Wilson v. Colvin

Filing 16

ORDER denying 14 Motion of plaintiff for Summary Judgment; denying 15 Motion of defendant for Summary Judgment; the Commissioners judgment is REVERSED IN PART due to inadequate analysis. The case is REMANDED for further proceedings. Signed by Magistrate Judge Stephanie A Gallagher on 5/16/2017. (jnls, Deputy Clerk)

UNITED STATES DISTRICT COURT
DISTRICT OF MARYLAND
CHAMBERS OF
STEPHANIE A. GALLAGHER
UNITED STATES MAGISTRATE JUDGE

101 WEST LOMBARD STREET
BALTIMORE, MARYLAND 21201
[phone]
Fax [phone]

May 16, 2017
LETTER TO COUNSEL
RE:

Samuel Wilson v. Commissioner, Social Security Administration;
Civil No. SAG-16-3233

Dear Counsel:
On September 23, 2016, Plaintiff Samuel Wilson petitioned this Court to review the
Social Security Administration’s final decision to deny his claim for Disability Insurance
Benefits. (ECF No. 1). I have considered the parties’ cross-motions for summary judgment.
(ECF Nos. 14, 15). 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.
Mr. Wilson filed a claim for Disability Insurance Benefits (“DIB”) on May 23, 2012,
alleging a disability onset date of March 1, 2012.1 (Tr. 246-49). His claim was denied initially
and on reconsideration. (Tr. 135-38, 141-42). A hearing was held on April 2, 2015, before an
Administrative Law Judge (“ALJ”). (Tr. 42-67). Following the hearing, the ALJ determined
that Mr. Wilson was not disabled within the meaning of the Social Security Act during the
relevant time frame. (Tr. 19-41). The Appeals Council denied Mr. Wilson’s request for review,
(Tr. 1-7), so the ALJ’s decision constitutes the final, reviewable decision of the Agency.
The ALJ found that Mr. Wilson suffered from the severe impairments of “gout, obesity,
hepatitis C, history of alcohol and cocaine dependence, depression, and a specific learning
disorder.” (Tr. 24). Despite these impairments, the ALJ determined that Mr. Wilson retained the
residual functional capacity (“RFC”) to:
perform light work as defined in 20 CFR 404.1567(b) with exceptions. The
claimant can lift and carry twenty pounds occasionally and ten pounds frequently.
In an eight-hour workday, the claimant can stand for six hours, walk for six hours,
and sit for six hours. He can occasionally climb ramps and stairs, balance, kneel,
crawl, stoop, and crouch. The claimant must avoid concentrated exposure to
1

On February 16, 2012, Mr. Wilson received a fully favorable decision from the Commissioner regarding a prior
application for disability benefits for the closed period from June 30, 2009 through September 1, 2011. (Tr. 10517).

Samuel Wilson v. Commissioner, Social Security Administration
Civil No. SAG-16-3233
May 16, 2017
Page 2
extreme temperatures and hazardous machinery and avoid working at unprotected
heights, climbing ladders, ropes, and scaffolds, and work on vibrating surfaces.
The claimant is able to understand, remember, and carry out simple instructions in
repetitive, unskilled work.
(Tr. 27). After considering the testimony of a vocational expert (“VE”), the ALJ determined that
Mr. Wilson could perform his past relevant work and that, therefore, he was not disabled. (Tr.
35-37).
Mr. Wilson raises two primary arguments on appeal: (1) that the ALJ’s holding runs
afoul of the Fourth Circuit’s decision in Mascio v. Colvin, 780 F.3d 632, 638 (4th Cir. 2015); and
(2) that the ALJ failed to properly evaluate the opinion of the treating physician, Dr. Speedie.2
Pl. Mot. 6-13. I concur that the ALJ’s opinion is deficient under Mascio, and therefore remand
to allow compliance with that decision. In remanding for additional explanation, I express no
opinion as to whether the ALJ’s ultimate conclusion that Mr. Wilson is not entitled to benefits is
correct or incorrect.
Beginning with Mascio, the United States Court of Appeals for the Fourth Circuit
determined that remand was appropriate for three distinct reasons, including, as pertinent to this
case, the inadequacy of the ALJ’s evaluation of “moderate difficulties” in concentration,
persistence, or pace. Mascio, 780 F.3d at 638. At step three of the sequential evaluation, the
ALJ determines whether a claimant’s impairments meet or medically equal any of the
impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. Listings 12.00 et. seq., pertain
to mental impairments. 20 C.F.R. Pt. 404, Subpt. P, App. 1 § 12.00. The relevant listings
therein consist of: (1) a brief statement describing a subject disorder; (2) “paragraph A criteria,”
which consists of a set of medical findings; and (3) “paragraph B criteria,” which consists of a
set of impairment-related functional limitations. Id. at § 12.00(A). If both the paragraph A
criteria and the paragraph B criteria are satisfied, the ALJ will determine that the claimant meets
the listed impairment. Id.
Paragraph B consists of four broad functional areas: (1) activities of daily living; (2)
social functioning; (3) concentration, persistence, or pace; and (4) episodes of decompensation.
The ALJ employs the “special technique” to rate a claimant’s degree of limitation in each area,
based on the extent to which the claimant’s impairment “interferes with [the claimant’s] ability
to function independently, appropriately, effectively, and on a sustained basis.” 20 C.F.R. §
404.1620a(c)(2). The ALJ uses a five-point scale to rate a claimant’s degree of limitation in the
first three areas: none, mild, moderate, marked, or extreme. Id. at § 404.1620a(c)(4). In order to
2

