Tilghman v. Kijakazi

Filing 17

MEMORANDUM OPINION. Signed by Magistrate Judge Charles D. Austin on 9/25/2024. (bg3s, Deputy Clerk)

UNITED STATES DISTRICT COURT
DISTRICT OF MARYLAND
CHAMBERS OF

101 WEST LOMBARD STREET
BALTIMORE, MARYLAND 21201
[phone]

CHARLES D. AUSTIN

UNITED STATES MAGISTRATE JUDGE

[e-mail]

September 25, 2024
LETTER TO ALL COUNSEL OF RECORD
Shawanda T. v. Martin O’Malley, Commissioner, Social Security Administration 1
Civil No. 23-2663-CDA

Re:

Dear Counsel:
On October 2, 2023, Plaintiff Shawanda T. (“Plaintiff”) petitioned this Court to review
the Social Security Administration’s (“SSA’s” or “Commissioner’s” or “Defendant’s”) final
decision to deny Plaintiff’s claim for Social Security benefits. ECF 1. This case was then
referred to me with the parties’ consent. See 28 U.S.C. § 636; Loc. R. 301 (D. Md. 2023). I
have considered the record in this case (ECF 8) and the parties’ briefs (ECFs 11, 15, 16). I find
that no hearing is necessary. See Loc. R. 105.6 (D. Md. 2023). This Court must uphold the
decision of the SSA if it is supported by substantial evidence and if the SSA 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 REVERSE the Commissioner’s decision and REMAND
the case to the Commissioner for further consideration. This letter explains why.
I.

PROCEDURAL BACKGROUND

Plaintiff protectively filed a Title II application for Disability Insurance Benefits (“DIB”)
on July 1, 2019, alleging a disability onset of June 15, 2019. Tr. 398-401. Plaintiff’s claims
were denied initially and on reconsideration. Tr. 262-65, 268-273. On October 6, 2022, an
Administrative Law Judge (“ALJ”) held a hearing. Tr. 177-238. Following the hearing, on
December 1, 2022, the ALJ determined that Plaintiff was not disabled within the meaning of the
Social Security Act 2 during the relevant time frame. Tr. 143-68. The Appeals Council denied
Plaintiff’s request for review, Tr. 1-7, so the ALJ’s decision constitutes the final, reviewable
decision of the SSA, Sims v. Apfel, 530 U.S. 103, 106-07 (2000); see also 20 C.F.R.
§ 422.210(a).

1

Plaintiff filed this case against Kilolo Kijakazi, the Acting Commissioner of Social Security, on
October 2, 2023. ECF 1. Martin O’Malley became the Commissioner of Social Security on
December 20, 2023. Accordingly, Commissioner O’Malley has been substituted as this case’s
Defendant pursuant to Federal Rule of Civil Procedure 25(d). See Fed. R. Civ. P. 25(d).
2

42 U.S.C. §§ 301 et seq.

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Civil No. 23-2663-CDA
September 25, 2024
Page 2
II.

