PUBLISHED
UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT
No. 15-1098
GEORGE G. MONROE,
Plaintiff - Appellant,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security,
Defendant - Appellee.
Appeal from the United States District Court for the Eastern District of North Carolina, at Wilmington. Louise W. Flanagan, District Judge. (7:13-cv-00074-FL)
Argued: May 10, 2016 Decided: June 16, 2016
Before TRAXLER, Chief Judge, GREGORY, Circuit Judge, and Joseph F. ANDERSON, Jr., Senior United States District Judge for the District of South Carolina, sitting by designation.
Reversed and remanded with instructions by published opinion. Chief Judge Traxler wrote the opinion, in which Judge Gregory and Senior Judge Anderson concurred.
ARGUED: William Lee Davis, III, Lumberton, North Carolina, for Appellant. Marc David Epstein, SOCIAL SECURITY ADMINISTRATION, Baltimore, Maryland, for Appellee. ON BRIEF: Thomas G. Walker, United States Attorney, R.A. Renfer, Jr., Assistant United States Attorney, OFFICE OF THE UNITED STATES ATTORNEY, Raleigh, North Carolina, for Appellee. TRAXLER, Chief Judge:
George Monroe appeals the Social Security Administration’s
denial of his applications for disability insurance benefits
(DIB) and supplemental security income (SSI). Because we
conclude that the administrative law judge erred by not
conducting a function-by-function analysis of Monroe’s
limitations and by not adequately explaining his decision, we
reverse and remand.
I.
In October 2007, Monroe filed applications for DIB and SSI,
alleging disability beginning December 8, 2006, due to uveitis 1;
back pain, breathing and memory problems; anxiety; depression;
and blackouts.
His applications were denied initially and on
reconsideration in 2008, and he requested a hearing before an
administrative law judge. Following the hearing, the ALJ (Judge
Leopold) denied the applications as well. In 2011, however, the
Appeals Council granted Monroe’s request for review, vacated
Judge Leopold’s decision, and remanded to an ALJ for a new
decision that would include determinations on several specific
1 Dorland’s Illustrated Medical Dictionary defines “uveitis” as “an inflammation of part or all of the uvea, the middle (vascular) tunic of the eye, and commonly involving the other tunics (the sclera and cornea, and the retina).” Dorland’s Illustrated Medical Dictionary 1798 (27th ed. 1988).
2 issues. The Appeals Council decision noted that Monroe had
filed subsequent DIB and SSI claims on May 7, 2010, and the
decision specified that the ALJ on remand was to associate the
files and issue a new decision on all claims.
A second ALJ (Judge Allen) then held a supplemental hearing
in late 2011. He subsequently found that Monroe was not
disabled from December 8, 2006, to February 7, 2012, the date of
his decision.
Monroe lost his administrative appeal and filed a complaint
in district court. Considering cross-motions for judgment on
the pleadings, a United States magistrate judge issued a
memorandum and recommendation (M&R). In the M&R, the magistrate
judge recommended that the district court deny Monroe’s motion,
grant the Commissioner’s motion, and affirm the denial of
benefits. The district court indeed granted the Commissioner’s
motion, thereby upholding the benefits denial. Monroe has now
appealed.
Legal Background
Before discussing the evidence in the record and the ALJ’s
analysis thereof, we begin with an overview of the five-step
sequential evaluation that ALJs must use in making disability
determinations. The applicable Social Security Administration
regulations set out the five-step process in significant detail.
3 We recently summarized the process in Mascio v. Colvin, 780 F.3d
632 (4th Cir. 2015):
[T]he ALJ asks at step one whether the claimant has been working; at step two, whether the claimant’s medical impairments meet the regulations’ severity and duration requirements; at step three, whether the medical impairments meet or equal an impairment listed in the regulations; at step four, whether the claimant can perform her past work given the limitations caused by her medical impairments; and at step five, whether the claimant can perform other work.
Id. at 634. The burden is on the claimant to make the requisite
showing at the first two steps, see Bowen v. Yuckert, 482 U.S.
137, 146 n.5 (1987), and if he fails to carry that burden, he is
determined not to be disabled. At the third step, the burden
remains on the claimant, see Pass v. Chater, 65 F.3d 1200, 1203
(4th Cir. 1995), and he can establish his disability if he shows
that his impairments match a listed impairment, see Mascio, 780
F.3d at 634-35.
However, if the claimant fails at that step, the ALJ then
must determine the claimant’s residual functional capacity
(RFC), “which is ‘the most’ the claimant ‘can still do despite’
physical and mental limitations that affect h[is] ability to
work.” Id. at 635 (quoting 20 C.F.R. § 416.945(a)(1)). In
making this assessment, the ALJ “‘must first identify the
individual’s functional limitations or restrictions and assess
his or her work-related abilities on a function-by-function
4 basis, including the functions’ listed in the regulations.” 2 Id.
at 636 (quoting Social Security Ruling 96-8p, 61 Fed. Reg.
34,474, 34,475 (July 2, 1996)). Only after such a function-by-
function analysis may an ALJ express RFC “‘in terms of the
exertional levels of work.’” Id. (quoting SSR 96-8p, 61 Fed.
Reg. at 34,475).
