Brian Reid v. Commissioner of Social Security

Opinion

PUBLISHED

UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT

No. 13-1480

BRIAN EDWARD REID,

Plaintiff - Appellant,

v.

COMMISSIONER OF SOCIAL SECURITY,

Defendant - Appellee.

Appeal from the United States District Court for the District of South Carolina, at Greenville. Timothy M. Cain, District Judge. (6:11-cv-02408-TMC)

Argued: May 15, 2014 Decided: July 2, 2014

Amended: September 16, 2014

Before TRAXLER, Chief Judge, and NIEMEYER and DUNCAN, Circuit Judges.

Affirmed by published opinion. Judge Niemeyer wrote the opinion, in which Chief Judge Traxler and Judge Duncan joined.

ARGUED: Beatrice E. Whitten, Mt. Pleasant, South Carolina, for Appellant. Sarah Van Arsdale Berry, SOCIAL SECURITY ADMINISTRATION, Denver, Colorado, for Appellee. ON BRIEF: William N. Nettles, United States Attorney, Barbara M. Bowens, Assistant United States Attorney, OFFICE OF THE UNITED STATES ATTORNEY, Columbia, South Carolina; John Jay Lee, Regional Chief Counsel, Kirsten A. Westerland, Assistant Regional Counsel, Dorrelyn K. Dietrich, Special Assistant United States Attorney, SOCIAL SECURITY ADMINISTRATION, Denver, Colorado, for Appellee.

2 NIEMEYER, Circuit Judge:

Brian Edward Reid, who suffers from degenerative disc

disease, applied for Social Security disability benefits. The

Commissioner of Social Security denied Reid’s claim, and the

district court affirmed the Commissioner’s decision.

On appeal, Reid contends (1) that the Commissioner ignored

several years of his medical history and (2) that the

Commissioner failed to consider the combined effects of his

multiple impairments. Because we find that the Commissioner’s

decision was based on all the medical evidence and that the

Commissioner did indeed consider Reid’s impairments in

combination, we affirm.

I

Reid filed for disability benefits under Title II of the

Social Security Act, 42 U.S.C. §§ 401-434, on December 7, 2006,

alleging that he became unable to work on June 4, 2004, when,

during work, he fell off of a roof.

Reid’s medical history, as documented by the record, shows

that, prior to his fall, on November 18, 2003, Reid visited Dr.

George Khoury for his chronic neck pain. Dr. Khoury diagnosed

Reid with cervical disc disease and, in December 2003, performed

a two-level anterior cervical discectomy and fusion.

3 When Reid fell off the roof on June 4, 2004, he suffered

two spinal fractures. After he was discharged from the hospital

four days later, he still complained of pain and returned to the

doctor on multiple occasions in the subsequent months. Although

Dr. Khoury noted on September 9, 2004, that Reid was “feeling

better” and that he had “minimal complaints,” on January 13,

2005, he nonetheless reported that Reid had “not seen any

improvement” and decided that a posterior fusion was

appropriate. Dr. Khoury performed the procedure on February 11,

2005, and, by March 29, 2005, noted that Reid was “really

progressing well” and was cutting back on his use of pain

medication. On May 5, 2005, Dr. Todd Joye -- another doctor

Reid was seeing for pain -- found that the fusion surgery “was

very successful and ha[d] nearly resolved [Reid’s] thoracic

pain” and that steroid injections “help[ed] him tremendously in

regards to his back pain.” And on November 23, 2005, Dr. Khoury

reported that Reid’s “original thoracic pain ha[d] totally

resolved.”

Several months later, on March 24, 2006, Reid began seeing

another doctor, Dr. Kerri Kolehma, complaining of “severe

bilateral leg pain” that was aggravated by walking, difficulty

using his left ankle, and numbness in several of his toes. Dr.

Kolehma’s physical exam revealed that Reid had “[n]ormal muscle

bulk and tone,” and Reid’s tests yielded normal results, except

4 for some loss of reflexes. Subsequent testing revealed that

Reid’s leg pain was related to vascular problems. Reid

underwent an iliac artery angioplasty on May 30, 2006, performed

by Dr. Kevin Beach. By July 10, 2006, Dr. Beach found that Reid

was “doing amazingly well” and “appear[ed] to be a changed man,”

noting that he had lost weight and was exercising.

On October 25, 2006, Reid again visited Dr. Khoury, whom he

had not seen since February. Dr. Khoury concluded that Reid was

“at maximum medical improvement and ha[d] essentially total

disability to the lumbar spine because of his fracture.” He

also concluded that Reid was “not able to return to any kind of

work activity at this point.” A few months later, however, on

January 17, 2007, when Reid visited Dr. Kolehma, he said that he

felt “like a million bucks” after changing drugs. He reported

that he had been cleaning his home and working out.