THE ALJ’S DECISION

Under the Social Security Act, disability is defined as the “inability to engage in any
substantial gainful activity by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which has lasted or can be expected to
last for a continuous period of not less than 12 months[.]” 42 U.S.C. § 423(d)(1)(A); 20 C.F.R.
§§ 404.1505(a), 416.905(a).
The ALJ is required to evaluate a claimant’s disability
determination using a five-step sequential evaluation process. See 20 C.F.R. §§ 404.1520,
416.920. “Under this process, an ALJ evaluates, in sequence, whether the claimant: ‘(1) worked
during the alleged period of disability; (2) had a severe impairment; (3) had an impairment that
met or equaled the requirements of a listed impairment; (4) could return to [their] past relevant
work; and (5) if not, could perform any other work in the national economy.’” Kiser v. Saul, 821
F. App’x 211, 212 (4th Cir. 2020) (citation omitted) (quoting Hancock v. Astrue, 667 F.3d 470,
472 (4th Cir. 2012)).
Here, at step one, the ALJ determined that Plaintiff had “not engaged in substantial
gainful activity since June 15, 2019, the alleged onset date.” Tr. 148. At step two, the ALJ
found that Plaintiff suffered from the severe impairments of “degenerative disc disease of the
cervical, thoracic, and lumbar spines; obesity; carpal tunnel syndrome; and degenerative joint
disease of the knees.” Tr. 149. The ALJ also determined that Plaintiff suffered from the nonsevere impairments of “neutrophilic leukocytosis with intermittent thrombocytosis, hypertension,
gastroesophageal reflux disease (GERD), and lipodermatosclerosis.” Tr. 149. At step three, the
ALJ determined that Plaintiff “does not have an impairment or combination of impairments that
meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404,
Subpart P, Appendix 1.” Tr. 150. Despite these impairments, the ALJ determined that Plaintiff
retained the residual functional capacity (“RFC”) to:
perform light work as defined in 20 CFR 404.1567(b). Further, the claimant
needs to alternate positions between sitting and standing every 30 minutes without
having to leave the workstation or abandon tasks. She can occasionally climb
ramps and stairs. She can occasionally stoop and crouch. She should never climb
ladders, ropes or scaffolds. She should never kneel or crawl. She can balance on
even surfaces and can stand and walk on level terrain. She can tolerate occasional
exposure to extreme heat, extreme cold, humidity, vibration, concentrated
respiratory irritants such as fumes, odors, dusts, gases, and poorly ventilated
areas, and hazards of unprotected heights and dangerous, unguarded machinery.
She can frequently reach and handle (perform gross manipulation) with the upper
extremities.
Tr. 153. The ALJ determined that Plaintiff was unable to perform past relevant work as a
correctional officer (work in the kitchen) (DOT 3 #372.667-018) and a correction officer head
3

The “DOT” is the Dictionary of Occupational Titles. “The Dictionary of Occupational Titles,
and its companion, Selected Characteristics of Occupations Defined in the Revised Dictionary of

Shawanda T. v. O’Malley
Civil No. 23-2663-CDA
September 25, 2024
Page 3
(DOT #372.137-010) but could perform other jobs that existed in significant numbers in the
national economy. Tr. 160. Therefore, the ALJ concluded that Plaintiff was not disabled. Tr.
162.
III.

LEGAL STANDARD

The scope of the Court’s review is limited to determining whether substantial evidence
supports the ALJ’s factual findings and whether the decision was reached through the application
of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). “The
findings of the [ALJ] . . . as to any fact, if supported by substantial evidence, shall be conclusive
. . . .” 42 U.S.C. § 405(g). Substantial evidence is “evidence which a reasoning mind would
accept as sufficient to support a particular conclusion.” Laws v. Celebrezze, 368 F.2d 640, 642
(4th Cir. 1966). It is “more than a mere scintilla . . . and somewhat less than a preponderance.”
Id. In conducting the “substantial evidence” inquiry, my review is limited to whether the ALJ
analyzed the relevant evidence and sufficiently explained their findings and rationale in crediting
the evidence. See, e.g., Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439–40 (4th Cir.
1997); DeLoatche v. Heckler, 715 F.2d 148, 150 (4th Cir. 1983) (“Judicial review of an
administrative decision is impossible without an adequate explanation of that decision by the
[ALJ].”).
IV.

