United States District Court, D. Maryland
November 2, 2015, Plaintiff Charles Matthews petitioned this
Court to review the Social Security Administration's
final decision to deny his claims for Disability Insurance
Benefits and Supplemental Security Income. (ECF No. 1). I
have considered the parties' cross-motions for summary
judgment. (ECF Nos. 14, 17). I find that no hearing is
necessary. See Loc. R. 105.6 (D. Md. 2016). This
Court must uphold the decision of the Agency if it is
supported by substantial evidence and if the Agency employed
proper legal standards. See 42 U.S.C. §§
405(g), 1383(c)(3); Craig v. Chater, 76 F.3d 585,
589 (4th Cir. 1996). Under that standard, I will deny
Plaintiff's motion, grant the Commissioner's motion,
and affirm the Commissioner's judgment pursuant to
sentence four of 42 U.S.C. § 405. This letter explains
Matthews filed claims for Disability Insurance Benefits
(“DIB”) and Supplemental Security Income
(“SSI”) on February 27, 2012. (Tr. 172-79). He
alleged a disability onset date of September 1, 2007.
Id. His claims were denied initially and on
reconsideration. (Tr. 116-23, 127-30). A hearing was held on
March 27, 2014, before an Administrative Law Judge
(“ALJ”). (Tr. 27-52). During the hearing, Mr.
Matthews amended his alleged onset date from September 1,
2007, to January 14, 2013. (Tr. 186). Following the hearing,
the ALJ determined that Mr. Matthews was not disabled within
the meaning of the Social Security Act during the relevant
time frame. (Tr. 8-26). The Appeals Council denied Mr.
Matthews's request for review, (Tr. 1-5), so the
ALJ's decision constitutes the final, reviewable decision
of the Agency.
found that Mr. Matthews suffered from the severe impairments
of “asthma, hypertension, sarcoidosis and back
pain.” (Tr. 13). Despite these impairments, the ALJ
determined that Mr. Matthews retained the residual functional
capacity (“RFC”) to:
perform light work as defined in 20 CFR 404.1567(b) and
416.967(b) except can stand/walk for a total of 6 hours in an
8-hour day; can sit for a total of 6 hours in an 8-hour day;
can occasionally climb ramps/stairs; can occasionally climb
ladders, ropes and scaffolds; can frequently balance, stoop,
kneel, crouch and crawl; and must avoid concentrated exposure
(Tr. 16). After considering the testimony of a vocational
expert (“VE”), the ALJ determined that Mr.
Matthews could perform jobs existing in significant numbers
in the national economy and that, therefore, he was not
disabled. (Tr. 21).
Matthews raises five primary arguments on appeal: (1) that
the ALJ failed to find Mr. Matthews's alleged mood
disorder to be a severe impairment; (2) that the ALJ assigned
inadequate weight to the medical opinion evidence of the
treating physician; (3) that the ALJ erroneously substituted
her own opinion as to Mr. Matthews' mental limitations;
(4) that the ALJ's holding runs afoul of the 4th
Circuit's decision in Mascio v. Colvin, 780 F.3d
632, 638 (4th Cir. 2015); and (5) that the ALJ provided an
inadequate hypothetical question to the VE. Each argument
lacks merit and is addressed below.
Mr. Matthews contends that the ALJ erred by not determining
that his “mood disorder” constitutes a severe
impairment. Pl. Mem. 13-14. An impairment is considered
“severe” if it significantly limits the
claimant's ability to work. See 20 C.F.R. §
404.1521(a). The claimant bears the burden of proving that
his impairment is severe. See Johnson v. Astrue,
2012 WL 203397, at *2 (D. Md. Jan. 23, 2012) (citing Pass
v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995)). Here,
the ALJ thoroughly considered Mr. Matthews's mood
disorder at Step Two. (Tr. 14). Most significantly, the ALJ
noted that Mr. Matthews did not require ongoing mental health
treatment or psychotropic medication, nor did he demonstrate
difficulty performing daily tasks as a result of his mental
symptoms. (Tr. 14-15). Accordingly, the ALJ fairly concluded
that the impairment had no more than a de minimis
effect on his ability to work. Id. Moreover, even if
the ALJ had erred in her evaluation of Mr. Matthews's
mood disorder at Step Two, such error would be harmless.
Because Mr. Matthews made the threshold showing that his
asthma, hypertension, sarcoidosis, and back pain constituted
severe impairments, the ALJ continued with the sequential
evaluation process and properly considered all of the
impairments, both severe and non-severe, that significantly
impacted Mr. Matthews's ability to work. See 20
C.F.R. §§ 404.1523, 416.923. Any Step Two error,
then, does not necessitate remand.
