                                      PUBLISHED

                      UNITED STATES COURT OF APPEALS
                          FOR THE FOURTH CIRCUIT


                                      No. 17-1500


BILLIE J. WOODS,

                    Plaintiff - Appellant,

             v.

NANCY A. BERRYHILL, Acting Commissioner of Social Security,

                    Defendant - Appellee.


Appeal from the United States District Court for the Western District of North Carolina,
at Asheville. Max O. Cogburn, Jr., District Judge. (1:16-cv-00058-MOC-DLH)


Argued: March 20, 2018                                         Decided: April 26, 2018


Before MOTZ, TRAXLER, and DIAZ, Circuit Judges.


Vacated and remanded with instructions by published opinion. Judge Motz wrote the
opinion, in which Judge Traxler and Judge Diaz joined.


ARGUED: Charlotte W. Hall, CHARLES T. HALL LAW FIRM, P.C., Raleigh, North
Carolina, for Appellant.       Leo Rufino Montenegro, SOCIAL SECURITY
ADMINISTRATION, Baltimore, Maryland, for Appellee. ON BRIEF: Leah F.
Golshani, Special Assistant United States Attorney, SOCIAL SECURITY
ADMINISTRATION, Baltimore, Maryland; Jill Westmoreland Rose, United States
Attorney, Gill Beck, Assistant United States Attorney, OFFICE OF THE UNITED
STATES ATTORNEY, Charlotte, North Carolina, for Appellee.
DIANA GRIBBON MOTZ, Circuit Judge:

       Billie Jean Woods appeals the Social Security Administration’s denial of her

application for disability insurance benefits.          Because we conclude that the

Administrative Law Judge erred by not according adequate weight to a prior disability

determination by the North Carolina Department of Health and Human Services, we

vacate and remand.



                                             I.

       Before turning to the facts of this case, we set forth the framework that an

Administrative Law Judge (“ALJ”) must use to determine a claimant’s eligibility for

Social Security disability insurance benefits.

       “Disability” means “inability to engage in any substantial gainful activity by

reason of any medically determinable physical or mental impairment which can be

expected to result in death or which has lasted or can be expected to last for a continuous

period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). To determine whether an

individual is disabled, ALJs use the “five-step sequential evaluation process” outlined in

the Social Security Administration’s (“SSA”) regulations. 20 C.F.R. § 404.1520(a)(4).

“[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 . . . .” Mascio v. Colvin, 780 F.3d 632, 634 (4th Cir.

2015); see 20 C.F.R. § 404.1520(a)(4).            If the ALJ cannot make a conclusive

                                             2
determination at the end of the third step, the ALJ must then determine the claimant’s

residual function capacity, meaning the most a claimant can still do despite “all of the

claimant’s medically determinable impairments of which the ALJ is aware, including

those not labeled severe at step two.” Mascio, 780 F.3d at 635 (brackets and internal

quotation marks omitted); see 20 C.F.R. §§ 404.1520(a)(4); 404.1545(a). Only once the

ALJ has identified the claimant’s “functional limitations or restrictions” and assessed the

claimant’s “work-related abilities on a function-by-function basis” may the ALJ express

the claimant’s residual function capacity “in terms of the exertional levels of work,

sedentary, light, medium, heavy, and very heavy.” SSR 96-8p, 61 Fed. Reg. 34,474,

34,475 (July 2, 1996); see 20 C.F.R. § 404.1567 (defining exertional levels).

       After the ALJ determines the claimant’s residual function capacity, the ALJ

proceeds to step four, where the claimant must show that she cannot perform her past

work. 20 C.F.R. § 404.1520(a)(4). If the claimant makes that showing, the burden shifts

to the SSA to prove at step five that the claimant is capable of performing other work, in

light of her residual function capacity, age, education, and work experience, that “exists

in significant numbers in the national economy.” Id. §§ 404.1560(c); 404.1520(c). If the

SSA satisfies that burden, the ALJ will find the claimant not disabled and deny her

application for benefits. See id. § 404.1520(a)(4).




                                             3
                                           II.

                                           A.