In determining a claimant’s RFC, the ALJ must consider
“‘all of [the claimant’s] medically determinable impairments of
which [the ALJ is] aware,’ including those not labeled severe at
step two.” Id. at 635 (quoting 20 C.F.R. § 416.945(a)(2)). He
also must “consider all [the claimant’s] symptoms, including
pain, and the extent to which [his] symptoms can reasonably be
accepted as consistent with the objective medical evidence and
2 The listed functions include
the claimant’s (1) physical abilities, “such as sitting, standing, walking, lifting, carrying, pushing, pulling, or other physical functions (including manipulative or postural functions, such as reaching, handling, stooping, or crouching)”; (2) mental abilities, “such as limitations in understanding, remembering, and carrying out instructions, and in responding appropriately to supervision, coworkers, and work pressures in a work setting”; and (3) other work-related abilities affected by impairments “such as skin impairment(s), epilepsy, impairment(s) of vision, hearing or other senses, and impairment(s) which impose environmental restrictions.”
Mascio v. Colvin, 780 F.3d 632, 636 n.5 (4th Cir. 2015) (quoting 20 C.F.R. § 416.945(b)-(d)).
5 other evidence.” 20 C.F.R. § 404.1529(a); see 20 C.F.R.
§ 416.929(a). “When the medical signs or laboratory findings
show that [the claimant has] a medically determinable
impairment(s) that could reasonably be expected to produce [his]
symptoms, such as pain, [the ALJ] must then evaluate the
intensity and persistence of [the claimant’s] symptoms so that
[the ALJ] can determine how [his] symptoms limit [his] capacity
for work.” 20 C.F.R. §§ 404.1529(c)(1), 416.929(c)(1).
Once the ALJ has determined the claimant’s RFC, the ALJ
then proceeds to step four, where the burden rests with the
claimant to show that he is not able to perform his past work.
See Bowen, 482 U.S. at 146 n.5; Mascio, 780 F.3d at 635. If he
successfully makes that showing, the process proceeds to step
five. See Mascio, 780 F.3d at 635.
“At step five, the burden shifts to the Commissioner to
prove, by a preponderance of the evidence, that the claimant can
perform other work that ‘exists in significant numbers in the
national economy,’ considering the claimant’s residual
functional capacity, age, education, and work experience.” Id.
(quoting 20 C.F.R. §§ 416.920(a)(4)(v), 416.960(c)(2),
416.1429). “The Commissioner typically offers this evidence
through the testimony of a vocational expert responding to a
hypothetical that incorporates the claimant’s limitations.” Id.
If the Commissioner satisfies that burden, then the claimant is
6 found to be not disabled and his benefits application is denied.
See id.
Testimony
Having provided this background, we will now summarize the
evidence before the ALJ, as it is relevant to this appeal,
including testimony, medical records, and other evidence. Then
we will discuss the ALJ’s analysis, before moving on to address
the legal issues Monroe raises.
At the time of the hearing in late 2011, Monroe was 32. He
testified he left high school in his senior year because of
daytime tiredness, confusion, and seizures. His work record was
spotty in his early years after school.
He reported that in 2007, when he was 27, he was working as
a dockworker when he went temporarily blind in his left eye. He
testified he was nodding off and falling asleep and having
memory lapses and blackouts, and was diagnosed with sarcoidosis.
He went to see Dr. Somnath Naik, underwent a sleep study, and
was diagnosed with narcolepsy 3 and sleep apnea.
Monroe testified that he uses a continuous positive airway
pressure (CPAP) machine. He testified that the CPAP had “done a
little . . . but there’s always a vague like drifting type
3 Dorland’s Illustrated Medical Dictionary defines “narcolepsy” as “recurrent, uncontrollable, brief episodes of sleep, often associated with hypnagogic hallucinations, cataplexy, and sleep paralysis.” Dorland’s, at 1098.
7 feeling . . . at all times” and he also “still ha[s] sleep
problems sometimes like I drift off and just nod off and fall to
sleep.” A.R. 87. Monroe testified regarding the spaced-out
feeling that, when it is happening, he really needs to just wait
for it to pass. He stated that Dr. Naik wanted to prescribe him
medication but that he could not afford it. 4
Asked to describe his episodes of extreme sleepiness or
blackouts, Monroe testified:
I can say that the fatigue is usually pretty extreme. I do better sometimes when I can get a little more rest but I . . . work at the storehouse, I can be sitting and I’ll just drift off, I’ll just nod off. And as far as the seizures they stated them as absence seizures a while back. I basically just freeze up, I can even be talking to somebody and I’ll just freeze. And I . . . had to grow to notice it myself because you know if it’s happening to you I didn’t really notice it at first . . . .
A.R. 93. Monroe testified that the episodes happen “about two
or three times a day.” A.R. 93. He said they seem more
prevalent when “there’s a lot going on, if there’s a little
confusion or if I’m where I have to move back and forth a lot.”
A.R. 94. He also testified that he had fallen asleep while
driving before as well. Monroe reported that he usually can
only wait out these episodes until they pass.
4 Monroe’s attorney, in her opening statement at the hearing, represented that Monroe’s then-recent medical records were “quite sparse” because he had not had insurance and was going without treatment. A.R. 69.
8 Monroe also testified that he suffered from chronic
bronchitis. He reported having problems sustaining his breath
and he stated that he thought he could walk a block, but he
would have to walk slowly. He claimed that even folding clothes
sometimes tires him out so much that he needs to sit to catch
his breath. He stated that he volunteers at a church and during
the day he sits down and rests at least three or four times a
day, usually for a few minutes.
He also testified that he suffered from neck and back pain
as a result of multiple automobile accidents. And he reported
chest and knee pain as well.
Regarding his eye problems, Monroe represented that they
were under control, although he still had some problems at
times. He also reported that anxiety and depression, which had
been problems for him in the past, were under control.
