Document: 00516786292 Page: 5 Date Filed: 06/14/2023
No. 22-20609
Webster v. Kijakazi, 19 F.4th 715, 718 (5th Cir. 2021) (quotation marks and
citation omitted).
A claimant’s RFC represents the most the claimant can do in a work
setting with her limitations. 20 C.F.R. § 404.1545(a)(1). The RFC is used at
steps four and five to determine if she can still perform her past relevant work
or adjust to other work. Perez, 415 F.3d at 461–62 (citing 20 C.F.R. §
404.1520(e)).
Wills argues here, first, that the ALJ failed to develop the record
adequately before making her RFC determination. That led, second, to the
ALJ’s impermissibly drawing conclusions from raw medical data based only
on her lay interpretation. Finally, those shortcomings mean the RFC
determination is not supported by substantial evidence. We will separately
consider each of those arguments.
I. Development of the record
Wills argues the ALJ failed to develop the record, which led to
applying the incorrect legal standard, for two reasons: (1) the ALJ relied on
stale medical opinions, and (2) the ALJ should have obtained a consultative
examination regarding Wills’s ability to work in her deteriorated condition.
Wills contends the two SAMC opinions were “stale” because they
were rendered before her lumbar/cervical condition deteriorated and
additional procedures were performed, particularly her November 2019
surgery. Wills avers that, by relying on unusable medical opinions, the ALJ
effectively did not rely on any medical opinion.
First, the record does not support that the ALJ even relied on the
SAMC opinions. The ALJ stated she had “considered both prior
administrative medical findings; however, both [were] inconsistent with the
overall record and fail[ed] to consider all impairments.” Wills maintains that
5
Case: 22-20609 Document: 00516786292 Page: 6 Date Filed: 06/14/2023
No. 22-20609
the ALJ must have implicitly relied on those administrative findings, at least
in part, because her ordered limitations incorporate aspects of those findings.
That is unconvincing speculation, however, in light of the ALJ’s directly
indicating the contrary. The ordered limitations share some similarities with
the SAMC opinions, but that does not invalidate them.
Second, even if the ALJ did partially rely on the SAMC reports, and
even if those findings were stale, Wills fails to show this would constitute
error. That is particularly so here where the ALJ acknowledged the
shortcomings of the reports and proceeded to incorporate additional
symptoms in imposing her more restrictive limitations — that is, more
favorable to Wills — than those previously suggested. Rather, the applicable
regulations support that the ALJ was entitled to find the administrative
findings partially persuasive and then use those findings, together with other
relevant record evidence, in making her RFC determination. See 20 C.F.R.
§ 404.1520c (providing Commissioner will determine “how persuasive” it
finds medical opinions and prior administrative medical findings); id. §
404.1545(a)(3) (“We will assess your [RFC] based on all of the relevant
medical and other evidence.” (emphasis added)).
Wills additionally argues the ALJ at least should have obtained a
consultative examination to account for her deteriorated condition. Wills, in
her opening brief, appears to interpret a series of district court decisions —
not holdings from this court — as stating a per se rule that the ALJ fails to
develop the record if: (a) the only medical opinion speaking to the effect of a
claimant’s impairments on her ability to work is provided prior to a
significant development in the claimant’s condition; and (b) the ALJ does not
order a consultative examination to consider that development. We interpret
her reply brief as arguing a lesser point that, in this case, an additional medical
opinion was needed.
6
Case: 22-20609 Document: 00516786292 Page: 7 Date Filed: 06/14/2023
No. 22-20609
We conclude that any per se rule is inappropriate and instead rely on
the duty of an ALJ “to develop the facts fully and fairly relating to an
applicant’s claim for disability benefits.” See Boyd v. Apfel, 239 F.3d 698, 708
(5th Cir. 2001) (quotation marks and citations omitted). “A consultative
examination is required to develop a full and fair record only if the record
establishes that such an examination is necessary to enable the ALJ to make
the disability decision.” Webster, 19 F.4th at 720 (alteration omitted)
(quotation marks and citations omitted). Indeed, even where the record lacks
any medical opinions “describing the types of work that the applicant is still
capable of performing,” “[t]he absence of such a statement . . . does not, in
itself, make the record incomplete.” Ripley v. Chater, 67 F.3d 552, 557 (5th
Cir. 1995). Instead, these types of medical opinions are just one of several
categories of evidence the ALJ considers in making RFC determinations. See
20 C.F.R. § 404.1513. In fact, “where no medical statement has been
provided, our inquiry focuses upon whether the decision of the ALJ is
supported by substantial evidence in the existing record.” Ripley, 67 F.3d at
557.
