ELROD v. COLVIN

Filing 14

MEMORANDUM OPINION AND RECOMMENDATION OF UNITED STATES MAGISTRATE JUDGE signed by MAG/JUDGE JOE L. WEBSTER on 9/7/2017; that Plaintiff's motion for judgment on the pleadings (Docket Entry 10 ) be DENIED and that Defendant's motion for judgment on the pleadings be GRANTED. (Docket Entry 12 .) (Sheets, Jamie)

IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF NORTH CAROLINA
TAMARA LYNN ELROD,
Plaintiff,
v

NANCY A. BERRYHILL,
Acting Commissioner of Social
Security,

Defendant.

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l:l6CYll7l

MEMORANDUM OPINION AND RECOMMENDATION
OF UNITED STATES MAGISTRATE JUDGE
Plaintiff

T

amaralynn Elrod btought this action to obtain review of a ftnaldecision of

the Commissioner of Social Securityl denying her claims fot disability insurance benefits

("DIB") and supplemental security income ('SSI'). The Court has before it the certified
administrative record and cross-motions for judgment.

I. PROCEDURAL HISTORY
Plaintiff filed applications fot DIB and SSI on September 6, 201,2
onset date of December 31.,2007,Iater amended to July 10,

allegSng a

disability

2013. Qr. 12,35,250,269-70,

218-221',224-230.)2 The applications were denied initially and again upon reconsiderarion.

t

Nancy Berryhill recently became the Âcting Commissioner of Social Security. Pursuant to
Rule 25(d) of the Federal Rules of Civil Procedure, Nancy Berryhill should be substituted for Carolyn
!7. Colvin as Defendant in this suit. No further action need be taken to continue this suit by reason
of the last sentence of section 205(g) of the Act,42 U.S.C. $ 405(9).

2 Transcrþt
citations tefer to the administrative record which was filed with Defendant's
Answer. (Docket Enty 7.)

(Id. at1,25-34, 1,37-45.) Plaintiff tequested a hearing before an ,{.dminisuative Law Judge

("ALJ').
Qd.

Qd.

at1,46.) After

a hearing, the

ALJ determined that Plaintiff was not disabled.

at 12-23.) The Appeals Council denied a request for review, making the ALJ's

detetmination the Commissionet's final decision for purposes of

review.

Qd. at 1,-4.)

II. STANDARD FOR REVIEW
The scope of judicial review of the Commissioner's final decision is specifìc and

narrow.

Smith u. Schweiker, 795 tr.2d 343, 345 (4th Cir.

determining

decision.

if

there is substantial evidence

1986). Review is limited

in the record to support the Commissioner's

42 U.S.C. $ a05þ); Huntera. Sulliuan,gg3F,2d,31,,34(4th

907 tr.2d 1.453,1456

(th

to

Cir.

1992);

Hay

u. Sulliuan,

Cir. 1990). In reviewing for substanttal evidence, the Court does

not re-weigh conflicting evidence, make credibility determinations, or substitute its judgment

for that of the Commissioner. Craigu. Chater,76F.3d 585,589 (4th Cir. 1996). The issue

before the Court, therefore,

is not

whether Plaintiff

is

disabled

but whether the

Commissioner's finding that she is not disabled is supported by substantial evidence and was
reached based upon a correct application of the relevant

law.

Id.

III. THE ALI'S DISCUSSION
The,{LJ followed the well-established five-step sequential
the claimant is disabled, which is set forth in 20 C.F.R.
u. Comm 'r of

S oe S ec.

Admin. ,

17

4

tr .3d 47

SS

analysis to ascertain whether

404.1520 and 41,6.920.

See

Albright

3, 47 5 n.2 (4th Cir. 1999).3 The ,{.LJ determined at

3 "The Commissioner uses a five-step process to evaluate disabiJity claims." Hancvck u,
Astrae, 667 tr.3d 470, 472-73 (4th Cft. 201,2) (citing 20 C.F.R. SS 404.1520(a)(4),416.920(Q$\.
"lJndet this process, the Commissioner asks, in sequence, whether the claimant: (1) worked during
the alleged period of disability; Q)hada severe impairment; (3) had an impaitment that met or equaled
2

step one that Plaintiff had not engaged
application

in

substantial gainful activity since the July 201,3

date. Çr 1,4,35,250.) The ,{,LJ next fou4d

the following severe impairments

at step two: asthma, fibromyalgia, sleep disordet, sciatica, shoulder disorder, and affective

disordet.

Qd. at 14-1,5.)

At step three, the ALJ found that Plaintiff did not have an impairment or combination
of impairments that meets or medically equals one listed in Appendix

1.

(d. at 15-16.) The

,{LJ next set forth Plaintifls Residual Functional Capacity ("RFC") and determined that
could perform

a

she

reduced range of light work in that she is limited to

occasionally climb, balance, stoop, kneel, crouch, and crawl.
She can frequently perform grasping and fìne manipulation.
The claimant cannot reach above shouldet level with the left
upper extremity. She must avoid temperature extremes, fumes,
odors, dusts, poor ventilation, andhazards including heights and
moving machinety. The claimant can understand, remember,
and carcy out toutine instructions. She can tolerate only
occasional interaction with the public.
(Id. at 1,6.)
past relevant

-{t the fourth

work.

step, the ALJ determined that Plaintiff was unable to perfotm any

Qd. at

21,.) Last, at step five, the ,A,LJ determined that there were jobs

in the national economy that Plaintiff could

petform. (d. at21,-22.)

Consequendy, the ALJ

concluded that Plaintiff was not disabled.

ry. ISSUES AND ANALYSIS
Plaintiff raises

a

numbet of issues in her

brief.