A vocational expert (VE) also testified at the hearing. In
questioning the VE, the ALJ described the following hypothetical
person:
Now, if you assume a hypothetical individual who has the same age, education and work experience as the claimant and has an RFC to perform light exertional work. This individual should only have occasional climbing of stairs or ramps, only occasional bending, balancing, stooping, crawling, kneeling or couching. This individual should never climb ropes, ladders or scaffolds, this individual should avoid occupations with hazardous machinery and concentrated exposure to fumes. This individual would be limited to simple,
9 routine, repetitive tasks and would need to work in a well lit environment.
A.R. 107. The VE testified that such a hypothetical person
could not perform any of Monroe’s past work, either as Monroe
actually performed it or as it is performed in the national
economy. However, the VE testified that there were jobs that
such a person could perform. The VE specifically identified the
jobs of cashier, sales attendant, and cafeteria attendant.
When questioned by Monroe’s attorney, the VE testified that
if the hypothetical person the ALJ described “need[ed] to take a
break approximately three to four times a day voluntarily and
then is having also two to three times a day moments where he
either falls asleep or . . . blacks out and . . . goes off task
for . . . five to ten minutes at a time,” he would not be able
to sustain competitive employment and “that would be excessive
breaks.” A.R. 110.
Medical Records
In light of the issues presented on appeal, we will limit
our discussion of the medical records primarily to those
relating to Monroe’s episodes of fatigue and loss of
consciousness and to Monroe’s mental limitations.
Dr. Naik treated Monroe in early 2008. A January 2008
record from Dr. Naik noted that Monroe reported a “history of
blacking out spells and headaches”; that Monroe “state[d] his
10 symptoms have been present . . . at least for 15 years including
symptoms of excessive daytime sleepiness and sleep attacks and
symptoms of cataplexy”; and that he had a “history of asthma for
20 years,” a “history of seizure disorder,” and a “[h]istory of
obstructive sleep apnea disorder for 20 years.” A.R. 550. 5 The
record states, “The patient also gives symptoms of cataplexy
where he has had mild generalized weakness as if he is going to
fall, though he was conscious. These episodes occurred when he
was excited or laughing, which is classic for cataplexy, but he
never had fall.” A.R. 551.
Dr. Naik’s “impression” stated in part, “Symptoms of
uncontrollable sleep and daytime confusional episodes and
symptoms of cataplexy which goes with diagnosis of narcolepsy
with cataplexy and symptoms of obstructive sleep apnea
disorder.” A.R. 552. The report indicated Dr. Naik would “send
[Monroe] for diagnostic sleep study followed by MSLT testing 6
5 Dorland’s Illustrated Medical Dictionary defines “cataplexy” as “a condition in which there are abrupt attacks of muscular weakness and hypotonia triggered by an emotional stimulus such as mirth, anger, fear, or surprise” and notes that “[i]t is often associated with narcolepsy.” Dorland’s, at 282.
6 An MSLT is a full-day test consisting of five scheduled naps that tests for excessive daytime sleepiness related to narcolepsy or hypersomnia. See Sleep Education, Multiple Sleep Latency Test (MSLT) – Overview and Facts, http://www.sleepeducation.org/disease-detection/multiple-sleep- latency-test/overview-and-facts (saved as ECF opinion attachment).
11 where MSLT will be done if sleep study is negative for
obstructive sleep apnea disorder. This is to rule out
narcolepsy.” A.R. 552 (footnote added). The report also noted,
“His symptoms of cataplexy narcolepsy diagnosis [are] definite.
The patient obviously is disabled to work and should not work
until his problems are fixed because he ha[s] [a] high risk of
getting hurt on the job or hurting somebody else and he also
should not drive due to his symptoms [until] these symptoms are
fully evaluated and taken care of.” A.R. 552.
Monroe underwent a sleep study on February 7, 2008.
Concerning the results, Dr. Naik observed, “Mildly reduced sleep
efficiency with significantly decreased N3 stage, 7 mildly reduced
REM sleep. Patient appears to have mainly central apneas during
CPAP titration. However, these were corrected with high CPAP
pressures.” A.R. 611. Dr. Naik recommended “CPAP at 8cm of
water by using heated humidification and by using full face
mask.” A.R. 611. He also stated, “If patient has symptoms of
restless leg syndrome or periodic limb movement disorder,
7 “The two main types of sleep are rapid-eye-movement (REM) sleep and non-rapid-eye-movement (NREM) sleep.” Healthy Sleep – Natural Patterns of Sleep, http://healthysleep.med.harvard.edu/healthy/science/what/sleep- patterns-rem-nrem (saved as ECF opinion attachment). “NREM sleep can be broken down into three distinct stages: N1, N2, and N3.” Id. Stage N3 is “the deepest stage of NREM.” Id.
12 treatment of that may improve sleep efficiency and sleep
architecture.” A.R. 611.
A treatment note from Dr. Naik from the day after the study
indicated that Monroe continued to be sleepy and fatigued and
that he had been turned down for government assistance paying
for medications. The note reported that a pulmonary function
test on January 21, 2008, produced normal results. Dr. Naik’s
impression was “[m]ild obstructive apnea disorder with excessive
daytime sleepiness with symptoms of narcolepsy and cataplexy
with excessive daytime sleepiness.” A.R. 612. The record
stated that Dr. Naik planned for Monroe to “repeat [the] sleep
study” using a CPAP and undergo “MSLT testing to evaluate for
continue[d] daytime sleepiness to see if the patient does have
narcolepsy.” A.R. 612. The report stated that after testing,
[Monroe] might benefit from [an] agent like venlafaxine for cataplexy. He also would benefit from [an] agent like modafinil for excessive daytime sleepiness, but . . . he needs financial help. Note will be given to take to social services to assess for financial help of his medical treatment and further evaluation by doing repeat sleep study and MSLT testing. In meantime, [Monroe] is cautioned . . . not to drive long distance[s] and [to] stop driving when he is sleepy. . . . Neurological evaluation also will be helpful to make sure he does not have partial complex seizures causing passing out episodes.
