Case Name in Social Security Case - Unavailable

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IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF NORTH CAROLINA
CHARLOTTE DIVISION
3:25-cv-00121-MEO-WCM
STEFANIE PICKARD, )
)
Plaintiff, ) MEMORANDUM AND
) RECOMMENDATION
v. )
)
COMMISSIONER OF THE SOCIAL )
SECURITY ADMINISTRATION, )
)
Defendant. )
_______________________________ )
This matter has been referred to the undersigned pursuant to 28 U.S.C.
§ 636 for the entry of a recommendation.
I. Procedural Background
In January of 2021, Stefanie Pickard (“Plaintiff”) filed an application for
disability insurance benefits. Transcript of the Administrative Record (“AR”)
3164-3170. Plaintiff alleges disability beginning December 1, 2020. AR 3167.
On November 22, 2023, following an administrative hearing at which
Plaintiff appeared and testified, an Administrative Law Judge (“ALJ”) issued
an unfavorable decision. AR 14-44. That decision is the Commissioner’s final
decision for purposes of this action.
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II. The ALJ’s Decision
The ALJ found that Plaintiff had the severe impairments of lumbar
degenerative disc disease; left shoulder osteoarthritis; major depressive
disorder; generalized anxiety disorder with panic; and post-traumatic stress
disorder. AR 19. After determining that Plaintiff’s impairments did not meet
or medically equal any of the listed impairments, the ALJ found that Plaintiff
had the residual functional capacity (“RFC”):
to perform light work… with some exceptions.
Specifically, the claimant is frequently able to reach
overhead with the nondominant left upper extremity,
is frequently able to climb ramps and/or stairs, is
occasionally able to stoop and crawl, and is able to
tolerate occasional exposure to vibration, to extreme
cold, and to hazards such as unprotected heights and
moving mechanical parts. The claimant is able to
understand, remember, and carry out simple and
detailed but not complex instructions, is occasionally
able to interact with the public, is frequently able to
interact with coworkers and supervisors but should
avoid tasks requiring close coordination with
coworkers, is precluded from performing work
requiring a specific production rate (i.e., assembly
line), and is able to tolerate occasional changes in the
routine work setting.
AR 22.
Applying this RFC, the ALJ found that Plaintiff could perform other jobs
that exist in significant numbers in the national economy such that Plaintiff
was not disabled. AR 36-38.
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III. Plaintiff’s Allegations of Error
Plaintiff contends that when developing the RFC, the ALJ erred in his
consideration of the opinion of Dr. Chad R. Christensen, a licensed
psychologist.
Additionally, Plaintiff asserts that the Appeals Council erred in failing to
remand the matter for further consideration following Plaintiff’s submission of
medical records from the Department of Veterans Affairs (the “VA Medical
Records,” AR 69-3069).
IV. Standard of Review
A claimant has the burden of proving that he or she suffers from a
disability, which is defined as a medically determinable physical or mental
impairment lasting at least 12 months that prevents the claimant from
engaging in substantial gainful activity. 20 C.F.R. §§ 404.1505(a); 416.905(a).
The regulations require the Commissioner to evaluate each claim for benefits
using a five-step sequential analysis. 20 C.F.R. §§ 404.1520(a); 416.920(a).
The burden rests on the claimant through the first four steps to prove
disability. Monroe v. Colvin, 826 F.3d 176, 179-80 (4th Cir. 2016). If the
claimant is successful at these steps, then the burden shifts to the
Commissioner to prove at step five that the claimant can perform other work.
Mascio v. Colvin, 780 F.3d 632, 635 (4th Cir. 2015); Monroe, 826 F.3d at 180.
Under 42 U.S.C. § 405(g), judicial review of a final decision of the
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Commissioner denying disability benefits is limited to whether substantial
evidence exists in the record as a whole to support the Commissioner’s
findings, and whether the Commissioner’s final decision applies the proper
legal standards. Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). When a
federal district court reviews the Commissioner’s decision, it does not “re-weigh
conflicting evidence, make credibility determinations, or substitute [its]
judgment for that of the [Commissioner].” Craig v. Chater, 76 F.3d 585, 589
(4th Cir. 1996). Accordingly, the issue before the Court is not whether Plaintiff
is disabled but, rather, whether the Commissioner’s decision that she is not
disabled is supported by substantial evidence in the record and based on the
correct application of the law. Id.
