Watson v. Commissioner of Social Security

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF COLUMBIA
NANCY W.,1
Plaintiff,
v.
Civil Action No.
20-cv-2505-MAU
KILOLO KIJAKAZI, Acting
Commissioner of Social Security,2
Defendant.
MEMORANDUM OPINION
Plaintiff Nancy W. (“Plaintiff”) filed this action seeking to reverse the final decision of the
Acting Commissioner of Social Security, Dr. Kilolo Kijakazi (“Defendant” or “Commissioner”),
denying her claim for Disability Insurance Benefits (“DIB”) and Supplemental Security Income
(“SSI”) under Titles II and XVI of the Social Security Act (“the Act”), 42 U.S.C. §§ 405(g),
1383(c)(3). Plaintiff seeks judgment for entry of benefits or, in the alternative, remand for further
proceedings. The Commissioner argues that the Administrative Law Judge’s (“ALJ”) decision
should be affirmed as it is based on substantial evidence.
Having reviewed the Administrative Record, the Parties’ briefs, and the relevant law, this
Court will GRANT IN PART and DENY IN PART the Parties’ motions (ECF Nos. 13 and 14)
1
Plaintiff’s name has been partially redacted in accordance with the recommendation of the
Committee on Court Administration and Case Management of the Judicial Conference of the
United States. See Memorandum from Hon. Wm. Terrell Hodges, Chair, Comm. on Ct. Admin.
& Case Mgmt. to Chief Judges of the U.S. Cts. of Appeals, Chief Judges of the U.S. Cts., Clerks
of the U.S. Cts. of Appeals, and Clerks of the U.S. Dist. Cts. (May 1, 2018), available at
https://www.uscourts.gov/sites/default/files/18-ap-c-suggestion_cacm_0.pdf (last visited July 27,
2023).
2
Pursuant to Federal Rule of Civil Procedure 25(d), the current Defendant has been
substituted for her predecessor. See Fed. R. Civ. P. 25(d).
1
and remand this case to the Social Security Administration for further proceedings consistent with
this Memorandum Opinion.
BACKGROUND
A. THE SOCIAL SECURITY ACT
To qualify for disability insurance and/or supplemental security income benefits under the
Act, the Commissioner must find that the claimant has a “disability” as defined in the statute.
See 42 U.S.C. §§ 423(a)(1)(E), 1382(a)(1). The Act defines “disability” as the “inability to engage
in any substantial gainful activity by reason of any medically determinable physical or mental
impairment which . . . has lasted or can be expected to last for a continuous period of not less than
12 months.” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A).
The Commissioner uses a five-step sequential evaluation process for assessing a claimant’s
alleged disability, with the claimant carrying the burden of proof for establishing her inability to
work. See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); see also Butler v. Barnhart, 353 F.3d 992,
997 (D.C. Cir. 2004). At the first three steps, the claimant must prove that: (1) she is not “presently
engaged in substantial gainful activity”; (2) she has a “medically severe impairment or
impairments”; and (3) her impairment is equivalent to one of the impairments listed in the appendix
of the relevant disability regulation. See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); see also 20
C.F.R. Pt. 404, Subpt. P, App. 1 (2017) (“the Listings”) (setting forth various physical and mental
conditions—categorized by the body system they affect—that are automatically presumed severe
enough to preclude a claimant’s gainful employment); Sullivan v. Zebley, 493 U.S. 521, 532 (1990)
(“[I]f an adult is not actually working and his impairment matches or is equivalent to a listed
impairment, he is presumed unable to work and is awarded benefits without a determination
whether he actually can perform his own prior work or other work.”).
2
If the claimant cannot satisfy the third step, the inquiry proceeds to steps four and five,
“following an assessment of the claimant’s residual functional capacity RFC [“Residual Functional
Capacity”].” Hall v. Kijakazi, No. 20-cv-2073, 2022 WL 343505, at *2 (D.D.C. Feb. 4, 2022)
(citing 20 C.F.R. § 416.920(e)). The RFC is “what an individual can still do despite his or her
limitations.” SSR 96-8p, 1996 WL 374184, at *2. It requires an assessment of “the extent to
which an individual’s medically determinable impairment(s), including any related symptoms . . .
may cause physical or mental limitations or restrictions that may affect his or her capacity to do
work-related physical and mental activities.” Id. The RFC reflects an individual’s “maximum
remaining ability to do sustained work activities.” Id. (emphasis in original).
At step four, the claimant must show that her impairment(s) prevent her from performing
her past relevant work. See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). At step five, the burden
shifts to the Commissioner to identify specific jobs available in the national economy that the
claimant can perform in light of her age, education, work experience, and RFC. See id.; see also
Callahan v. Astrue, 786 F. Supp. 2d 87, 89 (D.D.C. 2011). In making this determination, the ALJ
may call upon a vocational expert to testify at the administrative hearing as to whether a claimant
can perform other work that exists in the national economy. Id. at 90.
B. PLAINTIFF’S DISABILITY CLAIMS AND PROCEDURAL HISTORY
Plaintiff was born on March 6, 1958. ECF No. 8-3 at 2. Plaintiff’s highest level of
education is a bachelor’s degree. ECF No. 8-2 at 37. She held several jobs from 2006 through
2014, including as a teacher, sales clerk, instructor, and manager. ECF No. 8-3 at 9. At the time
of the administrative hearing, Plaintiff lived with her mother and served as her mother’s primary
caretaker. ECF No. 8-2 at 14-15.