Mr. Matthews contends that the ALJ failed to give proper
weight to the opinion of Mr. Matthews's treating
psychiatrist, Dr. Witte. A treating physician's opinion
is given controlling weight when two conditions are met: 1)
it is well-supported by medically acceptable clinical
laboratory diagnostic techniques; and 2) it is consistent
with other substantial evidence in the record. See
Craig, 76 F.3d 585 (4th Cir. 1996); see also 20
C.F.R. §§ 404.1527(d)(2), 416.927(d)(2). However,
where a treating source's opinion is not supported by
clinical evidence or is inconsistent with other substantial
evidence, it should be accorded significantly less weight.
Craig, 76 F.3d at 590. If the ALJ does not give a
treating source's opinion controlling weight, the ALJ
will assign weight after applying several factors, such as,
the length and nature of the treatment relationship, the
degree to which the opinion is supported by the record as a
whole, and any other factors that support or contradict the
opinion. 20 C.F.R. §§ 404.1527(c)(1)-(6),
416.927(c)(1)-(6). The Commissioner must also consider, and
is entitled to rely on, opinions from non-treating doctors.
See SSR 96-6p, at *3 (“In appropriate
circumstances, opinions from State agency medical and
psychological consultants and other program physicians and
psychologists may be entitled to greater weight than the
opinions of treating or examining sources.”).
assigned Dr. Witte's opinion “very little”
evidentiary weight because it was not supported by clinical
evidence and inconsistent with the medical evidence. (Tr.
19). Dr. Witte opined that Mr. Matthews's mental
impairments would result in a substantial loss in his ability
to understand, carry out, and remember simple instructions,
respond appropriately to supervision, coworkers and unusual
work settings, and deal with changes in a routine work
setting. (Tr. 19, 612). The ALJ found, however, that Dr.
Witte's opinion “sharply contrast[ed] with the
objective medical evidence of record” and was
“grossly inconsistent with the sporadic and
conservative level of treatment received and generally normal
findings on mental status examination.” (Tr. 19).
Substantial evidence elsewhere in the record, including the
fact that Mr. Matthews does not participate in ongoing mental
health treatment, is not required to take psychotropic
medication, and manages to perform a broad range of
activities in his daily living, further belies Dr.
Witte's opinion. Id. The ALJ also explained
that, “Dr. Witte primarily based her opinions on [Mr.
Matthews's] own subjective reports rather than objective
clinical evidence.” Id. For example, although
Dr. Witte claimed Mr. Matthews would experience a substantial
loss of ability to respond appropriately to others in the
workplace based on his reports of past conflicts, Mr.
Matthews contradicted that determination in his disability
paperwork by admitting that he generally gets along well with
others. Id. These inconsistencies, in addition to
others cited by the ALJ, provide sufficient justification for
the ALJ's decision to accord little weight to Dr.
Matthews also argues that the ALJ failed to consider the
factors outlined in 20 C.F.R. §§
404.1527(c)(1)-(6), 416.927(1)-(6), when assigning weight to
Dr. Witte's opinion. The regulations require an ALJ to
assess several factors when determining what weight to assign
to the medical opinions presented. 20 CFR 404.1527(d),
416.927(d). These factors include: the examining relationship
between the physician and the claimant; the treatment
relationship between the physician and the claimant; the
specialization of the physician; the consistency of a medical
opinion with the record as a whole; and the extent to which a
medical opinion is supported by evidence. 20 CFR §§
404.1527(d)(1)-(5), 416.927(d)(1)-(5). Upon review of the
record, I find that the ALJ cited each factor required under
the regulations. Specifically, the ALJ noted that Dr. Witte
was Mr. Matthews's treating physician and examined Mr.
Matthews in March 2014. (Tr. 19). The ALJ also adduced Dr.
Witte's opinion, (Tr. 19), and cited her Medical
Assessment Report, which contains Dr. Witte's original
notes and denotes her specialization as a psychiatrist, (Tr.
19, 611-15). The ALJ then held that Dr. Witte's opinion
was “grossly inconsistent” and “sharply
contrast[ed] with the objective medical evidence of
record.” (Tr. 19). Considering the entirety of the
ALJ's RFC analysis, I find that the ALJ properly applied
the regulations in assigning weight to Dr. Witte's
opinion, and that her findings are supported by substantial
and relatedly, Mr. Matthews contends that the ALJ
impermissibly substituted her own opinion as to his mental
RFC for that of his treating psychiatrist, Dr. Witte.