F'irst, she contends that the ALJ erred

the requirements of a listed impairment; (4) could return to his [or her] past relevant work; and (5) if
not, could perform any other work in the national economy." Id. A finding adverse to the claimant
of several points in this five-step sequence forecloses a disability desþation and ends the
^t ^ny

inquiry. Id.

.

in finding that Plaintiff has the physical and mental RFC to perform a reduced range of light

work.

(Docket Etttty

11,

at

9-12.)

Second, Plaintiff asserts that the ALJ erred in failing to

accord proper weight to the opinion evidence in the

record.

(Id. at 12-1,4.) Third, Plaintiff

alleges that the ALJ failed to find her osteoarthritis as a severe impairment at Step 2
Sequential Evaluation Process

("SEP").

of the

(Id. at1,4-1,5.) Last, Plaintiff contends that the ALJ

erred by failing to adequately address the impact of Plaintifls obesity on her ability to perform

work activities. (Id. at 15-16.) F'or the following reasons, these arguments lack merit.

1. The ALJ's RFC determination

is Legally Correct and Supported by Substantial

Evidence.

Plaintiff fìrst contends that the -A.LJ's RFC determination is not supported by
substantial evidence. (Docket Et tty 1,1 at9-11.)

-A.s

explained below, the Court concludes

that the ¡,LJ did not materially en in the RFC determination, and therefore there was not

a

misapplication of the medical-vocational guidelines.
RFC measutes the most a claimant can do despite any physic
F[ines, 453 F.3d

at 562;20

C.F'.R. SS 404.1520, 41.6.945(a).

aI

An

and,mental limitations.

,A.LJ

must determine

claimant's exertional and non-exertional capactty only after considering all

pain.

a

of a claimant's

impairments,

as

20 C.tr.R.

404.1520,41,6.945þ)-(.). The ,\LJ then must match the claimant's exeftional

SS

well as any telated symptoms, including

See

Hines, 453 F.3d at 562-63;

abilities to an appropriate level of work (i.e., sedentary, light, medium, heavy, or very heavy).
See

20 C.F'.R. SS 404.1520, 416.967. Ary non-exertional limitations may further restrict

claimant's ability to perfotm jobs within an exertionallevel. See20 C.F.R.

$S

a

404.1520,41,6.969.

,{n ALJ need not discuss every piece of evidence in making an RFC determination.
4

See Reid u. Commi¡¡ioner of Soc.

F3d

1,206,12'11. (11th

5ec.,769 F.3d 861, 865 (4th Cn.201,4) (citing Dler u. Barnhart,395

Cit. 2005)). However, the ALJ "must build an

bridge from the evidence to [the] conclusion." Clffird

2000).

,{.s

u.

^ccura;te

and logical

Apfil,227 F.3d,863,872(7th Cit.

to the role of the function-by-function analysis, "[t]he RFC assessment must first

identify the individual's functional limitations or restrictions and

assess his

or her work-related

abilities on a function-by-function basis . . . . Only after that may RFC be expressed in terms

of the exertional levels of wotk, sedenta{, light, medium, heavy, and very heavy.'?
8p, 1996 WL 37 41,84, at

SSR 96-

*'1..

A. The ALJ's physical RFC determination is supported

by substantial evidence.

Here, the -A.LJ's conclusion that Plaintiff could perform a limited range of light work is

supported by substantial evidence

fot a number of reasons. First, the medical

supports the ÂLJ's RFC determination.

Fot

example, the

AU

considers

evidence

Dr.

I(ola

Adekanmbi's, medical consultative evaluation report in April 2,2013 that indicates Plaintiff
had a"notmal gait, tenderness of the joints, pain with rz;nge of motion testing, and strong grip

strength." (Tr. 18 referencing Tr.975-78.) The ,{LJ also notes Dr. Adekanmbi's

stating

Plaintifls ability "to sit, stand, and move around the examination room without much

diffìculty."

(Id. at 18 referencing Tr.

975.)

The ÂLJ gave his opinion "great weight" and

Plaintiff has not challenged the ALJ's conclusion.
pointed out that in July 8,

20'1,4,

Qd.

at 19.) Beyond this the ALJ correctly

Plaintiffs phalen and tinel signs were negative and motor

strength was 5/5 in all four extremities. Qd. at"l.7 referencing 1297 .)
Second, the ALJ accurately pointed to Plaintiffs activities of daily living in support

of

her physical RFC determination. (Id. at 1,5.) For example, the ÂLJ noted that Plaintiff
5

reported no problems in het petsonal care and further stated helping taking care of her
mother's house and

yatd.

Qd. at

meals for her mother and does

1,5,298-305.) In addition, Plaintiff indicated

she prepares

laundry. Qd.) The ALJ also accurately noted that a third

party function teport ftom October 9, 20L2, indicated that Plaintiff continued to perform

a

wide number of daily activities. Qd. at 282,289.) The ALJ found Plaintiffs ümitations in
this domain "mild" and the evidence the

,A.LJ

relied upon to make this supports her physical

RFC determination findings for a reduced range of light

work.

This evidence supports

a

physical RFC for a reduced range of light work.

Plaintiffs arguments to the

conûaLty are

unpersuasive. In support of her contention

that the .{LJ erred in het physical RFC assessment, Plaintiff repeats her own subjective
testimony from the administrative heating and references a number

(Docket Entry

11,

at

9-1,1, teferencing

Nevertheless, Plaintiff does

not

Tt.

^ppeat

.41.,

to

of

medical records.