On April 11, 2007, Reid visited Dr. William Kee, a clinical

psychologist, for help with his anxiety and pain management.

Reid told Dr. Kee that he cooked on a daily basis and cared for

his 12-year-old daughter.

In September 2007, Reid began seeing Drs. Marc Dubick and

Tony Azzolino, who noted that Reid had severe pain below the

fusion site and weakness in the lower lumbar area. Dr. Dubick

administered an epidural injection and Reid experienced “total

5 pain relief.” Dr. Dubick reported on December 17, 2007, that

Reid’s “functional level ha[d] increased dramatically.”

Reid continued to go to Dr. Dubick from January 2008 to

July 2009 for injection therapy and pain medication, and during

this period, Dr. Dubick reported that Reid was “doing very

well,” “gardening and doing his normal activities,” “leading a

normal lifestyle,” and “showing some improvement,” although Reid

sometimes complained of “significant pain” and experienced

“quite a bit of discomfort.” In July 2009, Reid suffered a fall

that exacerbated his back pain, but the next month, on August

19, 2009, Dr. Dubick noted that Reid’s “injuries [were] markedly

improved from his fall” and that his back discomfort was

“minor.”

Finally, several times in 2008, Reid visited Summerville

Behavioral Health, complaining of obsessive-compulsive disorder

symptoms and panic attacks.

Reid filed his claim for disability benefits on December 7,

2006, which was denied. Following his request, a hearing was

conducted before an administrative law judge (“ALJ”) on

September 11, 2009. While the ALJ did find that Reid suffered

from several medical impairments, he did not find credible

Reid’s statements about the intensity, persistence, and effects

of his pain and other symptoms in light of the objective

evidence of his residual functionality and positive response to

6 treatment. Accordingly, the ALJ found that because Reid could

engage in sedentary work, he “ha[d] not been under a disability

. . . from June 4, 2004 through the date of this decision.”

On review of the ALJ’s decision, the Appeals Council

remanded the case, ordering the ALJ to consider the evidence

from June 4, 2004, forward, which the ALJ had not done because

he thought that res judicata applied to the 2004-2006 period.

The Appeals Council also instructed the ALJ to consider the

effect of Reid’s mental impairments and obesity on his

disability claim.

The ALJ conducted a second hearing on January 18, 2011,

after which he again denied Reid benefits. The ALJ found that

Reid’s severe impairments included adjustment disorder and a

history of obesity, in addition to degenerative disc disease.

Nonetheless, the ALJ found that Reid “did not have an impairment

or combination of impairments that met or medically equaled one

of the listed impairments in 20 CFR Part 404, Subpart P,

Appendix 1.” In making that finding, the ALJ explained that he

“ha[d] considered the combined effects of the claimant’s

impairments, both severe and non-severe, and ha[d] determined

that the findings related to them [were] not at least equal in

severity to” a listed impairment. After recounting Reid’s

medical history in substantial detail, the ALJ found that Reid

7 had the residual functional capacity to perform unskilled

sedentary work and thus was not disabled.

Reid again appealed to the Appeals Council, which largely

adopted the ALJ’s findings and conclusions, including the

findings that Reid’s impairments did not meet or medically equal

in severity a listed impairment and that Reid’s subjective

complaints were not credible in light of his residual functional

capacity. Differing from the ALJ, however, the Appeals Council

found that Reid’s adjustment disorder was not severe, and,

therefore, that Reid retained the ability to perform “the full

range of sedentary work.” The Appeals Council’s decision was

the final decision of the Commissioner.

Reid commenced this action, seeking review of the

Commissioner’s decision. He argued, among other things, that

(1) the decision was not based on substantial evidence because

the ALJ failed to consider the evidence between 2004 and 2006

and (2) the ALJ had not evaluated the combined effects of Reid’s

multiple impairments. With respect to the substantial evidence

argument, a magistrate judge found that Reid had failed to show

how he was harmed by any failure on the part of the ALJ to

specifically cite evidence from the 2004-2006 period and that,

in any event, the record indicated that the ALJ and Appeals

Council had indeed considered all the evidence before them. The

magistrate judge also found that the ALJ had explicitly

8 considered and discussed Reid’s combination of impairments.

Thus, the magistrate judge recommended affirming the

Commissioner.

The district court followed the magistrate judge’s

recommendation and affirmed, adopting the magistrate judge’s

report and providing additional explanation for its decision.