3
On June 20, 2017, Plaintiff filed applications for DIB and SSI benefits, in which she alleged
that her disability began on April 6, 2015. Id. at 11. Plaintiff’s claims were based on her physical
impairments, including spinal pain, arthritis, and hypertension. ECF No. 8-3 at 12-13. The
Commissioner denied Plaintiff’s claims on October 26, 2017, and again upon reconsideration on
February 1, 2018. ECF No. 8-2 at 11. On March 4, 2018, Plaintiff filed a written request for a
hearing, which the ALJ held on July 24, 2019. Id.
C. THE ADMINISTRATIVE HEARING
At the hearing, the ALJ heard testimony from Plaintiff and a vocational expert. ECF No.
8-2 at 35-78. Plaintiff testified as to her work history, explaining that her most recent job as a
teacher had involved standing, bending, and carrying about twenty pounds, and that a previous job
at the Burlington Coat Factory involved bending, standing, reaching, and lifting about fifty pounds.
Id. at 38-39. Plaintiff described how she was laid off from her teaching job when the organization
closed, and that she did not look for another job because she began experiencing pain in her neck
and shoulders that required treatment. Id. at 39-40.
Plaintiff noted her symptoms and treatment, testifying that she had undergone neck surgery
on April 6, 2015, and shortly afterward began attending physical therapy. Id. at 41-42. Plaintiff
discussed her abilities, explaining that she had arthritis and “this nerve thing” that caused her leg
to stiffen up and “bounce” to the extent where she “does not rest at night.” Id. at 43-45. She stated
that she had trouble going to medical appointments because of difficulty driving caused by shaking
in her knee and lower back pain. Id. at 42-43, 51-52. She also stated that her right leg was weak
from the waist down, making it difficult for her to get dressed in the morning, and despite therapy,
she still had problems washing and drying herself. Id. at 44-46. Plaintiff testified that despite
trying to stay as independent as possible, she was still walking with two canes that were prescribed
4
by one of her doctors around 2014 or 2015 after her neck surgery. Id. at 48-49. Even with these
assistive devices, however, she testified that still had difficulty getting out of a chair or the sofa.
Id. at 48-49.
Plaintiff also described her daily routine to the ALJ, which included kicking her laundry
down the stairs and waiting for someone to help her bring it up, or bringing it back up in intervals,
so that she could hold the rail with one hand and her cane in the other. Id. at 54-55. She described
how she needed to work together with her mother to accomplish harder tasks, such as taking out
the trash. Id. at 56. Plaintiff stated that she goes to a rehabilitative pool twice a week to work on
her strength. Id. at 70-71. She reiterated that she could sit for about twenty minutes before feeling
pain and discomfort to the point where she needed get up and walk around, and that that she had
trouble sleeping due to this pain in her legs. Id. at 71-72, 74-75.
The ALJ then heard from the vocational expert (“VE”). Id. at 75. The ALJ asked the VE
a series of hypothetical questions about an individual of the same age, education, and work
experience as Plaintiff. Id. at 76-78. The ALJ asked the VE if the hypothetical individual with
the RFC the ALJ formulated could perform Plaintiff’s past relevant jobs. Id. at 76. The VE
responded that the individual could not perform work as a cashier because it required a “medium”
level of exertion, but could perform work as an instructor which required only “light” exertion. Id.
at 77. The VE noted, however, that if the hypothetical individual were to be off task for more than
ten percent of the workday, the individual would have difficulty maintaining employment as an
instructor. Id. at 78.
D. THE ALJ’S DECISION
The ALJ issued her decision on November 29, 2019, finding that Plaintiff was not disabled.
ECF No. 8-2 at 8, 19-20. At step one, the ALJ found that Plaintiff had not engaged in substantial
5
gainful activity since April 6, 2015, the alleged onset date of her disability. Id. at 14. At step two,
the ALJ found that Plaintiff had the following severe impairments: (1) degenerative disc disease
of the lumbar spine; (2) osteoarthritis of the knees; and (3) obesity. Id. The ALJ noted that
Plaintiff’s degenerative disc disease of the cervical spine did not cause more than minimal
limitation of the claimant’s ability to perform basic work activities. Id. And, given the lack of
evidence of complaints or treatment since an April 2017 MRI, the ALJ found that the disc disease
was not severe. Id.
At step three, the ALJ found that Plaintiff’s impairment or combination of impairments did
not meet or medically equal the severity of any of the impairments in the Listings. Id. Specifically,
the ALJ considered Listing 1.04 (Disorders of the Spine). 3 ECF No. 8-2 at 14-15. The ALJ
determined that:
Although the claimant has a “severe” impairment, it does not meet the criteria of
any listed impairments described in Appendix 1 of the Regulations. No treating or
examining physician has mentioned findings equivalent in severity to the criteria
of any listed impairment, nor does the evidence show medical findings that are the
same or equivalent to those of any listed impairment of the Listing of Impairments.
The medical evidence establishes degenerative disc disease of the lumbar spine, but
the evidence does not satisfy the criteria of section 1.04. Specifically, the record is
devoid of evidence of nerve root compression, spinal arachnoiditis, or lumbar spinal
stenosis with accompanying ineffective ambulation.