V. Discussion
A. Evaluation of Dr. Christensen’s Opinion
During a consultative examination on October 28, 2021 (AR 3595 –
3598), Dr. Christensen observed that Plaintiff was “tearful and depressed,”
exhibited “delayed…verbal responses,” had “adequate grooming and hygiene
skills,” “normal motor activity,” was oriented to person, place, time, and
situation, exhibited “poor working memory ability” and “poor concentration
and attention, and a slow thought process speed.” AR 3596. Dr. Christensen
opined that, at the time, Plaintiff did “not demonstrate the ability to perform
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work related mental abilities such as concentration, attention, and memory”
or “the ability to relate with others.” AR 3597.
In considering Dr. Christensen’s opinion, the ALJ explained that
Plaintiff “had not previously presented with anything approaching such slowed
processing speed or deficits in memory” and that Plaintiff had previously
acknowledged (in December of 2020) that she stopped working “for physical
versus mental reasons.” AR 33. The ALJ further stated that Dr. Christensen
“was also somewhat vague in his wording” and that “a finding of ‘extreme’
limitations with no ability whatsoever to concentrate, pay attention,
remember, or relate to others is in stark contrast to the claimant’s own
allegations, acknowledged abilities, ability to persist at a highly skilled job
until her hours were reduced due to the pandemic, and…to the claimant’s
ability to care for her young child and manage her household independently.”
Id. The ALJ concluded that “to the extent that Dr. Christensen intended to
opine with regard to listing level severity, such opinion has no support in
available medical evidence and is inconsistent with the claimant’s own
allegations and acknowledged abilities.” Id.
Plaintiff contends that to the extent the ALJ believed Dr. Christensen’s
opinion was “vague,” the ALJ should have gotten clarification from Dr.
Christensen before issuing a ruling. Plaintiff also argues that the ALJ failed
to explain adequately the purported inconsistencies between Plaintiff’s
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allegations and abilities and Dr. Christensen’s opinion, and improperly
considered Plaintiff’s ability to care for her child and manage her household.
An ALJ is required to consider and articulate how persuasive he or she
finds each medical opinion to be, and, in doing so, to consider numerous factors
including “supportability” and “consistency.” See 20 C.F.R. §§ 404.1520c(a) &
(c); 416.920c(a) & (c). “Supportability is the degree to which a provider supports
their opinion with relevant, objective medical evidence and explanation, and
consistency is the degree to which a provider's opinion is consistent with the
evidence of other medical and non-medical sources in the record.” Oakes v.
Kijakazi, 70 F.4th 207, 212 (4th Cir. 2023) (citation omitted); see also Bright v.
Saul, No. 1:19CV504, 2020 WL 4483008, at *3 (M.D.N.C. Aug. 4, 2020)
(“Supportability is an internal check that references objective medical evidence
and supporting explanations that come from the source itself. Consistency is
an external check that references evidence from other medical and nonmedical
sources.”).
“In the course—and aftermath—of this persuasion analysis, an ALJ will
render a disability determination based on the available evidence when that
evidence is consistent and sufficient.” Oakes, 70 F.4th at 212–13 (citing 20
C.F.R. § 404.1520b(a)). “Conversely, an ALJ will not render a determination
when the available evidence is incomplete, insufficient, or inconsistent.” Id. In
that regard, the Fourth Circuit has explained that:
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Evidence is incomplete or insufficient “when it does
not contain all the information [that the ALJ] need[s]
to make [its] determination.” Evidence is inconsistent
“when it conflicts with other evidence, contains an
internal conflict, [or] is ambiguous.” If the available
evidence suffers from any of these inadequacies, an
ALJ will determine “the best way” to resolve the issue,
which may include one or more of four paths forward:
(1) recontacting a medical source for clarification; (2)
requesting additional existing evidence; (3) asking the
claimant to undergo a consultative examination; or (4)
asking the claimant or others for more information. If
“there are inconsistencies in the evidence that [the
ALJ] cannot resolve or when, despite efforts to obtain
additional evidence, the evidence is insufficient to
determine whether [a claimant is] disabled, [the ALJ]
will make a determination or decision based on the
evidence [it possesses].”