43, 46-47,48, 50-51, 81.3,972-78,

1099.)

specifìcally challenge the ,{.LJ's credibility

determination which was inconsistent with the medical evidence and the activities of daily
living discussed above. Beyond this, the Coutt agrees with the Commissioner that Plaintiffs
record citations fatl to ptovide any objective evidence to support Plaintiffls allegations nor do
they tefute the ALJ's

findings.

(See

Docket Entry 13 at 1,0-1,L) For the following reasons,

the ALJ's physical RFC determination is supported by substantial evidence.

B. The ALJ's mental RFC determination is both legally correct and supported
by substantial evidence.
Plaintiff asserts that the ALJ failed to accur^tely account for her mental limitations in
concentration, persistence, and pace

("CPP"). pocket Entry
6

11. at- 11,-1,2.) Specifically,

Plaintiff contends that the

,A.LJ

did not address her "ability to stay on task and work at a

suffìcient pace to perform substantial gainful employment."

(d. at 12.) This objection

lacks metit as well.

In Manio, 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

moderate diffìculties in maintaining

specifìcally held that

it

CPP.

Masdo,780 F.3d

"agreefs] with other

^t

had

637-38. The Fourth Circuit

iircuits that an ALJ does not account for

a

claimant's limitations in concentration, persistence, and pace by resticting the hypothetical
question to simple, routine tasks ot unskilled
Soc. Sec., 631,

work."

Id. at 638 (quoting Win¡chel u. Comm'r of

tr.3d 1176,1180 (11th Cir. 201,1)) (internal quotation marks omitted). In

so

holding, the Fourth Citcuit 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,{LJ's eror might have been cured ïry anexplanation

as

to why moderate

diffìculties in CPP did not translate into a limitation in the claimant's RFC, it held that absent
such an explanation, remand was necessary.Id.

Hete, the ALJ determined at step three that the claimant had moderate limitations in

CPP. (It. 15-16.) I.

support, the ALJ's assessment in its entirety was:

\X/ith tegatd to concenffation, persistence, or pace, the claimant
has moderate diffìculties. The claimant reported she c n pay
attention for one hour. She indicated she follows written and
spoken insttuctions very well. However, the claimant also
reported she has problems with memory and concentration
7

@,xhibit 8E).
Qd. at 15 referencing

Tr. 298-05.)

"Pursuant to Masù0, once an,A,LJ has made a step three finding that a claimant suffers

from moderate difficulties in concentation, persistence, or pace, the r{LJ must either include

a coresponding limitation in her RFC assessment, or explain why no such limitation
necessary."

See Talmo u. Comm'r, Soc'.

Sec.,Civil Case No. ELH- 14-2214,2015

ì7L

is

2395108,

at *3 (D.Md. May 19,201,5) (unpublished). Here, in contrast to Mønio,the ALJ explained at

considerable length why Plaintiffs moderate limitations

in CPP were accounted for by the

RFC finding stating that Plainttff "can understand, remember, and carry out routine
instructions[,]" and "can tolerate only occasional interaction with the public." (Tr. 16.)
Specifically, the .A.LJ fìrst evaluated Plaintifls mental impairments at step three to
detetmine whether she met or medically equaled the requirements of a disabling impairment

under the Listing of Impairments. (Tr.
1,2.04,

1,5-1,6; :ee also

20 C.F.R. pt. 404, subpt. P, app. 1,

$$

1,2.06.) In pettinent p^rt, the ALJ determined that Plaintiffs affective disorder and

sleep disorder did not meet or equal a listed impairment because, in part, her disorders resulted

in only moderate difficulties in maintaining CPP. Qr. at 15-1,6.) Nevertheless, the ALJ
went on to provide additional explanation and support for her mental RFC determination.
First, the ALJ accvately pointed out that Plaintiffs mental health status had imptoved
over time. For example, the ALJ explained that:

As for her mental impairments, mental health treatment notes
generally showed an improvement in the claimant's mental status
examinations through 2013 and 2014. The claimant presented
for an evaluation in June 201,3 and was diagnosed with bipolar
disorder, mood disorder, generalized anxiety disorder, alcohol
8

abuse, cocaine dependence, and bordedine personaliry disorder.
At that time, she was assessed a Global Assessment of
Functioning (G,A,F) score of 42 @,xhibit 17F). Following that
evaluation, the claimant's mood was variously normal, good,
euthymic, and relaxed. She was noted to be making progress
effectively using her coping skills. In August 2014, the claimant
reported doing much better with a change in her medications and

she continued to do well throughout the remainder of 201,4.
The most recent progress notes from January 201,5 reflected a
huppy and tired mood with the claimant visibly more relaxed
(Exhibits óF, 10F, 1,7F,25F, and 34F).

(fr.

18, referencing 804-07,993-96,1060-85, 1221-41,,1324-28.) The Court concludes that

this is substantial evidence in support of the ALJ's mental RFC fìnding.
Second, the ALJ also accutately pointed to evidence demonstrating that Plaintiff could

perform

a

wide variery of activities of daily living and had no deficits in CPP beyond those set

forth in the

RFC.

Specifìcally, Plaintiff self-reported that she could perform her own

personal care and do her own
she prepared meals

laundry.

Qd.

at 15,299-300.) Plaintiff also self-reported that

with her mother and helped her mother

cate

for her house andyard. (Id.)

Âdditionally, Plaintiff further indicated that she could pay attention for one hour, and that she
understood written and spoken instructions "very

well[]"

Qd. at 15 teferencing

303.) ,{

third-party function report further indicated that Plaintiff could pay attention for several

houts. Qd. at 20

referencing

287.) The record also indicates that Plaintiff went

outside

everyday alone; could shop for groceries, clothing and household goods; and regulady went to

church. (d. at'1,5,301,-02.) Plaintiff could

also pay her own bills, count change, handle a

savings account, and use a check book/money

order.

