United States District Court, D. Maryland
COMMISSIONER, SOCIAL SECURITY
REPORT AND RECOMMENDATIONS
Stephanie A. Gallagher United States Magistrate Judge
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 5. I have
considered the parties' cross-motions for summary
judgment, and Plaintiff's reply. ECF 10, 13, 14. I find
that no hearing is necessary. See Loc. R. 105.6 (D.
Md. 2018). This Court must uphold the decision of the Social
Security Administration (“SSA”) if it is
supported by substantial evidence and if the SSA 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
the Court deny both motions, reverse the SSA's decision
in part, and remand the case to the SSA for further
proceedings in accordance with this report and
applied for Disability Insurance Benefits (“DIB”)
on August 12, 2014, alleging a disability onset date of
January 27, 2014. Tr. 123-26. His application was denied
initially and on reconsideration. Tr. 64-67, 69-70. An
Administrative Law Judge (“ALJ”) held a hearing
on March 21, 2017, at which Plaintiff was accompanied by a
non-attorney representative. Tr. 24-42. Following the
hearing, the ALJ determined that Plaintiff was not disabled
within the meaning of the Social Security Act. Tr. 12-18. The
Appeals Council (“AC”) denied Plaintiff's
request for further review, Tr. 1-5, so the ALJ's
decision constitutes the final, reviewable decision of the
found that Plaintiff suffered from the severe impairments of
“post laminectomy syndrome; radiculopathy; degenerative
disc disease (DDD); pseudoarthrosis; and cervicalgia.”
Tr. 14. Despite these impairments, the ALJ determined that
Plaintiff retained the residual functional capacity
perform less than a full range of sedentary work as defined
in 20 CFR 404.1567(a). The claimant has to avoid lifting and
carrying below waist level. The claimant has to avoid
crawling, crouching, kneeling and climbing ladders, ropes,
and scaffolds, but he can stoop on an occasional basis. The
claimant has to avoid constant reaching. 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 found that Plaintiff was
capable of performing his past relevant work as a systems
analyst. Tr. 18. Therefore, the ALJ concluded that Plaintiff
was not disabled. Id.
appeal, Plaintiff raises two arguments, both relating to the
ALJ's failure to consider the side effects he experienced
from his prescribed medications, which include drowsiness,
grogginess, forgetfulness, and difficulty with concentration.
ECF 10 at 10-15. I agree that the ALJ's RFC analysis was
inadequate and, therefore, I recommend remand. In so
recommending, I express no opinion as to whether the
ALJ's ultimate conclusion that Plaintiff is not entitled
to benefits is correct.
contends that the ALJ failed to consider his non-exertional
limitations caused by the side effects from his pain-related
medications. Those side effects represent only one example of
the mental and non-exertional limitations reflected in the
medical record, and ignored by the ALJ. As Plaintiff argues,
in February, 2016, he described to his doctor a feeling of
sedation with use of his prescribed muscle relaxant. Tr.
1011. Approximately two months later, he again told his
physician that the hydrocodone makes him sleepy when used
with the muscle relaxant. Tr. 1024. In the fall of 2016,
Plaintiff's physician sent him for a neurological
evaluation to address ongoing concerns about his memory and
sensory disturbances. Tr. 1111. He had a follow up
neurological appointment on November 4, 2016, during which he
reported feelings of confusion and forgetfulness. Tr. 1115.
Additionally, though not mentioned by Plaintiff in his
filings, the record reflects that he was previously diagnosed
with depression with anxiety, and prescribed a variety of
medications to address his mental health symptoms. Tr.
1071-73 (reflecting a diagnosis of depression and a
prescription of Zoloft to address symptoms including
difficulty concentrating); Tr. 1076 (showing an increase of
Zoloft dosage to address symptoms of depression with
anxiety); Tr. 1081 (adding Bupropion for depression with
is required to discuss each diagnosis that is supported by
objective medical evidence in the claimant's record.
See Boston v. Barnhart, 332 F.Supp.2d 879, 885 (D.
Md. 2004); Albert v. Astrue, Civil Action No.
CBD-10-2071, 2011 WL 3417109, at *2-3 (D. Md. July 29, 2011).
This Court has held that an ALJ's failure to consider the
severity of a particular diagnosis at step two is harmless
where the ALJ corrects his or her error by “fully
consider[ing] the impact” of the neglected evidence
when determining the claimant's RFC. See Burroughs v.
Comm'r, Soc. Sec. Admin., Civil No. SAG-14-1081,
2015 WL 540719, at *1 (D. Md. Feb. 9, 2015). Here, however,
the ALJ did not consider the impact of Plaintiff's mental
or non-exertional limitations anywhere in the RFC assessment.
In determining a claimant's RFC, the ALJ is required to
consider all of the claimant's impairments, both severe
and non-severe, in combination. See 20 C.F.R. §
404.1545(a)(2); Walker v. Bowen, 889 F.2d 47, 49-50
(4th Cir. 1989). In contrast, the ALJ in this case did not
evaluate Plaintiff's mental or non-exertional impairments
at any point. There is no mention of depression, confusion,
fatigue, or forgetfulness, and no analysis to explain whether
any RFC limitations would be needed to address any of those
diagnoses or symptoms. The complete absence of analysis is
particularly significant in this case, where the ALJ
concluded that Plaintiff would be capable of his past skilled
work as a systems analyst. In light of the mental demands
necessary to fulfill a skilled position, see 20
C.F.R. § 404.1568(c), and the failure of the ALJ to
assess the potential mental limitations evidenced in the
record, I recommend remand for the ALJ to explain his
reasons set forth above, I respectfully recommend that:
1. the Court DENY Defendant's Motion for Summary
Judgment, ECF 13;
2. the Court DENY Plaintiff's Motion for Summary
Judgment, ECF 10;
3. the Court REVERSE IN PART the SSA's decision under
sentence four; and 4. the Court order the Clerk to REMAND the
case to the SSA for further ...