Trahan v. Commissioner of Social Security

Filing 16

MEMORANDUM OPINION. Signed by Magistrate Judge Charles D. Austin on 5/10/2024. (bas, 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]

May 10, 2024
LETTER TO ALL COUNSEL OF RECORD
Re:

Marie T. v. Martin O’Malley, Commissioner, Social Security Administration
Civil No. 23-1320-CDA

Dear Counsel:
On May 18, 2023, Plaintiff Marie T. (“Plaintiff”) petitioned this Court to review the Social
Security Administration’s (“SSA’s” or “Commissioner’s” or “Defendant’s”) final decision to deny
her claim for 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 10)
and the parties’ briefs (ECFs 12, 14, 15). No hearing is necessary. See Loc. R. 105.6 (D. Md.
2023). This Court must uphold the SSA’s decision 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 SSA’s decision and
REMAND the case to the SSA for further consideration. This letter explains why.
I.

PROCEDURAL BACKGROUND

Plaintiff protectively filed a Title II application for Disability Insurance Benefits (“DIB”)
and a Title XVI application for Supplemental Security Income (“SSI”) benefits on August 16,
2020, alleging a disability onset of January 1, 2019. Tr. 10, 213–26. Plaintiff’s claims were denied
initially and on reconsideration. Tr. 112–19, 132–39. On November 15, 2022, an Administrative
Law Judge (“ALJ”) held a hearing. Tr. 38–56. Following the hearing, on November 28, 2022,
the ALJ determined that Plaintiff was not disabled within the meaning of the Social Security Act 1
during the relevant time frame. Tr. 7–30. The Appeals Council denied Plaintiff’s request for
review, Tr. 1–6, 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).
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
1

42 U.S.C. §§ 301 et seq.

Marie T. v. O’Malley
Civil No. 23-1320-CDA
May 10, 2024
Page 2
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 “has not engaged in substantial gainful
activity since January 1, 2019, the alleged onset date.” Tr. 12. At step two, the ALJ found that
Plaintiff suffered from severe “schizoaffective disorder, depressive type; posttraumatic stress
disorder (PTSD); obesity; and obstructive sleep apnea.” Tr. 13. The ALJ also determined that
Plaintiff suffered from non-severe “status/post folliculitis of the bilateral breasts.” Id. 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.” Id. Despite these impairments, the ALJ determined that
Plaintiff retained the residual functional capacity (“RFC”) to:
perform medium work as defined in 20 CFR 404.1567(c) and 416.967(c). Further,
she can frequently climb ramps and stairs, stoop, crouch, kneel, and crawl. She can
occasionally climb ladders, ropes, or scaffolds. She can occasionally tolerate
exposure to extreme cold, extreme heat, humidity, and respiratory irritants such as
fumes, odors, dust, gases, and poorly ventilated areas. She should avoid all
exposure to hazards of unprotected heights and dangerous, unguarded machinery.
She cannot tolerate any contact with the general public. She is capable of only
superficial interaction with co-workers and supervisors. Superficial interaction is
defined as occasional and casual contact not involving prolonged conversation or
discussion of involved issues. Contact with supervisors still involves necessary
instruction. She is not capable of sustaining work requiring a specific production
rate such as assembly line work or work that requires hourly quotas. She is capable
of using judgment to make simple work-related decisions, dealing with occasional
changes in a routine work setting, and understanding, remembering, and carrying
out simple instructions. She can perform tasks on a regular and sustained basis to
complete a normal workday and week.
Tr. 18. The ALJ determined that Plaintiff was unable to perform any past relevant work but could
perform other jobs that existed in significant numbers in the national economy. Tr. 23–24.
Therefore, the ALJ concluded that Plaintiff was not disabled. Tr. 25.
III.

LEGAL STANDARD

The Court’s review is limited to determining whether substantial evidence supports the
ALJ’s factual findings and whether the decision was reached by applying 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

Marie T. v. O’Malley
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mere scintilla . . . and somewhat less than a preponderance.” Id. In conducting the “substantial
evidence” inquiry, the Court considers 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