Qd.

at 301.) Plaintiff also self-

reported that she fìnished what she started and spent time with others

daily.

Qd.

at302-03.)

Plaintiffs assertions of disabling limitations in CPP are inconsistent with this evidence.
9

Third, the only medical evidence that Plaintiff points to suggesting that she might have
additional limitations
discounted by the

in CPP-þaLfi of Dt.

Bradford's medical opinion-u/as specifìcally

ALJ. pocket Ent y 1,1, at1,2-1,3.)

'{,s

discussed below, the ALJ's decision

to discount Dt. Bradford on this point was supported by substantial evidence. Consequently,

unlike the claimant in Masùz, there is no credible evidence here that Plaintiff suffered from
limitations in CPP that tequire additional limitations in the

RF'C.

Consequently, Plaintiffs

contention that rcmand for additional explanation is required by Ma:cio is without merit.

2, The ALJ's assessment of the opinion evidence is legally

correct and supported

by substantial evidence.
Next, Plaintiff argues that the ,{LJ failed to accord appropriate weight to the opinion
evidence in the

record. (Docket Etrtty 1,1, at1,2-1,4.) More

specifically, Plaintiff asserts that

(1) the ALJ failed to accotd proper weight to the opinion of psychological consultative
examiner, Dr. Dan Bradfotd; (2) the ALJ failed to addtess PlaintifÎs Global Assessment

of

Functioning ("GAF") scores; and (3) the ALJ failed to give proper weight to Plaintiffs
Medicaid disability determination.

(Id.)

Again, Plaintiffls arguments fail.

A. Dr. Bradford's Opinion
Plaintiff. argues that the ALJ failed
psychological consultative

opinion.

Qd.

to give proper weight to Dr.

Bradford's

at 12-13 referencing Tr. 19.) The "reating

physician rule," 20 C.F.R. S 404.1,527 (.X2), generally provides more weight to the opinion

a teattng source, because

it

may "provide a detailed, longitudinal picture

of fthe

claimant's]

medical impaitmentþ) [which] may bring a unique petspective to the medical evidence

l0

of

20 C.F.R. S 404.1,527(r)Q);

¡ee al¡o

20 C.F'.R. S 41,6.927(r)(2)! ,{n

-A.LJ

refusing to accord

of a teaang physician must consider various

controlling weight to the medical opinion

"factots" to determine how much weight to give it. 20 C.F.R

S 404.1,527 (c)(Z)-(6);

see

al¡o 20

C.F.R. S 41,6.927(Ð(2)-(6). These factots include: (i) the frequency of examination and the

length, nature and extent of the treatment relationship; (ü) the evidence in support

reating physician's opinion; (rir) the consistency of the opinion with the record

as a

of the

whole; (iv)

whether the opinion is from a specialist; and (v) other factors brought to the Social Security

Administtation's attention that t'end to support or contradict the
404.1,527

(c)Q)-$);

¡ee al¡o

opinion. 20 C.F.R

S

20 C.F.R. $ 41,6.927 (c)Q)-$).

Significantly, as subsections (2) through (4) of the rule describe in great detail, atreatsng
source's opinion, like all medical opinions, must be both well-supported by medical signs and
lat:,oratoty fìndings as well as consistent with the other substantial evidence in the case record.
20 C.F.R S 404.1,527 (c)(2)-@;

¡ee al¡o

20 C.F.R.

\

a1,6.927

(c)Ø-(4). "[I]f

a

physician's opinion

is not supported by clinical evidence ot if it is inconsistent with other substantial evidence,

it

should be accorded signifìcantly less weight." Craigu. Chater,76tr.3d 585, 590 (4th Cir. 1,996).

As for a claimant's subjective report of bodily limitations, the claimant's report will be rejected
unless supported by the treating physician's tecord, such as notes and medical tests, and other

objective medical evidence. Id.

Hete, the ALJ gave Dr. Bradford's opinion "some weight" reasoning that:

Dr. Bradford opined the

claimant would have

a

moderate

4 SSR 96-2p ptovides that "[c]ontrolling
weight may not be given to a treating source's medical
opinion unless the opinion is well-supported by medically acceptable clinical and laboratory diagnostic
techniques." SSR 96-2p,1996 ìøL 374788, at xl fluly 2,1,996).
11

diffìculty performing work activities on a consistent basis,
marked difficulty interacting with coworkers and the public,
moderate difficulty interacting and accepting instructions from
supervisors, and marked difficulty dealing with the stress of a
competitive work environment @,xhibit 9F). -{lthough this
opinion is based on [Dr.] Bradford's evaluation of the claimant,
he did not have the benefit of reviewing the more recent
treatment notes, which document improvement in the claimant's
symptoms with regular treatment and a change in her psychiattic
medications[.]

(Ir.

19 referencing Tr.982-89.)

A review of the tecord indicates that the ALJ provided substantial evidence for her
findings. As the ALJ noted, Dt. Bradford's,\pril

1.3,2013, one-time examination was before

much of Plaintiffs recent mental health treatment. Overall, Plaintiff had improvemenrs in
her mental health status from2013 to 20"1.4. (SeeTr 1,060-66,1221,,1224,1236-39,1,324'28.)

For example, on -A.ugust 29,201,3, Plaintiff denied any suicidal or homicidal thoughts. (d. at

1,063.) In Noveml¡er
demonstrating full

201,3, treatment notes showed

affect.