ANALYSIS

Plaintiff raises two arguments on appeal. First, Plaintiff contends that the RFC was not
supported by substantial evidence because the ALJ failed to apply the proper legal standards
when assessing Plaintiff’s exertional capacity. ECF 11, at 7-19. She contends that the ALJ
failed to conduct a function-by-function assessment of Plaintiff’s ability to perform the physical
requirements of light work and conflated the RFC assessment with a symptom analysis. Id.
Second, Plaintiff avers that the ALJ failed to properly consider Plaintiff’s lipodermatosclerosis at
step two, which infected each step in the sequential evaluation. Id. at 19-22. Defendant counters
that substantial evidence supported the ALJ’s RFC because this Court “can plainly trace the
ALJ’s reasoning in finding Plaintiff’s ability to perform the relevant functions required by light
work[,]” and that the ALJ properly determined Plaintiff’s lipodermatosclerosis was not a severe
impairment. ECF 15, at 7-20.
After carefully reviewing the record, the Court determines that the ALJ erred in assessing
Plaintiff’s RFC. A claimant’s RFC represents “the most [they] can still do despite [their]
limitations.” 20 C.F.R. § 416.945(a). In assessing RFC, an ALJ must “consider all of the
claimant’s ‘physical and mental impairments, severe and otherwise, and determine, on a
function-by function basis, how they affect [the claimant’s] ability to work.’” Thomas v.
Occupational Titles . . . , are [SSA] resources that list occupations existing in the economy and
explain some of the physical and mental requirements of those occupations. U.S. Dep’t of
Labor, Dictionary of Occupational Titles (4th ed. 1991); U.S. Dep’t of Labor, Selected
Characteristics of Occupations Defined in the Revised Dictionary of Occupational Titles
(1993).” Pearson v. Colvin, 810 F.3d 204, 211 n.1 (4th Cir. 2015).

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September 25, 2024
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Berryhill, 916 F.3d 307, 311 (4th Cir. 2019) (quoting Monroe v. Colvin, 826 F.3d 176, 188 (4th
Cir. 2016)). Pursuant to Social Security Ruling (“SSR”) 96-8p, an RFC assessment must include
an evaluation of a claimant’s ability to perform the physical functions listed in 20 C.F.R.
§ 416.945(b), including “sitting, standing, walking, lifting, carrying, pushing, pulling, or other
physical functions” that “may reduce [a claimant’s] ability to do . . . work.” 20 C.F.R.
§ 416.945(b); see SSR 96-8p, 1996 WL 374184, at *5 (July 2, 1996).
Only after such an analysis may an ALJ express RFC in terms of the exertional level of
work of which the ALJ believes the claimant to be capable. See Dowling v. Comm’r of Soc. Sec.
Admin., 986 F.3d 377, 387 (4th Cir. 2021). As Dowling explained, “every conclusion reached by
an ALJ when evaluating a claimant’s RFC must be accompanied by ‘a narrative discussion
describing [ ] the evidence’ that supports it.” 986 F.3d at 387 (alteration in original) (citation
omitted). Thus, an ALJ must identify evidence that supports their conclusions and build an
accurate and logical bridge from that evidence to their conclusions. See Woods v. Berryhill, 888
F.3d 686, 694 (4th Cir. 2018).
Plaintiff argues that the ALJ failed to analyze Plaintiff’s ability to sit, stand, walk, lift,
carry, push, and pull. See ECF 11, at 7-19. With respect to walking, Plaintiff maintains that the
ALJ’s RFC “is legally insufficient to allow for judicial review” because “the RFC determination
is entirely silent about how long Plaintiff can walk on level terrain in an eight-hour workday.”
Id. at 13. Plaintiff avers that substantial evidence shows Plaintiff’s impaired capacity for
prolonged walking and that “the “ALJ recounted examinations documenting Plaintiff’s gait to be
cautious, guarded, and antalgic,” yet the RFC merely states that Plaintiff “can stand and walk on
level terrain.” Id.
The Court agrees that the ALJ committed reversible error by failing to explain how the
evidence supports the RFC’s implicit conclusion regarding Plaintiff’s ability to walk at a light
exertional level. Here, the ALJ evaluated the opinions of three sources who assessed Plaintiff’s
ability to walk. Plaintiff’s treating orthopedist, Mr. Hjorth, Physician Assistant – Certified (“PAC”), evaluated Plaintiff’s left knee pain and opined, among other things, that Plaintiff’s “[g]ait
pattern show[ed] mild favoring of involved knee,” and Plaintiff “was advised to avoid
aggravating activities.” Tr. 159, 682. The ALJ found Mr. Hjorth’s opinion unpersuasive,
concluding that “[w]hile supported by a clinical interview and physical examination,” Mr.
Hjorth’s opinion “[was] too vague and [was] not akin to any exertional level.” Tr. 159.
Next, the ALJ considered the opinion of the consultant at the initial level, Dr. C. Pio
Roda, M.D. Dr. Pio Roda opined, among other things, that Plaintiff was capable of light work,
limited Plaintiff to walking for six hours in an eight-hour workday, and “did not find [Plaintiff]
to have any additional nonexertional limitations.” Tr. 159, 243-44. The ALJ did not find Dr. Pio
Roda’s “opined full range of light work fully persuasive.” Tr. 159. As to supportability, the ALJ
found the opinion “supported by citations to the medical and nonmedical evidence.” Tr. 159. As
to consistency, the ALJ noted that Dr. Pio Roda “only found the claimant to have one severe
impairment: degenerative disc disease,” and found that the opinion was “inconsistent with the
claimant’s other impairments of obesity, carpal tunnel syndrome, and degenerative joint disease