On appeal, Plaintiff argues that the ALJ erred by (1) failing to properly evaluate the medical
opinion of Travis Roberts, CRNP-PMH and (2) failing to provide valid reasons for discounting
Plaintiff’s testimony regarding her mental impairments. ECF 12, at 3–13. Defendant counters
that the ALJ “was justifiably unpersuaded by [Mr.] Roberts’s opinion” and that the ALJ complied
with SSA regulations and policies in evaluating Plaintiff’s testimony. ECF 14, at 10–17.
An ALJ “must follow certain procedures when assessing the weight to which medical
opinions are entitled.” Adrianna S. v. Comm’r of Soc. Sec., No. SAG-20-3136, 2022 WL 112034,
at *1 (D. Md. Jan. 12, 2022) (citing 20 C.F.R. §§ 404.1520c, 416.920c). Specifically, the ALJ
must “articulate . . . how persuasive [the ALJ] finds each medical opinion.” Id. (citing 20 C.F.R.
§§ 404.1520c(b), 416.920c(b)). “Supportability and consistency are the most important factors
when considering the persuasiveness of medical opinions.”
Id. (citing 20 C.F.R.
§§ 404.1520c(b)(2), 416.920c(b)(2)). Thus, the ALJ must “explain how [they] considered [these]
factors” when assessing a medical opinion. Id. “Supportability generally refers to ‘the objective
medical evidence and supporting explanations provided by a medical source.’” Id. (quoting 20
C.F.R. §§ 404.1520c(c)(1), 416.920c(c)(1)). In assessing consistency, the ALJ considers the
degree of cohesion between the medical opinion and “the evidence from other medical sources
and nonmedical sources in the claim.” Id. (quoting 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2)).
Here, the ALJ considered the medical opinion of Travis Roberts, who opined that Plaintiff
had “marked” and “extreme” limitations in 19 areas of mental functioning. Tr. 22, 623–24. The
ALJ found Mr. Roberts’s opinion unpersuasive for lack of supportability and consistency. Tr. 22.
In addressing the opinion’s supportability, the ALJ noted that the opinion was “minimally
supported[,] with only a mention of the claimant’s diagnoses.” Id. In addressing consistency, the
ALJ noted only that Mr. Roberts’s opinion was “inconsistent with his own treatment records.” Id.
As an initial matter, the ALJ did not err by considering the lack of alignment between Mr.
Roberts’s opinion and his treatment records. In addition to requiring an ALJ to consider
supportability and consistency, SSA regulations direct an ALJ to consider factors that are not
enumerated in the regulations if those factors “tend to support or contradict” a medical opinion.
20 C.F.R. §§ 404.1520c(c)(5), 416.920c(c)(5). Accordingly, the ALJ was entitled to find that Mr.
Roberts’s opinion was “less persuasive” on the basis that it contradicted Mr. Roberts’s treatment
notes. 20 C.F.R. §§ 404.1520c(c)(5), 416.920c(c)(5).
This analysis was nonetheless irrelevant to a proper evaluation of the consistency of Mr.
Roberts’s opinion. SSA regulations provide that “[t]he more consistent a medical opinion[] is with

Marie T. v. O’Malley
Civil No. 23-1320-CDA
May 10, 2024
Page 4
the evidence from other medical sources and nonmedical sources in the claim, the more persuasive
[it] will be.” 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2); see also Revisions to Rules Regarding
the Evaluation of Medical Evidence, 82 Fed. Reg. 5854 (Jan. 18, 2017) (to be codified at 20 C.F.R.
pts. 404, 416) (explaining that “[a] medical opinion . . . that is inconsistent with evidence from
other sources[] will not be persuasive” under sections 404.1520c(c)(2) and 416.920c(c)(2))
(emphasis added). The ALJ was thus required to consider whether Mr. Roberts’s opinion was
consistent with evidence from sources other than Mr. Roberts. Because the ALJ merely
determined that Mr. Roberts’s opinion was “inconsistent with his own treatment records,” Tr. 22,
the ALJ failed to provide the consistency analysis described in 20 C.F.R. §§ 404.1520c(c)(2) and
416.920c(c)(2). Thus, the ALJ contravened SSA regulations in reaching their decision.
The ALJ’s failure to determine whether Mr. Roberts’s opinion was consistent with
evidence from other sources was not inconsequential. Mr. Roberts opined that Plaintiff possessed
19 “marked” and “extreme” limitations in mental functioning. Tr. 22, 623–24. Additionally, the
ALJ acknowledged that Plaintiff’s mental impairments could have met or equaled certain listed
impairments if the ALJ had determined that Plaintiff possessed “one extreme limitation or two
marked limitations in a broad area of functioning.” Tr. 13. A finding that Plaintiff’s impairments
meet or equal a listed impairment would direct a conclusion that Plaintiff is disabled. See 20
C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii). Therefore, remand is warranted because a proper
evaluation of Mr. Roberts’s opinion may alter this case’s outcome.
Because the case is being remanded on this basis, the Court need not address Plaintiff’s
other argument. On remand, the ALJ is welcome to consider that argument and, if warranted, to
adjust their decision accordingly. 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, the SSA’s judgment is REVERSED due to inadequate
analysis pursuant to sentence four of 42 U.S.C. § 405(g). 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.
Sincerely,
/s/
Charles D. Austin
United States Magistrate Judge