A.R. 613.
Monroe underwent a second sleep study on April 1, 2008.
Dr. Naik observed, “Good sleep efficiency with good sleep stages
13 with increased REM sleep stage” and “[n]o significant periodic
limb movement disorder.” A.R. 656.
The day after the second study, Monroe underwent MSLT
testing using a CPAP machine. Dr. Naik’s impression from the
testing was “Abnormal multiple sleep latency testing with short
sleep latency period and more than 2 SOREMPS. In view that the
patient has symptoms of cataplexy, this strongly favors the
diagnosis of narcolepsy with cataplexia. Patient has very good
sleep efficiency and had poor control of his sleep apnea
disorder based on preceding sleep study on CPAP.” A.R. 657.
Several months later, on September 28, 2008, Monroe was
admitted to the Southeastern Regional Medical Center for mental
distress and medication management. A record from Dr. Audrea
Marchant noted that Monroe was “very focused on having
narcolepsy” and that he reported having “sleep attacks of at
least 60 seconds in duration,” which frequently occurred while
he was driving. A.R. 674, 676. She also reported that Monroe
was “focused on seizures” and “confusion.” A.R. 674 (internal
quotation marks omitted).
Based on his complaints, a neurologist, Dr. Indra Gatiwala,
was brought in for a consultation. A report from Dr. Gatiwala
stated that, considering Monroe’s complaints, “[w]e will make
sure that [Monroe] had completed the MSLT and sleep study to
evaluate for narcolepsy, cataplexy, and obstructive sleep
14 apnea.” A.R. 681. The report also recommended several tests,
including an “EEG awake and asleep to rule out complex partial
seizures.” A.R. 681. Following the EEGs, the results of which
Dr. Gatiwala described as “normal,” A.R. 690, Dr. Gatiwala
concluded that there was “no evidence for any seizure activity
of any kind,” A.R. 677. Apparently because he was unaware that
Monroe had already undergone sleep studies and an MSLT earlier
in the year, A.R. 679 (“He was sent for the MSLT and sleep
study, but it was never completed.”), Dr. Gatiwala “noted that
the narcolepsy testing was incomplete,” A.R. 677.
Monroe was discharged from Southeast Regional on October 1.
Dr. Merchant’s discharge summary noted,
There was no time, whether the patient was working in one-to-one or was social on the unit, where he presented with any type of sleep attack, drop attack, or period of staring into space that would be consistent with absence seizures. He did at no time display any symptoms that would be consistent with complex partial seizures. When assured that he likely did not have seizures or narcolepsy, the patient began to complain of “significant difficulty breathing.”
A.R. 677. But testing did not support that Monroe was having
trouble breathing either. Dr. Merchant noted that she “informed
[Monroe] that there was absolutely no functional impairment
noted during this hospitalization and that would not support his
request for disability.” A.R. 678.
Related to his second DIB and SSI applications, Monroe
underwent two consultative examinations in December 2010. A
15 December 11, 2010, report from Dr. Morton Meltzer indicated that
Monroe had continued to complain of daily seizures and that he
had reported that he could not return to one of his past jobs
until he had been “cleared of the seizures for at least six
months.” A.R. 837. Dr. Meltzer stated that what Monroe “seems
to describe is more narcolepsy [than seizures because] he just
falls asleep.” A.R. 837.
Shortly thereafter, Monroe underwent another consultative
examination with a Dr. Ferriss Locklear. Monroe reported to Dr.
Locklear that he had been diagnosed with sleep apnea and
narcolepsy, that he uses a CPAP machine, and that he falls
asleep easily if he is driving.
Regarding Monroe’s mental limitations, two particular
reports are relevant. Ashley L. Booth, M.A., Licensed
Psychological Associate, and Henry William Link, Ph.D., Licensed
Practicing Psychologist, conducted a consultative examination of
Monroe on January 11, 2008, as a result of his initial DIB and
SSI applications, and determined that Monroe “appeared
marginally low in terms of reliably and safely mastering
directions and procedures” and that his “ability to sustain
attention, efforts, and constructive interpersonal relationships
over time in goal-oriented activities was . . . moderately low.”
A.R. 558. In contrast, Dr. Meltzer opined after his
consultative examination, conducted on December 11, 2010, that
16 Monroe was “able to understand, retain, and follow instructions”
and able to “sustain attention to perform simple repetitive
tasks.” A.R. 839.
Additionally, state agency medical consultants determined
in relation to Monroe’s second DIB and SSI applications that
Monroe was mentally limited in the following ways: (1) he was
“[m]oderately limited” in his “ability to understand and
remember detailed instructions” in that he could only
“understand and carry out s/r/r tasks for [two–hour] periods
during [a normal] workday,” A.R. 144, 159; (2) he was
“moderately limited” in his “ability to carry out detailed
instructions” and in his “ability to complete a normal workday
and workweek without interruptions from psychologically based
symptoms and to perform at a consistent pace without an
unreasonable number and length of rest periods” in that Monroe
could “make simple work related decisions psych based s/s will
intrude but rarely,” A.R. 144-45, 159-60; he was “[m]oderately
limited” in his “ability to interact appropriately with the
general public” in that he could “accept supervision and
interact [with] coworkers” but “would work best in
enviro[n]ments that d[id] not require frequent interpersonal
contacts,” A.R. 145, 160; and he was “[m]oderately limited” in
his “ability to respond appropriately to changes in the work
17 setting,” although he could “adapt to simple change and avoid
hazards,” A.R. 145, 160-61.