Shawanda T. v. O’Malley
Civil No. 23-2663-CDA
September 25, 2024
Page 5
of the knees.” Tr. 159. The ALJ concluded that these impairments “were not adequately
considered[,]” and “would have resulted in greater limitations.” Tr. 159.
The ALJ also evaluated the opinion of the consultant at the reconsideration level, Dr.
Gurcharan Singh, M.D., who found Plaintiff “to only have degenerative disc disease as a severe
impairment” and opined, among other things, that Plaintiff was capable of light work, limited
Plaintiff to walking for six hours in an eight-hour workday, and “found [Plaintiff] to have
postural, manipulative, and environmental limitations.” Tr. 159, 253-57. The ALJ found these
limitations opined by Dr. Singh “partially persuasive.” Tr. 159. As to supportability, the ALJ
found that “the limitations [we]re supported by citations to the medical and nonmedical
evidence.” Tr. 159. As to consistency, the ALJ concluded that the limitations “[we]re not fully
consistent with the objective and subjective evidence.” Tr. 159-60. The ALJ found that
Plaintiff’s “complaints of being unable to stand or sit for prolonged periods warrants the option
to alternate positions[,]” and that Plaintiff’s “degenerative joint disease of the left knee would
make stooping and kneeling very difficult.” Tr. 160.
The Court agrees with Plaintiff that the ALJ’s RFC lacks the support of substantial
evidence. “Light work involves lifting no more than 20 pounds at a time with frequent lifting or
carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little,
a job is in this category when it requires a good deal of walking or standing[.]” 20 C.F.R.
§ 404.1567(b) (emphasis added). “Since frequent lifting or carrying requires being on one’s feet
up to two-thirds of a workday, the full range of light work requires standing or walking, off and
on, for a total of approximately 6 hours of an 8-hour workday.” SSR 83-10, 1983 WL 31251, at
*6 (S.S.A. Jan. 1, 1983). Here, the ALJ limited Plaintiff to performing light work with several
additional restrictions, including limiting Plaintiff to “walk on level terrain.” Tr. 153. However,
the ALJ found Drs. Pio Roda’s and Singh’s opinions, both of which limited Plaintiff to walking
for six hours in an eight-hour workday, “not fully persuasive” and “partially persuasive,”
respectively. Tr. 159-60. The ALJ offered no explanation for this incongruity. Moreover, the
ALJ provided no analysis that would permit the Court to understand how they ultimately
determined that Plaintiff could perform the walking requirements of light work. 4 Because the
inconsistency between the ALJ’s analysis and the RFC “frustrate[s] meaningful review” of the
ALJ’s decision, remand is “appropriate.” Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015).

4

The RFC assessment does state that Plaintiff “needs to alternate positions between sitting and
standing every 30 minutes without having to leave the workstation or abandon tasks.” Tr. 153.
But the ALJ’s decision provides no insight into how this provision affects the length of time that
Plaintiff is able to walk during a workday. The ALJ acknowledged that the vocational expert
(“VE”) was “asked about the courier position and opportunity to alternate between sitting and
standing[,]” and noted that the VE “responded that when driving, they are sitting and when
delivering they are standing and/or walking,” and that “there is a lot of flexibility in that position
that offers adjustments.” Tr. 161, 230-31. However, this does not explain how the sit/stand
provision accounts for the length of time that Plaintiff is required to walk at a light exertional
level.