       In the years leading up to her alleged disability onset date, Woods held various

production and manufacturing jobs that required her to lift up to 50 pounds and to walk,

stand, and crouch for seven hours or more per day. In 2010, Woods began exhibiting

symptoms consistent with inflammatory arthritis, osteoarthritis, and fibromyalgia. She

also began complaining of persistent pain that limited her ability to perform her job. Her

symptoms progressed over the next three years, and in April 2013, Woods stopped

working.    The next month, Woods applied for Social Security disability insurance

benefits.

       The SSA initially denied her application and her petition for reconsideration.

Woods then requested a hearing before an ALJ.

       Before the ALJ, Woods presented medical records from Dr. Aasheim (her primary

care physician), Dr. de Wit (her rheumatologist through January 2013), and a prior

decision by the North Carolina Department of Health and Human Services (“NCDHHS”)

that found that Woods was disabled and entitled to Medicaid benefits. The ALJ also

reviewed the opinions of Drs. Burgess and Pardoll, who conducted consultative

examinations at NCDHHS’s request, and Dr. Clayton, the state agency medical

consultant who reviewed Woods’s medical record but did not treat or examine her in

person. In addition, Woods submitted disability questionnaires and testified before the

ALJ.



                                            4
We briefly summarize the relevant evidence from each source.

   • Beginning in 2010, Drs. de Wit and Aasheim documented various
     symptoms consistent with inflammatory arthritis, osteoarthritis, and
     fibromyalgia. In early 2013, both doctors concluded that because of her
     condition, Woods “should not do heavy manual labor” as required by her
     current job. In November 2013, Dr. Aasheim concluded that Woods could
     occasionally lift up to ten pounds but frequently could not lift any weight,
     she could stand one of eight hours, could sit one of eight hours, and could
     occasionally balance independently, but could not climb, stoop, crouch,
     kneel, or crawl.
   • The NCDHHS decision found that Woods was eligible to receive Medicaid.
     The state hearing officer noted that Woods had several positive laboratory
     results and physical exams that supported her claims of pain. That officer
     also found that Woods’s testimony at the state hearing was “wholly
     credible and substantiated the alleged disabilities.”
   • Dr. Burgess, who conducted a physical consultation, concluded that
     Woods’s “ability to perform work-related activities such as bending,
     stooping, lifting, walking, crawling, squatting, carrying, traveling, pushing
     and pulling heavy objects . . . appears to be mildly to moderately
     impaired . . . . Claimant’s insight into and description of limitations
     appears not inconsistent with the objective findings.”
   • Dr. Pardoll, who conducted a psychological consultation, found that
     although Woods has “few mental health symptoms that interfere with her
     social and occupational functioning,” it did not “appear that she would be
     able to tolerate the stressors and pressures associated with a day to day
     work activity since she is experiencing a lot of pain.”
   • Dr. Clayton, the state agency’s non-treating, non-examining consultant,
     found Woods’s “[a]llegations and statements . . . partially credible,” but
     concluded that the “evidence does not support the level of limitations
     alleged.” He also concluded that Woods could occasionally lift 50 pounds
     and frequently lift 25 pounds, and could stand or sit for six hours of an
     eight-hour workday. Thus, he found that Woods could perform medium
     work.
   • Woods wrote in her disability questionnaires that her typical activities
     varied daily depending on her pain. For example, although she could
     “prepare simple meals,” it was difficult to “cut, chop, or dice.” Woods also
     testified before the ALJ that she could lift approximately three to four
     pounds, could comfortably sit or stand for 20 minutes, walked with a limp
     and otherwise had poor balance and stumbled frequently, and had limited
     grip strength and dropped things “consistently.”


                                    5
                                           B.

      After reviewing the evidence, the ALJ found that Woods did not meet the legal

definition of “disabled” and denied her claim for Social Security disability insurance

benefits. At step one, the ALJ found that Woods was not employed since her onset date.

At step two, he concluded that her impairments were “severe.” Because her impairments

did not meet the requirements of step three, the ALJ proceeded to the residual function

capacity assessment.

