Williamson v. Comm'r of Soc. Sec.

1

KIMBERLY KAY WILLIAMSON, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.

No. 1:21-CV-452 (MAC)

United States District Court, E.D. Texas, Beaumont Division

August 30, 2023

REPORT AND RECOMMENDATION

Zack Hawthorn, United States Magistrate Judge

The claimant, Kimberly Kay Williamson, requests judicial review of a denial of benefits by the Commissioner of the Social Security Administration pursuant to 42 U.S.C. § 405(g). The District Court referred the case to the undersigned magistrate judge pursuant to 28 U.S.C. § 636(b) and a standing order of reference. The undersigned finds that the Administrative Law Judge (“ALJ”) erred in assessing the medical opinion evidence and that remand is warranted.

I. FACTUAL AND PROCEDURAL HISTORY

Williamson filed applications for Title II Social Security Disability Insurance and Title XVI Supplemental Security Income benefits on August 15, 2019 and September 23, 2020, respectively. (Tr 15, 70.) In both applications, she claimed disability beginning June 14, 2019, due to herniated disc, back problems, and neck problems. (Tr. 56-57.) Williamson's claims were denied initially on February 20, 2020 (Tr. 70) and upon reconsideration May 19, 2020 (Tr. 85). Her administrative hearing was held on December 19, 2020 (Tr. 34-44) before Administrative Law Judge (“ALJ”) Thomas Helget, who ultimately issued an unfavorable decision dated January 7, 2021. (Tr. 15-29.)

ALJ Helget utilized the five-step sequential analysis model specified by regulations and approved by courts.^[1] At step one, ALJ Helget found that Williamson has not engaged in substantial gainful activity since the alleged onset date. (Tr. 17-18.) At steps 2 and 3, ALJ Helget determined that she had the following severe impairments: degenerative disc disease of the cervical and lumbar spines, sciatica, osteoarthritis in multiple joints, neuropathy, major depression, and anxiety, none of which meet or medically equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926).^[2] (Tr. 18, 20-21.) ALJ Helget determined that Williamson has the residual functional capacity (“RFC”) to perform light work as defined in 20 C.F.R. §§ 404.1567(b) and 419.967(b) except that she can:

lift and/or carry 20 pounds occasionally and 10 pounds frequently; stand and/or walk for 6 hours in an 8-hour workday; and sit for 6 hours in an 8-hour workday with normal breaks. There should be no climbing of ladders, ropes, or scaffolds. She can occasionally balance, stoop, kneel, crouch, crawl, and climb ramps and stairs. Reaching overhead is limited to occasionally, bilaterally. She can frequently do gross handling and fine fingering with the bilateral upper extremities. [Plaintiff] is able to understand, remember, and carry out detailed, but not complex instructions, but no work performed in a fast-paced production environment.

(Tr. 24.) At step four, ALJ Helget concluded that Williamson was not capable of performing any of her past relevant work, but could perform other light, unskilled work in the national economy as an office helper, office cleaner, and fast food worker.^[3] (Tr. 27-28). Thus, ALJ Helget found that she is not disabled. (Tr. 29.) The Appeals Council denied review on June 21, 2021, making this decision the final decision of the Commissioner. (Tr. 1-3.) Williamson filed this lawsuit to challenge the Commissioner's decision. This court has jurisdiction of this action pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3).

II. JUDICIAL REVIEW

This court reviews the Commissioner's denial of social security disability benefits “only to ascertain whether (1) the final decision is supported by substantial evidence and (2) whether the Commissioner used the proper legal standards to evaluate the evidence.” Keel v. Saul, 986 F.3d 551, 555 (5th Cir. 2021) (quotation marks and citation omitted). Substantial evidence is merely enough that a reasonable mind could arrive at the same decision; though the evidence “must be more than a scintilla[,] it need not be a preponderance.” Taylor v. Astrue, 706 F.3d 600, 602 (5th Cir. 2012) (quotation marks and citation omitted).

Reviewing courts, therefore, give the Commissioner's decisions great deference. See Leggett v. Chater, 67 F.3d 558, 564 (5th Cir. 1995). Courts may not re-weigh evidence, try issues de novo, or substitute their judgments for those of the Commissioner. Bowling v. Shalala, 36 F.3d 431, 434 (5th Cir. 1995). A court cannot reverse the Commissioner simply because the court might have decided the case differently in the first instance. Elfer v. Texas Workforce Commission, 169 Fed.Appx. 378, 380 (5th Cir. 2006); Ripley v. Chater, 67 F.3d 552, 555 (5th Cir. 1995) (stating that the court may not “substitute [its] judgment for that of the Secretary”). Rather, it is for the Commissioner to weigh evidence and resolve conflicts. See Selders v. Sullivan, 914 F.2d 614, 617 (5th Cir. 1990).