(Id. at

Plaintiff having a hopeful mood and

1239.) Her therapist indicated that Plaintiff was 'lisibly

more relaxed," and making good progress towatd her treatment

goals. (Id.) Additionally,

rn January 2014, Plaintiff reported a happy mood and feelings of "joy and
1236-37

.)

relief." (d.

at

Later in August 201,4, Plaintiff reported that she was doing "much better" and was

toletating changes in her medication

well. (Id. at 1,221,.) She was alet and cooperative, her

mood was euthymic, her cognition and thought process was intact, and she had improved

judgment. (Id.) This evidence supports the ALJ's decision to give Dr. Bradford's opinion
some weight as it was inconsistent with subsequent treatment notes displaying improvements

in PlaintifPs mental status.
t2

PlaintifÎs argument to the conúary is unpersuasive. Plaintiff relies upon Monroe u.
Coluin,826 F.3d

1,7

6, 191, (4th Cir. 201,6), to argue that the ALJ

s

explanation of Dr. Bradford's

opinion is "precisely the kind of conclusory analysis that . . . did not allow for meaningful
substantial evidence

review." (Docket Entry

1,1,

at 1,2.) Plaintiffs reliance upon

Monroe,

however, is misplaced.

"Social Security Ruling 96-8p explains that the RFC 'assessment must include

a

narattve discussion describing how. the evidence supports each conclusion, citing specific
medical facts (e.g., labotatory fìndings) and nonmedical evidence (e.g., daily activities,
observatiotts).'
held that

" Monme,826 F.3d at 189 (internal quotations omitted). The Fourth Circuit

" 'a necessary predicate to engaging in substan'jal

evidence review is a record of the

basis fot the A.LJ's ruling," including "a discussion of which evidence the ALJ found credible

and why, and specific application

of the pettinent

evidence."'Id. at 189 (citing Radþrd

Coluin,734F.3d288,295 (4th Cir. 201,3)).

This case is distinguishable
discussion as to why

concluded that

u.

legal requirements

fuor.r' Monroe because

to the record

the ALJ provided meaningful

Dt. Bradford's opinion received "some weight." (Tr. 19.) Having

Dr. Bradford was not afforded the opportunity to review "more

treatment notes, which document improvement

in fPlaintiffs]

recent

symptoms," çid.¡, the ,{.LJ's

assignment of weight is supported by substanttal evidence. Thus, Plaintiffs argument fails.

B. PlaintifPs GAF Scores
Next, Plaintiff argues that the ALJ etred

"in

signifìcance" of Plaintifls GAF scores. (Docket Ent"y

failing

1,1,

to

specifically address the

at1,3.) "A GAF'score

to be used in treatment decision and may have little to no beadng
l3

on

is intended

. occupational

functioning."

I-.oue a.

Attrae, No. 3:11-CV-014,2011nfl- 4399989, at x4 CX/.D.N.C. Sept. 6,

20"11) (unpublished), adopted 201,1,WL 4899984 CX/.D.N.C. Oct.

1,4,201,1). Consequently, "ir

is unsurprising that courts have concluded that 'the failure to reference a GÂF score is not,
standing alone, sufficient ground to reverse a disability determinatioÍr.'" Clemins

u.

Astrae,No.

5:13-CV-00047,201,4WL4093424,4tx1 CX/.D.Va. Aug. 18,2014) (unpublished) (qøotingParis
u. Coluin,

No. 7:12-CV-00596 , 2014 WL

534057

, at x6 (tW.D.Va. Feb. 10, 201,4); Loue, 2011

WL 4899989, at*5 (quotation marks omitted). Additionally, reversal on the grounds that the

ALJ failed to consider a GAF score "is particulady inappropriate 'where the ALJ fully
evaluated the records and treatment notes upon which the
(qaoting Pari¡, 201, 4

Gr\F

scores were based.'

"

Id.

VfL 534057, at * 6).

Hete, the ALJ considered PlaintifPs entire recotd and specifically referenced two
relevant GAF scores and ptopedy evaluated the records upon which the G,{F scores were

based. (Tt. 18-19.) Contraty to Plaintiffs argumenq "an ALJ is not
'impossible burden

,{.dministrative

of mentioning

Record."

L,ong

every piece

of

tasked

with the

evidence' that may be placed into the

u. Coluin, No. 1:13CV0659, 2015 wL

1,31,291,9,

at

*8

(À4.D.N.C. Mar.24,20'J5) (unpublished),reportandretvmmendation adopted,No. 1:13CY659,2015

WL

1,646985 (tvI.D.N.C.

explain how the

mental RFC

AIJ"

Âpr. 14,201,5) (citation omitted). Additionally, "Plaintiff does not
furthet considetation of þerl GAF scores would have altered the

in this case."

Williams u. Coluin,

No. 1:13CV236,2015 WL

68281,1,4,

at *5

(I\4.D.N.C. Nov. 6, 201,5) (unpublished) (emphasis in original). The Court notes that the

other G,{'F scores

in the record cited by Plaintiff Qr. 362,373,377,386,423) reflecr a

timeframe well before her alleged onset date, which brings into question the degree of
t4

relevancy such scores may have upon Plaintiffs disability determination.

No. CIV.Â. 1,4-'1187-JìøL, 2015 WL

1,863591,,

See

Dancan u. Coluin,

at x4 (D. I(an. Apr. 23,201,5) ("Two of the

GAF' scores to which þ]laintiff appeals were assigned more than nine years before þ]laintiff
submitted his SSI application at issue here," thus "fthey are not relevant to a determination
whether Plaintiff is disabled ."); Sirio u. Coluin, No. 12-CV-02578-MSK, 2013 WL 45103 24, at

*7 (D. Colo. Atg. 24,2013) (.'GAF' scores assess an individual's level of functioning at a
specific point time. A.'snapshot'dated six months before the requested disability period was

minimally relevant to the ,{LJ's disability determination."). As the ALJ did not err in her
consideration of Plaintiffs GAF scores, this argument too fails.