      The ALJ began his assessment of Woods’s residual function capacity by

summarizing the relevant medical evidence. For example, the ALJ found that certain

tests showed only “mild degenerative changes” and that some reports indicated that

Woods did not display other typical signs of her alleged impairments, such as swollen

joints. The ALJ then concluded that Woods’s “medically determinable impairments

could reasonably be expected to cause the alleged symptoms,” but that her “statements

concerning the intensity, persistent and limiting effects of these symptoms are not

entirely credible.” In support of this adverse credibility finding, the ALJ noted that

Woods’s “daily activities are not those typically associated with an individual alleging

the pain, severity, and limitations as posed by the claimant.” The ALJ also identified the

relative weight he accorded to the various medical experts: great weight to Dr. Clayton,

some-to-great weight to Dr. Pardoll, some weight to Dr. Burgess, little weight to Drs.

Aasheim and de Wit, and little weight to the NCDHHS decision. Based on this evidence,

the ALJ found — consistent with Dr. Clayton’s opinion — that Woods had the residual

function capacity to perform “medium work” (subject to certain exceptions).

                                            6
       At step four, the ALJ concluded that Woods “is capable of performing past

relevant work in production of manufacturing textiles,” as that work “does not require the

performance of work-related activities precluded by” her residual function capacity. At

step five, he found that “other jobs exist[] in the national economy that [Woods] is also

able to perform,” like janitorial work. The ALJ therefore concluded that Woods did not

meet the legal definition of “disabled” and denied her application for benefits.

                                            C.

       After exhausting her administrative appeals, Woods filed this action against the

Acting Commissioner of Social Security. The parties filed cross-motions for summary

judgment, and a magistrate judge recommended granting the Commissioner’s motion,

denying Wood’s motion, and affirming the denial of benefits. The district court adopted

this recommendation in full. Woods now appeals.



                                            III.

       We review de novo a district court’s grant of summary judgment. Martin v. Lloyd,

700 F.3d 132, 135 (4th Cir. 2012). “We will affirm the Social Security Administration’s

disability determination ‘when an ALJ has applied correct legal standards and the ALJ’s

factual findings are supported by substantial evidence.’”       Mascio, 780 F.3d at 634.

(quoting Bird v. Comm’r of Soc. Sec. Admin., 699 F.3d 337, 340 (4th Cir. 2012)).

       We first address the ALJ’s treatment of the prior NCDHHS disability decision.




                                             7
                                            A.

       A disability decision by another entity does not bind the SSA. See 20 C.F.R

§ 404.1504. But in considering a claim for Social Security disability insurance benefits,

an ALJ must still “evaluate all the evidence in the case record that may have a bearing on

our determination or decision of disability, including decisions by other governmental

and nongovernmental agencies.” SSR 06-03P, 71 Fed. Reg. 45,593, 45,596 (Aug. 9,

2006). Accordingly, the ALJ “should explain the consideration given to these decisions

in the notice of decision for hearing cases.” Id. at 45,597. 1 Thus, we have previously

held that in an SSA disability proceeding, “the [prior] disability determination of a state

administrative agency is entitled to consideration.” DeLoatche v. Heckler, 715 F.2d 148,

150 n.1 (4th Cir. 1983).

       This court has not yet addressed the precise weight an ALJ must give to a state

agency’s disability determination. In a related context, however, we have held that “in

making a disability determination, the SSA must give substantial weight to a [Veterans

Affairs] disability rating.” Bird, 699 F.3d at 343. That is so because “the purpose and

evaluation methodology of” the SSA and VA disability determinations are “closely

related.” Id. Accordingly, “a disability rating by one of the two agencies is highly

relevant to the disability determination of the other agency.” Id.

       1
        This regulation only applies to claims filed before March 27, 2017. See 82 Fed.
Reg. 5,844, 5,848 (Jan. 18, 2017); 20 C.F.R. § 404.1504. For claims filed on or after
March 27, 2017, ALJs must still consider the existence of disability decisions by other
governmental or nongovernmental entities, and any evidence underlying those decisions,
but are no longer required “to provide written analysis about how they consider the
decisions from other governmental agencies.” 82 Fed. Reg. at 5,848.