Id.
The ALJ also found that Plaintiff’s obesity did not qualify as a severe impairment because
it is no longer a listed impairment in the regulations, 20 C.F.R. Part 404, Subpart P, Appendix 1,
3
On April 2, 2021, the SSA updated musculoskeletal listings. See Revised Medical Criteria
for Evaluating Musculoskeletal Disorders Final Rules Questions and Answers, SSA,
https://www.ssa.gov/thirdparty/materials/pdfs/21-489_Musculoskeletal_FAQs.pdf (last visited
May 12, 2023). Listing 1.04 now falls under Listing 1.15. See 1.00 Musculoskeletal Disorders –
Adult, SSA, https://www.ssa.gov/disability/professionals/bluebook/1.00-Musculoskeletal-
Adult.htm#1_15 (last visited July 27, 2023). The Court will refer to the prior Listing 1.04
throughout as it was applicable at the time of Plaintiff’s application.
6
but considered Plaintiff’s obesity in relation to and in combination with Plaintiff’s other
impairments. ECF No. 8-2 at 15.
At step four, the ALJ determined that Plaintiff had the RFC to perform light work as
defined in 20 C.F.R. 404.1567(b) and 416.967(b) except frequently climb, crouch, kneel, crawl,
and use foot controls. ECF No. 8-2 at 15. The ALJ found that although Plaintiff’s medically-
determinable impairments could reasonably be expected to cause the alleged symptoms, Plaintiff’s
statements concerning the intensity, persistence, and limiting effects of the symptoms were not
consistent with the record. Id. at 17-19. The ALJ determined that:
[T]he record as a whole, including the overall evidence of record, the medical
evidence, the claimant’s testimony, the claimant’s activities, and other factors
described above support some functional limitations. However, they do not fully
support claimant’s statements regarding the severity or frequency of her symptoms
as more supportive of any greater limitations or restrictions than those included in
the residual functional capacity. Consequently, there is no basis for finding that the
claimant had suffered any other symptoms that would further reduce the residual
functional capacity.
Id. at 19.
At step five, ALJ determined that Plaintiff was not disabled under the Act as Plaintiff could
perform past relevant work. Id. at 19-20. Plaintiff appealed the ALJ’s decision, and the Appeals
Council denied Plaintiff’s petition on February 6, 2020. Id. at 2-8.
LEGAL STANDARD
A federal district court has jurisdiction over a challenge to the final decision of the
Commissioner. 42 U.S.C. § 405(g). A reviewing court must affirm the Commissioner’s decision
if it is based on substantial evidence in the record and the correct application of the relevant legal
standards. Id.; Butler, 353 F.3d at 999; Smith v. Bowen, 826 F.2d 1120, 1121 (D.C. Cir. 1987).
Substantial evidence is “‘more than mere scintilla’” and means only “‘such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.’” Biestek v.
7
Berryhill, 139 S. Ct. 1148, 1154 (2019) (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197,
229 (1938)). Ultimately, substantial evidence is a “low bar,” La. Pub. Serv. Comm’n v. FERC, 20
F.4th 1, 7 (D.C. Cir. 2021), and “requires considerable deference to the decision rendered by the
ALJ.” Crosson v. Shalala, 907 F. Supp. 1, 3 (D.D.C. 1995). Even so, although there is no
requirement that the ALJ refer to every piece of evidence in her decision, the ALJ is “prohibited
from ignoring an entire line of evidence that supports a disability finding.” Goodman v. Colvin,
233 F. Supp. 3d 88, 109 (D.D.C. 2017) (internal quotations and citations omitted).
On review, a court may not reweigh the evidence. Butler, 353 F.3d at 999. Instead, it is
the court’s role to “carefully scrutinize the entire record to ensure that the Commissioner, through
the ALJ, has both analyzed all of the evidence available and has sufficiently explained his/her
reasoning and the weights given to the facts.” Pinkney v. Astrue, 675 F. Supp. 2d 9, 14 (D.D.C.
2009). Moreover, the court’s job is to “consider the grounds actually proffered by the ALJ” rather
than to make those determinations for itself. See Ward v. Berryhill, 246 F. Supp. 3d 202, 210
(D.D.C. 2017).
In performing this role, a court must “. . . be mindful of the harmless-error rule.
Consequently, even if [the Court] perceive[s] error,” it must “affirm the Commission’s decision
unless the error is prejudicial.” Saunders v. Kijakazi, 6 F.4th 1, 5 (D.C. Cir. 2021) (internal citation
omitted). A “‘[p]laintiff bears the burden of demonstrating that the Commissioner’s decision [is]
not based on substantial evidence or that incorrect legal standards were applied.’” Settles v. Colvin,
121 F. Supp. 3d 163, 169 (D.D.C. 2015) (quoting Muldrow v. Astrue, No. 11-1385, 2012 WL
2877697, at *6 (D.D.C. July 11, 2012)).
8
DISCUSSION
Plaintiff makes two arguments in support of her motion to reverse the ALJ’s decision.
First, Plaintiff argues that the ALJ failed to find her disabled pursuant to the Listing 1.04(A) under
step three. ECF No. 13-1 at 5-6. Second, Plaintiff argues that the ALJ erred in formulating
Plaintiff’s RFC when the ALJ determined that Plaintiff can perform light work. Id. at 6-11. The
Commissioner responds that the ALJ properly considered the Listings and that her decision is
based on substantial evidence. ECF No. 14.