Contrary to Mr. Matthews's assertion, the ALJ's RFC
decision is soundly supported by the record. As noted above,
the Fourth Circuit has stated that “if a
physician's opinion is not supported by clinical evidence
or if it is inconsistent with other substantial evidence, it
should be accorded significantly less weight.”
Craig, 76 F.3d at 590; Johns v. Comm'r, Soc.
Sec. Admin., 2014 WL 333552, at *2 (D. Md. Jan. 28,
2014). Considering the entirety of the record, the ALJ
properly found that Dr. Witte's opinion “sharply
contrast[ed] with the objective medical evidence of
record” and was “grossly inconsistent with the
sporadic and conservative level of treatment received and
generally normal findings on mental status
examination.” (Tr. 19). The ALJ also properly found
that Mr. Matthews had mild limitations in activities of daily
living, social functioning, and concentration, persistence,
or pace, and no episodes of decompensation. (Tr. 14-15). The
ALJ based her finding on the absence of medical evidence
supporting Mr. Matthews's claims of mental impairment,
the suspect credibility of Mr. Matthews's testimony
concerning his impairments, the specious nature of Dr.
Witte's medical opinion, the objective medical evidence,
and the credible findings of the State medical and
psychological consultants. (Tr. 19). Accordingly, the ALJ
properly assigned weight to the medical opinions in the case,
and provided substantial evidence to support her conclusions.
Mr. Matthews contends that the ALJ's RFC assessment did
not comport with the Fourth Circuit's ruling in
Mascio v. Colvin, 780 F.3d 632, 638 (4th Cir. 2015).
Pertinent to this case, the Fourth Circuit remanded
Mascio because the hypothetical the ALJ posed to the
VE - and the corresponding RFC assessment - did not include
any mental limitations other than unskilled work, despite the
fact that, at step three of the sequential evaluation, the
ALJ determined that the claimant had moderate difficulties in
maintaining concentration, persistence, or
pace. Mascio, 780 F.3d at 637-38. The
Fourth Circuit specifically held that it “agree[s] with
other circuits that an ALJ does not account for a
claimant's limitations in concentration, persistence, and
pace by restricting the hypothetical question to simple,
routine tasks or unskilled work.” Id. at 638
(quoting Winschel v. Comm'r of Soc. Sec., 631
F.3d 1176, 1180 (11th Cir. 2011) (internal quotation marks
omitted)). Even so, the Fourth Circuit noted that failure to
include additional limitations might not constitute error
when an ALJ offers an explanation as to why the
claimant's moderate difficulties in concentration,
persistence, or pace did not translate into a limitation in
the claimant's RFC. Id. Under this framework, I
find that the ALJ provided adequate explanation of how Mr.
Matthews's RFC assessment accounts for his mild
limitations in activities of daily living, social
functioning, and concentration, persistence, or pace.
present case is distinguishable from Mascio, and
thus does not require remand, for a number of reasons.
Principally, the ALJ found Mr. Matthews suffers mild
limitations, as opposed to the moderate limitations the
claimant in Mascio faced. This Court holds that,
“[p]ursuant to Mascio, once an ALJ has made a
step three finding that a claimant suffers from
moderate difficulties in concentration, persistence,
or pace, the ALJ must either include a corresponding
limitation in her RFC assessment, or explain why no such
limitation is necessary.” Willis v. Colvin,
2016 WL 3440126, at *6 (D. Md. June 22, 2016) (quoting
Talmo v. Comm'r, Soc. Sec., 2015 WL
2395108, at *3 (D. Md. May 19, 2015), report and
recommendation adopted (D. Md. June 5, 2015) (emphasis
added). This Court has yet to extend Mascio to cover
a finding of only mild limitations, and will not do so on
even assuming that Mascio applies in the context of
mild limitations, the ALJ sufficiently explained why Mr.
Matthews's mild limitations did not translate into
further restrictions in the RFC. After a thorough evaluation
of Mr. Matthews's testimony, the medical opinion evidence
of Dr. Witte, and the State psychiatric consultants, the ALJ
did not find evidence of severe mental limitations. (Tr.
13-14). Moreover, the ALJ discussed Mr. Matthews's
testimony and the objective medical evidence, (Tr. 13-17),
and found Plaintiff's subjective complaints not entirely
credible, (Tr. 17), and his past mental symptoms transient.
(Tr. 14). Most significantly, the ALJ found that “the
evaluating psychiatrist noted that [Mr. Matthews] had a
‘fair' capability to work, ” that Mr.
Matthews did not allege any mental impairment at his
psychiatric consultative evaluation affecting his ability to
work, and that there was “no evidence that [Mr.
Matthews] [was] ...