Id. at 213 (internal citations omitted).
In Oakes, the court found that an ALJ improperly discounted a
consultative examiner’s opinion that the claimant should use an ambulatory
device. The court explained that “[t]o the extent [the examiner’s] justification
for his ambulatory-device recommendation was ambiguous,” the medical
record was “incomplete and the ALJ should have ‘take[n] additional action’ to
seek clarification.” Id. The court pointed out that the medical record was
“extremely sparse” (which was the reason the ALJ had ordered the consultative
examination in the first place) and that “[a]lthough it is not the within the
purview of an ALJ to help a claimant accumulate favorable evidence in an
advocative capacity, this Court has ‘long recognized that the administrative
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hearing process is not an adversarial one, and an ALJ has a duty to investigate
the facts and develop the record.’” Id. at 213-214 (quoting Pearson v. Colvin,
810 F.3d 204, 210 (4th Cir. 2015) (citing Cook v. Heckler, 783 F.2d 1168, 1173–
74 (4th Cir. 1986)). The court concluded that because the “insufficiency of the
record” could have been resolved but that the ALJ failed to “reasonably
endeavor[] to obtain additional evidence to remedy” that insufficiency, “the
ALJ's determination based only on the evidence that it possessed was woefully
premature.” Id. at 214.
Here, the ALJ noted that Dr. Christensen was “somewhat vague in his
wording,” but the ALJ interpreted Dr. Christensen’s opinion to state that
Plaintiff “had essentially no ability to perform work-related mental activities
involving concentration, attention, or memory, and no ability to relate to
others, an opinion that would be consistent with extreme limitations….” AR
33. The ALJ went on to state that specific medical records reflected Plaintiff’s
generally normal mental status findings, and that such findings stood “in
significant contrast to [Dr. Christensen’s] opinions.” AR 33 (citing AR 4708-
4739 (May 2023 – June 2023 treatment records reflecting that Plaintiff’s
memory was “good” or “intact” and that her attention span was intact)).
Accordingly, while the ALJ did refer to Dr. Christensen’s wording as
being “somewhat vague,” the ALJ was able to consider the substance of Dr.
Christensen’s opinion regarding Plaintiff’s functional limitations and was able
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to determine the persuasiveness of that opinion by reference to other mental
health treatment records. See Jasper Y. v. Bisignano, No. 8:25-CV-01370-DCC-
WSB, 2025 WL 4067036, at *9 (D.S.C. Dec. 30, 2025), report and
recommendation adopted sub nom., Youngblood v. Bisignano, No. 8:25-CV-
001370-DCC, 2026 WL 165170 (D.S.C. Jan. 20, 2026) (“the record in this
matter is not ‘extremely sparse,’ as was the record in Oakes…there was
additional evidence in the record which the ALJ could and did evaluate to reach
a decision….”) (citing Crawford v. Comm'r of Soc. Sec. Admin., No. 8:24-CV-
2882-DCC, 2025 WL 2778366, at *5 (D.S.C. Sept. 30, 2025) (“To the extent that
Dr. Ruffing's opinion was ambiguous, unlike the ‘extremely sparse’ record in
Oakes, the record in this case contained additional evidence…from which the
ALJ could glean information to resolve ambiguities. Indeed, there was
substantial evidence to support the ALJ's conclusion that Dr. Ruffing's opinion
concerning what Plaintiff ‘may struggle with’ was inconsistent with other
record evidence, and accordingly, unpersuasive. The ALJ permissibly relied on
means other than recontacting Dr. Ruffing for clarification.”); Fisher v.
O'Malley, No. 2:23-CV-25-KS, 2024 WL 1434504, at *3 (E.D.N.C. Apr. 3, 2024)
(“Plaintiff is correct to take issue with the ALJ's assessment of the consultative
examiners’ opinion as ‘speculative, somewhat vague at times, and [ ] not
adequately specify[ing] [Plaintiff]’s vocational limitations.’ Were this the only
reason given by the ALJ for discounting the Shaw-Currin opinion, remand
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might be warranted. However, as explained above, the ALJ provided several
additional reasons for not adopting in full the Shaw-Currin opinion limitations.
