United States District Court, D. Maryland
November 20, 2016, Plaintiff Charity Walters petitioned this
Court to review the Social Security Administration's
final decision to deny her claim for Supplemental Security
Income. (ECF No. 1). I have considered the parties'
cross-motions for summary judgment, and the related filings.
(ECF Nos. 18, 19, 25, 28, 29). 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 Commissioner's decision in part, and
remand the case to the Commissioner for further
consideration. This letter explains my rationale.
Walters filed her claim for benefits on December 18, 2012,
alleging a disability onset date of January 1, 2012. (Tr.
156-66). Her claim was denied initially and on
reconsideration. (Tr. 100-04, 108-09). A hearing was held on
April 15, 2015, before an Administrative Law Judge
(“ALJ”). (Tr. 49-66). Following the hearing, the
ALJ determined that Ms. Walters was not disabled within the
meaning of the Social Security Act during the relevant time
frame. (Tr. 19-48). The Appeals Council (“AC”)
denied Ms. Walters's request for review, (Tr. 1-6), so
the ALJ's decision constitutes the final, reviewable
decision of the Agency.
found that Ms. Walters suffered from the severe impairments
of “arthralgias, migraine headaches, obesity, mood
disorder, and anxiety disorder.” (Tr. 24). Despite
these impairments, the ALJ determined that Ms. Walters
retained the residual functional capacity (“RFC”)
perform a range of light work as defined in 20 CFR
416.967(b), which generally involves lifting/carrying 20
pounds occasionally and 10 pounds frequently,
standing/walking about 6 hours, and sitting about 6 hours in
an 8-hour workday. She cannot climb ladders/ropes/scaffolds
and cannot crawl, but she can perform other postural
activities, like balancing and stooping, on an occasional
basis; and she must avoid concentrated exposure to vibration
and fumes/odors/dust/ gases/poor ventilation, and any
significant exposure to hazards, like unprotected heights or
dangerous moving machinery. Further, the claimant is able to
handle simple tasks; sustain concentration toward such tasks
for 2-hour segments; interact as needed with coworkers and
supervisors, at least on an occasional basis, with no
significant public contact; and respond appropriately to
change in a routine work setting.
(Tr. 27). After considering the testimony of a vocational
expert (“VE”), the ALJ determined that Ms.
Walters could perform jobs existing in significant numbers in
the national economy and that, therefore, she was not
disabled. (Tr. 41-43).
Walters makes several arguments on appeal: (1) that the ALJ
erred in the assignment of weight to the opinions of her
treating physician; (2) that the ALJ erred by failing to deem
her carpal tunnel syndrome to be a severe or non-severe
impairment; and (3) that the ALJ failed to obtain a
consultative examination, which was required in light of the
record. I concur that the ALJ provided inadequate evaluation
of some of the treating physician's opinions, and thus
remand is required. Each of Ms. Walters's arguments is
Ms. Walters's treating psychiatrist, Dr. Lowtan, issued
three opinions about her mental impairments and one opinion
about her physical impairments. (Tr. 289-91, 331-32, 335-37,
476-78). The ALJ provided detailed summaries of the contents
of each of those opinions (Tr. 38-40), and concluded:
While Dr. Lowtan is a treating physician with a longitudinal
treating history with claimant, his findings and opinions are
not consistent with or supported by the other evidence of
record, including his own treatment notes. Specifically, Dr.
Lowtan's mental assessments of multiple marked
limitations appears [sic] disproportionate to the
weight of the evidence of record as a whole. Further, Dr.
Lowtan's physical assessment falls outside his area of
expertise as a psychiatrist, and is otherwise inadequately
supported. Accordingly, the undersigned affords little weight
to the opinions and assessments of Dr. Lowtan.
(Tr. 40). Ms. Walters submits that the ALJ's evaluation
of Dr. Lowtan's opinions is insufficient and conclusory,
citing the cases of Michel v. Comm'r, Social Sec.
Admin., No. SAG-13-2311, 2014 WL 2565900 (D. Md. June 5,
2014) and Lewis v. Berryhill, 858 F.3d 858 (4th Cir.
respect to Ms. Walters's physical impairments, the ALJ
provided a sufficient explanation elsewhere in the opinion
for the conclusory statement that Dr. Lowtan's opinion
“is otherwise inadequately supported.” (Tr. 40).
Specifically, the ALJ listed a lengthy number of
“entirely normal physical exam[s]” during office
visits from 2012 through 2015, (Tr. 36), and a list of other
examinations at which Ms. Walters had “no
complaints.” (Tr. 37-38). The ALJ also noted that the
record showed treatment that was “routine,
conservative, and unremarkable” with “no extended
hospitalizations.” (Tr. 36). The ALJ further
cited Ms. Walters's activities of daily living, including
extensive housecleaning, and her reported lack of side
effects from her medications. (Tr. 36, 37). Accordingly, the
ALJ did not simply reject Dr. Lowtan's physical
assessment due to his lack of expertise because he is a
psychiatrist. Instead, the ALJ provided sufficient reasoning
and substantial evidence to support the conclusion that Dr.
Lowtan's opinion that Ms. Walters had serious physical
limitations (such as an inability to sit for more than one
hour or stand/walk for more than one hour total in an eight
hour workday) lacked support in the record.
the ALJ's analysis was less comprehensive as to Ms.
Walters's mental impairments. The ALJ did include an
eight-page summary of all of Ms. Walters's physical and
mental treatment records, including regular monthly
appointments with Dr. Lowtan. (Tr. 28-36). At many of those
appointments, Ms. Walters displayed some symptoms, but other
portions of the exam were normal. See, e.g., (Tr.