A. THE ALJ ERRED IN FAILING TO ARTICULATE SUFFICIENTLY WHY PLAINTIFF FAILED
TO MEET LISTING 1.04(A) UNDER STEP THREE.
Listing 1.04 requires a claimant to show that she had a disorder of the spine and that she
met an additional criterion contained in paragraphs A, B, or C. See 20 C.F.R. Part 404, Subpart P,
App. 1, 1.04. Paragraph A, at issue here, requires a claimant to show “nerve root compression
characterized by neuro-anatomic distribution of pain, limitation of motion of the spine, motor loss
(atrophy with associated muscle weakness or muscle weakness) accompanied by sensory loss or
reflex loss and, if there is involvement of the lower back, positive straight-leg raise test (sitting
and supine).” Id. § 1.04A. A claimant bears the burden of demonstrating that all the criteria in
the listings are met. Zebley, 493 U.S. at 525.
The criteria for the Listings in step three “are more restrictive than the statutory disability
standard,” as the plaintiff must establish that her impairments are “severe enough to prevent a
person from doing any gainful activity.” Zebley, 493 U.S. at 532 (quoting 20 C.F.R. § 416.925(a))
(emphasis added). In evaluating the ALJ’s decision here, a “Court is not confined to the ALJ’s
analysis at step three and instead must consider the reasoning provided by the ALJ in the decision
in its entirety.” Gibson v. Kijakazi, No. 1:21-CV-660-ZMF, 2022 WL 17172189, at *4 (D.D.C.
Nov. 23, 2022) (citing Al Hulais v. Comm’r. of Soc. Sec. Admin., No. 18-cv-118, 2018 WL
9
6704756, at *6 (D. Md. Dec. 20, 2018). Although “the ALJ need not articulate his reasons for
rejecting every piece of evidence, he must at least minimally discuss a claimant’s evidence that
contradicts the Commissioner’s position.” Lane-Rauth v. Barnhart, 437 F. Supp. 2d 63, 67
(D.D.C. 2006) (quoting Godbey v. Apfel, 238 F.3d 803, 808 (7th Cir. 2000)). The ALJ must
indicate not only “‘what evidence is credited but whether other evidence was rejected,’ rather than
simply ignored.” Gibson, 2022 WL 17172189, at *6 (quoting Brown v. Bowen, 794 F.2d 703,708
(D.C. Cir. 1986); Watson v. Berryhill, No. 1:16-CV-00089, 2018 WL 3434711, at *4 (N.D. Ind.
July 17, 2018) (finding that the ALJ’s three-sentence conclusory dismissal, which stated only that
there was no evidence to establish the factors required at step three, was inadequate because it
failed to provide any explanation of why the plaintiff’s impairments were not severe enough to
qualify him as disabled); see also Ribaudo v. Barnhart, 458 F.3d 580, 583 (7th Cir. 2006) (finding
that the ALJ did not have substantial evidence, in part because he did not use any of the evidence
favorable to the plaintiff when evaluating the Listing criteria).
Plaintiff argues that she meets Listing 1.04(A). ECF No. 13-1 at 5-6. First, Plaintiff points
to medical records that document nerve root compression characterized by a neuroanatomic
distribution of pain in her 2014 MRI showing “grade I spondylolisthesis at L3-4 and mild
discogenic spondylosis with diffuse posterior bulge and a moderate degree of facet joint
arthropathy bilaterally . . . with a mild degree of right recess and right neural foraminal stenosis.”
See id. Second, she cites to several records which allegedly show a distribution of pain,
radiculopathy, weakness, decreased mobility, areflexia, and decreased sensation. Id. For example,
she cites to a March 30, 2017, visit with Dr. Fossett where Plaintiff was diagnosed with lumbar
radiculopathy. See id. Lastly, Plaintiff cites medical records which reflect that her straight leg
tests were positive on multiple occasions. See id.10
The Commissioner responds that the ALJ’s finding was supported by substantial evidence.
ECF No. 14 at 10-12. The Commissioner argues that Plaintiff did not show any evidence of
consistent limitation of motion of the spine or motor loss because there was no evidence in the
record of atrophy or sensory or reflex loss. See ECF No. 14 at 11-12. In particular, the
Commissioner notes that at “virtually every visit,” Plaintiff’s gait and station were normal without
any assistive devices. See id. Further, the Commissioner asserts, Plaintiff’s three positive straight-
leg tests were insufficient to meet Listing 1.04(A) because there was no indication that the tests
were performed in both seated and supine position as required by the Listing. Id. at 12. Moreover,
the record includes evidence of other negative straight-leg raising tests. Id.
The Court agrees with Plaintiff.
The ALJ’s discussion as to whether Plaintiff met Listing 1.04(A), which is no more than
four sentences, is perfunctory at best. ECF No. 8-2 at 14-15. Her reasoning is as follows:
Although the claimant has a “severe” impairment, it does not meet the criteria of
any listed impairments described in Appendix 1 of the Regulations. No treating or
examining physician has mentioned findings equivalent in severity to the criteria
of any listed impairment, nor does the evidence show medical findings that are the
same or equivalent to those of any listed impairment of the Listing of Impairments.