III. POINTS OF ERROR AND RESPONSE

Williamson raises two points of error on appeal. First, that ALJ Helget failed to properly evaluate the medical opinion evidence consistent with Agency authority and Fifth Circuit precedent. Second, she claims that ALJ Helget's mental RFC determination is not supported by substantial evidence because he failed to reconcile the RFC with the persuasive opinion of the consultative examiner, Dr. Correia. (Doc. No. 20, p. 14.)

The Commissioner responds that contrary to Williamson's allegations, ALJ Helget properly addressed the medical opinion evidence in accord with the new, relevant regulations and that substantial evidence supports his decision. She further contends that the ALJ's analysis of her mental RFC is supported by the record and entitled to judicial deference. The undersigned recommends remanding her case based on the first argument presented, and therefore declines to address the second point of error.

IV. EVALUATION OF MEDICAL OPINION EVIDENCE

Pursuant to the revised rules for evaluating medical opinions, the ALJ must determine the persuasiveness of a physician's medical opinion. 20 C.F.R. § 404.1520c(b). When evaluating whether a medical opinion is persuasive, the ALJ considers five factors: 1) supportability; 2) consistency; 3) the relationship with the claimant; 4) specialization; and 5) other factors which “tend to support or contradict the opinion.” Id. § 404.1520c(c). When addressing the sufficiency of an ALJ's persuasiveness discussion under § 404.1520c(b)(2), one court described the ALJ's obligation as follows:

An ALJ's persuasiveness discussion is critical to his analysis and . . . must provide the Court with an ‘adequate discussion' of his reasons for finding a particular medical opinion to be persuasive or unpersuasive. The measuring stick for an ‘adequate discussion' is whether the ALJ's persuasiveness explanation enables the court to undertake a meaningful review of whether his finding with regard to the particular medical opinion was supported by substantial evidence, and does not require the Court to merely speculate about the reasons behind the ALJ's persuasiveness finding or lack thereof. Stated differently, there must be a discernible ‘logic bridge' between the evidence and the ALJ's persuasiveness finding.

Cooley v. Comm'r of Soc. Sec., 587 F.Supp.3d 489, 500 (S.D.Miss. 2021) (citing Pearson v. Comm'r, 2021 WL 3708047, at *5 (S.D.Miss. Aug. 11, 2021); Kilby v. Kijakazi, No. 4:20-CV-03035, 2022 WL 1797043, at *4 (S.D. Tex. Mar. 15, 2022). The most important factors in this analysis are supportability and consistency. See id.; 20 C.F.R. § 404.1520c(b)(2) (The ALJ must “explain how [he] considered the supportability and consistency factors for a medical source's medical opinions or prior medical findings in [his] determination or decision.”).

“Supportability” focuses on how well the medical evidence and supporting explanations given by the medical provider support the provider's opinion. See 20 C.F.R. § 404.1520c(c)(1) (“The more relevant the objective medical evidence and supporting explanations presented by a medical source are to support his or her medical opinion(s) or prior administrative medical finding(s), the more persuasive the medical opinions or prior administrative medical finding(s) will be.”); see also, Vellone v. Saul, 1:20-cv-00261, 2021 WL 319354, at *6 (S.D.N.Y. Jan. 29, 2021) (“[T]he strength of a medical opinion increases as the relevance of the objective evidence and explanations presented by the medical source increase.” (citing 20 C.F.R. § 404.1520c(c)(1)). “Consistency,” on the other hand, is “an all-encompassing inquiry focused on how well a medical source is supported, or not supported, by the entire record.” (Id.)

V. DISCUSSION

Wesley Palmer, D.O., treated Williamson for neck and low back pain. (Tr. 305-347.) Records show that he first treated her in August 2015, but did not examine her again until March 29, 2018. (Tr. 302-311.) Dr. Palmer treated Williamson consistently beginning in March 2018, (Tr. 305-311), and referred her for an MRI of the cervical spine, which was done on June 18, 2018. (Tr. 312-313.)

Dr. Palmer examined Williamson on September 4, 2018 (Tr. 318), February 7, 2019 (Tr. 328-331), February 15, 2019 (Tr. 333-336), and July 10, 2019 (Tr. 343 347). He referred her to a neurosurgeon, Marco Silva, M.D., who examined her on September 1, 2018, and provided a summary of his findings to Dr. Palmer. (Doc. No. 302-303). On August 26, 2019, Dr. Palmer completed a Physical Assessment Form (Tr. 354-355), which ALJ Helget summarized in his decision:

Diagnoses included chronic neck and lower back pain and lumbar disc disease. Her symptoms associated with her impairments were constantly severe enough to interfere with the attention

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