29) (“A mental status exam showed her mood was
depressed and anxious, and her affect was labile, but the
remainder of the exam was normal.”); (Tr. 30) (“A
mental status exam noted that she walked with a limp, and she
had an anxious mood and labile affect, but was otherwise
unremarkable.”); (Tr. 31) (“A mental status exam
found her to have a depressed and anxious mood, with a labile
affect, but no problems with concentration or memory, and her
judgment was deemed good.”); id. (“A
mental status exam noted that her mood and affect were both
normal, she had preoccupations, and her thought process was
circumstantial, but her memory and concentration were normal,
as was the remainder of the exam.”); (Tr. 35)
(“[C]laimant reported getting frustrated and angry, and
having a meltdown. A mental status exam noted that her mood
was anxious, and her affect was labile, but she was
cooperative, alert, and oriented, and her concentration and
memory were normal.”). At other appointments, there
were unremarkable examinations and little adjustment to Ms.
Walters's medications. (Tr. 33, 35). The ALJ's
analysis states only that Dr. Lowtan's “findings
and opinions are not consistent with or supported by the
other evidence of record, including his own treatment notes.
Specifically, Dr. Lowtan's mental assessments of multiple
marked limitations appears [sic] disproportionate to
the weight of the evidence of record as a whole.” (Tr.
40). The ALJ provides no other explanation for his conclusion
that there were inconsistencies between the treatment records
and the opinions regarding mental limitations. The portion of
the ALJ's opinion analyzing Ms. Walters's credibility
references only a single November 14, 2012 visit to Dr.
Lowtan, despite the fact that Dr. Lowtan's treatment
records comprise a substantial portion of the overall medical
record. (Tr. 36). In light of the treatment notes
demonstrating ongoing mental health symptoms, the
longitudinal record and opinion from Ms. Walters's
longtime and frequent treating psychiatrist, and the lack of
any specific analysis of that record, the ALJ failed to
“build an accurate and logical bridge from the evidence
to his conclusion” as required by the law.
Lewis, 858 F.3d at 868 (quoting Monroe v.
Colvin, 826 F.3d 176, 189 (4th Cir. 2016)). In fact, the
ALJ's language in this case is not materially different
from the discussion the Fourth Circuit deemed inadequate in
Lewis. See Id. at 865 (evaluating the language,
“The undersigned gives these opinions partial weight,
because the severity of assessed exertional and
non-exertional limitations is not entirely consistent with
the longitudinal conservative treatment record, the
documented clinical and examination findings, and Ms.
Lewis' stated ongoing capabilities.”). Accordingly,
remand is warranted for the ALJ to provide a complete
evaluation of his assignment of weight to Dr. Lowtan's
mental health opinions. In so holding, I express no opinion
as to whether the ALJ's ultimate conclusion that Ms.
Walters is not disabled is correct or incorrect.
Walters's remaining arguments are unpersuasive. As the
ALJ acknowledges, Ms. Walters was diagnosed with
“right-sided carpal tunnel syndrome (CTS), mild to
moderate” on January 9, 2013, (Tr. 30), after a finding
of a “positive Tinel's sign over both carpal
tunnels” in September, 2012, (Tr. 29). See
(Tr. 30-31). She was advised to use a soft wrist splint.
Id. No further discussion of CTS-related symptoms or
impairments appears in any medical record, and there was no
mention of any CTS-related symptoms at the hearing before the
ALJ. Ms. Walters mentions no CTS-related symptoms or
impairments in her January 15, 2013 adult function report,
(Tr. 213-20), and did not even report the diagnosis of CTS to
a consultative examiner when describing her physical medical
history in April, 2013. (Tr. 294). Accordingly, while the ALJ
should have evaluated the CTS diagnosis and presumably deemed
it to be a non-severe impairment, the failure to do so, in
the absence of a showing that the impairment met the
durational requirement or had any impact on Ms. Walters's
functioning, is harmless error. However, since the case is
being remanded on other grounds, while on remand, the ALJ
should address Ms. Walters's CTS and determine whether it
is a severe impairment.
Ms. Walters argues that the ALJ failed to adequately develop
the administrative record by neglecting to order a physical
consultative examination, despite “wildly
inconsistent” opinions from the State agency medical
consultants (“consultants”). [ECF No. 18, pp.
19-20]. I disagree. An ALJ “has a duty to explore all
relevant facts and inquire into the issues necessary for
adequate development of the record, and cannot rely only on
the evidence submitted by the claimant when that evidence is
inadequate.” Cook v. Heckler, 783 F.2d 1168,
1173 (4th Cir. 1986). However, an ALJ has discretion in
deciding whether to order a consultative examination.
See 20 C.F.R. § 416.919a(a); Bishop v.
Barnhart, 78 F. App'x 265, 268 (4th Cir. 2003). A
consultative examination is only needed when the evidentiary
record before the ALJ is inadequate. See France v.
Apfel, 87 F.Supp.2d 484, 489-90 (D. Md. 2000). A
consultative examination may be used to “resolve any
conflicts or ambiguities within the record” or
“to secure needed medical evidence the file does not
contain such as clinical findings, laboratory tests, a
diagnosis or prognosis necessary for decision.”
Kersey v. Astrue, 614 F.Supp.2d 679, 693 (W.D. Va.
2009); see also 20 C.F.R. § 416.919a(b). Here,
Ms. Walters has not established that the ALJ improperly
relied on the opinions of the consultants or otherwise had an
inadequate evidentiary record. The ALJ summarized the
findings of both the initial consultants and the consultants
on reconsideration, acknowledging the discrepancies between
the two opinions. (Tr. 40-41). The ALJ explained that both
sets of consultants deemed Ms. Walters “capable of at
least a range of light work, even with additional
non-exertional limitations[.]” (Tr. 41). The ...