C. PlaintifPs the Medicaid Disability Determination.
Plaintiff next contends that the ALJ erred by not giving proper weight to her Medicaid
disability determination. (Docket Entty 11 at

14

referencing

Tr. 1036-89.) In

support,

Plaintiff argues that "[t]he Nonh Carolina Department of Health and Human Services
('NCDHHS") detetmination should be considered relevant" to her disability determination.
(Id.)

More specifìcally, SSR 06-03p provides in pertinent part that:
evidence of a disability decision by another governmental or
nongovernmental agency cannot be ignored and must be
considered. . . .

ffie

are not bound by disability decisions by other governmental

and norìgovetnmental agencies. In addition, because other

diffetent des and standards than we do for
detetmining whether an individual is disabled, this may limit the
relevance of a determination of disability made by another
agencies may apply

âgency. However, the adjudicator should explain the
considetation given to these decisions in the notice of decision
15

for

hearing cases and

in the case record for initial and

reconsideration cases.
SSR 06-03p, Considering Opiruions and Other Euideace F'rom Soarces ll/ho
Source.ç"

N

in

Disabiliry Clairn; Conidering Dedion¡ on Divbiligt

ongouernm enta /

Agenties, 2006

WL 2329939, at x 6-7 (,{."g. 9,

Are

þt

NoT 'Acceþtable Medical

Other Gouernmental and

2006).

In intetpreting SSR 06-03p, the Fourth Circuit has considered "the precise weight that
the SSÂ must afford to a VA. disability
337

rating."

Bird u. Comm'r of

Soc. Sec.

Admin, 699 F.3d

,343 (4th Cir. 201,2). In addtessing this question, the Fourth Circuit noted that, "the VA

and Social Security programs serve the same governmental purpose of providing benefits to
persons unable to work because of a serious

disability."

Id.

It reasoned further that "þ]oth

programs evaluate a claimant?s ability to perform full-time work in the natsonal economy on
sustained and continuing basis; both focus

on

a

arralyzing a claimant's functional limitations;

and both require claimants to present extensive medical documentation

in support of their

claims." Id. (quotaions omitted).
The Foutth Circuit concluded that "þ]ecause the purpose and evaluation methodology

of both programs ate closely related, a disability rating by one of the two agencies is highly
relevant

to the disability detetmination of the other agency." Id. Thus, "in making

a

disability determination, the SS",{ [Social Security Administration] musr give substantial weight

to a VA disability ra:jng."

Id.

"However, because the SSA employs it's own standards for

evaluating a claimant's alleged disability, and because the effective date

of

for

a

claimant's disability under the fwo programs likely will vary, an ALJ may give less weight to

a

coverage

VA disability rating when the record before the ALJ cleady demonstrates that such a deviation

l6

is appropriate."

Id.

but Medicaid awards
Consequently,

Birdhas subsequently been interpreted to include not only VA awards

as well.s

in order to satisfy SSR 06-03p and Bird an ALJ must

meaningfully

articulate how substanial evidence supports a conclusion that the disability determination

another
Coluin,

^gency

No.

weight.

is entitled to limited or no

5:14-CY-689-KS, 201,6

wL

See, e.g.,

697138,

(unpublished); Hildreth u. Coluin,No. 1:14CV6ó0,2015

*4

ffl,

Bird, 699 F.3d at 343; Adam

(E.D.N.C. February 22,

of
u.

201,6)

5577430,x4 (X4.D.N.C. September

22, 201 5) (unpublished).

Hete, the NCDHHS concluded that due to Plaintiff's "severe impairments of fm]ajor
deptessive disorder, bipolar disorder, and personality disorder," her "ability to perform work

at all exertional levels ha[d] been compromised .
appropriate.

.

"

such that a fìnding of disabled was

Gt. 1087-88.) In her decision, the ALJ specifically

Plainti ff s Medicaid dis ability

de

termina rion

recognized and discussed

:

I

also considered the decision of the INCDHHS] from October
201,3. In that decision, the claimant was found disabled and

therefore eligible for Medicaid due

to an inability to perform

basic work-related activities under SSRs 85-15 and 96-9p

(Exhibit

18F). This opinion is given little weight because the more

fecent tfeatment notes document an improvement in the
claimant's mental status with regulat tre tment and a change to
her psychiatric medications, as fpreviously] discussed [in the
decision].

5

See Perryt a. Berryhill, No. 2:16-CV-00058-D , 201.7 WL 3044573, at *4 (E.D.N.C.
June 28,
2017) (unpublished) ('Subsequent case law within the Fourth Circuit has explicitly extended the
holding tn Bird to Medicaid decisions, noting that both the Medicaid and VA disability programs share
markedly similar standards and requirements with the DIB and SSI programs at issue here.'),
recommendation adoþted,2017 WL 3038222 (E.D.N.C. July 77,2017) (unpublished).

l7

(r

20 referencing

1

08ó-89.)

Hete, the ALJ's analysis is adequate. The ALJ did not just merely mention the agency
determination, but also consideted

it.

She explained that the agency's decision was afforded

little weight because Plaintiffs mental status had since improved.

(See

Tr 20.) Since the

,{.LJ's explanation is adequate and supported by substantial evidence, this argument too lacks

merit.

See

Cilli¡

u. Coluin,

No. 1:14CY426,2015 ìøL 4644777, at *5 (14.D.N.C. Aug. 4, 201,5)

(unpublished) (concluding that the ,{.LJ's "handling of the V-4. determination is supported by
substantial evidence.").