                                             8
       We see no reason why this logic does not also apply to NCDHHS disability

decisions. Both NCDHHS and Social Security disability insurance benefits “serve the

same governmental purpose of providing benefits to persons unable to work because of a

serious disability.”   Id. (describing purpose of Social Security disability insurance

benefits); see NCDHHS, Aged, Blind, and Disabled Medicaid Manual § 200 (2008)

(defining “Medicaid” as “A program to assist eligible . . . disabled [individuals] . . . with

the cost of medical care”). Moreover, NCDHHS defines “Medicaid to the Disabled” as a

“program of medical assistance for individuals under age 65 who meet Social Security’s

definition of disability.” Id. (emphasis added); see also id. § 2525. As a result, a “person

who receives Social Security based on disability meets the disability requirement for

Medicaid,” although he or she must still “apply for Medicaid and must meet all other

eligibility requirements.” Id. § 2525. “Because the purpose and evaluation methodology

of both programs are closely related, . . . . in making a disability determination, the SSA

must give substantial weight to” an NDCHHS disability decision. Bird, 699 F.3d at 343.

       Of course, an ALJ may deviate from this default rule and accord an NCDHHS

disability decision less than “substantial weight” if “the record before the ALJ clearly

demonstrates that such a deviation is appropriate.” Id. We have not previously defined

what an ALJ must do to satisfy this standard. We now conclude, consistent with our

sister circuits, that in order to demonstrate that it is “appropriate” to accord less than

“substantial weight” to an NCDHHS disability decision, an ALJ must give “persuasive,

specific, valid reasons for doing so that are supported by the record.” McCartey v.

Massanari, 298 F.3d 1072, 1076 (9th Cir. 2002) (describing standard for VA decisions);

                                             9
Chambliss v. Massanari, 269 F.3d 520, 522 (5th Cir. 2001) (per curiam) (explaining that

ALJs need not give great weight to VA disability determinations “if they adequately

explain the valid reasons for not doing so”).

       For example, an ALJ could explain which aspects of the prior agency decision he

finds not credible and why, describe why he finds other evidence more credible, and

discuss the effect of any new evidence made available after NCDHHS issued its decision.

This list is not exclusive, but the point of this requirement — and of these examples — is

that the ALJ must adequately explain his reasoning; otherwise, we cannot engage in a

meaningful review. See Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013) (explaining

that because we review an ALJ’s factual findings for substantial evidence, an ALJ’s

decision must generally “include a discussion of which evidence the ALJ found credible

and why, and specific application of the pertinent legal requirements to the record

evidence”).

                                            B.

       The ALJ in this case concluded that the NCDHHS decision deserved only “little

weight.” Because this is less than the “substantial weight” such decisions are generally

due, we must consider whether the ALJ adequately justified this “deviation.”

       The entirety of the ALJ’s reasoning on this point is as follows:

                    The undersigned has considered the State of North Carolina
              Department of Health and Human Services’ ruling finding the
              claimant met the criteria for Medicaid eligibility (Exhibit 11E).
              However, Social Security Ruling 06-03p states that:

                           “[a] decision by any . . . other governmental
                     agency about whether you are disabled to blind is

                                            10
                     based on its rules and is not our decision about
                     whether you are disabled or blind. We must make a
                     disability or blindness determination based on social
                     security law. Therefore, a determination made by
                     another agency that you are disabled or blind is not
                     binding on us.”

              As such, the undersigned assigns this ruling little weight, as each
              program is independent and distinct enough to make it possible that
              even a disabled Medicaid recipient can be denied SSA benefits.
              Moreover, the Medicaid determination specifically states that “this
              decision in no way affects any pending or future claims for Social
              Security or Supplemental Security Income benefits.”

This generic explanation, which could apply to every NCDHHS decision, is neither

persuasive nor specific. See McCartey, 298 F.3d at 1076.          Thus, the ALJ did not

adequately justify his decision to accord the NCDHHS decision less than the substantial

weight it generally deserves.

       The Commissioner raises two arguments for the ALJ’s contrary approach. First,

the Commissioner suggests that the NCDHHS hearing officer did not actually consider

the “same underlying evidence” as the ALJ because the state hearing officer’s report did

not discuss Dr. Clayton’s opinion. See Bird, 699 F.3d at 343; Appellee Br. at 15. 2 Of

course, where a prior decision does not rely on substantially the same underlying

evidence, such as where a state issued its disability decision a number of years before the

claimant applied for Social Security disability insurance benefits, the state decision may


       2
         That the NCDHHS report does not specifically refer to Dr. Clayton’s opinion
does not necessarily mean that the hearing officer did not consider it. Nothing in the
record indicates that Dr. Clayton’s opinion — which the state agency ordered and which
Dr. Clayton produced five months before NCDHHS issued its disability decision — was
not available to the NCDHHS hearing officer.