The medical evidence establishes degenerative disc disease of the lumbar spine, but
the evidence does not satisfy the criteria of section 1.04. Specifically, the record
is devoid of evidence of nerve root compression, spinal arachnoiditis, or lumbar
spinal stenosis with accompanying ineffective ambulation.
Id.
Plaintiff, however, cites to conflicting medical records reflecting evidence that allegedly
comports with the Listing. See ECF No. 8-7 at 35, 38, 103 (various treatment records noting
radiculopathy, weakness, decreased mobility, and decreased sensation); ECF No. 8-8 at 96 (same);
ECF No. 8-9 at 17-19, 159-60 (same); see also ECF No. 8-7 at 10 (medical record of a 2014 MRI
showed a “grade I spondylolisthesis at L3-4 and mild discogenic spondylosis and diffuse posterior
11
bulge and a moderate degree or facet joint arthropathy . . . .”); ECF No. 8-8 at 262 (“Pt exhibits
major difficulty performing supine SLR”); ECF No. 8-9 at 5-6, 9 (positive straight leg tests). At
a minimum, the ALJ was obliged to address Plaintiff’s contradictory evidence. See Lane-Rauth,
437 F. Supp. 2d at 67 (“[although] the ALJ need not articulate his reasons for rejecting every piece
of evidence, he must at least minimally discuss a claimant’s evidence that contradicts the
Commissioner’s position.”). The ALJ erred because she failed to acknowledge and discuss the
evidence, or even provide “a breath of explanation.” Brown, 794 F.2d at 708 (“The judiciary can
scarcely perform its assigned review function, limited though it is, without some indication not
only of what evidence was credited, but also whether other evidence was rejected rather than
simply ignored”); see also Gibson, 2022 WL 17172189, at *6-7 (finding that although an ALJ
need not spell out every aspect of a Listing, his discussion of the evidence must not be superficial);
Minnick v. Colvin, 775 F.3d 929, 935-36 (7th Cir. 2015) (finding an ALJ’s two-sentence
explanation inadequate to dismiss plaintiff’s claim under the Listings); Watson, 2018 WL
3434711, at *4 (N.D. Ind. July 17, 2018) (finding ALJ’s three sentences inadequate to dismiss
plaintiff’s claim under the Listings); cf. Broyles v. Astrue, 910 F. Supp. 2d 55, 62 (D.D.C. 2012)
(finding an ALJ’s analysis sufficient because the ALJ clearly explained how he weighed certain
evidence).
The Commissioner does not address the ALJ’s failure to consider contrary evidence; rather,
the Commissioner provides a litany of post-hoc rationalizations, effectively assuming the role of
the ALJ. ECF No. 14 at 13-14. The Commissioner’s refutation of Plaintiff’s argument that she
met the Listing grapples with contradictory evidence and is well-supported by citations to the
record. Id. None of this discussion, however, is in the ALJ’s decision. ECF No. 8-2 at 14-15.
Although the record may well reflect that Plaintiff failed to meet her burden, the Court is unable
12
to discern this from the ALJ’s decision. See Ward, 246 F. Supp. 3d at 210 (holding that the court’s
job is to consider the grounds that the ALJ actually proffered for its decision); Cooper v. Berryhill,
No. 16-1671 DAR, 2017 WL 4326388, at *5 (D.D.C. Sept. 28, 2017) (prohibiting the
Commissioner from offering “post-hoc rationalization[s]” to support the ALJ’s actions).
In effect, the ALJ’s conclusory analysis at step three effectively “ignored evidence and
mischaracterized the record.” See Watson, 2018 WL 3434711, at *4. The ALJ’s failure to even
“minimally discuss” the contradictory evidence Plaintiff raised, coupled with the absence of
citations to the record engaging with the evidence, deprives Plaintiff of any shot at meaningful
judicial review. Lane-Rauth, 437 F. Supp. 2d at 67; Cobb v. Astrue, 770 F. Supp. 2d 165, 171
(D.D.C. 2011). As such, the Court remands this case to the Social Security Administration for
further administrative proceedings consistent with this Memorandum Opinion. See Ademakinwa
v. Astrue, 696 F. Supp. 2d 107, 111 (D.D.C. 2010) (citation omitted) (finding remand appropriate
where the court cannot discern “the ALJ’s rationale . . . without further findings or clearer
explanation for the decision.”); Wells v. Astrue, No. 02–1357, 2009 WL 2338047, at *7 n.5 (D.D.C.
Jul. 30, 2009) (“When the evidence in the administrative record clearly generates an issue as to a
particular listing and the ALJ fails to . . . explain clearly the medical evidence of record supporting
the conclusion reached[,] a remand can be expected to result.” ).
B. THE ALJ’S RFC DETERMINATION THAT PLAINTIFF CAN PERFORM LIGHT WORK IS
SUPPORTED BY SUBSTANTIAL EVIDENCE.
Plaintiff also contends that the ALJ’s determination of Plaintiff’s RFC was not supported
by substantial evidence because the ALJ failed to afford proper weight to the opinions of Plaintiff’s
treating providers. See ECF No. 13-1 at 6-11; ECF No. 16 at 3-4. Plaintiff asserts that the ALJ
was required to give greater weight to the opinions of Plaintiff’s treating providers under this
Circuit’s treating physician rule. ECF No. 13-1 at 11 (citing Butler, 353 F.3d at 1003); ECF No.