These reasons make this case distinguishable from Oakes and permit
meaningful review.”) (internal citations omitted); Cf., Smith v. Comm'r of Soc.
Sec., No. 1:23-CV-00303-KDB, 2024 WL 3160318, at *5 (W.D.N.C. June 25,
2024) (“Here, as in Oakes, the ALJ ordered a consultative exam but then
dismissed the consultative examiner's conclusion….The ALJ found that the
evaluation was too ‘vague and not in specific function-by-function terms
consistent with Agency rules and regulations.’ Following Oakes, the Court
finds that the ALJ failed to make a § 404.1520b(b)(2) inquiry when he
attributed less weight to Dr. Burgess's opinion solely because of its vagueness.
This was an easily clarified ambiguity and therefore the ALJ's RFC
determination was premature and warrants remand.”) (internal citations
omitted).
Further, while Plaintiff argues that the ALJ failed to explain the
inconsistencies between Dr. Christensen’s opinions and Plaintiff’s “own
allegations and acknowledged abilities,” the ALJ’s decision referenced
Plaintiff’s self-report to Dr. Christensen that Plaintiff had “last worked in
December 2020 as a nurse,” but that she “could not do the physical work of the
job anymore.” AR 33; AR 3595-96. In addition, the ALJ found significant
Plaintiff’s December 1, 2020 meeting with a social worker in which Plaintiff
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reported that her hours as a nurse had been “cut back due to COVID” and that
she hoped her hours would “return to normal soon.” AR 26 (citing AR 3507).
The ALJ explained that the timing of this meeting “directly correspond[ed]
with [Plaintiff’s] alleged onset date and reasoned that “[s]uch acknowledgment
on the part of the claimant [did] not support a finding of severe deterioration
in physical or mental functioning corresponding with the alleged onset date.”
AR 26.
Additionally, though the ALJ found that the limitations Dr. Christensen
identified were inconsistent with Plaintiff’s “ability to care for her young child
and manage her household independently,” the ALJ acknowledged Plaintiff’s
need for help with such activities from family members. See AR 33; AR 23-24
(discussing the help Plaintiff received from her mother and that Plaintiff’s
brother drove a U-Haul when Plaintiff moved to North Carolina); see also
Woods v. Berryhill, 888 F.3d 686, 694 (4th Cir. 2018) (“An ALJ may not
consider the type of activities a claimant can perform without also considering
the extent to which she can perform them.”).
Finally, while the ALJ found Dr. Christensen’s opinion that Plaintiff had
extreme limitations in concentration, attention, memory, and her ability to
relate to others to be unpersuasive, the ALJ did not discount Plaintiff’s mental
limitations completely. Rather, the ALJ found that Plaintiff had “moderate
limitations” in her ability to understand, remember, and apply information;
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interact with others; concentrate, persist, or maintain pace; and adapt or
manage herself “given the claimant’s reports of recent partner abuse and wide
variety of situational stressors that appear to have triggered PTSD symptoms
more frequently, and when taking into consideration heightened levels of
anxiety throughout the relevant time period….” AR 21; AR 33-34.
Under these circumstances, the undersigned is not persuaded that the
ALJ erred in his consideration of Dr. Christensen’s opinion.
B. Evidence Submitted to the Appeals Council
As noted above, the ALJ issued an unfavorable decision on November 22,
2023. AR 14-44. On February 19, 2024, Plaintiff submitted the VA Medical
Records, which total approximately 3000 pages. On December 17, 2024, the
Appeals Council denied Plaintiff’s request for review of the ALJ’s unfavorable
decision. AR 1-3.
The social security regulations permit claimants who are requesting
review by the Appeals Counsel to submit additional evidence that was not
before the ALJ. Meyer v. Astrue, 662 F.3d 700, 704 (4th Cir. 2011) (citing 20
C.F.R. §§ 404.968, 404.970(b)). “In such cases, the Appeals Council first
determines if the submission constitutes ‘new and material’ evidence that
‘relates to the period on or before the date of the [ALJ's] hearing decision.’
