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West v. Commissioner, Social Security

United States District Court, D. Maryland

September 7, 2018



          Stephanie A. Gallagher United States Magistrate Judge.

         Pursuant to Standing Order 2014-01, the above-captioned case has been referred to me to review the parties' dispositive motions and to make recommendations pursuant to 28 U.S.C. § 636(b)(1)(B) and Local Rule 301.5(b)(ix). [ECF No. 8]. I have considered the parties' cross-dispositive motions. [ECF Nos. 22, 23]. I find that no hearing is necessary. See Loc. R. 105.6 (D. Md. 2016). This Court must uphold the decision of the Social Security Administration (“SSA”) if it is supported by substantial evidence and if the Agency employed proper legal standards. 42 U.S.C. §§ 405(g), 1383(c)(3); Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996); Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). For the reasons set forth below, I recommend that both motions be denied, that the SSA's decision be reversed in part, and that the case be remanded to the SSA for further analysis.

         Mr. West filed applications for Disability Insurance Benefits and Supplemental Security Income in July, 2014, originally alleging a disability onset of January 1, 2014.[2] (Tr. 181-91). His applications were denied initially and on reconsideration. (Tr. 99-128). An Administrative Law Judge (“ALJ”) held a hearing on January 25, 2017. (Tr. 29-62). Following the hearing, the ALJ determined that Mr. West was not disabled within the meaning of the Social Security Act during the relevant time frame. (Tr. 15-28). The Appeals Council denied Mr. West's request for review, (Tr. 1-6), so the ALJ's decision constitutes the final, reviewable decision of the SSA.

         The ALJ found that Mr. West suffered from the severe impairments of diabetes mellitus and right eye macular degeneration. (Tr. 20). Despite these impairments, the ALJ determined that Mr. West retained the residual functional capacity (“RFC”) to:

perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except he must avoid concentrated exposure to moderate noise and hazards, and he cannot perform work tasks requiring depth perception.

(Tr. 21). After considering testimony from a vocational expert (“VE”), the ALJ determined that Mr. West could perform his past relevant work as a substance abuse counselor, and that, therefore, he was not disabled. (Tr. 23-24).

         Mr. West raises a number of arguments on appeal, including: (1) that the ALJ should have found “wet macular degeneration” to be a severe impairment at step two; (2) that the ALJ insufficiently considered the relevant Listings at step three; (3) that the ALJ should have considered the treatment notes from Mr. West's treating ophthalmologist to be opinion evidence; and (4) that the ALJ's RFC assessment was not based on any medical opinions in the record. Pl. Mot. 2-17. I agree that portions of the ALJ's analysis are deficient, and I therefore recommend remand.

         Initially, two of Mr. West's arguments are unpersuasive. First, the ALJ determined that Mr. West suffered from the severe impairment of “right eye macular degeneration.” (Tr. 20). The omission of the word “wet” from the description of his diagnosis, at step two, does not warrant remand. A claimant's burden of showing one or more severe impairments at step two is only a “de minimis screening device used to dispose of groundless claims.” Taylor v. Astrue, Civil No. BPG-11-032, 2012 WL 294532, at *8 (D. Md. Jan. 31, 2012) (quoting Webb v. Barnhart, 433 F.3d 683, 687 (9th Cir. 2005) (emphasis added)); see also Felton-Miller v. Astrue, 459 Fed.Appx. 226, 230 (4th Cir. 2011) (“Step two of the sequential evaluation is a threshold question with a de minimis severity requirement.”) (citing Bowen v. Yuckert, 482 U.S. 137, 153-54 (1987); SSR 88-3c, 1988 WL 236022 (S.S.A. 1988)). Once a severe impairment is found, the ALJ continues with the sequential evaluation and considers how each of the claimant's impairments impacts his ability to perform work. See 20 C.F.R § 404.1520. Later in his decision the ALJ noted Mr. West was diagnosed with “wet macular degeneration.” (Tr. 22). Although, as described below, I do believe the ALJ's subsequent evaluation of Mr. West's visual condition was deficient, the description of his macular degeneration during the threshold finding at step two does not provide a basis for remand.

         Second, Mr. West's argument that the treatment notes from his ophthalmologist, Dr. Laird, should have been treated as a medical opinion lacks merit. Opinion evidence relates to a claimant's ability to perform work-related functions. See SSR 96-5p, 1996 WL 374183 (S.S.A. 1996); 20 C.F.R. § 404.1527(a)(1) (“Medical opinions are statements from acceptable medical sources that reflect judgments about the nature and severity of your impairment(s), including your symptoms, diagnosis and prognosis, what you can still do despite impairment(s), and your physical or mental restrictions.”). Although Dr. Laird's treatment notes do contain diagnoses and information about the severity of Mr. West's impairments, (Tr. 329-89), they do not contain Dr. Laird's judgments on Mr. West's vocational restrictions or his ability to perform tasks. Moreover, if every treatment note or progress report (most of which contain symptoms and diagnoses) were to constitute a medical opinion, the requirement that an ALJ assign weight to each medical opinion in the record would be simply unsustainable. In this case, Mr. West did not offer any opinion evidence from Dr. Laird, or any other treating or examining medical sources.

         Despite those two unpersuasive arguments, I agree with Mr. West that the ALJ's opinion is deficient in two other respects: (1) his listing analysis and (2) his overall evaluation of Mr. West's visual impairment as it affects his RFC assessment and his ability to perform past relevant work.

         Beginning with the ALJ's listing analysis, the ALJ found the following:

No treating or examining physician has indicated finding [sic] that would satisfy the severity requirements of any listed impairment. Particular attention was given to the listings in sections 2.02-2.04 and 11.02, but the available medical evidence did not demonstrate the specified criteria required of any listing.

(Tr. 21). In Fox v. Colvin, 632 Fed.Appx. 750 (4th Cir. 2015), the Fourth Circuit clarified the evidentiary requirements needed to support an ALJ's determination of whether any of a claimant's impairments meets a listing at step three of the sequential evaluation. The ALJ in Fox stated:

Although the claimant has “severe” impairments, they do not meet the criteria of any listed impairments described in Appendix 1 of the Regulations (20 CFR, Subpart P, Appendix 1). No. treating or examining physician has mentioned findings equivalent in severity to the criteria of any listed impairment, nor does the evidence show medical findings that are the same or equivalent to those of any listed impairment of the Listing of ...

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