Court Opinion

ID: 3163727
Source: CourtListenerOpinion
Date Created: 2015-12-17 20:01:00.169809+00
Date Added: 2024-06-11T12:02:02.804605
License: Public Domain

UNPUBLISHED

                    UNITED STATES COURT OF APPEALS
                        FOR THE FOURTH CIRCUIT

                              No. 14-2237

GARRETT W. FOX,

                  Plaintiff - Appellant,

           v.

CAROLYN W. COLVIN, Acting Commissioner of Social Security,

                  Defendant - Appellee.

Appeal from the United States District Court for the Western
District of North Carolina, at Asheville. Max O. Cogburn, Jr.,
District Judge. (1:13-cv-00244-MOC-DLH)

Argued:   October 27, 2015                  Decided:   December 17, 2015

Before AGEE, FLOYD, and THACKER, Circuit Judges.

Vacated and remanded by unpublished per curiam opinion.

ARGUED: Charlotte Williams Hall, CHARLES T. HALL LAW FIRM, P.C.,
Raleigh, North Carolina, for Appellant.     Jeanne Dana Semivan,
SOCIAL SECURITY ADMINISTRATION, Boston, Massachusetts, for
Appellee.   ON BRIEF: Anne M. Tompkins, United States Attorney,
Paul B. Taylor, Assistant United States Attorney, OFFICE OF THE
UNITED STATES ATTORNEY, Charlotte, North Carolina, for Appellee.

Unpublished opinions are not binding precedent in this circuit.
PER CURIAM:

            Garrett       W.     Fox    (“Appellant”)          appeals       the     district

court’s    order       upholding        the   denial      of    his        application    for

disability insurance benefits and supplemental security income.

Appellant       argues    that        the   administrative           law     judge    (“ALJ”)

failed to sufficiently explain his findings, in violation of

Radford v. Colvin, 734 F.3d 288 (4th Cir. 2013), and improperly

evaluated the medical opinion of Appellant’s doctor.

            We conclude that the ALJ’s opinion failed to provide

sufficient reasoning to allow for meaningful judicial review.

Accordingly, we vacate the district court’s judgment and direct

the     district       court     to    remand      to    the        agency    for     further

proceedings consistent with this opinion.

                                              I.

                                              A.

                                              1.

                          Appellant’s Medical History

            In 2009, Appellant injured his back at work, and over

the next year, the pain worsened, progressing into both of his

legs.      As     a    result,     Appellant       could       no    longer     work     as   a

self-employed construction laborer.                     Beginning in 2010, several

physicians        diagnosed        Appellant        with       chronic         inflammatory

demyelinating polyneuropathy (“CIDP”) and diabetes.                                  Appellant

applied     for       disability       insurance        benefits       and     supplemental

                                              2
security income in March 2011, alleging that the diabetes and

CIDP had left him disabled since August 2009.

              In      2011,     Appellant       sought    the     care     of     Dr. Rob

Armstrong, a neurologist.                During a visit to Dr. Armstrong in

November 2011, Dr. Armstrong described Appellant’s neuropathy as

“severe,”       and    having     “occur[red]      in     a    persistent       pattern.”

A.R. 329. 1        In March 2012, Dr. Armstrong opined that Appellant’s

neuropathy         caused     general    fatigue,       leg    weakness,    imbalance,

pain,     “clear      gait    difficulties,”      and    sensory    deficits,       which

significantly limited Appellant’s physical capabilities.                           Id. at

339-41.

              Dr. Armstrong        determined       that       Appellant     had       both

exertional      and        non-exertional   limitations.           Specifically,        he

determined that Appellant could lift 20 pounds occasionally and

lift less than ten pounds frequently.                         Dr. Armstrong further

determined that Appellant could stand for a total of one to two

hours     during      an    eight-hour    work    day,    but    only     five    to   ten

minutes at a time, and he could sit for a total of four to five

hours, but only 15 to 30 minutes at a time.                       Per Dr. Armstrong,

Appellant could never perform climbing, balancing, or crouching

and     could      only     occasionally    stoop,       kneel,     and    crawl,      and

      1Citations to the “A.R.” refer to the Administrative Record
filed by the parties in this appeal.