Reid v. Astrue, No. 6:11-2408-TMC, 2013 U.S. Dist. LEXIS 17815

(D.S.C. Feb. 11, 2013).

This appeal followed.

II

Reid raises two issues on appeal. First, he argues that

“[t]he Commissioner’s decision to deny [his] benefits was not

based on the entire record.” Specifically, he criticizes the

ALJ’s discussion of his medical history in the period from 2004

to 2006, noting that “[t]he ALJ referenced evidence from the

period 2004 to 2006 just a few times; and he never mentioned

objective findings which supported Mr. Reid’s claims.” He

contends that this “[f]ailure to consider all relevant evidence

precludes a proper substantial evidence test analysis.” Second,

Reid argues that “the Commissioner failed to provide any

meaningful analysis of the combined effect of his multiple

impairments.”

9 We review the district court’s judgment de novo, applying

the same standard of review applied by the district court, and

thus we review the Commissioner’s decision for substantial

evidence. See Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir.

2005) (per curiam). While the Commissioner’s decision must

“contain a statement of the case, in understandable language,

setting forth a discussion of the evidence, and stating the

Commissioner’s determination and the reason or reasons upon

which it is based,” 42 U.S.C. § 405(b)(1), “there is no rigid

requirement that the ALJ specifically refer to every piece of

evidence in his decision,” Dyer v. Barnhart, 395 F.3d 1206, 1211

(11th Cir. 2005) (per curiam); accord Russell v. Chater, No. 94-

2371, 1995 U.S. App. LEXIS 17254, at *8 (4th Cir. July 7, 1995)

(per curiam) (explaining that this Court has not “establish[ed]

an inflexible rule requiring an exhaustive point-by-point

discussion in all cases”).

After carefully reviewing the record in the present case,

we conclude that the Commissioner’s decision satisfied the

statutory requirements. The Commissioner, through the ALJ and

Appeals Council, stated that the whole record was considered,

and, absent evidence to the contrary, we take her at her word.

See Hackett v. Barnhart, 395 F.3d 1168, 1173 (10th Cir. 2005)

(“[O]ur general practice, which we see no reason to depart from

here, is to take a lower tribunal at its word when it declares

10 that it has considered a matter”). Moreover, the record shows

that the ALJ’s decision, on which the Commissioner’s decision

was based, specifically referenced Reid’s “history of thoracic

and lumbar fusion,” noting that “treatment notes from the

relevant period document that the claimant was responding well

to treatment with minimal complaints.” This finding -- which

relates to the time period that Reid claims the Commissioner

ignored -- is amply supported by the record. Indeed, Reid has

failed to point to any specific piece of evidence not considered

by the Commissioner that might have changed the outcome of his

disability claim. As such, we conclude that the Commissioner’s

decision was based on the entire record and supported by

substantial evidence.

Reid’s other argument -- that the Commissioner failed to

consider his impairments in combination -- is similarly without

merit. To be sure, an ALJ must “adequately explain his or her

evaluation of the combined effects of [a claimant’s]

impairments.” Walker v. Bowen, 889 F.2d 47, 50 (4th Cir. 1989).

But in the present case, the ALJ did consider Reid’s impairments

in combination. After meticulously describing why Reid’s three

severe impairments -- his degenerative disc disease, adjustment

disorder, and obesity -- did not, individually, qualify as

disabling, the ALJ then considered whether these three

11 impairments, cumulatively, would “equal in severity” a listed

impairment:

[T]he undersigned has considered the combined effects of the claimant’s impairments, both severe and non- severe, and has determined that the findings related to them are not at least equal in severity to those described in Listings 1.00, 4.00, 11.00, and 12.00. In this consideration, the undersigned has specifically considered the cumulative effects of the impairments on the claimant’s ability to work. See also Walker v. Bowen, 889 F.2d 47 (4th Cir. 1989). The undersigned notes that the claimant’s heart condition was asymptomatic despite his history of obesity. Even with consideration of the combined effects of the claimant’s obesity, treatment records fail to indicate that the claimant’s degenerative disc disease status post fusion resulted in an inability to ambulate or perform fine or gross motor movements effectively. The claimant’s physical impairments obviously affected his mental health condition. Nevertheless, when considered in conjunction, no further limitation in the claimant’s mental health condition, other than those discussed above, are warranted.

(Emphasis added). Relying on this analysis, the ALJ concluded

that Reid “did not have an impairment or combination of

impairments that met or medically equaled one of the listed

impairments.” (Emphasis added). It is thus readily apparent

that the Commissioner specifically contemplated the

combinatorial effects of Reid’s various impairments and, in

doing so, more than satisfied the statutory requirements and our

guidance set forth in Walker.

AFFIRMED