Opinion ID: 4691244
Heading Depth: 2
Heading Rank: 1

Heading: Evaluation of medical evidence

Text: On appeal, Britt mainly challenges the administrative law judge’s alleged failure to properly evaluate and assign weight to the opinions of her treating physicians and mentalhealth professionals. Throughout the five-step evaluation process, the agency must evaluate every medical opinion received, regardless of the source. 20 C.F.R. §§ 404.1527(c), 416.927(c); see Dowling v. Comm’r of Soc. Sec. Admin., 986 F.3d 377, 384 (4th Cir. 2021). 1 In general, 1 “Several years ago, new rules were promulgated altering the way in which the Commissioner evaluates medical opinion evidence. Because these new rules apply only to (Continued) 7 the administrative judge should give more weight to the opinion of an examining medical source than to the opinion of a non-examining source. §§ 404.1527(c), 416.927(c). And “more weight” is also given to opinions of treating sources 2—who have provided ongoing treatment, equipping them with the ability to provide “a detailed, longitudinal picture” of a claimant’s alleged disability—than non-treating sources, such as consultative examiners. §§ 404.1527(c), 416.927(c); see Arakas v. Comm’r of Soc. Sec. Admin., 983 F.3d 83, 106 (4th Cir. 2020); Dowling, 986 F.3d at 384. Weighing other evidence, including medical evidence that is not a medical opinion, remains largely within the province of the administrative law judge. Shinaberry v. Saul, 952 F.3d 113, 123 (4th Cir. 2020). The administrative law judge must afford this greater weight only to a medical opinion from a treating physician, not all medical evidence in a physician’s file or statement. 20 C.F.R. §§ 404.1527(c), 416.927(c); see Dowling, 986 F.3d at 384; Arakas, 983 F.3d at 106–07. Medical opinions are “statements from acceptable medical sources that reflect judgments about the nature and severity of [a claimant’s] impairment(s), including [the claimant’s] symptoms, diagnosis, and prognosis, what [the claimant] can still do despite impairment(s), and [the claimant’s] physical or mental restrictions.” 20 C.F.R. §§ 404.1527(a)(1), 414.927(a)(1) (emphasis added); see also Brown v. Comm'r Soc. claims filed ‘on or after March 27, 2017,’ they have no impact on [Britt’s] case.” Barbare v. Saul, 816 F. App’x 828, 832 n.2 (4th Cir. 2020) (quoting 20 C.F.R. § 404.1520c). 2 A treating source is “your own acceptable medical source who provides you, or has provided you, with medical treatment or evaluation and who has, or has had, an ongoing treatment relationship with you.” 20 C.F.R. §§ 404.1527(a)(2), 416.927(a)(2). 8 Sec. Admin., 873 F.3d 251, 271 (4th Cir. 2017) (finding a doctor’s “interpretation of the MRI and conclusion that it showed an impairment” to be a “medical opinion”). It is the medical opinion—reflecting medical judgment about the nature and severity of a claimant’s symptoms, diagnoses, or limitations—and not statements recounting facts or a claimant’s subjective complaints that is entitled to greater weight. The information on which Britt seeks to rely—such as mere observations and her recorded subjective complaints during office visits—contains no medical judgment, which is the essence of medical opinions. Many documents Britt cites merely record the symptoms Britt has reported feeling and state past diagnoses, among other information Britt does not specifically discuss. See A.R. 408–22. But these recitations need not be given dispositive weight. Because the administrative law judge need only evaluate and attribute weight to a treating doctor’s medical opinions, there was no reversible error in failing to assign weight to this medical evidence. For example, in one report from Southeastern Regional Physician Services, the physician recorded that Britt had lower abdominal pain radiating to her back, that she was experiencing rectal bleeding, and that she had previously been diagnosed with anemia. See A.R. 437. But this is the physician’s summary of Britt’s descriptions of symptoms and past diagnoses, not medical opinions, as the doctor exercised no judgment in describing those matters. While the report also includes a diagnosis of rectal bleeding and constipation, the administrative law judge gave that weight, acknowledging this diagnosis in his decision. See A.R. 48. Looking to a Cape Fear Podiatry Associates report, a physician diagnosed Britt with plantar fasciitis, stated that she had a pins and needle type 9 sensation in the medical band of the plantar facia, and prescribed her a dancer’s pad. See A.R. 432. And again, the administrative law judge accepted the diagnosis of plantar fasciitis, finding it to be a severe impairment. See J.A. 44. Britt also directs us to Dr. Patrick Ricotta’s report which noted that Britt had trouble being independent and could not work based on her pain level of 8/10. See A.R. 686–88. Yet this information was recorded under the “Subjective Examination” section, which records Britt’s subjective assessment of her abilities, lacking any judgment from an acceptable medical source. See A.R. 686. In contrast, the report included a section labeled “Objective Examination”—which explains the results of certain tests conducted—and a section labeled “Assessment” where Dr. Ricotta explicitly said, “In my professional opinion, this patient requires skilled psychical therapy . . . Overall rehabilitation potential is good.” J.A. 686–87. Ultimately, Britt’s assertion that the administrative law judge erred by failing to assign more weight to the opinions of her treating physicians and mental health professionals lacks merit. What opinions she did submit, the administrative law judge appropriately weighed. The agency must consider the entire record, but is only required to attribute weight to medical opinions in the record. And that was done. We need not reweigh the non-medical-opinion evidence Britt identifies in her brief. Shinaberry, 952 F.3d at 123.