13
16 at 3-4. The Commissioner responds that this Circuit no longer adheres to such a rule and that
substantial evidence supports the ALJ’s determination that Plaintiff can perform light work. See
ECF No. 14 at 13 (citing Revisions to Rules Regarding the Evaluation of Medical Evidence, 82
Fed. Reg. 5844 (Jan. 18, 2017)).
Plaintiff misses the mark. In formulating a claimant’s RFC for claims filed after March
27, 2017, ALJs cannot defer or give specific evidentiary weight to medical opinions from
claimants’ treating providers. 20 C.F.R. § 404.1520c(a). Before the SSA issued revised
regulations in 2017, courts in this Circuit followed the “treating physician rule” which interpreted
prior regulations, 20 C.F.R. § 404.1527(d)(2), to require ALJs to give “controlling weight” to
physicians’ opinions so long as they were consistent with the record. Butler, 353 F.3d at 1003.
Under the revised regulations, 20 C.F.R. §§ 404.1520c and 416.920c, an ALJ shall not give specific
evidentiary weight to any medical opinion, “including those from [the claimant’s] medical
sources.” 20 C.F.R. §§ 404.1520c(a), 416.920c. Instead, an ALJ must evaluate each medical
opinion under a multifactorial test.4 See 20 CFR § 404.1527(a) (1996) (rescinded by 82 Fed. Reg.
15263 (Mar. 27, 2017)); see also De Deaux v. Kijakazi, No. 21-CV-682, 2022 WL 14760678, at
*3-4 (D.D.C. Oct. 25, 2022) (applying the revised regulation for a claim filed after March 27,
2017); Demetria R. v. Kijakazi, No. 20-cv-3227 (RJL/GMH), 2022 WL 3142376, at *24 (D.D.C.
4
The revised regulation requires the ALJ to decide how persuasive she finds all medical
opinions based on an analysis of five factors: (1) supportability, (2) consistency, (3) the medical
source’s relationship with the claimant, (4) specialization, and (5) “other factors that tend to
support or contradict a medical opinion.” 20 C.F.R. § 404.1520c(b)-(c). When evaluating the
persuasiveness of a medical opinion, the most important factors for an ALJ to consider are
supportability and consistency, and ALJs must explain how these factors were considered. Id. §
404.1520c(b)(2).
14
June 30, 2022) (same). Because Plaintiff filed her claim on June 20, 2017, the new regulations
apply to her claim. ECF No. 8-2 at 11. 5
1. WEIGHT AFFORDED TO PLAINTIFF’S TREATING PROVIDERS
As part of her argument that the ALJ erred in formulating her RFC, Plaintiff contends that
the ALJ incorrectly disregarded the opinions of her treating providers. See ECF No. 13-1 at 6-12;
ECF No. 16 at 3-4. Specifically, Plaintiff argues that the ALJ should have placed greater weight
on the opinions of two of Plaintiff’s treating physicians, Dr. Janaki Kalyanam and Dr. Andre
Duerinckx, who noted that Plaintiff had significant limitations. ECF No. 13-1 at 9-11.
As the Court discussed above, an ALJ cannot accord specific evidentiary weight to the
opinion of a claimant’s treating provider. When evaluating the persuasiveness of a medical
opinion, the most important factors for an ALJ to consider are supportability and consistency—
ALJs must explain how those two factors were considered. See 20 C.F.R. § 404.1520c(b)(2). If a
medical source provides multiple findings or opinions, the ALJ may articulate in a single analysis
how she considered the factors for each finding or opinion. Id. § 404.1520c(b)(1); see also
Massicotte v. Comm’r of Soc. Sec., No. 20-cv-2923, 2022 WL 2663406, at *5 (M.D. Fla. July 11,
2022) (“[T]he ALJ need not adopt every part of an opinion he or she finds persuasive.”); McClure
v. Saul, No. 20-cv-150, 2021 WL 3856577, at *7 (E.D. Mo. Aug. 30, 2021) (same). The ALJ is
required to “provid[e] a sufficient basis for this Court to understand his reasoning when viewing
the decision as a whole.” Colter v. Kijakazi, No. 20-0632 (CKK), 2022 WL 715218, at *11 (D.D.C.
5
Plaintiff insists that “this Circuit maintains its own ‘treating physician rule’ for claims filed
after March 27, 2017.” ECF No. 16 at 3. Plaintiff is wrong. See e.g., De Deaux, 2022 WL
14760678, at *3-4 (applying the revised regulation for a claim filed after March 27, 2017). The
single case upon which Plaintiff relies to suggest that the treating physician rule still applies in his
Circuit does not apply because that case involves claims filed in March 2015 and October 2016,
well before the SSA propounded the new regulations. See Erica R. v. Kijakazi, No. 20-cv-0635
(JEB/GMH), 2021 WL 4267924, at *3 (D.D.C. Aug. 31, 2021).
15
Mar. 10, 2022). “In performing the RFC assessment, the ALJ must explain how he considered and
resolved any material inconsistencies,” not just state that that the opinion was rejected. See Cobb,
770 F. Supp. 2d at 171 (holding the ALJ’s RFC insufficient where the assessment of opinions
contained only broad generalizations rather than analysis and citation to specific facts).