Mr. Wilson also argues that the ALJ failed to properly evaluate pertinent evidence from Dr. Collins, a physician at
the Maryland Division of Rehabilitative Services. Pl. Mot. 7-8. Specifically, Mr. Wilson contends that the ALJ
improperly discredited Dr. Collins’s findings because they “relate[d] to [Mr. Wilson’s] vocational rehabilitation and
[did] not translate to the disability process.” (Tr. 35). Social Security regulations require that an ALJ “evaluate
every medical opinion” in the record “regardless of its source[.]” 20 C.F.R. § 404.1527(c). Ultimately, because the
ALJ’s RFC analysis warrants remand, the ALJ should, on remand, address the evidence identified by Mr. Wilson to
ensure that every medical opinion in the record is evaluated.

Samuel Wilson v. Commissioner, Social Security Administration
Civil No. SAG-16-3233
May 16, 2017
Page 3
satisfy paragraph B, a claimant must exhibit either “marked” limitations in two of the first three
areas, or “marked” limitation in one of the first three areas with repeated episodes of
decompensation. See, e.g., 20 C.F.R. Pt. 404, Subpt. P, App. 1 § 12.02. Marked limitations
“may arise when several activities or functions are impaired, or even when only one is impaired,
as long as the degree of limitation is such as to interfere seriously with [the claimant’s] ability to
function.” Id. at § 12.00(C).
The functional area of “concentration, persistence, or pace refers to the ability to sustain
focused attention and concentration sufficiently long to permit the timely and appropriate
completion of tasks commonly found in work settings.” Id. at § 12.00(C)(3). Social Security
regulations do not define limitations in concentration, persistence, or pace “by a specific number
of tasks that [a claimant is] unable to complete.” Id. The regulations, however, offer little
guidance on the meaning of “moderate” limitations.
The Fourth Circuit remanded Mascio because the hypothetical the ALJ posed to the VE –
and the corresponding RFC assessment – did not include any mental limitations other than
unskilled work, despite the fact that, at step three of the sequential evaluation, the ALJ
determined that the claimant had moderate difficulties in maintaining concentration, persistence,
or pace. Mascio, 780 F.3d at 637-38. The Fourth Circuit specifically held that it “agree[s] with
other circuits that an ALJ does not account for a claimant’s limitations in concentration,
persistence, and pace by restricting the hypothetical question to simple, routine tasks or unskilled
work.” Id. at 638 (quoting Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1180 (11th Cir.
2011)) (internal quotation marks omitted). In so holding, the Fourth Circuit emphasized the
distinction between the ability to perform simple tasks and the ability to stay on task, stating that
“[o]nly the latter limitation would account for a claimant’s limitation in concentration,
persistence, or pace.” Id. Although the Fourth Circuit noted that the ALJ’s error might have
been cured by an explanation as to why the claimant’s moderate difficulties in concentration,
persistence, or pace did not translate into a limitation in the claimant’s RFC, it held that absent
such an explanation, remand was necessary. Id.
In the instant case, the ALJ found Mr. Wilson to have moderate difficulties maintaining
concentration, persistence, or pace. (Tr. 26). The entirety of the analysis states, “[W]hile mental
status examinations have been fairly benign, [Mr. Wilson] has endorsed problems with memory
and concentration. Testing has been suggestive of a learning disorder and [Mr. Wilson] has
reported some difficulty in his college classes. In considering the record as a whole, the
undersigned finds that [Mr. Wilson] has a moderate limitation here and should be limited to
unskilled work.” Id. According to 20 CFR § 404.1520a(c)(2), the rating of “moderate
difficulties” is supposed to represent the result of application of the following technique:
We will rate the degree of your functional limitation based on the extent to which
your impairment(s) interferes with your ability to function independently,
appropriately, effectively, and on a sustained basis. Thus, we will consider such
factors as the quality and level of your overall functional performance, any