ALJ’s Opinion
The ALJ issued his decision in early 2012 and determined
that Monroe was not disabled during the relevant time period.
The ALJ found that Monroe met his burden at step one to show he
had not been working. At step two, he found that Monroe had the
following severe, medically determinable impairments: sleep
apnea, narcolepsy, myalgias, uveitis, anxiety, and mood
disorder. 8 At step three, the ALJ determined that none of
Monroe’s impairments nor any combination thereof met or
medically equaled any of the impairments in the Listing of
Impairments.
The ALJ next determined that Monroe had the RFC to perform
“light work,” 9 except that “he should climb stairs or ramps
8 A claimant has a severe impairment if an impairment or combination of impairments significantly limits his physical or mental ability to perform basic work activities. See 20 C.F.R. §§ 404.1520(c), 404.1521(a), 416.920(c), 416.921(a).
9 “Light work” is defined in the regulations as involving
lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, [the (Continued) 18 occasionally,” “should never climb ropes or ladders,” “is
limited to occasional bending, balancing, stooping, crawling,
kneeling, or crouching,” “should avoid hazardous machinery and
concentrated exposure to fumes,” “is restricted to work in a
well-lit environment,” and “is limited to simple, routine, and
repetitive tasks.” A.R. 16. The ALJ recognized that this
determination was in conflict with some of Monroe’s testimony
regarding his symptoms and resulting functional limitations.
Although the ALJ found that Monroe’s claimed symptoms could
reasonably be expected to be caused by the impairments that the
ALJ found, the ALJ nonetheless found that Monroe’s “statements
concerning the intensity, persistence and limiting effects of
these symptoms [were] not credible to the extent they [were]
inconsistent with the” RFC that the ALJ had described. A.R. 17.
Most relevant to this appeal is the ALJ’s analysis
concerning the severe impairments of sleep apnea and narcolepsy.
As to these impairments, the ALJ stated the following:
The claimant has a history of respiratory problems. While these conditions may cause the claimant some discomfort, they do not preclude work. In January 2008, he complained of excessive daytime sleepiness. At that time, the claimant reported having a history of sleep apnea and narcolepsy. A pulmonary function
claimant] must have the ability to do substantially all of these activities.
20 C.F.R. §§ 404.1567(b), 416.967(b).
19 test, taken earlier that month, had yielded normal results. Upon examination, the claimant’s respiratory system was also within normal limits. At that time, sleep testing showed evidence of moderate obstructive sleep apnea and periodic limb [movement] disorder. He was then diagnosed with mild obstructive apnea disorder with excessive daytime sleepiness with symptoms of narcolepsy. One month later, a sleep study indicated that the claimant had mildly reduced sleep efficiency with significantly decreased [N3] stage, mildly reduced REM sleep. The claimant’s treating physician . . . then recommended treating the claimant’s condition with a continuous positive airway pressure machine (CPAP) (Ex.18F). From that point forward, his conditions were controlled with conservative treatment. In September 2008, the claimant underwent electroencephalography [EEG], after complaining of confusion and narcolepsy. The study yielded normal results. Since then, the claimant has not reported any exacerbations of [his] condition. At a consultative examination in December 2010, he reported that he continued to use a CPAP machine. Upon examination, however, the claimant’s respiratory system was normal. He was then diagnosed with a history of sleep apnea and narcolepsy. (Ex.33F). The claimant has not reported any exacerbations of his condition, since then. The undersigned considered the claimant’s subjective complaints and the objective evidence in determining the residual functional capacity. As such, the undersigned finds that the claimant’s resulting limitations are consistent with the residual functional capacity.
A.R. 17.
The ALJ also noted later in his opinion that Monroe had
“alleged that he was unable to work because of . . . sleep
apnea,” but in fact that “condition is controlled.” A.R. 19.
The ALJ cited the fact that Dr. Naik “consistently described the
claimant’s sleep apnea as mild or moderate.” A.R. 19.
20 As for the limitations resulting from Monroe’s myalgias,
eye problems, anxiety, and mood disorder, the ALJ found that
they were “consistent with” with the RFC that the ALJ had
described. A.R. 18, 19, 20.
The ALJ also addressed evidence in the record concerning
Monroe’s mental limitations. Regarding Mr. Booth and Dr. Link’s
January 2008 determination that Monroe “appeared marginally low,
in terms of mastering basic directions or procedures reliably
and safely” and that his “ability to sustain attention, efforts,
and constructive interpersonal relationships over time in goal-
oriented activities was moderately low,” the ALJ stated simply
that he gave it “limited weight” because “the objective evidence
or the claimant’s treatment history did not support” it. A.R.