Here, the ALJ adequately articulated her rationale for weighing certain reports more
heavily than others.6 The ALJ began her analysis by reviewing the opinions of Plaintiff’s own
medical providers, then reviewed the opinions of the state agency consultants, explaining why she
found the opinions of Plaintiff’s providers less supported and consistent than the state agency
consultants. ECF No. 8-2 at 17-19; see 20 C.F.R. § 404.1520c(b)-(c) (requiring ALJs to articulate
only how they considered factors supporting supportability and consistency of opinion evidence).
The ALJ did not “broadly generalize” that Plaintiff’s providers were not credible, Cobb, 770 F.
Supp. 2d at 171, but cited to specific reports and facts from the record, comparing findings from
objective medical tests with subjective reports. See ECF No. 8-2 at 17-18. As the Commissioner
raises, both treatment notes that Dr. Kalyanam and Dr. Duerinckx provided, which suggested that
Plaintiff was significantly limited, were merely notations of Plaintiff’s subjective complaints, not
objective medical evidence. See ECF No. 14 at 18-19. Plaintiff’s complaints alone are insufficient
to satisfy Plaintiff’s burden to establish disability. See Davis v. Saul, No. 18-CV-1714
(RMC/GMH), 2019 WL 12251884, at *17 (D.D.C. Nov. 27, 2019), report and rec. adopted, No.
CV 18-1714 (RMC), 2020 WL 9439346 (D.D.C. Jan. 28, 2020). In any event, the ALJ’s thorough
6
Even under the old, more stringent treating source regulation upon which Plaintiff bases
her argument, courts routinely found that ALJs were permitted to afford less weight when the
opinion was contradicted by other objective medical evidence. See, e.g., Grant v. Astrue, 857 F.
Supp. 2d 146, 155 (D.D.C. 2012) (finding ALJ’s assessment sufficient that a treating physician’s
opinion was not entitled to controlling weight when the opinion was “contradicted by other
evidence in the record” and clinical findings did not support it).
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evaluation of the record demonstrates that the ALJ conducted a holistic evaluation of all pertinent
medical evidence, and that substantial evidence supports the ALJ’s determination. ECF No. 8-2
at 17-19.
For example, the ALJ noted that, following Plaintiff’s complaint of knee pain, x-rays
showed mild degenerative disease leading to a diagnosis of osteoarthritis in both knees. Id. at 17.
The ALJ ultimately observed, however, that follow-up knee exams showed a normal gait, full
range of motion, and 5/5 strength in both knees. Id. The ALJ also acknowledged Plaintiff’s
complaints of lumbar pain but found that Plaintiff had tolerated physical therapy well and
subsequently reported only 2/10 pain. Id. at 18. Further, the ALJ evaluated Plaintiff’s opinion
evidence where she noted that, although Plaintiff reported that she used a cane that one of her other
treating physicians prescribed, there was no evidence of any such prescription in the record. Id.
The ALJ provided a similar analysis of the state agency consultants’ findings, noting that
their opinions should be afforded greater weight because they were “consistent with other objective
medical evidence of record and consistent with claimant’s alleged activities of daily living.” ECF
No. 8-2 at 19. The ALJ found the state agency consultants’ opinions persuasive because they were
“rendered by expert medical personnel” and “consistent with other objective medical evidence of
record.” Id. The ALJ also concluded that “the evidence received after the state agency consultants
rendered their opinions does not show any significant decline in [Plaintiff’s] condition.” Id. The
ALJ briefly noted that the state agency consultants’ limitation to occasional balancing was less
persuasive because “the record does not include any evidence that the claimant requires a cane to
ambulate,” observing that Plaintiff’s treatment notes consistently showed normal gait, strength,
reflexes, and range of motion. Id.
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The Court does not find error in how the ALJ weighed the opinion evidence within the
record. She considered the reports of Plaintiff’s providers and methodically explained why she
viewed certain other evidence more credible than the opinions of Plaintiff’s providers. ECF No.
16 at 4; see Caitlin O. v. Kijakazi, No. 17-CV-1939, 2022 WL 17370231, at *28 (D.D.C. Oct. 27,
2022) (holding that the ALJ’s analysis was sufficient when he did not merely provide a “bare
statement” but instead acknowledged the contradictory evidence in the record and explained why
he viewed certain evidence as more credible); cf. McGraw v. Berryhill, No. 17-cv-1011, 2019 WL
4222703, at *4 (D.D.C. Sept. 5, 2019) (“An ALJ is generally not expected to provide more detail
than citing . . . the contradictory evidence in his report.”). The ALJ provided citations to the record,
pointing to specific tests, such as range of motion and strength tests, contrasting those with
Plaintiff’s subjective reports. ECF No. 8-2 at 17-18. The contrast the ALJ drew in her analysis
underscores her finding that Plaintiff’s subjective complaints were not “supportable” and
“consistent” with the entire record. Id.; 20 C.F.R. § 404.1520c(b)-(c); see also Caitlin O., 2022
WL 17370231, at *28 (finding no error in an ALJ’s assessment when providers’ reports were
inconsistent with objective medical findings). Accordingly, substantial evidence in the record
supports the ALJ’s decision to give less weight to Plaintiff’s treating providers.
2. PLAINTIFF’S RFC DETERMINATION
Plaintiff further claims that the ALJ incorrectly formulated her RFC in discounting
Plaintiff’s subjective complaints and finding that Plaintiff can perform light work. ECF No. 13 at
6-11. The Commissioner responds that substantial evidence supports the ALJ’s RFC
determination. ECF No. 15 at 17-18.