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The potential harm from this error is palpable due to the conflicting record evidence
surrounding Plaintiff’s ability to walk. Here, the ALJ made inconsistent findings on this point.
In some instances, the ALJ noted that Plaintiff’s walking was cautious, guarded, or antalgic. See
Tr. 151 (“[Plaintiff] had an abnormal gait . . . .”), 153-54 (Plaintiff’s Function Reports “indicated
difficulties with . . . walking,” among other things), 155 (Plaintiff “ambulated cautiously and
guardedly” in both November 2019 and in January 2021), 156 (Plaintiff “again ambulated
cautiously and guarded” in April 2021, had a “cautious and guarded gait” in June 2021, and “had
an antalgic gait” in October 2022), 157 (Plaintiff’s “gait pattern showed mild favoring of the
involved [knee]” in August 2021), 158 (Plaintiff testified that “[s]he even had difficulty walking
from the car to the store. She had to take a break after this walking.”). In other portions of the
narrative, the ALJ characterized Plaintiff’s ability to walk as normal. See Tr. 151 (“[S]he did not
use an assistive [walking] device.”), 156 (“[S]he was also noted to have a normal gait and station
and ambulated unassisted” in April 2021, Plaintiff’s “gait and station were normal” in December
2021, and Plaintiff’s “gait was normal” in May 2022). SSA regulations require the ALJ to
“explain how any material inconsistencies or ambiguities in the evidence in the case record were
considered and resolved.” SSR 96-8p, 1996 WL 374184, at *7 (July 2, 1996). Because the
ALJ’s evaluation of this evidence “was internally inconsistent,” and there appears to be no
reconciliation of these inconsistencies, the Court’s ability to trace the ALJ’s reasoning is
impeded, making remand necessary. Rodney G. v. Kijakazi, No. BAH-22-3007, 2023 WL
6465436, at *4 (D. Md. Oct. 3, 2023) (citing Mallett v. Berryhill, No. 5:18-CV-241-D, 2019 WL
2932776, at *4 (E.D.N.C. June 17, 2019)).
The Fourth Circuit has declined to adopt a per se rule requiring remand when an ALJ
fails to perform an explicit function-by-function analysis. See Mascio, 780 F.3d at 636.
However, when a function is “critically relevant to determining [a claimant’s] disability status,”
remand for failure to perform such an analysis is appropriate. Dowling, 986 F.3d at 389. Had
the ALJ properly evaluated Plaintiff’s ability to walk, they may have found Plaintiff to possess
greater limitations in walking that, in turn, could have altered the ultimate disability
determination in this case. See ECF 11, at 18-19 (noting that if Plaintiff were limited to a
sedentary RFC, she would be found disabled under Grid Rule 201.10). Thus, remand is
warranted. Because the case is being remanded on these grounds, I need not address Plaintiff’s
other arguments. On remand, the ALJ is welcome to consider these arguments and make any
required adjustments to the opinion. Additionally, in remanding for further explanation, the
Court expresses no opinion as to whether the ALJ’s conclusion that Plaintiff is not entitled to
benefits is correct.
V.

CONCLUSION

For the reasons set forth herein, pursuant to sentence four of 42 U.S.C. § 405(g), the
SSA’s judgment is REVERSED due to inadequate analysis. The case is REMANDED for
further proceedings in accordance with this opinion. The clerk is directed to CLOSE this case.
Despite the informal nature of this letter, it should be flagged as a Memorandum Opinion.
A separate implementing Order follows.

Shawanda T. v. O’Malley
Civil No. 23-2663-CDA
September 25, 2024
Page 7
Sincerely,
/s/
Charles D. Austin
United States Magistrate Judge