                                            3
Appellant’s       neuropathy          also    affected            his     ability    to        reach,

handle,     feel,       push,    and       pull.       As     a    result,     Dr.    Armstrong

recommended         Appellant           avoid         heights,            moving     machinery,

temperature       extremes,          humidity,        vibration,        and   any    repetitive

activity.          He     noted        that     these         limitations          were        normal

consequences of neuropathy and described the neuropathy as a

“lifelong     issue”       that       would     create        hardships       on    Appellant’s

employment, including causing Appellant to be absent from work

“more than four times a month.”                    A.R. 341.

                                                2.

                                           ALJ Hearing

             The Social Security Administration denied Appellant’s

initial application for disability benefits in June 2011 and his

request for reconsideration in September 2011.                                Appellant then

filed a written request for an ALJ hearing.                               On April 20, 2012,

at his hearing, Appellant testified that he was experiencing

extensive        pain    causing        him     to     move        very    slowly,        to     have

difficulty climbing stairs, and to use a cane to walk.

             A      vocational             expert       (“VE”)          testified         that       a

hypothetical individual with similar limitations to Appellant’s

could not perform any of Appellant’s past relevant work.                                        Next,

the   ALJ   asked       the     VE    to    consider         the    work    prospects          for   a

hypothetical        individual             with        the        exertional        limitations

                                                  4
described          by    Dr. Armstrong.            The   VE   testified       that     this

hypothetical individual would be unemployed.

                                              B.

                                              1.

                           Evaluation of Disability Claims

               Disability claims are considered by using a five-step

process.       See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).                           The

five       steps    are     evaluated    in   sequential          order,    and   each    is

potentially             dispositive     --    thus,      if   a      determination        of

disability can be made at any step, the inquiry ceases.                              See 20

C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).                      The five-step process

entails evaluating 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; 2 (4) could return to his past relevant work;

and (5) could perform any other work in the national economy if

he cannot return to his past relevant work.                                See 20 C.F.R.

§§ 404.1520(a)(4), 416.920(a)(4).                    If a claimant reaches step

       2
       The listing of impairments “describes for each of the
major body systems impairments that [are] consider[ed] to be
severe enough to prevent an individual from doing any gainful
activity, regardless of his or her age, education, or work
experience.”   20 C.F.R. § 404.1525(a); see also 20 C.F.R.
Pt. 404, Subpt. P, App. 1 (Appendix describing the listing of
impairments).

                                              5
three     and    has       an    impairment    that      meets    or     equals    a   listed

impairment, the claimant will be automatically found disabled

and   entitled         to       benefits.      See       20 C.F.R. §§ 404.1520(a)(4),

416.920(a)(4).             Otherwise, before proceeding to step four, the

claimant’s        residual          functional        capacity         (“RFC”)     must      be

determined, which will then be used at steps four and five. 3                               See

20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).                        The burden of proof

is on the claimant in the first four steps, but shifts to the

Commissioner          at    the    fifth,    and    final,      step.      See    Mascio     v.

Colvin, 780 F.3d 632, 635 (4th Cir. 2015).

                                               2.

                                        ALJ’s Decision

                The    ALJ      first   determined       that    Appellant’s       CIDP     and

diabetes        diagnoses          qualified        as    severe        impairments,        but

thereafter       concluded         that     these    impairments        were     not   severe

enough    to     warrant         finding    Appellant      disabled       pursuant     to    20

C.F.R.     Part        404,       Subpart     P,    Appendix       1.       In    assessing

Dr. Armstrong’s treatment of Appellant, the ALJ summarized some,

but not all, of Dr. Armstrong’s medical notes.                              The ALJ then

stated,

      3A claimant’s residual functional capacity is the “most
[the claimant] can still do [in a work setting] despite” the
claimant’s  physical  and  mental  limitations.    20  C.F.R.
§ 404.1545.

                                               6
             Dr. Armstrong’s        opinion      regarding
             [Appellant’s] non-exertional limitations is
             given some weight because it is supported by
             medical signs and finding[s], because it is
             consistent with the medical evidence of
             record and because it was rendered by a
             treating source.     However, less weight is
             given to the exertional and manipulative
             limitations     because     they   are    not
             well[-]supported by the medical record.

A.R. 22.

             Ultimately,           after       considering            Appellant’s             age,

education,     work       experience,      and      RFC,      the    ALJ     concluded        that

Appellant was “not disabled” because other jobs existed in the

national     economy       in    which    Appellant          was    capable      of     working.