The RFC assessment is a “function-by-function inquiry based on all the relevant evidence
of a claimant’s ability to do work and must contain a narrative discussion identifying the evidence
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that supports each conclusion.” Butler, 353 F.3d at 1000. In determining the RFC, an ALJ “must
build a logical bridge from the evidence to his conclusion.” Banks v. Astrue, 537 F. Supp. 2d 75,
84 (D.D.C.) (internal quotation and citation omitted). Evaluating a claimant’s RFC as to their
subjective complaints involves a two-step process. First, the ALJ must determine whether there
is an underlying physical or mental impairment that can be shown by clinical or laboratory
diagnostic techniques that could reasonably be expected to cause the claimant’s symptoms. 20
C.F.R. § 404.1529. If so, then 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 functional
abilities. Id. In fashioning an RFC, “the ALJ must explain how he considered and resolved any
material inconsistencies or ambiguities evident in the record, as well as the reasons for rejecting
medical opinions in conflict with the ultimate RFC determination.” Butler, 353 F.3d at 1000(internal quotation marks omitted).
Here, under the first step, the ALJ found that Plaintiff’s impairments could reasonably be
expected to cause her alleged symptoms. ECF No. 8-2 at 17. At the second step, however, the
ALJ found that the intensity, persistence, and limiting effects of Plaintiff’s symptoms were
inconsistent with the record evidence and therefore did not support Plaintiff’s claimed functional
limitations. Id. The ALJ considered the longitudinal treatment record, listing Plaintiff’s subjective
complaints, as well as information from her treatment notes regarding her cervical discectomy,
knee pain, knee degenerative disease, knee osteoarthritis, lumbar spinal stenosis, obesity, and
neurological symptoms. ECF No. 8-2 at 15-18. The ALJ found that none of these complaints
about the intensity, persistence, and limiting effects of Plaintiff’s symptoms were consistent with
the objective medical record. ECF No. 8-2 at 18. The ALJ expressly set forth the inconsistencies
in the record, including that: (1) Plaintiff stopped working several years prior to her alleged onset
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date; (2) Plaintiff testified that she is the primary caregiver for her legally blind mother, for whom
Plaintiff must grocery shop, drive and do laundry; and (3) Plaintiff testified that that Dr. Rankin
prescribed a cane and brace, but there was no record of such a prescription in his treatment notes.
Id. Based on these inconsistencies, the ALJ found that the objective evidence of the intensity,
persistence, and limiting effects of Plaintiff’s symptoms was not consistent with her subjective
complaints. Id. at 18.
Plaintiff argues that the ALJ failed to weigh the evidence properly. ECF No. 13-1 at 6-11.
Plaintiff is incorrect. The ALJ appropriately provided a “detailed and precise” analysis of
Plaintiff’s medical history, symptoms, and how the record evidence related to the intensity,
persistence, and limiting effects of her alleged symptoms. See Banks, 537 F. Supp. 2d at 84-85
(holding that a narrative discussion of a plaintiff’s function limitations is required, but that the ALJ
need not engage in a function-by-function analysis for the RFC determination). The ALJ went
beyond mere recitation of the facts and conclusory generalizations. See Cobb, 770 F. Supp. 2d at
171; see also Lane-Rauth, 437 F. Supp. 2d at 67 (remanding where ALJ merely listed evidence
without explaining how it related to his conclusion). Rather, the ALJ cited to particular portions
of the record to support her conclusions. ECF No. 8-2 at 15-19. This included a three-page
narrative discussion of Plaintiff’s testimony, opinion evidence from the hearing, and other medical
evidence. See, e.g., id. at 15-17 (recounting Plaintiff’s hearing testimony regarding her symptoms
and activities of daily living); see also Colter, 2022 WL 715218, at *9 (approving of an ALJ’s
decision where the ALJ included a narrative discussion of the record and explained how he reached
his conclusions from that evidence). A review of the record confirms that the ALJ’s decision is
based on substantial evidence. See, e.g., ECF No. 8-2 at 18 (citing to particular medical records
and explaining why she found inconsistencies in the record, for example, “claimant testified that
20
she was prescribed a cane and brace . . . . However, . . . there is no indication that she required the
use of a cane or brace to ambulate.”); id. at 17 (describing Plaintiff’s complaints of knee pain and
contrasting this with medical reports documenting that Plaintiff had full range of motion and 5/5
strength). Through the use of concrete examples from the record to illustrate her findings, the ALJ
“built a logical bridge” between the evidence and her conclusions. See Cobb, 770 F. Supp. 2d at
171.
Accordingly, the ALJ’s decision need not be disturbed. Lane-Rauth, 437 F. Supp. 2d at
64.
CONCLUSION
For the foregoing reasons, Plaintiff’s Motion for Reversal, is GRANTED IN PART and
DENIED IN PART. Defendant’s Motion for Judgment of Affirmance is GRANTED IN PART
and DENIED IN PART. With respect to the single issue outlined in Part A., this case is
REMANDED to the Social Security Administration for further proceedings consistent with this
Opinion.
SO ORDERED.
Date: July 28, 2023 _______________________________
MOXILA A. UPADHYAYA
United States Magistrate Judge
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