19-20. On the other hand, the ALJ noted that Dr. Meltzer’s
subsequent December 2010 consultative examination, which
produced the opinion that Monroe “was able to understand, retain
and follow instructions” and “able to sustain attention to
perform simple, repetitive tasks,” was “supported by the
objective evidence.” A.R. 20. Accordingly, he gave it “some
weight, to the extent that it [was] consistent with the” RFC
that the ALJ had identified. A.R. 20. Finally, the ALJ
considered the state agency medical consultants, whom he
identified as having “opined that [Monroe] had mild limitations
in activities of daily living and maintaining social
21 functioning” and “a moderate limitation in concentration,
persistence, and pace.” A.R. 20. The ALJ stated simply that
the opinions were “supported by the objective evidence and the
claimant’s subjective complaints” and that the he gave them
“significant weight.” A.R. 20.
At step four, considering the RFC that the ALJ had
identified, he determined that Monroe was unable to perform his
past work. However, based on the testimony of the vocational
expert, the ALJ determined that jobs did exist in the national
economy for a person with Monroe’s age, education, work
experience, and RFC. He therefore determined that Monroe was
not disabled, and he denied his application for benefits.
II.
We review de novo a district court’s decision on a motion
for judgment on the pleadings. See Korotynska v. Metropolitan
Life Ins. Co., 474 F.3d 101, 104 (4th Cir. 2006). A district
court will affirm the SSA’s disability determination “when an
ALJ has applied correct legal standards and the ALJ’s factual
findings are supported by substantial evidence.” Bird v.
Commission of Soc. Sec. Admin., 699 F.3d 337, 340 (4th Cir.
2012).
Monroe argues that the ALJ committed several legal errors
in analyzing the record before him.
22 A.
Monroe first argues that Judge Allen erred in not affording
great weight to the findings Judge Leopold made regarding his
severe impairments in the now-vacated 2010 decision. We
disagree.
The fact that the Appeals Council vacated Judge Leopold’s
decision and remanded for a new decision is dispositive here.
The SSA treats the doctrine of res judicata as applying when it
has “made a previous determination or decision . . . on the same
facts and on the same issue or issues, and this previous
determination or decision has become final by either
administrative or judicial action.” 20 C.F.R. §§ 404.957(c)(1),
416.1457(c)(1) (emphasis added); see Lively v. Secretary of
Health and Human Servs., 820 F.2d 1391, 1392 (4th Cir. 1987)
(“Congress has clearly provided by statute that res judicata
prevents reappraisal of both the Secretary’s findings and his
decision in Social Security cases that have become final.”).
Here, Judge Leopold’s decision, having been vacated, never
became final, and thus the doctrine of res judicata did not
apply.
Monroe maintains that our decisions in Lively and Albright
v. Commissioner of the Social Security Administration, 174 F.3d
473 (4th Cir. 1999), and Social Security Acquiescence Ruling 00-
1(4), 65 Fed. Reg. 1936-01 (Jan. 12, 2000), require a different
23 result. That is not the case, however. Interpreting Albright
and Lively, Acquiescence Ruling 00-1(4) explained that “where a
final decision of SSA after a hearing on a prior disability
claim contains a finding required at a step in the sequential
evaluation process for determining disability, SSA must consider
such finding as evidence and give it appropriate weight in light
of all relevant facts and circumstances when adjudicating a
subsequent disability claim involving an unadjudicated period.” 10
65 Fed. Reg. at 1938 (emphasis added). Nothing in that rule, or
in our circuit precedent, indicates that findings in prior non-
final decisions are entitled to any weight. See 20 C.F.R.
§§ 404.981, 416.1481 (“The Appeals Council’s decision, or the
decision of the [ALJ] if the request for review is denied, is
binding unless you or another party file an action in Federal
district court, or the decision is revised.” (emphasis added)).
Accordingly, Judge Allen did not err in considering Monroe’s
applications de novo.
B.
Monroe next maintains that the ALJ erred in not determining
his RFC using a function-by-function analysis. We agree.
10 Monroe fails to come to terms with the finality requirement and simply omits the language pertaining to finality when he quotes the SSA’s Acquiescence Ruling.
24 The process for assessing RFC is set out in Social Security
Ruling 96-8p. See Mascio, 780 F.3d at 636. Under that ruling,
the “‘assessment must first identify the individual’s functional
limitations or restrictions and assess his or her work-related
abilities on a function-by-function basis, including the
functions’ listed in the regulations.” Id. (quoting SSR 96-8p,
61 Fed. Reg. at 34,475). Only after such a function-by-function
analysis may an ALJ express RFC “‘in terms of the exertional
levels of work.’” Id. (quoting SSR 96-8p, 61 Fed. Reg. at
34,475). We have explained that expressing the RFC before
analyzing the claimant’s limitations function by function
creates the danger that “‘the adjudicator [will] overlook
limitations or restrictions that would narrow the ranges and
types of work an individual may be able to do.’” 11 Id. at 636
(quoting SSR 96-8p, 61 Fed. Reg. at 34,476).
By expressing Monroe’s RFC first and only then concluding
that the limitations caused by Monroe’s impairments were
consistent with that RFC, the ALJ made this very error and
thereby created the danger that the ruling identifies. The
error is most concerning regarding Monroe’s alleged episodes of
11 Expressing a claimant’s RFC in exertional terms without conducting a function-by-function analysis also could lead the adjudicator to “‘find that the individual has limitations or restrictions that he or she does not actually have.’” Mascio, 780 F.3d at 636 (quoting SSR 96-8p, 61 Fed. Reg. at 34,476).