A.R.   23.     Appellant          appealed     to      the    Appeals      Council       of    the

Social       Security           Administration’s             Office        of         Disability

Adjudication        and    Review        (“Appeals       Council”).             The      Appeals

Council denied Appellant’s appeal because it “found no reason

under [its] rules to review the [ALJ]’s decision.”                              Id. at 1.

                                             3.

                            District Court’s Decision

             Appellant          then   filed       a   complaint        in      the    district

court.       Appellant          alleged     that       the     ALJ    (1) insufficiently

explained     the    finding       that    Appellant’s         CIDP     did     not     meet   or

equal the requirement of a listed impairment, i.e. Listing 11.14

for peripheral neuropathy, in violation of Radford v. Colvin,

734 F.3d 288 (4th Cir. 2013); and (2) improperly evaluated the

                                               7
medical opinion of Appellant’s doctor.                   Both Appellant and the

Commissioner of Social Security (“Commissioner” or “Appellee”)

moved for summary judgment.               The magistrate judge recommended

affirming the ALJ’s opinion on the basis that the ALJ provided

sufficient reasoning to allow for meaningful judicial review,

and substantial evidence existed to support the ALJ’s findings.

The district court adopted the magistrate judge’s recommendation

and       granted   Appellee     summary        judgment.     Appellant     timely

appealed to this court.

                                          II.

              We review a district court’s grant of summary judgment

de novo.       Elderberry of Weber City, LLC v. Living Centers-Se.,

Inc., 794 F.3d 406, 411 (4th Cir. 2015).                    We “will affirm the

Social Security Administration’s disability determination when

an ALJ has applied correct legal standards and the ALJ’s factual

findings      are   supported    by     substantial      evidence.”      Mascio    v.

Colvin, 780 F.3d 632, 634 (4th Cir. 2015) (internal quotation

marks omitted); 42 U.S.C. § 405(g) (The Commissioner’s findings

“as to any fact, if supported by substantial evidence, shall be

conclusive.”).          “Substantial evidence is such relevant evidence

as    a    reasonable    mind   might    accept     as   adequate   to   support    a

conclusion.”        Gestamp S. Carolina, L.L.C. v. NLRB, 769 F.3d 254,

263 (4th Cir. 2014) (internal quotation marks omitted).                           “It

consists of more than a mere scintilla of evidence but may be

                                           8
less than a preponderance.”                Hancock v. Astrue, 667 F.3d 470,

472 (4th Cir. 2012) (internal quotation marks omitted).

                                          III.

                                           A.

            Here, Appellant relies on our decision in Radford v.

Colvin,    wherein    the    ALJ    denied       a   claimant’s        application   for

benefits     because        the    claimant          did    not        have     qualified

impairments.       See 734 F.3d 288, 291-92 (4th Cir. 2013).                       There,

the ALJ simply concluded at step three that he “considered, in

particular,” the impairment listings.                  Id. at 292.        The district

court reversed the ALJ’s decision after reviewing the record

because the “ALJ’s opinion failed to apply the requirements of

the listings to the medical record,” and then the district court

proceeded to award benefits to the claimant.                     Id.

            On appeal, we explained, “[a] necessary predicate to

engaging in substantial evidence review is a record of the basis

for the ALJ’s ruling.         The record should include a discussion of

which   evidence     the    ALJ    found    credible       and    why,    and   specific

application of the pertinent legal requirements to the record

evidence.”     Radford, 734 F.3d at 295 (citations omitted); Arnold

v. Sec’y of Health, Ed. & Welfare, 567 F.2d 258, 260 (4th Cir.

1977) (ALJ failed to include an adequate discussion “in what

amount[ed]    to     no    more    than    a    bare   recital         that   [the   ALJ]

considered the evidence.”).               We reasoned that it is best for us

                                            9
to     “remand      to    the    agency     for    additional     investigation       or

explanation” when we cannot evaluate the record of the basis

that    underlies        the    ALJ’s    ruling.     Radford, 734 F.3d     at   295

(quoting Florida Power & Light Co. v. Lorion, 470 U.S. 729, 744

(1985)); see also Mascio v. Colvin, 780 F.3d 632, 640 (4th Cir.