3. The ALJ's Assessment of PlaintifPs Osteoarthritis is Legally Correct

and

Supported by Substantial Evidence.
Plaintiff next contends that the

,A,LJ

erred by not addressing her osteoarthritis6 in the

Step 2 discussion of severe impairments or any-çvhere else in the

decision. @ocket Entry

11

at 1,4-15.) In regatds to Step 2, the ALJ has the duty "to determine which impairments
fP]laintiff has and whether the impairments are severe or non-severe."

Coakle1 u. Coluin, 8:15-

CV-2788-MGL-JDA, 2016WL7364643, at x9 (D.S.C. Nov. 29,201,6),

reþort and recommendation

adoþted, CV81,5027

B8MGLJDA,2016 WL 7338716 Q).S.C. Dec. 19,

Attrue, C/A No. 2:10-1882-RMG,
as the

2011,

WL

51,01,531,,

201,6); See al¡o Solesbee

u.

at*4-5 (D.S.C. Oct. 25,201,1). As long

ALJ detetmines that the claimant has at least one severe impairment and proceeds to

6 Osteoarthdtis is defined as
"a noninflammatory degenerative joint disease seen mainly in
older persons, chatactetized by degeneration of the articular cartiage, hypertrophy of bone at the
margins, and changes in the synovial membrane. It is accompanied by pain, usually after prolonged
acttvrty, and stiffness, particulady in the morning or with inactivity." Dodand's Illustrated Medical
Dictionary 1333 (30th Ed.2003). Danielu.AsTruqCIV. A. 6:07CY020,2008WL2901.342,at*7 (W.D.
Va. July 27,2008), reþort and rervmmendation adoþted, CIV.6:07CV00020, 2008 ì7L 3201231, (W.D. Va.
Aug. 7,2008)
18

discuss all of the medical evidence, any ettor regarding failure to list a specific impairment as
severe at step [2] is

harmless." McClain u, Coluin, No. 1:12CV1374,201,4WL2167832, at*4

(À4.D.N.C. May 23,2014) (citations omitted).

Further, the ALJ's detetmination of whethet an impairment is severe is a threshold
determination.

See

20 C.F.R.

SS

404.1520(c),416.920(c). "[S]evere" is a term of art, which

mearls the impairment at issue "significantly limits fPlaintiffs] physical or mental ability to do
basic work

activities." 20 C.F.R. S 404.1520(c),41,6.967.

Social Security Ruling ("SSR") 96-

8p exemplifies that a "severe" impairment "has more than aminimal effect on Plaintifls ability

to do basic work activities." SSR 96-8p. She bears the burden of proving an impairment is
"severe."

Bowen u.

Yuckert,482 U.S. 137,1,46, (1987).

Hete, Plaintiff argues osteoarthritis affected het ability to perform certain kinds of

work.

(Docket Etttty

11,

at 1,4-1,5.) In support, Plaintiff provides as evidence her self-

teported symptoms contained within the

record. Qd.) Further, at the hearing Plaintiff

discussed with the VE that:

Physically I can't lift my patients any more. It's just too much
on my back, my hips. I have trouble walking and lifting for
extended periods of time. My hands will not grip any more. I
won't even use a rcgtlar glass glass [sic] to drink out of because
my hands will go numb and I'll drop whatever's in them.

Çr.

a1,.)

The ALJ points to PlaintifPs activities of daily

living.

For example, the ALJ points to

PlaintifPs self-report that she could perform her own personal care a¡d do her own laundry.

(d. at'15,299-300.) Plaintiff also self-repoted that she prepared meals with her mother and
helped her mothet c^re for her house and

yard.
t9

(Id.)

Second,

in tetms of Plaintiffls

osteoarthritis

in her shoulder, the ALJ points

to

Plaintiffs 5f 5 motor strength and sensation being grossly intact. (Id. at 1,7,874.) In
addition, the ALJ points to Plaintiffs stable left shoulder with slow but steady improvement
aftet PlaintifPs physical therapy. (f d. at'17 ,11,07,1110-1,1.)
Because the evidence

of the recotd suggests that Plaintiff s osteoarthritis does not have

more "than a minimal effect on [her] ability to do basic work activities [,]" the ALJ only has

the duty to discuss medical evidence regarding Plaintiffs osteoarthrins. McClain, 2014 WL
2167832, at

*4.

However, a review of the ALJ's decision shows that the ALJ discussed the

medical evidence regarding Plaintiffs osteoarthritis by stating:

for her pain complaints, the claimant complained of pain and
swelling in her hands and lower back pain ín 2013. Physical
examination of the back revealed moderate tenderness and

,{.s

painful range of motion. X-rays of the lumbar spine
demonsttated bilateral L4 spondylosis with L4-L5
spondylolisthesis and mild lower lumbar facet arthropathy. The
claimant was diagnosed with aî a,cvte exacerbation of lower back
pain (Exhibit 7F). Physical examination of her hands showed
swelling and tenderness but no synovitis, warmth, or effusion,
intact range of motion, and normal sensation. An ultrasound of
the bilateral upper extremities was normal. Phalen and Tinel
signs were negative and motor strength was 5/5 in all four
exttemities. Diagnoses included joint effusion of the hands,
osteoarthritis, and inflammatory arthropathy (Exhibits 7F, 22F,
29F, and 33F).

(Ir.

18 teferencing

Tr. 874,1200-08, 1292-99,1321-33.) In conclusion, the ALJ states that

due to Plaintiff s osteoarthritis, she is limited to "work at the light exertional level with postural

limitations and only frequent grasping and fìne manipulation."

Qd.)