Samuel Wilson v. Commissioner, Social Security Administration
Civil No. SAG-16-3233
May 16, 2017
Page 4
episodic limitations, the amount of supervision or assistance you require, and the
settings in which you are able to function.
20 CFR § 404.1520a(c)(2). Once the technique has been applied, the ALJ is supposed to include
the results in the opinion as follows:
At the administrative law judge hearing and Appeals Council levels, the written
decision must incorporate the pertinent findings and conclusions based on the
technique. The decision must show the significant history, including examination
and laboratory findings, and the functional limitations that were considered in
reaching a conclusion about the severity of the mental impairment(s). The
decision must include a specific finding as to the degree of limitation in each of
the functional areas described in paragraph (c) of this section.
20 CFR § 404.1520a(e)(4). The cursory analysis provided by the ALJ in Mr. Wilson’s case
suggests that the finding of “moderate difficulties” was based exclusively on Mr. Wilson’s
allegations of “problems with memory and concentration,” since the remaining sentences in the
analysis would suggest mild or no limitations. Without further explanation, I am unable to
ascertain whether the ALJ truly believed Mr. Wilson to have moderate difficulties in
concentration, persistence, and pace, instead of mild, or no difficulties, and how those difficulties
restrict his RFC to “simple instructions in repetitive, unskilled work.” (Tr. 27). Indeed, the
ALJ’s analysis entirely fails to address Mr. Wilson’s ability to sustain work over an eight-hour
workday. In light of this inadequacy, I must remand the case to the Commissioner for further
analysis consistent with the Fourth Circuit’s mandate in Mascio. On remand, the ALJ should
consider the appropriate level of limitation in the area of concentration, persistence, or pace and,
if a moderate limitation is again found, should explain the reasons for that finding in order to
permit an adequate evaluation of the moderate limitation under the dictates of Mascio.
Next, Mr. Wilson contends that the ALJ assigned inadequate weight to the opinion of the
treating physician, Dr. Speedie. Pl. Mem. 8-9. 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 sources.”).

Samuel Wilson v. Commissioner, Social Security Administration
Civil No. SAG-16-3233
May 16, 2017
Page 5
Contrary to Mr. Wilson’s assertion, the ALJ properly evaluated Dr. Speedie’s opinion.
Notably, Dr. Speedie opined that “[Mr. Wilson] could not lift over twenty pounds due to back
pain, stating that he could lift and carry twenty pounds occasionally and ten pounds frequently.”
(Tr. 33). Additionally, Dr. Speedie opined that “[Mr. Wilson] did not require a cane for
ambulation, but stated that he was limited to two hours of standing/walking in an eight-hour day
due to back and knee pain.” Id. Moreover, Dr. Speedie opined that “[Mr. Wilson] could never
climb, balance, stoop, kneel, crouch, or crawl.” Id. Furthermore, Dr. Speedie opined that “[Mr.
Wilson] had no limitations in manipulative movements, seeing, hearing, or speaking, also
reporting that he did not require environmental restrictions.” Id.
The ALJ assigned Dr. Speedie’s opinion “little weight” because it was inconsistent with
the medical evidence. (Tr. 34-35). Although the ALJ afforded Dr. Speedie’s opinion “some
weight as far as it is consistent with the ability to perform light work,” the ALJ gave “little
weight…to the proposed walking/standing and postural limitations provided.” (Tr. 34). Most
significantly, the ALJ noted that, “Dr. Speedie based these limitations on [Mr. Wilson’s]
subjective complaints.” Id. However, the ALJ found that there was “reason to doubt [Mr.
Wilson’s] contentions.” Id. Specifically, the ALJ noted that Mr. Wilson’s “subjective
complaints [were] out of proportion to the weak and inconsistent objective medical findings
contained in the record.” (Tr. 34-35). For example, the ALJ noted that, contrary to Mr. Wilson’s
claims, “[t]here is no evidence of reduced grip strength in the hands, loss of color in the allegedly
affected regions, muscle spasm with examination or muscle atrophy.” (Tr. 35). In addition, the
ALJ noted that “[t]he medical records do not support consistent multi-joint inflammation,
indicated by joint swelling stiffness, redness, and/or warmth[,]” and “do not contain notes that
[Mr. Wilson] exhibited difficulty-initiating movement, difficulty moving generally, or muscle
tremors.” Id. Moreover, the ALJ noted that although “records indicated some problems with an
antalgic gait, as well as some swelling in the right knee…these problems were intermittent and
appear to be generally well managed by medication.” Id. These inconsistencies, in addition to
others cited by the ALJ, provide sufficient justification for the ALJ’s decision to accord only
“little weight” to Dr. Speedie’s opinion.
Ultimately, my review of the ALJ’s decision is confined to whether substantial evidence,
in the record as it was reviewed by the ALJ, supports the decision and whether correct legal
standards were applied. See Richardson v. Perales, 402 U.S. 389, 390, 404 (1971). Even if
there is other evidence that may support Mr. Wilson’s position, I am not permitted to reweigh the
evidence or to substitute my own judgment for that of the ALJ. See Hays v. Sullivan, 907 F.2d
1453, 1456 (4th Cir. 1990). Accordingly, the ALJ properly evaluated Dr. Speedie’s opinion and
supported her conclusion with substantial evidence. Remand on this basis is therefore
unwarranted.
For the reasons set forth above, Plaintiff’s Motion for Summary Judgment (ECF No. 14)
is DENIED and Defendant’s Motion for Summary Judgment (ECF No. 15) 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.

Samuel Wilson v. Commissioner, Social Security Administration
Civil No. SAG-16-3233
May 16, 2017
Page 6

Despite the informal nature of this letter, it should be flagged as an opinion and docketed
as an order.
Sincerely yours,
/s/
Stephanie A. Gallagher
United States Magistrate Judge