Court Opinion

ID: 4322449
Source: CourtListenerOpinion
Date Created: 2018-10-18 19:00:21.196047+00
Date Added: 2024-06-11T14:46:11.754360
License: Public Domain

UNPUBLISHED

                      UNITED STATES COURT OF APPEALS
                          FOR THE FOURTH CIRCUIT

                                      No. 17-1366

LEON L. LADDA, JR.,

            Plaintiff – Appellant,

v.

NANCY A. BERRYHILL,

            Defendant – Appellee.

Appeal from the United States District Court for the Western District of North Carolina,
at Charlotte. Richard L. Voorhees, Senior District Judge. (3:15-cv-00257-RLV)

Argued: September 26, 2018                                  Decided: October 18, 2018

Before DUNCAN and DIAZ, Circuit Judges, and John A. GIBNEY, Jr., United States
District Judge for the Eastern District of Virginia, sitting by designation.

Affirmed by unpublished opinion. Judge Duncan wrote the opinion, in which Judge Diaz
and Judge Gibney joined.

ARGUED: Dana Wayne Duncan, DUNCAN DISABILITY LAW, S.C., Nekoosa,
Wisconsin, for Appellant.        Christian Michael Vainieri, SOCIAL SECURITY
ADMINISTRATION, Baltimore, Maryland, for Appellee.            ON BRIEF:         Jill
Westmoreland Rose, United States Attorney, Charlotte, North Carolina, Gill P. Beck,
Assistant United States Attorney, OFFICE OF THE UNITED STATES ATTORNEY,
Asheville, North Carolina, for Appellee.
Unpublished opinions are not binding precedent in this circuit.

                                            2
DUNCAN, Circuit Judge:

       Plaintiff-Appellant Leon Ladda, Jr. challenges the decision of a Social Security

Administration (“SSA”) Administrative Law Judge (an “ALJ”) finding him not disabled

and denying his application for disability insurance benefits and supplemental security

income. Ladda contends that the ALJ erred in finding Ladda’s subjective statements

about his symptoms not entirely credible and in determining Ladda’s residual functional

capacity to work (his “RFC”). We hold that the ALJ applied correct legal standards and

that his factual findings were supported by substantial evidence. Accordingly, we affirm

the district court and uphold the ALJ’s decision.

                                                 I.

       In December 2011, Ladda applied for disability insurance benefits and

supplemental security income with the SSA. The SSA denied Ladda’s application, and

he filed a request for reconsideration, which the SSA also denied.

       Ladda requested an administrative hearing and appeared before an SSA ALJ in

August 2013. The ALJ heard testimony from Ladda and from a vocational expert (a

“VE”), and he reviewed Ladda’s medical records and the opinions of his physicians.

Medical evidence that the ALJ considered included x-rays that showed that Ladda’s

injuries were healing, test results that showed that Ladda’s sensation and range of motion

were normal, and records that showed no significant changes to Ladda’s pain medications

and no reports of side effects from those medications. The ALJ considered Ladda’s

reports that he could perform some daily tasks, such as brushing his hair, shopping for

                                             3
groceries, and performing household chores. The ALJ also considered Ladda’s testimony

that he experiences regular pain, frequently uses a wheelchair or crutches, experiences

side effects from his pain medications, and cannot walk for more than ten to fifteen

minutes or lift more than ten pounds.

      Following the hearing, the ALJ denied Ladda’s claims and found that Ladda was

not disabled. In his analysis, the ALJ found that Ladda’s subjective statements about his

symptoms were not entirely credible and that Ladda was capable of light work. The SSA

Appeals Council declined to review the decision. Ladda sought review of the ALJ’s

decision in the district court, which granted summary judgment for the SSA and affirmed

the ALJ’s decision in February 2017. This appeal followed.

                                               II.

      Ladda challenges (1) the ALJ’s determination that Ladda’s testimony regarding

his pain and abilities was not entirely credible and (2) the ALJ’s procedures and

reasoning in his assessment of Ladda’s RFC. This court “review[s] a district court’s

grant of a motion for summary judgment de novo, applying the same legal standards as

the district court.” Nader v. Blair, 549 F.3d 953, 958 (4th Cir. 2008). Accordingly,

“[w]hen examining an SSA disability determination, a reviewing court is required to

uphold the determination when an ALJ has applied correct legal standards and the ALJ’s

factual findings are supported by substantial evidence.” Bird v. Comm’r of Soc. Sec.