Evidence is new ‘if it is not duplicative or cumulative’ and is material if there
is ‘a reasonable possibility that the new evidence would have changed the
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outcome.’” Id. (citations omitted); see also White v. Colvin, No. 3:15-CV-00197-
FDW, 2016 WL 3381265, at *3 (W.D.N.C. June 14, 2016) (stating that the court
“has the authority to remand a case based on new evidence submitted to the
Appeals Council under Sentence Six of 42 U.S.C. § 405(g)” and that “[t]he
burden is on the plaintiff to show that Sentence Six requirements are met.”)
(citing Hayes v. Colvin, No. 2:12-CV-4, 2013 WL 5729538, at *3 (W.D.N.C. Oct.
21, 2013)).
Here, when denying Plaintiff’s request that the ALJ’s decision be
reviewed, the Appeals Council explained that the VA Medical Records were not
“exhibited” because there was not “a reasonable probability” that the records
would change the outcome of the case. AR 2.
Plaintiff argues that two specific documents – a March 2022 evaluation
signed by Cherish Smith, P.A. (AR 136-151) and a February 2022 evaluation
signed by Megan Gierhart, Psy.D. (AR 889-898) – supported her claim for social
security disability benefits and therefore the Appeals Council erred in denying
her request for review without considering those two records.
1. Evaluation by Ms. Smith
In March of 2022, Ms. Smith performed a physical examination and found
that Plaintiff exhibited a reduced range of motion in her lower back, with pain
and localized tenderness, normal muscle strength, decreased sensation in the
lower right extremity, positive straight leg raise on the right, and some
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intermittent bladder and bowel incontinence related to degenerative disc
disease and spinal stenosis. AR 140, 142, 143, 145. Ms. Smith opined that
“[d]ue to constant moderate-severe pain in multiple prolonged positions,
[Plaintiff] would need a job that allows position changes every 5-10 minutes
and shift durations to less than several hours. Also, during flares she would
not be able to work due to inability to perform normal movement and even
getting out of bed. She would not be able to lift more than 10 pounds from the
floor, jump, run, or perform repeated lateral flexion or rotation.” AR 151.
The Commissioner contends that, if it had been considered, Ms. Smith’s
opinion would not have changed the outcome of this case because the ALJ
considered “contemporaneous treatment records with similar reported
symptoms and findings, as well as evidence of subsequent treatment (that was
not available to PA Smith in March 2022) showing improvement in [Plaintiff’s]
symptoms with periodic epidural steroid injections and physical therapy.” Doc.
8 at 12.
It does appear that the ALJ considered other records that include findings
similar to those set out by Ms. Smith and that cover a generally
contemporaneous timeframe. See AR 30 (discussing December 2021 progress
note that Plaintiff reported ongoing back pain with pain radiating down the
right leg, with no marked weakness, as well as intermittent bladder
incontinence, and that on exam, Plaintiff had full motor strength, no “foot
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drop,” and pain with palpitation (citing AR 3605-3607)). Further, the ALJ
referenced other treatment records that indicated that Plaintiff’s symptoms
improved with epidural injections. See e.g., AR 31 (discussing February 2022
through November 2022 treatment notes reflecting some diminished strength
in the lower extremities and that Plaintiff received epidural steroid injections
that were reported to provide “significant improvement” in radicular pain
(citing AR 4150-4183)).
The ALJ also discussed a consultative medical examination that was
conducted by Dr. Kurt Reintjes in September 2021, during which Plaintiff
reported that she needed to change positions approximately every ten minutes
of sitting and standing, and was unable to lift anything greater than 50 pounds.
AR 28 (discussing AR 3588-3593). The ALJ noted, though, that Dr. Reintjes’
objective findings indicated that Plaintiff’s straight leg raises were negative
bilaterally, that Plaintiff exhibited full range of motion with the upper and
lower extremities bilaterally including 5/5 strength and was able to “get on/off
the examination table and move to a supine position and sit back up easily.”
AR 28-29. The ALJ also explained that Dr. Reintjes concluded that Plaintiff
demonstrated “completely normal functionality of the lower extremities,
although she may experience some pain into the right hip.” AR 29. The ALJ
found Dr. Reintjes’ findings to be “clearly supportive” of the limitations set
forth in Plaintiff’s RFC. Id.