Á,lthough the ALJ does

not mention in Step 2 that Plaintiffs osteoarthritis is a severe impairment, the ,\LJ correctly
considered

it. In any event, failure to do so was harmless error.
20

McClairu, 201,4 WL

21,67832,

^tx4.

Thus, Plaintiffls argument fails.

4. The ALJ's Evaluation

of PlaintifPs Obesity is Legally Correct.

Next, Ptaintiff argues that the ALJ failed to discuss her "diagnosis of obesity and its
effects on her ability to

work."

(Docket Entry 11 at 15-1,6.) More specifically, Plaintiff

contends "nowhere in the decision did [the ÂLJ] specifically analyze the impact" of obesiry on

Plaintiff.

(Id.)

The determination process fot obesity tequires an

AIJ to consider impairments about

which the ALJ receives evidence. Edge u. Coluin, 1,:1,0CY493,

201,3

WL

1621.993,

(À4.D.N.C. Apr. 15, 201,3), report and retvrumendation adoþted,1:10-CV-493, 201,3

WL

at

x4

4671,649

(À4.D.N.C. A.ug. 30, 201,3). ('rWe will consider only impairment(s) ... about which we receive

evidence.'). Yet, an ALJ's failure to consider an impairment about which a claimantprovided
evidence does not necessarily require a temand,
the action.

See

if

remand would not affect the outcome

of

Ratherþrd a. Barnhart,399 tr.3d 546,553 (3d Cir. 2005) (concluding that "remand

[tó consider plaintiffs obesiry] is not required here because it would not affect the outcome

of the case");

Prochaska u. Barnhart, 454

F.3d 731,736-37 (7th Cn. 2006) (concludin g that "a

failure to explicitly consider the effects of obesity may be harmless error').
ConÚary to PlaintifFs argument, the ALJ thoroughly discussed Plaintiffs obesity, by
stating:

Further exacerbating the claimant's physical impairments is her
obesity. Treatment notes fiom April 201.4 documented a height
of 65 inches and weight of approximately 210 pounds, which
resulted in a body mass index (BMI) of 34.9 (Exhibit 19F).
Social Secudty Ruling 02-1,p requires me ro consider obesity

when determining whether claimants have

medically
determinable impairments that are severe, when determining

2t

whether those impairments meet or equal any listing, and finally

when determining the residual functional capacity. In
parucula4 obesity may limit an individual's ability to sustain
activity on a regulat and continuing basis during an eight-hour

day, five-day week or equivalent schedule. These
considerations have been taken into account in reaching the
conclusions contained in this decision.

Gt. 18.)

Second, Plaintiff refers to no limitations related to obesity for which the ,tLJ failed

to account for with a reduced
2012WL

684987

25S5-MGL ,2013

rzLnge

of light work. Clark

4, ñx1,0 (D.S.C. Dec. 14, 2012),

ìfL

u. Astrwe,

S:11-CV-02585-MGL,

reþort and. renmmendarion

adopted,ClV.A. 8:11-

145037 (D.S.C. Jan. 1,4,2013) ("Plaintiff has offered no ârgument as to

what additional limitations she suffers as a result of her obesity beyond those that the ALJ
acknowledged.")

Moreover, the ALJ's RFC determination

is

supported by reports

of

physicians

referencing Plaintifls obesity, but none of them explaining or acknowledging any functional

limitations as a result of PlaintifPs

weight. For example,

the ALJ points to Dr. Âdekanmbi's

records indicating that Plaintiff was obese by stating Plaintiff was 65 inches in height and 201,

pounds in weight, but Dr. ,{dekanmbi never referenced a limitation based on his finding

of

obesity. Qr.18,974.) However, Dr. ,\dekanmbi found Plaintiffls gait normal, and further
noted that she could sit, stand, and move around the examination room without diffìculty.

(d. at97

5.)

The ,{LJ also pointed to the tecords showing Plaintiff having no muscle atrophy,

and the ability to raise her arms above her head without
Adekanmb i " great weight.

difficulty. (Id.)

The ALJ gave Dr.

"

,\dditionally, the ALJ duly noted state agency medical consultant Dr. Stevin Levin's

findings. The ,tLJ pointed to Dr. Levin's report of PlaintifFs abitiry to perform medium
22

work with the ability to "sit for up to 6 hours total in an 8 hour work day, and stand andf or
walk for up to 6 hours total in an 8 hour

workday."

(Id. at 1,9,1.1,1,-1,2) Dr. Levin did not

refet to any limitations Plaintiff would suffer from due to her obesity. The ALJ afforded Dt.
Levin "some weight."

Plaintifls weight was also noted in several medical documents which the ALJ
referenced in his

findings.

(See, e.g.,

Tr.

841,

(weight at 195); Tr. 120L (weight is 216.8); Tr.

1322 (weight is 218); Tr. 1006 (weight at 201); Tr. 7 62 (weight 265); Tr. 796 (weigh t at 265)).

All of

these reports throughout Plaintiffs medical records recognize Plaintiffs obesity or

weight, but no report expressed concerns of great limitations as a result

of her weight.

Cetainly Plaintifls treating physician would have further addressed the issue of obesiry if he
believed

it to cause significant limitations for her. ,{.fter reviewing the findings in this case,

the Court concludes that the ALJ supported her finding with substanttalevidence. Thus, this

argumeût too fails.

V. CONCLUSION

In light of the above, the Court RECOMMNEDS that Plaintiffs motion for
judgment on the pleadings pocket Entry 10) be

DENIED

and that Defendant's morion for

judgment on the pleadings be GRANTED. (Docket F,ntry 12.)

Uni
Septembet 7,201,7
Durham, North Carolina

23

L. ebstet
J
States Magistrate Judge