Admin., 699 F.3d 337, 340 (4th Cir. 2012). When reviewing for substantial evidence,

“we do not undertake to reweigh conflicting evidence, make credibility determinations,

                                           4
or substitute our judgment for that of the [ALJ].” Hancock v. Astrue, 667 F.3d 470, 472

(4th Cir. 2012) (alteration in original) (citation omitted).

       In this case, the ALJ’s credibility determination and RFC assessment apply correct

legal standards and are supported by substantial evidence. Accordingly, we affirm the

district court’s grant of summary judgment for the SSA and the ALJ’s decision to deny

Ladda’s application for disability insurance benefits and supplemental security income.

We briefly describe the statutory and regulatory framework that the ALJ applied before

explaining our decision to uphold the ALJ’s credibility determination and RFC

assessment.

                                                   A.

       The Social Security Act entitles eligible disabled individuals to disability

insurance benefits and supplemental security income. 42 U.S.C. §§ 423, 1382. ALJs

follow a five-step procedure when determining whether a claimant is disabled.

20 C.F.R. §§ 404.1520, 416.920. If the ALJ determines at any step that a claimant is or is

not disabled, the inquiry ends. Step 1 asks whether the claimant is working. Id. If not,

step 2 asks whether he has a “severe medically determinable physical or mental

impairment.” Id. Step 3 asks whether the claimant’s impairment “meets or equals” a

listed impairment that would automatically define him as disabled. Id. If the ALJ does

not find the claimant disabled at step 3, he must determine the claimant’s RFC--his

remaining capacity to do sustained work activities despite his physical or mental

impairments. See id. §§ 404.1520(e), 404.1545, 416.920(e), 416.945. As part of this

                                               5
determination, the ALJ must assess the credibility of any subjective statements by the

claimant about his symptoms. Id. §§ 404.1529(c)(4), 416.929(c)(4); Soc. Sec. Ruling

(“SSR”) 96-8p, 1996 WL 374184 at *7 (Jul. 2, 1996).

       After the RFC assessment, the ALJ proceeds to step 4 and determines whether the

claimant can still do his “past relevant work” in light of his impairments and the RFC

assessment.   20 C.F.R. §§ 404.1520, 416.920.      If the claimant cannot perform past

relevant work, the burden of proof shifts from the claimant to the SSA at step 5. See

42 U.S.C. § 423(5)(A); 20 C.F.R. §§ 404.1512(a)–(b), 416.912(a)–(b), 404.1520(g),

416.920(g). There, the SSA must “demonstrate that the impairment does not prevent the

claimant from engaging in other substantial gainful employment.” Patterson v. Comm’r

of Soc. Sec. Admin., 846 F.3d 656, 660 (4th Cir. 2017); see 20 C.F.R. §§ 404.1520,

416.920. At this stage, the ALJ considers the RFC assessment and the claimant’s age,

education, and work experience. 20 C.F.R. §§ 404.1520, 416.920. The ALJ will often

rely on the testimony of a VE at this step to establish whether a hypothetical person with

the claimant’s limitations and abilities could readily find employment that “exists in

significant numbers in the national economy.” Mascio v. Colvin, 780 F.3d 632, 635 (4th

Cir. 2015) (internal quotation marks and citations omitted).

       In this case, at steps 1 and 2, the ALJ found that Ladda was not working and had

severe impairments. At step 3, he found that Ladda’s impairments did not meet or equal

any listed impairment. The ALJ performed an RFC assessment and found that Ladda had

the residual functional capacity to perform “light work” except that Ladda was “limited

to [only] occasional climbing and balancing.” A.R. 22. Critically, at this stage, the ALJ

                                            6
found that Ladda’s statements about his pain and limitations were only partially credible.

At step 4, the ALJ found that Ladda was not able to perform any past relevant work

because the demands of his past work as a baker “exceed[ed] his residual functional

capacity.” A.R. 27. At step 5, however, the ALJ concluded that Ladda was not disabled

because VE testimony established that someone with Ladda’s RFC, age, 1 education, and

work experience could perform certain available occupations.           On appeal, Ladda

challenges both the ALJ’s determination that Ladda’s testimony regarding his pain and

abilities was not entirely credible and the ALJ’s procedures and reasoning in his RFC

assessment.

                                                 B.

