United States District Court, D. Maryland
November 21, 2016, Plaintiff Ronald Lowell Sample petitioned
this Court to review the Social Security Administration's
final decision to deny his claim for Supplemental Security
Income. [ECF No. 1]. I have considered the parties'
cross-motions for summary judgment and supplemental briefing.
[ECF Nos. 16, 18, 24, 25]. 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.
Sample filed his claim for benefits on October 31, 2012, and
later amended his alleged onset date to February 28, 2013.
(Tr. 173-78, 197). His claim was denied initially
and on reconsideration. (Tr. 74-83, 85-96). A hearing was
held on March 3, 2015 before an Administrative Law Judge
(“ALJ”). (Tr. 35-73). Following the hearing, the
ALJ determined that Mr. Sample was not disabled within the
meaning of the Social Security Act during the relevant time
frame. (Tr. 11-34). The Appeals Council (“AC”)
denied Mr. Sample's request for review, (Tr. 1-6), so the
ALJ's decision constitutes the final, reviewable decision
of the Agency.
found that Mr. Sample suffered from the severe impairment of
“mild degenerative disc disease, ” along with
other nonsevere impairments. (Tr. 16-17). Despite these
impairments, the ALJ determined that Mr. Sample would retain
the residual functional capacity (“RFC”) to
“perform the full range of medium work as defined in 20
CFR 416.967(c).” (Tr. 20). After considering the
testimony of a vocational expert (“VE”), the ALJ
determined that Mr. Sample could perform several jobs
existing in the national economy and that, therefore, he was
not disabled. (Tr. 28-29).
Sample raises three primary arguments on appeal: (1) that the
ALJ did not support his RFC assessment with substantial
evidence; (2) that several of his impairments should have
been deemed severe; and (3) that the ALJ improperly assessed
his credibility. I concur that the RFC assessment lacks
appropriate support and the ALJ's credibility analysis is
lacking, and thus remand for further explanation. In so
holding, I express no opinion as to whether the ALJ's
ultimate conclusion that Mr. Sample is capable of substantial
gainful employment is correct or incorrect.
Sample's primary argument is that he is disabled due to
his back pain, although he also alleges some mental health
conditions that the ALJ did not find to be severe. (Tr. 18).
“In determining the credibility of the individual's
statements, the adjudicator must consider the entire case
record, including the objective medical evidence, the
individual's own statements about symptoms, statements
and other information provided by treating or examining
physicians…and any other relevant evidence in the case
record.” SSR 96-7P, 1996 WL 374186, at *1 (S.S.A. July
2, 1996). An ALJ cannot rely exclusively on objective
evidence to undermine a claimant's subjective assertions
of disabling pain. See Lewis v. Berryhill, 858 F.3d
858, 866 (4th Cir. 2017).
case, the ALJ repeatedly cites to objective evidence to
undermine Mr. Sample's assertions of disabling back pain.
Oddly, the ALJ's discussion of “[t]he subjective
factors in this case” focuses exclusively on his mental
health conditions. (Tr. 22). The ALJ does not discuss any
evidence undermining his subjective allegations of disabling
pain. Instead, in considering Ms. Sample's back
condition, the ALJ repeatedly discussed the fact that
diagnostic imaging had normal results or only mild findings.
Id. Although the ALJ referred to indicia of pain
evident in the medical record, the ALJ did not specifically
evaluate the credibility of those assertions or findings.
See Id. (referencing “constant complaints of
back pain, ” “paraspinal tenderness, ”
“displaying spinal tenderness, ” and
“positive straight leg raises”).
as here, pain is the primary basis on which disability is
asserted, and the ALJ includes no analysis of the alleged
disabling pain, the ALJ's opinion is not susceptible to
effective appellate review. Accordingly, remand is
appropriate to allow the ALJ to assess the effect of Mr.
Sample's back pain on his ability to work. In
recommending remand, I express no opinion as to whether the
ALJ's ultimate conclusion that Mr. Sample is capable of
substantial gainful employment is correct or incorrect.
I note that there is no medical opinion suggesting that Mr.
Sample, who turned 50 years of age on his amended alleged
onset date, is able to perform the full range of medium work.
The ALJ acknowledged that, at each of three consultative
examinations, Mr. Sample exhibited symptoms such as slow
gait, spinal tenderness, and/or positive straight leg raises.
(Tr. 22-23). The ALJ assigned only “some weight”
to the opinions of those consultative examiners, who imposed
more significant restrictions than medium work, because the
ALJ deemed the opinions to be “vague.” (Tr.
24-25). Both physical State agency medical consultants opined
that Mr. Sample could perform “less than the full range
of light work.” (Tr. 23). Mr. Sample's treating
physician, Dr. Lwin, also opined that Mr. Sample would have
significant physical restrictions. Id. Another
treating physician, Dr. Seunarine, opined that Mr. Sample
would have extremely significant restrictions from his
physical limitations, including that he could only sit or
stand for two hours and walk for one hour in a workday. (Tr.
24). An ALJ need not adopt any particular medical opinion in
formulating an RFC assessment. However, in a case like this
where every medical source (both treating and non-treating)
opined that there would be restrictions more significant than
those found by the ALJ, additional explanation is required to
justify the apparent deviation from views of the medical
Sample's final argument, regarding impairments that, in
his view, should have been deemed severe, is less persuasive.
However, in light of some of the recommendations made by
various medical sources about limitations that would be
needed to address certain of the medical conditions, on
remand, the ALJ should consider whether any additional
diagnoses should be deemed severe and, if so, whether
additional restrictions in the RFC assessment are
reasons set forth above, Plaintiff's Motion for Summary
Judgment, (ECF No. 16), is DENIED, and Defendant's Motion
for Summary Judgment, (ECF No. 25), is DENIED. Pursuant to
sentence four of 42 U.S.C. § 405(g), the
Commissioner's judgment is REVERSED IN PART due to
inadequate analysis. The case is REMANDED for further
proceedings in accordance with this opinion. The Clerk is
directed to CLOSE this case.
the informal nature of this letter, it should be flagged as
an opinion and docketed as an order.
Stephanie A. Gallagher United ...