25 loss of consciousness and fatigue. Monroe testified that he
would lose consciousness about two or three times per day and
would need to take several breaks during the day because of
fatigue. The ALJ indeed found that Monroe had the severe
impairments of sleep apnea and narcolepsy, and he concluded that
Monroe’s impairments could reasonably be expected to cause his
claimed symptoms. Nevertheless, he never made specific findings
about whether Monroe’s apnea or narcolepsy would cause him to
experience episodes of loss of consciousness or fatigue
necessitating breaks in work and if so, how often these events
would occur. See SSR 96-8p, 61 Fed. Reg. at 34,478 (“In all
cases in which symptoms, such as pain, are alleged, the RFC
assessment must . . . [i]nclude a resolution of any
inconsistencies in the evidence as a whole” and “[s]et forth a
logical explanation of the effects of the symptoms, including
pain, on the individual’s ability to work”). Rather, he simply
concluded that Monroe was capable of light work (with the
exceptions he identified) and that Monroe’s claimed symptoms
were “not credible to the extent they are inconsistent with” the
RFC the ALJ identified. 12 A.R. 17; see also A.R. 19 (ALJ’s
finding that Monroe’s “allegations are not fully credible”).
12 In Mascio, we criticized the use by the ALJ of similar language, noting that it got “things backwards by implying that ability to work is determined first and is then used to (Continued) 26 We have not adopted a rule of per se reversal for errors in
expressing the RFC before analyzing the claimant’s limitation
function by function. See Mascio, 780 F.3d at 636. However, we
have held 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. (alterations and internal quotation marks omitted). We
conclude that this is just such a case.
Because the ALJ never determined the extent to which Monroe
actually experienced episodes of loss of consciousness and
extreme fatigue, we cannot determine whether the hypothetical
questions posed to the VE included all of Monroe’s functional
limitations, as they needed to do in order to be useful. See
Hines v. Barnhart, 453 F.3d 559, 566 (4th Cir. 2006) (“In order
for a vocational expert’s opinion to be relevant or helpful, it
must be based upon a consideration of all other evidence in the
record, and it must be in response to proper hypothetical
questions which fairly set out all of claimant’s impairments.”
determine the claimant’s credibility.” 780 F.3d at 639 (internal quotation marks omitted). On remand, the ALJ should assess Monroe’s credibility in the context of the function-by- function analysis of the limitations caused by Monroe’s impairments, which the ALJ will then use to determine Monroe’s RFC.
27 (alteration and internal quotation marks omitted)). On remand,
the ALJ will need to consider Monroe’s narcolepsy and apnea, and
all of his other physical and mental impairments, severe and
otherwise, and determine, on a function-by-function basis, how
they affect his ability to work. Only once the ALJ has
conducted such an analysis will he be able to move on to steps
four and five, concerning Monroe’s ability to perform past work
and his ability to perform other work that exists in significant
numbers in the national economy. See Mascio, 780 F.3d at 636.
C.
Independent from the aforementioned flaw in the ALJ’s
analysis, Monroe also contends that the ALJ did not
satisfactorily explain his decision to partly discredit Monroe’s
testimony regarding the symptoms and functional limitations
resulting from his impairments. Relatedly, Monroe maintains
that the ALJ did not satisfactorily explain his decision to not
rely on certain medical records that Monroe contends support his
testimony. 13 We agree that the ALJ’s opinion lacks the specific
analysis that would allow for meaningful review.
Social Security Ruling 96-8p explains that the RFC
“‘assessment must include a narrative discussion describing how
13 20 C.F.R. §§ 404.1527(c) and 416.927(c) describe how medical opinions are to be weighed in determining entitlement to disability benefits.
28 the evidence supports each conclusion, citing specific medical
facts (e.g., laboratory findings) and nonmedical evidence (e.g.,
daily activities, observations).’” Id. (quoting SSR 96-8p, 61
Fed. Reg. at 34,478; see also Clifford v. Apfel, 227 F.3d 863,
872 (7th Cir. 2000) (observing that the ALJ “must build an
accurate and logical bridge from the evidence to his
conclusion”). We have held that “[a] necessary predicate to
engaging in substantial evidence review is a record of the basis
for the ALJ’s ruling,” including “a discussion of which evidence
the ALJ found credible and why, and specific application of the
pertinent legal requirements to the record evidence.” Radford
v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013).
1.
The ALJ cited evidence that he appeared to believe tended
to discredit Monroe’s testimony regarding his claimed episodes
of loss of consciousness and fatigue. However, he failed to
“build an accurate and logical bridge from the evidence to his
conclusion” that Monroe’s testimony was not credible. Clifford,
227 F.3d at 872. The facts the ALJ cited were as follows:
The claimant has a history of respiratory problems. While these conditions may cause the claimant some discomfort, they do not preclude work. In January 2008, he complained of excessive daytime sleepiness. At that time, the claimant reported having a history of sleep apnea and narcolepsy. A pulmonary function test, taken earlier that month, had yielded normal results. Upon examination, the claimant’s respiratory system was also within normal limits. At that time,
29 sleep testing showed evidence of moderate obstructive sleep apnea and periodic limb [movement] disorder. He was then diagnosed with mild obstructive apnea disorder with excessive daytime sleepiness with symptoms of narcolepsy. One month later, a sleep study indicated that the claimant had mildly reduced sleep efficiency with significantly decreased stage, mildly reduced REM sleep. The claimant’s treating physician . . . then recommended treating the claimant’s condition with a continuous positive airway pressure machine (CPAP) (Ex.18F). From that point forward, his conditions were controlled with conservative treatment. In September 2008, the claimant underwent electroencephalography [EEG], after complaining of confusion and narcolepsy. The study yielded normal results. Since then, the claimant has not reported any exacerbations of [his] condition. At a consultative examination in December 2010, he reported that he continued to use a CPAP machine. Upon examination, however, the claimant’s respiratory system was normal. He was then diagnosed with a history of sleep apnea and narcolepsy. (Ex.33F). The claimant has not reported any exacerbations of his condition, since then. The undersigned considered the claimant’s subjective complaints and the objective evidence in determining the residual functional capacity. As such, the undersigned finds that the claimant’s resulting limitations are consistent with the residual functional capacity.