       We first determine whether the ALJ’s credibility determination applied correct

legal standards and was supported by substantial evidence.          An ALJ assesses the

credibility of a claimant’s subjective statements about his condition as part of the RFC

assessment. When conducting the RFC assessment, the ALJ must consider all relevant

evidence in the record, including medical records, reports of daily activities, and “effects

       1
        Regarding Ladda’s age, the ALJ stated that Ladda was “51 years old, which is
defined as a younger individual age 18–49, on the alleged disability onset date.” A.R. 27.
However, under the regulations, Ladda, who falls between the ages of 50–54, is a
“[p]erson closely approaching advanced age.” See 20 C.F.R. § 404.1563(d). ALJs are
required to consider a claimant’s age in step 5 of the disability determination if the
claimant falls into that category. Id. § 404.1563(c)–(d). Here, the ALJ did consider
Ladda’s age in step 5, see A.R. 28, so any mistake he committed with respect to his
statement about Ladda’s age category did not affect his disability determination.

                                             7
of symptoms, including pain, that are reasonably attributed to a medically determinable

impairment.” SSR 96-8p at *7. When a claimant makes statements about his symptoms,

the ALJ must determine the credibility of those statements and explain his assessment.

20 C.F.R. §§ 404.1529(c)(4), 416.929(c)(4); see SSR 96-7p, 1996 WL 374186 (Jul. 2,

1996). 2 Ladda argues that the ALJ did not have substantial evidence to support his

finding that Ladda’s statements about his pain and other symptoms were not entirely

credible. However, we uphold the ALJ’s credibility determination because the ALJ

explained his reasoning and weighed Ladda’s subjective statements against other

evidence.

       SSA regulations set out a two-step process that ALJs must follow when evaluating

a   claimant’s   subjective   statements    about   his   impairments     and   symptoms.

20 C.F.R. §§ 404.1529, 416.929. First, the ALJ considers the objective medical evidence

to determine whether the claimant’s medical impairments “could reasonably be expected

to produce the pain or other symptoms alleged.” Id. Second, the ALJ evaluates the

“intensity and persistence of [the claimant’s] symptoms” and “determin[es] the extent to

which [those] symptoms limit [the claimant’s] capacity for work.” Id. At the second

step, the ALJ must “assess the credibility of the claimant’s statements about symptoms

and their functional effects.” Lewis v. Berryhill, 858 F.3d 858, 866 (4th Cir. 2017) (citing

       2
        SSR 16-3p superseded SSR 96-7p on March 16, 2016. SSR 16-3p, 2016 WL
1119029 at *1 (Mar. 16, 2016). However, SSR 96-7p was in effect on November 21,
2013 when the ALJ made his determination here, and neither party contends that it does
not apply.

                                             8
20 C.F.R. §§ 404.1529(c)(4), 416.929(c)(4)).       Here, the ALJ found that Ladda’s

“medically determinable impairments could reasonably be expected to cause the alleged

symptoms” of pain and limited mobility at the first step of this analysis. A.R. 23.

However, at the second step, the ALJ explained that Ladda’s statements regarding the

extent to which the symptoms affected his ability to work were not fully credible when

compared with other evidence on the record.

       When an ALJ makes a credibility determination, he must “consider the entire case

record, including the objective medical evidence, the individual’s own statements about

symptoms, [and] statements . . . by treating or examining physicians.” SSR 96-7p at *1.

In this analysis, the ALJ must “build an accurate and logical bridge from the evidence to

his conclusion that the claimant’s testimony was not credible.” Brown v. Comm’r Soc.

Sec. Admin., 873 F.3d 251, 269 (4th Cir. 2017) (internal quotations and alterations

omitted).

       Here, after considering Ladda’s subjective statements, the ALJ concluded that

Ladda’s pain could be managed through medication and did not limit his ability to

perform light work. The ALJ supported this conclusion through discussion and analysis

of the evidence. The ALJ discussed Ladda’s relevant medical records, such as x-rays that

showed that he was healing and test results that demonstrated normal sensation and range

of motion.    The ALJ also discussed Ladda’s statements about his pain, physical

limitations, and daily abilities.   The ALJ gave a number of reasons, supported by

substantial evidence, for finding that these statements were “not entirely credible.” A.R.

