United States District Court, D. Maryland
November 18, 2015, the Plaintiff, James Pettiford (“Mr.
Pettiford”), petitioned this Court to review the Social
Security Administration's (“SSA”) final
decision to deny his claims for Disability Insurance Benefits
(“DIB”) and Supplemental Security Income
(“SSI”). (ECF No. 1.) The parties have filed
cross-motions for summary judgment. (ECF Nos. 14 & 15.)
These motions have been referred to the undersigned with the
parties' consent pursuant to 28 U.S.C. § 636 and
Local Rule 301. (ECF Nos. 2 & 7.) I find that no hearing
is necessary. See Loc. R. 105.6. This Court must
uphold the decision of the agency if it is supported by
substantial evidence and if the agency employed the proper
legal standards. 42 U.S.C. §§ 405(g), 1383(c)(3);
Mascio v. Colvin, 780 F.3d 632, 634 (4th Cir. 2015).
Following its review, this Court may affirm, modify, or
reverse the Commissioner, with or without a remand.
See 42 U.S.C. § 405(g); Melkonyan v.
Sullivan, 501 U.S. 89 (1991). Under that standard, I
will I will grant the Acting Commissioner's motion and
deny the Plaintiffs motion. This letter explains my
Pettiford protectively filed his applications for DIB and SSI
on March 6, 2012. (Tr. 204-212.) In both applications, he
alleged that he became disabled on April 1, 2008. (Tr. 92,
206, 240.) His claims were denied initially and on
reconsideration. (Tr. 141-50.) A hearing was held before an
Administrative Law Judge (“ALJ ”) on March 10,
2014. (Tr. 40-91.) On April 22, 2014, the ALJ determined that
Mr. Pettiford was not disabled under the Social Security Act.
(Tr. 26-34.) On September 24, 2015, the Appeals Council
denied Mr. Pettiford's request for review, making the
ALJ's decision the final, reviewable decision of the SSA.
evaluated Mr. Pettiford's claim for benefits using the
five-step sequential evaluation process set forth in 20
C.F.R. §§ 404.1520, 416.920. At step one, the ALJ
found that Mr. Pettiford was not engaged in substantial
gainful activity, and had not been engaged in substantial
gainful activity since April 1, 2008. (Tr. 28.) At step two,
the ALJ found that Mr. Pettiford suffered from the severe
impairments of “degenerative disc disease of the
cervical and lumbar spine status post lumbar fusion (in
August 2012); and degenerative changes in the right
shoulder.” (Id.) At step three, the ALJ found
that Mr. Pettiford's impairments, separately and in
combination, failed to meet or equal in severity any listed
impairment as set forth in 20 C.F.R., Chapter III, Pt. 404,
Subpart P, App. 1 (“Listings”) (Tr. 28-30.)
Before proceeding to step four, the ALJ determined that Mr.
Pettiford retained the residual functional capacity
to perform light work as defined in 20 C.F.R. 404.1567(B) and
416.967(b) except he can frequently reach overhead; and
occasionally climb ramps or stairs, balance, stoop, kneel,
crouch and crawl but can never ladders, ropes or scaffolds.
four, the ALJ determined that Mr. Pettiford was unable to
perform any past relevant work. (Tr. 33.) At step five, the
ALJ determined that, considering Mr. Pettiford's age,
education, work experience, and RFC, there are jobs that
exist in significant numbers in the national economy that he
can perform. (Tr. 33-34.) Accordingly, the ALJ found that Mr.
Pettiford was not disabled under the Social Security Act.
Pettiford raises three arguments on appeal: (1) the ALJ did
not give proper weight to his treating physician's
opinion; (2) the ALJ's RFC assessment is not supported by
substantial evidence; and (3) the ALJ improperly discredited
Mr. Pettiford's complaints of pain. I will address each
of these arguments below.
Pettiford first argues that the ALJ did not give the
appropriate weight to the opinion of his treating physician.
A treating physician's opinion is entitled to controlling
weight if 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 v. Chater, 76 F.3d
585, 590 (4th Cir. 1996); see also 20 C.F.R.
§§ 404.1527(c), 416.927(c). Where these conditions
are not met, the regulations instruct an ALJ to consider
several factors in deciding the weight to assign to the
opinion. 20 C.F.R. §§ 404.1527(c), 416.927(c).
These factors include: (1) the examining relationship between
the physician and the claimant; (2) the treatment
relationship between the physician and the claimant; (3) the
extent to which a medical opinion is supported by relevant
evidence; (4) the consistency of a medical opinion with the
record as a whole; and (5) whether the physician's
opinion relates to an area in which they are a specialist.
Id. The ALJ is not required to apply these factors
formulaically. See Laing v. Colvin, No. SKG-12-2891,
2014 WL 671462, at *8 (D. Md. Feb. 20, 2014)
treating physician's opinion is not supported by clinical
evidence, is inconsistent with other substantial evidence, or
is based on a short-term treating relationship, its probative
value is significantly reduced. 20 C.F.R. §§
404.1527(c)(2), 416.927(c)(2); see also Craig, 76
F.3d at 590; Hunter v. Sullivan, 993 F.2d 31, 35
(4th Cir. 1992) (“The ALJ may choose to give less
weight to the testimony of a treating physician if there is
persuasive contrary evidence[.]”) Regardless of the
weight given to the opinion of a treating source, the ALJ is
required to “explain in the decision the weight given
to . . . any opinions from treating sources, nonteaching
sources, and other non-examining sources who do not work for
[the SSA].” See 20 C.F.R. §§
the record in this case contains only one contemporaneous
treatment note from Dr. Higgs-Shipman, the ALJ considered her
to be Mr. Pettiford's treating physician. (Tr. 32.) Mr.