Here, the “record was replete with medical documents that spanned
years.” See Hardman v. Colvin, 820 F.3d 142, 148 (5th Cir. 2016). There
were over 1,000 pages of Wills’s medical records which included extensive
progress notes — prepared by health care professionals directly caring for
Wills — regarding her impairments, treatment, progress, mobility, and
symptoms. Many of those records corresponded to examinations and
procedures occurring subsequent to the medical consultants’ evaluations.
An important record was of a November 2019 discectomy and fusion.
Further, the ALJ heard testimony from Wills regarding her ability to
conduct daily tasks and from a vocational expert regarding jobs available for
someone with the RFC being considered. Although a consultative
examination may have been helpful, the record does not support that more
7
Case: 22-20609 Document: 00516786292 Page: 8 Date Filed: 06/14/2023
No. 22-20609
information was necessary in order for the ALJ to make the decision about
disability. See Webster, 19 F.4th at 720.
We find no error in the development of the record.
II. The ALJ did not draw medical conclusions
Next, Wills maintains that the allegedly undeveloped record led the
ALJ to engage in impermissible fact-finding by drawing medical conclusions
from raw medical data based only on her lay interpretation. In other words,
Wills claims, the ALJ was “playing doctor.” See Frank v. Barnhart, 326 F.3d
618, 621–22 (5th Cir. 2003). In doing so, Wills relies heavily on imaging
conducted on her neck and back relating to her November 2019 operation,
arguing that the ALJ lacked the medical expertise required to interpret that
data. Our review reveals the ALJ did not merely observe tests conducted on
Wills and opine on what conditions they presented and their effects. Rather,
the ALJ examined Wills’s extensive medical history documenting such
matters as test results, physicians’ interpretations of those tests, diagnoses,
treatments and procedures, and information regarding her recovery from
those procedures. Most important was the documentation related to Wills’s
mobility and reported pain following her November 2019 surgery.
An ALJ is to assess RFC “based on all the relevant evidence in [the]
case record.” 20 C.F.R. § 404.1545(a)(1). The record convinces us that the
ALJ did not improperly draw medical opinions from raw data but properly
examined the extensive medical documentation.
III. The RFC determination is supported by substantial evidence
Finally, we examine whether the RFC determination is supported by
substantial evidence. Once more, the record is “replete with medical
documents” describing Wills’s conditions, treatment, and recovery. See
Hardman, 820 F.3d at 148. The ALJ heard Wills’s testimony regarding her
8
Case: 22-20609 Document: 00516786292 Page: 9 Date Filed: 06/14/2023
No. 22-20609
mobility and symptoms, assessed her credibility against that objective
medical evidence, and determined her symptoms were legitimate, but not as
serious as she claimed. “Conflicts in the evidence are for the Commissioner
and not the courts to resolve.” Newton v. Apfel, 209 F.3d 448, 452 (5th Cir.
2000) (alterations omitted) (quotation marks and citations omitted). The
ALJ then correctly stated that the SAMC opinions failed to account for all of
Wills’s impairments. The ALJ then examined the relevant testimony and
medical records and gave a sufficient explanation of her analysis.
“Furthermore, the ALJ appropriately used the RFC when questioning the
vocational expert, and [claimant’s] counsel had the opportunity to correct
deficiencies in the ALJ’s question[s] by mentioning or suggesting to the
vocational expert any purported defects in the hypothetical questions.” See
Webster, 719 F.4th at 719 (quotation marks and citation omitted).
We have already acknowledged that a consultative examination
regarding Wills’s ability to work in her current state might have been helpful,
but “we cannot say that ‘no credible evidentiary choices or medical findings
support the [ALJ’s] decision.’” Whitehead, 820 F.3d at 781 (quoting Boyd,
239 F.3d at 704).
The decision is supported by substantial evidence.
AFFIRMED.
9