2015) (“ALJ’s lack of explanation requires remand” when the “ALJ

explain[ed] how he decided [the evidence] . . . [with a] vague

(and     circular)        boilerplate       statement.”).         In    vacating      the

district court’s decision, we emphasized that it was “not our

province -- nor the province of the district court -- to engage

in     these     [fact-finding]          exercises    in    the   first       instance.”

Radford, 734 F.3d at 296; see also Cook v. Heckler, 783 F.2d
1168, 1173 (4th Cir. 1986) (holding that without an explanation

from the ALJ, “it is simply impossible to tell whether there was

substantial evidence to support the determination”).

                                             B.

               We   now    turn     to     the    ALJ’s    finding     here    and    its

application of the particular listing.                     At step three, the ALJ

stated, in its entirety,

               Although    the   claimant    has   “severe”
               impairments, they do not meet the criteria
               of any listed impairments described in
               Appendix 1 of the Regulations (20 CFR,
               Subpart P, Appendix 1).      No treating or
               examining physician has mentioned findings
               equivalent in severity to the criteria of
               any listed impairment, nor does the evidence
               show medical findings that are the same or

                                             10
                 equivalent to those of any listed impairment
                 of the Listing of Impairments.    In reaching
                 this   conclusion,    the   undersigned   has
                 considered,    in     particular,    sections
                 9.00(B)(5) and 11.14.

A.R.   20.         In   short,   the   ALJ    did   not    apply      findings       to    the

disability         listing.      Rather,      the    ALJ       engaged   in    the        same

conclusory analysis that we found to be unacceptable in Radford.

As in Radford, where the ALJ stated that he had “reach[ed] this

conclusion” after he “considered, in particular,” the listings,

in this case, the ALJ’s analysis was likewise perfunctory and

offered nothing to reveal why he was making his decision.                                 Nor

was    there      any    “specific     application        of    the   pertinent       legal

requirements to the record evidence.”                    Radford, 734 F.3d at 295.

As a result, the ALJ’s findings lack the “necessary predicate”

for us to engage in review.             Id.

                 The    Commissioner    posits      that       substantial       evidence

exists to affirm the ALJ’s findings; therefore, the error is

harmless.         See Mickles v. Shalala, 29 F.3d 918, 921 (4th Cir.

1994) (concluding that “there is no question but that [the ALJ]

would have reached the same result notwithstanding” the error).

Thus, the Commissioner invites us to review the record and cure

the    ALJ’s       deficiency     ourselves.             See     Appellee’s      Br.       22

(explaining that the relatively sparse record here “does not

present      a    materially     ambivalent       body    of    evidence      that    would

prevent meaningful review”).                  This argument is unavailing and

                                             11
contrary to our established precedent in Radford.                         We cannot

begin to engage in a “meaningful review” when there is nothing

on which to base a review.

           The magistrate judge recognized the ALJ’s failure to

provide    sufficient       reasoning,        yet    he     still   engaged       in     a

fact-finding     expedition.         He       stated       the   “ALJ    could     have

addressed Listing 11.14 in a more specific manner and made this

Court’s review easier.”          Fox v. Colvin, No. 1:13-cv-00244, 2014
WL 4987135,   at    *3    (W.D.N.C.    Sept.       8,   2014),    adopted   by       No.

1:13-cv-00244,       2014 WL 4987206      (W.D.N.C.      Oct.   7,   2014).         In

turn, the district court concurred because the magistrate judge

“was able to engage in a substantive, meaningful review of the

final decision of the Commission despite the ALJ’s error.”                             Fox

v.   Colvin,    No.    1:13-cv-00244,         2014 WL 4987206,     at   *3       n.1

(W.D.N.C. Oct. 7, 2014).            Despite both courts’ recognition of

the ALJ’s error, they engaged in an analysis that the ALJ should

have done in the first instance.              To do so was in error.

           Our circuit precedent makes clear that it is not our

role to speculate as to how the ALJ applied the law to its

findings or to hypothesize the ALJ’s justifications that would

perhaps find support in the record.