Pettiford's preliminary argument that the ALJ should have
considered Dr. Higgs-Shipman as a treating physician raises a
non-issue because the ALJ did just that. Because the opinions
that the doctor expressed in her December 2012 assessment
(Tr. 531-35) were inconsistent with other evidence in the
record, the ALJ assigned Dr. Higgs-Shipman's findings
little weight. (Tr. 32.) The ALJ noted that Dr.
Higgs-Shipman's opinion that Mr. Pettiford requires a
cane to ambulate was contradicted by his own testimony before
the ALJ. (Tr. 31-32, 89, 534.) In addition, Dr.
Higgs-Shipman's opinion that Mr. Pettiford was limited to
sitting, walking, or standing for just two hours during an
eight hour day, and for no longer than 30 minutes at a time
is not supported by any objective medical evidence. (Tr. 32.)
Furthermore, these restrictions are inconsistent with Mr.
Pettiford's self-reported activities of daily living,
such as cooking his meals, cleaning his home, doing laundry,
driving, and shopping without assistance. See Johnson v.
Barnhart, 434 F.3d 650, 657 (4th Cir. 2005) (“The
ALJ logically reasoned that the ability to engage in such
activities is inconsistent with Johnson's statements of
excruciating pain and her inability to perform such regular
movements like bending, sitting, walking, grasping, or
maintaining attention.”). Because Dr.
Higgs-Shipman's opinions are not supported by clinical
evidence, are based on a limited examining and treating
relationship, and are contradicted by Mr. Pettiford's
self-reported activities, the ALJ appropriately assigned
little weight to the opinions.
Pettiford also argues that Dr. Higgs-Shipman's various
diagnoses and her recommendation that he undergo a lumbar
fusion prove that her opinion was entitled to greater weight.
But Dr. Higgs-Shipman's diagnoses and recommendation of a
lumbar fusion are not in dispute. The dispute as to Dr.
Higgs-Shipman's opinions is the degree to which Mr.
Pettiford's impairments led to corresponding functional
limitations. The diagnoses that Dr. Higgs-Shipman made simply
do not reflect what impact Mr. Pettiford's conditions had
on his functional abilities. See Gross v. Heckler,
785 F.2d 1163, 1166 (4th Cir. 1986) (“However, a
[diagnosed] disorder is not necessarily disabling. There must
be a showing of related functional loss.”);
Caldwell v. Astrue, No. 11-070-RLV-DSC, 2012 WL
2395196, at *3 (W.D. N.C. Mar. 2, 2012) (“The mere
diagnosis of a condition is not sufficient evidence to prove
a severe impairment, nor to corroborate a doctor's
opinion that an individual is disabled.”).
Higgs-Shipman's opinions are also contradicted by other
substantial evidence in the record, namely the opinions of
the State agency medical consultants. (Tr. 32.) As explained
by the ALJ, the opinions of the State agency medical
consultants are consistent with the evidence in the record,
including the improvement in Mr. Pettiford's range of
motion and pain levels after his lumbar fusion in 2012.
(Id.) Mr. Pettiford argues that the ALJ should not
have given such weight to the opinions of the State agency
medical consultants because they did not discuss his lumbar
fusion. But the opinion of a non-examining physician need not
be discarded simply because additional evidence is entered
into the record at a later time. In this case, the ALJ
considered evidence related to Mr. Pettiford's lumbar
fusion and discussed it in her opinion. In addition, it is
unclear how Mr. Pettiford believes this evidence contradicts
the opinions of the State agency medical consultants. After
all, the opinions are generally consistent with the
post-lumbar fusion evidence discussed by the ALJ. This
Court's role is not to reweigh the evidence and
substitute its opinion for the ALJ. See Craig, 76
F.3d at 589 (“In reviewing for substantial evidence, we
do not undertake to re-weigh conflicting evidence, make
credibility determinations, or substitute our judgment for
that of the Secretary.”). The ALJ's evaluation of
the medical opinion evidence is supported by substantial
Pettiford's second argument is that the ALJ's RFC
finding is not supported by substantial evidence. RFC is an
assessment of an individual's ability to do sustained
work-related physical and mental activities in a work setting
on a regular and continuing basis. SSR 96-8p, 1996 WL 374184
(S.S.A. July 2, 1996). The ALJ must consider even those
impairments that are not “severe” in formulating
the RFC. 20 C.F.R. §§ 404.1545(a)(2),
416.945(a)(2). In determining a claimant's RFC, the ALJ
must evaluate the claimant's subjective symptoms using a
two-part test. Craig, 76 F.3d at 594; 20 C.F.R.
§§ 404.1529(a), 416.929(a). First, the ALJ must
determine whether objective evidence shows the existence of a
medical impairment that could reasonably be expected to
produce the alleged symptoms. 20 C.F.R. §§
404.1529(b), 416.929(b). Once the claimant makes that
threshold showing, the ALJ must evaluate the extent to which
the symptoms limit the claimant's capacity to work. 20
C.F.R. §§ 404.1529(c), 416.929(c). At this second
stage, the ALJ must consider all available evidence,
including medical history, objective medical ...