23. For instance, he explained that, though Ladda complained of pain, the medical record

                                            9
did not show “any significant changes . . . to [Ladda’s] medications or dosages,” which

suggested to the ALJ that Ladda’s existing treatments sufficiently managed his pain.

A.R. 25. The ALJ also noted that Ladda failed to follow his doctor’s advice and pursue

physical therapy at home when such activities could have helped ease his pain. A.R. 26.

The ALJ sufficiently explained how he used the evidence to reach his conclusion that

Ladda’s statements about his symptoms were not entirely credible. 3

       When determining credibility, the ALJ must also consider whether a claimant’s

statements about pain and other symptoms conflict with other evidence on the record,

including objective medical evidence and statements by physicians about how the

claimant’s symptoms affect him. See 20 C.F.R. §§ 404.1529(c)(4), 416.929(c)(4) (stating

the standard for evaluating subjective symptoms); Brown, 873 F.3d at 269 (explaining

that this standard applies during the credibility determination). The ALJ cannot “reject [a

claimant’s] statements about the intensity and persistence of . . . pain or other symptoms”

or about the effect of those symptoms on a claimant’s ability to work “solely because the

available    objective    medical     evidence    does     not    substantiate    [them].”

20 C.F.R. §§ 404.1529(c)(2), 416.929(c)(2).

       3
          Ladda also contends that the ALJ failed to mention facts in the record that
supported Ladda’s statements. An ALJ “cannot simply cherrypick facts that support a
finding of nondisability while ignoring evidence that points to a disability finding.”
Lewis, 858 F.3d at 869 (citation omitted). However, when we review an ALJ’s
credibility determination, we do not “substitute our judgment for that of the [ALJ],”
Hancock, 667 F.3d at 472, and here, the ALJ cited adequate evidence from the record to
support his conclusion that Ladda’s statements were not entirely credible.

                                            10
      In this case, the ALJ acknowledged Ladda’s pain but explained that no medical

evidence demonstrated that his pain was a “continuing impairment of incapacitating

proportions.” A.R. 25. An ALJ cannot base his credibility determination solely on

objective medical evidence, but that was not the end of the ALJ’s analysis here. See 20

C.F.R. §§ 404.1529(c)(2), 416.929(c)(2).     Instead, the ALJ noted that Ladda made

conflicting statements at the hearing and to his physicians about whether his pain

medication caused side effects, and he considered Ladda’s medication and treatment

history, which also cut against Ladda’s statements about his pain.          We are not

unsympathetic to the difficulty of articulating a subjective symptom like pain, but the

ALJ did not reject Ladda’s statements out of hand. Instead, he compared them with the

other evidence on the record, including objective medical evidence and Ladda’s

conflicting statements. The weight he assigned to Ladda’s statements after comparing

them with other evidence is therefore supported by substantial evidence.

      Admittedly, our inquiry would be more straightforward if the ALJ had not made

comments that were unnecessary to the disability determination, such as his statement

that “despite the advice of his physicians, [Ladda] continues to smoke, which may well

be a factor in aggravation of his medical problems.” A.R. 26; see Lewis, 858 F.3d at 869

(chastising an ALJ for “playing doctor” when the ALJ’s statement is not supported by

any medical evidence). However, on appeal, we look to whether the ALJ’s decision was

supported by substantial evidence, and in doing so, “we do not undertake to reweigh . . .

[the] evidence.”    Hancock, 667 F.3d at 472.         Under this standard, the ALJ’s

                                           11
determination here was more than adequately in accord with the regulations and our

precedent, despite his extraneous remarks.

       Therefore, we uphold the ALJ’s determination that Ladda’s subjective statements

were only partially credible.

                                                  C.

       We next determine whether the ALJ’s RFC assessment applied correct legal

standards and was supported by substantial evidence.        Ladda alleges that the ALJ

(1) failed to include a narrative discussion of the evidence in the RFC assessment and

(2) failed to perform the RFC assessment on a function-by-function basis. We uphold the

RFC assessment because the ALJ explained his reasoning and assessed Ladda’s

functional abilities and limitations in accordance with our standard in Mascio, 780 F.3d
632.