           Inconsistent evidence abounds, and yet the ALJ “leaves

us to wonder” in such a way that we cannot conduct “meaningful

review.”   Mascio, 780 F.3d at 638; see also Radford, 734 F.3d at

                                         12
296.     Dr. Armstrong     states     numerous    times    Appellant’s         severe

limitations:      Appellant     had     (1) walking        difficulty;         (2) a

broad-based      gait;    (3) absent     reflexes     in     his       lower   legs;

(4) diminished       feeling     in      his      legs;      and        (5) limited

coordination,     among    others.      Nonetheless,       the     ALJ    makes   no

mention of how he discredited these diagnoses (or levelled them

with his findings) to conclude “the medical signs show only mild

to moderate limitations in his legs.”                A.R. 21.          Because the

ALJ’s opinion fails to provide any explanation connecting his

determination to that of Appellant’s failure to meet the listing

impairment, the ALJ’s analysis was insufficient.                         See, e.g.,

Murphy v. Bowen, 810 F.2d 433, 437 (4th Cir. 1987) (“[I]t is

simply   unacceptable     for   the    ALJ   to   adopt    one    diagnosis     over

another without addressing the underlying conflict.”); Smith v.

Heckler, 782 F.2d 1176, 1181 (4th Cir. 1986) (explaining that

the ALJ needs to filter through the evidence and explain “why”

the ALJ made the decision); Hammond v. Heckler, 765 F.2d 424,

426 (4th Cir. 1985) (per curiam) (stating that an ALJ has a

“duty    of     explanation”     of     what      informed       his     decision).

Accordingly, we must vacate and remand.

                                       C.

              Appellant also contends that the ALJ failed to accord

adequate weight to Dr. Armstrong’s opinion.                  “Courts typically

accord greater weight to the testimony of a treating physician

                                       13
because    the   treating    physician        has   necessarily   examined     the

applicant and has a treatment relationship with the applicant.”

Hines v. Barnhart, 453 F.3d 559, 563 (4th Cir. 2006) (internal

quotation marks omitted).           Thus, “a treating physician’s opinion

on the nature and severity of the claimed impairment is entitled

to    controlling   weight    if    it   is    well   supported   by    medically

acceptable clinical and laboratory diagnostic techniques and is

not   inconsistent   with     the    other     substantial   evidence     in   the

record.”    Mastro v. Apfel, 270 F.3d 171, 178 (4th Cir. 2001);

see also 20 C.F.R. § 404.1527(c)(2).                “By negative implication,

if a physician’s opinion is not supported by clinical evidence

or if it is inconsistent with other substantial evidence, it

should be accorded significantly less weight.”               Craig v. Chater,

76 F.3d 585, 590 (4th Cir. 1996).

            When denying an application,

            [T]he   notice   of  the   determination  or
            decision must contain specific reasons for
            the weight given to the treating source’s
            medical opinion, supported by the evidence
            in the case record, and must be sufficiently
            specific to make clear to any subsequent
            reviewers the weight the adjudicator gave to
            the treating source’s medical opinion and
            the reasons for that weight.

SSR 96-2p, 61 Fed. Reg. 34,490, 34,492 (July 2, 1996).                    Because

the ALJ failed to give “good reasons . . . for the weight [he]

g[a]ve    [Appellant’s]      treating     source’s     opinion”   and    did   not

provide any support as to why he was giving the physician less

                                         14
weight in certain areas, the ALJ’s analysis was insufficient and

merits vacating the judgment.                  20 C.F.R. § 404.1527(c)(2).

            Here,        the       ALJ          provided         “less      weight”       to

Dr. Armstrong’s          opinion          of         Appellant’s        exertional       and

manipulative      limitations           because         the      ALJ     believed     these

limitations were “not well[-]supported by the medical record.”

A.R. 22.     Such        a    cursory     and        conclusory     analysis     does    not

provide any reason, let alone a “good reason[],” why the ALJ

concluded   that     Dr. Armstrong’s             opinion      was      inconsistent     with

other medical findings.              20 C.F.R. § 404.1527(c)(2); see also

SSR 96-2p, 61 Fed. Reg. at 34,492.                     Once more, we are confronted

with   whether      we       can   give    meaningful           review    to   the    ALJ’s

decision.    See Radford, 734 F.3d at 296.                      Yet again, we cannot.

Accordingly, summary judgment for the Appellee cannot stand.

                                               IV.

            For    the       foregoing     reasons,        we    vacate    the   district

court’s judgment and remand the case with instructions to remand

the case to the agency for further proceedings consistent with

this opinion.

                                                                  VACATED AND REMANDED

                                               15