A.R. 17. The ALJ also noted Dr. Naik “consistently described
the claimant’s sleep apnea as mild or moderate.” A.R. 19.
Simply put, the ALJ does not indicate how any of the facts
he cited show that Monroe did not lose consciousness two or
three times daily or suffer extreme fatigue. Although Monroe at
times described his problems as blackouts and seizures,
significant evidence in the record suggests that Monroe’s
symptoms were caused by narcolepsy, see, e.g., A.R. 657 (Dr.
Naik’s conclusion that the MSLT results “strongly favor[ed] the
30 diagnosis of narcolepsy with cataplexia”); A.R. 837 (Dr.
Meltzer’s conclusion that Monroe’s explanation of his symptoms
“seems to describe . . . more narcolepsy [than seizures because]
he just falls asleep”), and the ALJ found that narcolepsy was a
severe impairment of Monroe’s. In citing “normal” results from
pulmonary and respiratory tests and an EEG, the ALJ did not
explain why he believed these results had any relevance to the
question of what symptoms Monroe suffered from narcolepsy. 14 Nor
does the ALJ explain why he believed that the intensity of
Monroe’s apnea had any relevance to that question.
As for the ALJ’s statement that Monroe started using a CPAP
machine and “[f]rom that point forward, his conditions were
controlled with conservative treatment,” A.R. 17, it is hard to
know what the ALJ meant. To the extent that the ALJ meant that
use of the CPAP was successful in reducing or eliminating his
fatigue episodes of loss of consciousness, he does not cite any
14 Dr. Naik, after all, was aware of all of the test results other than the EEG when he determined that the MSLT results “strongly favor[ed] the diagnosis of narcolepsy with cataplexia.” A.R. 657. And the records seemed to indicate that Dr. Gatiwala ordered the EEG to rule out “complex partial seizures,” as opposed to narcolepsy. See A.R. 681 (Dr. Gatiwala ordered EEGs “to rule out complex partial seizures”); see also A.R. 613 (report from Dr. Naik indicating that MSLT would test for narcolepsy and that neurological evaluation would help rule out partial complex seizures).
31 evidence for that conclusion. 15 In fact, Monroe has consistently
reported that use of the CPAP has not significantly helped those
problems, and that was his testimony as well. On remand, if the
ALJ decides to discredit Monroe’s testimony regarding his
episodes of loss of consciousness and fatigue, it will be
incumbent on him to provide a clearer explanation of his reasons
for doing so, such that it will allow meaningful review of his
decision.
2.
Another significant example of the ALJ’s failure to
“‘include a narrative discussion describing how the evidence
supports each conclusion’” Mascio, 780 F.3d at 636 (quoting SSR
96-8p, 61 Fed. Reg. at 34,478, concerns his explanation of the
varying degrees of weight he gave to differing opinions
concerning Monroe’s conditions and limitations. For example,
regarding Monroe’s mental impairments, the ALJ noted that Dr.
Link and Mr. Booth’s report concluded that Monroe “appeared
marginally low, in terms of mastering basic directions or
procedures reliably and safely” and that his “ability to sustain
attention, efforts, and constructive interpersonal relationships
over time in goal-oriented activities was moderately low.” A.R.
15 Nor did the ALJ even mention that Monroe’s testimony and Dr. Naik’s medical records indicated that Dr. Naik wanted to treat Monroe with medication but that Monroe could not afford it.
32 19-20. The ALJ stated that he gave that opinion only “limited
weight” based on a determination that “the objective evidence or
the claimant’s treatment history did not support the
consultative examiner’s findings.” A.R. 20. However, the ALJ
did not specify what “objective evidence” or what aspects of
Monroe’s “treatment history” he was referring to. As such, the
analysis is incomplete and precludes meaningful review. The ALJ
gave similarly conclusory analysis of other opinions. See,
e.g., A.R. 20 (“The undersigned gives the consultative
examiner’s findings some weight, to the extent that it is
consistent with the residual functional capacity. The
consultative examiner’s opinion is supported by the objective
evidence.”); A.R. 20 (“The undersigned gives this opinion, some
weight to the extent that it is consistent with the residual
functional capacity. The objective evidence supports the
consultative examiner’s findings.”); A.R. 20 (“The undersigned
also gives this opinion some weight. The consultative examiner
opinion is consistent with the objective evidence and other
opinions of record, such as the first consultative physical
examination.”); A.R. 20 (“The undersigned gives the state agency
findings limited weight. After reviewing the objective
evidence, the undersigned finds that the claimant’s limitations
are more consistent with a light level of exertion.”); A.R. 20
(“The undersigned gives the state agency consultants[’] findings
33 significant weight. The state agency findings are supported by
the objective evidence and the claimant’s subjective
complaints.”). Without more specific explanation of the ALJ’s
reasons for the differing weights he assigned various medical
opinions, neither we nor the district court can undertake
meaningful substantial-evidence review. See Radford, 734 F.3d
at 295.
III.
For the foregoing reasons, we reverse the district court’s
judgment and remand with instructions to vacate the denial of
Monroe’s application for benefits and remand for further
administrative proceedings.
REVERSED AND REMANDED WITH INSTRUCTIONS
34