United States District Court, D. Maryland
Stephanie A. Gallagher United States Magistrate Judge
September 19, 2016, Plaintiff Lattesha Kirkland petitioned
this Court to review the Social Security Administration's
final decision to deny her claim for Disability Insurance
Benefits. (ECF No. 1). I have considered the parties'
cross-motions for summary judgment, and the supplemental
briefing filed by each side. (ECF Nos. 10, 13, 15, 18). 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 both motions, reverse the judgment of
the Commissioner, and remand the case to the Commissioner for
further analysis pursuant to sentence four of 42 U.S.C.
§ 405(g). This letter explains my rationale.
Kirkland filed her claim for Disability Insurance Benefits on
May 4, 2012, originally alleging a disability onset date of
February 12, 2010. (Tr. 199-200). Her claim was
denied initially and on reconsideration. (Tr. 106-09,
111-12). A hearing was held on June 25, 2015, before an
Administrative Law Judge (“ALJ”). (Tr. 26-60).
Following that hearing, the ALJ determined that Ms. Kirkland
was not disabled during the relevant time frame. (Tr. 7-25).
The Appeals Council denied Ms. Kirkland's request for
review, (Tr. 1-4), so the ALJ's decision constitutes the
final, reviewable decision of the Agency.
found that Ms. Kirkland suffered from the severe impairments
of osteoarthritis, meniscus tear, patellofemoral syndrome,
idiopathic neuropathy, and personality disorder. (Tr. 12).
Despite these impairments, the ALJ determined that Ms.
Kirkland retained the residual functional capacity
perform less than a full range of sedentary work as defined
in 20 CFR 404.1567(a). The claimant is limited to lifting and
carrying from waist to chest level. The claimant can walk no
longer than one block at a time on a flat even surface at a
slow pace. The claimant requires a sit and stand option about
every 15-30 minutes, and she needs to use a cane as
necessary. The claimant has to avoid crawling, kneeling,
crouching and climbing ladders, ropes and scaffolds, but she
can stoop occasionally. The claimant requires work involving
no more than limited education. The claimant has to avoid
constant interpersonal interaction with the public, coworkers
and supervisors. The claimant has to avoid constant
fingering, grasping and handling. The claimant has to avoid
working around hazards, such as moving dangerous machinery
and unprotected heights.
(Tr. 15). After considering the testimony of a vocational
expert (“VE”), the ALJ determined that Ms.
Kirkland could perform jobs existing in significant numbers
in the national economy and that, therefore, she was not
disabled. (Tr. 18-20).
Kirkland raises several arguments on appeal: (1) that the ALJ
failed to properly evaluate the opinion of her treating
physician, Dr. Quainoo; (2) that the ALJ provided an
inadequate Listing analysis; (3) that the ALJ failed to
evaluate evidence proffered by the VE; and (4) that the ALJ
should have deemed her right shoulder pain and carpal tunnel
syndrome to be severe impairments. Pl. Mot. 6-20. I concur that
the ALJ did not consider Dr. Quainoo's opinion, and that
remand is warranted. In addition, in a supplemental filing,
Ms. Kirkland argues that the ALJ did not comply with the
Fourth Circuit's recent decision in Lewis v.
Berryhill, 858 F.3d 858 (4th Cir. 2017). However,
because this case is being remanded on other grounds, I need
not reach the Lewis issue. On remand, the ALJ should
assess Ms. Kirkland's credibility based on both her
subjective statements and the medical evidence, in accordance
with the successful argument, Ms. Kirkland contends that the
ALJ did not assign weight to the opinion of a treating
physician, Dr. Quainoo. Pl. Mem. 13-14. 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. § 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. § 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
case, the ALJ failed to properly evaluate Dr. Quainoo's
opinion. Dr. Quainoo opined that “[Ms. Kirkland] could
sit, stand and walk less than two hours within an eight-hour
workday, rarely stoop, would absent (sic) from work
more than four days per month and would need to take a
30-minute unscheduled break every two hours.” (Tr. 17).
Additionally, Dr. Quainoo opined that Ms. Kirkland had
“osteoarthritis of the knee, right shoulder pain,
genital herpes and other idiopathic peripheral
neuropathy.” Id. Moreover, Dr. Quainoo opined
that Ms. Kirkland had “left shoulder pain with
radiculopathy and recommended she take Gabapentin for pain,
with Motrin on an as needed basis.” Id.
However, the ALJ failed to assign specific weight to Dr.
Quainoo's opinion. Although implicit assignments of
weight can support meaningful review, Shaffer v.
Comm'r, Soc. Sec., No. CIV. SAG-10-1962,
2012 WL 707098, at *2 (D. Md. Mar. 2, 2012) (citation
omitted), Social Security regulations require an ALJ to
“always give good reasons in [the] notice of
determination or decision for the weight” given to a
claimant's treating source's opinion. 20 C.F.R.
§ 404.1527(d)(2). “Those good reasons must be
‘supported by the evidence in the case record, and must
be sufficiently specific to make clear to any subsequent
reviewers the weight the [ALJ] gave to the treating
source's medical opinion and the reasons for that
weight.'” Blakley v. Comm'r Soc.