       In the RFC assessment, the ALJ uses all relevant evidence, medical or otherwise,

to determine a claimant’s “ability to meet the physical, mental, sensory, and other

requirements of work.” 20 C.F.R. §§ 404.1545, 416.945. A claimant’s RFC represents

“the most [he] can still do despite [his] limitations.” Id. SSA guidance directs the ALJ to

first consider a claimant’s abilities on a “function-by-function basis” before expressing a

claimant’s RFC in terms of exertional levels: “sedentary, light, medium, heavy, [or] very

heavy.” SSR 96-8p at *1; see Mascio, 780 F.3d at 636–37 (explaining that an ALJ must

explain how he evaluated a claimant’s residual functional capacity). Here, the ALJ

                                             12
determined that Ladda was capable of light work, except that he was “limited to

occasional climbing and balancing.” A.R. 22.

          An RFC assessment “must include a narrative discussion describing how the

evidence supports each conclusion, citing specific medical facts . . . and nonmedical

evidence.” SSR 96-8p at *7. The ALJ must identify the evidence relied upon and “build

an accurate and logical bridge from the evidence to [the] conclusion.” Monroe v. Colvin,

826 F.3d 176, 189 (4th Cir. 2016) (holding that an ALJ’s failure to do so was reversible

error).

          Here, the ALJ sufficiently explained his conclusions when conducting the RFC

assessment. In Monroe, an ALJ’s RFC assessment was not supported by substantial

evidence when he failed to explain his decision to rely on certain medical records while

ignoring others and when he failed to include a narrative discussion describing how he

decided to weigh the evidence. Id. at 189–90. In contrast, the ALJ in this case used

evidence from the record to explain his finding that Ladda was capable of light work.

For example, the ALJ noted that Ladda claimed that he could walk for only ten to fifteen

minutes at a time and could not lift ten pounds, but he explained that the other evidence

in the record, such as medical records and opinion evidence, did not fully substantiate

these claims. The ALJ also explained the relative weight he assigned to the statements

made by Ladda, Ladda’s treating physician, and the state agency medical consultants.

The ALJ provided a sufficiently thorough discussion for us to agree that his conclusion

that Ladda was limited to light work was supported by substantial evidence.

                                           13
       SSA guidelines instruct the ALJ to take a “function-by-function” approach to

determining a claimant’s RFC. SSR 96-8p at *1. The function-by-function approach

asks the ALJ to consider a claimant’s specific “exertional and nonexertional functions”

when determining the claimant’s RFC. Id. at *5. In Mascio, we “rejected a per se rule

requiring remand when the ALJ does not perform an explicit function-by-function

analysis.” Mascio, 780 F.3d at 636 (citing Cichocki v. Astrue, 729 F.3d 172, 177 (2d.

Cir. 2013) (per curiam)). Instead, we stated that “remand may be appropriate where an

ALJ fails to assess a claimant’s capacity to perform relevant functions, despite

contradictory evidence in the record, or where other inadequacies in the ALJ’s analysis

frustrate meaningful review.” Id. (quotations, alterations, and citation omitted). For

example, in Mascio, remand was appropriate where an ALJ’s RFC assessment was not

supported by substantial evidence because he failed to address conflicting evidence in the

record and to include an analysis of whether the claimant could perform certain functions

for an entire workday. Id. at 637.

       Here, the ALJ satisfied the requirements of Mascio when he assessed Ladda’s

RFC. He discussed Ladda’s ability to sit, stand, and walk, and he explained that Ladda’s

physicians opined that Ladda did not need to rely on a cane or crutches. Ladda argues

that the ALJ did not perform a function-by-function analysis because the ALJ did not

discuss Ladda’s reduced grip strength and limited use of his left leg and right hand.

However, the ALJ did assess Ladda’s capacity to stand, walk, and lift, which are all

functions that are related to those physical limitations.

                                              14
      Further, we need not remand because the record in this case is adequate. Unlike

the ALJ in Mascio, the ALJ here addressed conflicting evidence in the record and

explained that Ladda’s pain would not prevent him from working for an entire workday. 4

See id. Accordingly, we uphold the ALJ’s RFC assessment as supported by substantial

evidence rather than remand.

                                                III.

      We affirm the district court and uphold the ALJ’s disability determination because

the ALJ applied correct legal standards and his conclusions were supported by substantial

evidence.

                                                                             AFFIRMED

      4
         Ladda claims that the ALJ erred in assessing Ladda’s daily activities as evidence
of Ladda’s ability to work for an entire day. However, the ALJ cited Ladda’s daily
activities for purposes of the credibility determination and not as examples of the
functions Ladda could perform for an entire day.

                                           15