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Additionally, the ALJ considered various records that reflected Plaintiff’s
physical abilities after Ms. Smith’s evaluation. AR 32 (discussing an initial
physical therapy session in June 2023 during which Plaintiff “was able to
tolerate a wide variety of exercises without severe exacerbation of symptoms”
for 28 minutes and that the therapist recommended that Plaintiff reinforce
therapeutic exercises with walking and swimming (citing
inter alia AR 4223)).
Under these particular circumstances, it is not clear that consideration of
Ms. Smith’s March 2022 evaluation would have changed the ALJ’s opinion.
Wiebusch v. Comm'r, Soc. Sec. Admin., No. 20-1590, 2022 WL 2965653, at *5
(4th Cir. July 27, 2022) (per curiam); Smart v. Berryhill, No. 1:18-CV-00333-
RJC, 2019 WL 7373826, at *3 (W.D.N.C. Dec. 30, 2019) (finding that a letter
from plaintiff’s treating therapist was not material because the letter
expressed “essentially the same opinions” that the therapist had expressed in
a separate opinion considered and not relied upon by the ALJ and which did
not “contradict or cast serious doubt on the original evidence reviewed by the
ALJ”) (citing McCallister v. Berryhill, No. 3:17-cv-00375, 2017 WL 6508373, at
*27 (S.D. W. Va. Nov. 30, 2017) (“Put simply, if the new evidence is not in
blatant contradiction with and does not cast serious doubt upon the original
evidence reviewed by the ALJ, then remand is unnecessary if the ALJ's
decision is supported by substantial evidence.”)); see also Meadows v.
Berryhill, No. 5:16-CV-00068-RJC-DSC, 2017 WL 4534771, at *4 (W.D.N.C.
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Oct. 11, 2017) (“District Courts have limited the applicability of Meyer to those
cases where an evidentiary gap exists in the medical record.”); cf., Wilkins v.
Sec'y, Dep't of Health & Hum. Servs., 953 F.2d 93, 95-96 (4th Cir. 1991)
(finding letter from a treating physician was both new and material where
“[n]o other evidence specifically addressed” the particular issue, and the letter
“might reasonably have changed the ALJ's conclusion” that the claimant was
not disabled); Kearse v. Saul, No. 1:18-CV-00318-RJC, 2019 WL 5105467, at
*4 (W.D.N.C. Oct. 11, 2019) (finding evidence to be material where the evidence
helped to fill an evidentiary gap and included a diagnosis that “compete[d] with
evidence relied on by the ALJ.”).
2. Evaluation by Dr. Gierhart
Dr. Gierhart indicated in a February 2022 evaluation that Plaintiff
suffered from a variety of Post-Traumatic Stress Disorder symptoms that
caused “clinically significant distress or impairment in social, occupational, or
other important areas of functioning.” AR 895-96.
Dr. Gierhart, though, was unclear regarding the level of impairment she
believed existed in functional terms, and, as stated above, the ALJ concluded
that Plaintiff had moderate limitations in all four areas of mental functioning,
which the ALJ considered in developing Plaintiff’s RFC.
Further , and as also referenced above, the ALJ considered other mental
health records following February 2022 that reflected Plaintiff’s generally
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normal mental status findings. AR 33 (citing AR 4708-4739 (May 2023 – June
2023 treatment records reflecting that Plaintiff’s memory was “good” or
“intact” and that her attention span was intact)).
In short, the undersigned does not find that Dr. Geirhart’s evaluation
would have changed the ALJ’s opinion.
VI. Recommendation
The undersigned therefore RESPECTFULLY RECOMMENDS that the
Commissioner’s decision be AFFIRMED.
Signed: February 25, 2026
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Time for Objections
The parties are hereby advised that, pursuant to Title 28, United States
Code, Section 636, and Federal Rule of Civil Procedure 72(b)(2), written
objections to the findings of fact, conclusions of law, and recommendation
contained herein must be filed within fourteen (14) days of service of same.
Responses to the objections must be filed within fourteen (14) days of service
of the objections. Failure to file objections to this Memorandum and
Recommendation with the presiding District Judge will preclude the parties
from raising such objections on appeal. See Thomas v. Arn, 474 U.S. 140, 140
(1985); United States v. Schronce, 727 F.2d 91, 94 (4th Cir. 1984).
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