Sec., 581 F.3d 399, 407 (6th Cir. 2009) (citing SSR
96-2p, 1996 WL 374188, at *5). Thus, an ALJ's failure to
identify “the reasons for discounting [a treating
physician's] opinions, ” and explain
“precisely how those reasons affected the weight given
denotes a lack of substantial evidence, even where the
conclusion of the ALJ may be justified based upon the
record.” Valley v. Astrue, No.
3:11-CV-260-HEH, 2012 WL 3257861, at *17 (E.D. Va. June 22,
2012), report and recommendation adopted, No. 3:11CV260-HEH,
2012 WL 3257876 (E.D. Va. Aug. 8, 2012) (internal citation
and quotation marks omitted).
the basis for the ALJ's evaluation of Dr. Quainoo's
opinion is not sufficiently clear to permit meaningful
review. The entirety of the ALJ's analysis states:
“Dr. Quainloo's (sic) opinion that [Ms.
Kirkland] can do less than sedentary exertional level work is
not supported by his own progress notes and physical
examination findings. Also, Dr. Quainloo's (sic)
opinion is not consistent with [Ms. Kirkland's] good
activities of daily living.” (Tr. 17). The ALJ
provided no other evidence to support an implicit assignment
of weight to Dr. Quainoo's opinion. Indeed, the ALJ's
conclusory analysis failed to cite to any specific evidence
in the record supporting his assessment. For example, the ALJ
failed to explain what physical examination findings were
inconsistent with Dr. Quainoo's opinion, or how those
findings undermined Dr. Quainoo's conclusion that Ms.
Kirkland required more restrictive limitations in her RFC
assessment. Id. Additionally, although the ALJ cited
Ms. Kirkland's “good” activities of daily
living to discredit Dr. Quainoo's opinion, the ALJ did
not identify those activities and also credited conflicting
testimony regarding the severity of Ms. Kirkland's
limitations in sitting, standing, and walking, by including
corresponding restrictions in the RFC assessment. (Tr. 16).
In light of the evidence of record, the ALJ failed to provide
sufficient explanation of his reasons for discrediting Dr.
Quainoo's opinion. Valley, 2012 WL 3257861, at
*17. Remand is therefore appropriate. In remanding for
additional explanation, I express no opinion as to whether or
not the ALJ's ultimate conclusion that Ms. Kirkland was
not entitled to benefits is correct or incorrect.
to the less persuasive arguments, Ms. Kirkland contends that
the ALJ did not engage in a proper analysis of Listing
1.02. Specifically, the ALJ in this case found
[Ms. Kirkland] does not meet the listing at 1.02A for
bilateral knee disorders. To meet the listing, [Ms.
Kirkland's] bilateral knee disorder(s) must be
characterized by gross anatomical deformity and chronic joint
pain and stiffness with signs of limitation of motion or
abnormal motion of affected joint, and joint space narrowing,
bony destruction, or ankylosis of the affective joint: with
involvement of one major peripheral weight-bearing joint
resulting in an inability to ambulate effectively. Although
[Ms. Kirkland's] February 2015 MRI of the left knee was
abnormal, the evidence of record shows [Ms. Kirkland] is able
to ambulate effectively as defined in 1.00B2b. Dr. Frank
Henn's March 2014 examination revealed that [Ms.
Kirkland] had a normal gait, with stability intact in all
planes on the left. Her left lower extremity was also
neurologically intact and her strength was 5/5. Also, when
Dr. Quainoo saw [Ms. Kirkland] in January and February 2015
[she] ha[d] no weakness or stumbling. [Ms. Kirkland]
ambulated without an assistive device with no obvious gate
(Tr. 14) (citing (Tr. 417-39, 445-47)). The ALJ engaged in
the required analysis of Listing 1.02 and cited to record
evidence in support of his conclusion that the Listing was
not met. Notably, in the RFC assessment, the ALJ cited to
substantial evidence from the record “connecting his
determination to that of [Ms. Kirkland's] failure to meet
the listing impairment[.]” Fox v. Colvin, 632
F. App'x 750, 755 (4th Cir. 2015). For example, the ALJ
noted that Ms. Kirkland “walked with a normal gait,
” “had a painless range of motion of the back and
hips, ” had a “functional” range of motion
in her knees “with no instability, ” and
“had 5/5 strength and was neurologically intact.”
(Tr. 16) (citing (Tr. 445-47)). Additionally, the ALJ noted
that Ms. Kirkland had “no swollen or tender joints,
” id., “no crepitus or swelling of the
knee, ” (Tr. 17), “no obvious gait disturbances
and no restricted range of motion involving any joint,
” id. Ultimately, Ms. Kirkland's argument
about the inadequacy of the Listing analysis focuses on the
weight the ALJ assigned to certain pieces of evidence over
other pieces of evidence. See Pl. Mot. 7-10. That
inquiry is not permissible, since this Court's role is
not to reweigh the evidence or to substitute its judgment ...