                                            11
not be entitled to substantial weight. If that is the case, however, the ALJ must explain

these facts. The ALJ’s opinion here never mentioned this alleged issue.

      Second, the Commissioner argues that because the ALJ’s decision as a whole

makes clear that he considered the same evidence on which the NCDHHS decision relied,

the ALJ did not need to refer expressly to that evidence in discussing the NCDHHS

decision. We cannot agree. It may well be that the ALJ considered this evidence in

deciding both which doctors and evidence to credit and whether the NCDHHS decision

deserved substantial weight. But meaningful review cannot rest on such guesswork. See

DeLoatche, 715 F.2d at 150 (“It may be, of course, as the Secretary suggests on appeal,

that the ALJ considered all of these factors and proposed to himself cogent reasons for

disregarding them. However, on this record we cannot so determine.”).

      We therefore conclude that the ALJ erred in failing to adequately explain why he

accorded the prior NCDHHS disability decision less than substantial weight. For this

reason, we must vacate the decision and remand the case to the ALJ.



                                          IV.

      Woods raises several other challenges to the ALJ’s decision. Because these issues

may recur on remand, we address them now. See Bird, 699 F.3d at 342–43.

                                           A.

      First, Woods contends that the ALJ did not adequately perform the residual

function capacity assessment. In performing this assessment, an ALJ “must include a

narrative discussion describing how the evidence supports each conclusion, citing

                                           12
specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily

activities, observations).” Mascio, 780 F.3d at 636 (quoting SSR 96-8p, 61 Fed. Reg. at

34,478) (internal quotation marks omitted). In other words, the ALJ must both identify

evidence that supports his conclusion and “build an accurate and logical bridge from

[that] evidence to his conclusion.” Monroe v. Colvin, 826 F.3d 176, 189 (4th Cir. 2016)

(quoting Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000)) (internal quotation marks

omitted).

       We agree with Woods that the ALJ did not do so here. The ALJ concluded that

Woods could perform “medium work” and summarized evidence that he found credible,

useful, and consistent. But the ALJ never explained how he concluded — based on this

evidence — that Woods could actually perform the tasks required by “medium work,”

such as lifting up to 50 pounds at a time, frequently lifting or carrying up to 25 pounds, or

standing or walking for six hours. See SSR 83-10, 1983 WL 31251, at *6 (Jan. 1, 1983).

The ALJ therefore failed to build an “accurate and logical bridge” from the evidence he

recounted to his conclusion about Woods’s residual function capacity. On remand, the

ALJ should remedy this error.

                                             B.

       Woods also contends that the ALJ erred in finding Woods not credible because her

“daily activities are not those typically associated with an individual alleging the pain,

severity, and limitations as posed by the claimant.”

       An ALJ may not consider the type of activities a claimant can perform without

also considering the extent to which she can perform them. See Brown v. Commissioner,

                                             13
873 F.3d 251, 263 (4th Cir. 2017). The ALJ here did just that. For example, the ALJ

noted that Woods can “maintain her personal hygiene, cook, perform light household

chores,” “shop,” “socialize with family members, and attend church services on a regular

basis.” But the ALJ did not consider Woods’s statements that she cannot button her

clothes, has trouble drying herself after bathing, and sometimes needs help holding a

hairdryer; that she can prepare simple meals but has trouble cutting, chopping, dicing,

and holding silverware or cups; it takes her all day to do laundry; she shops only for

necessities, and that process takes longer than normal; when she reads to her

grandchildren, they have to turn the pages because of severe pain in her hands; and that

some days, she spends the entire day on the couch.

       On remand, the ALJ should consider not just the type of Woods’s daily activities,

but also the extent to which she can perform them in assessing her credibility.

                                            C.

       Finally, we note two additional problems with the ALJ’s analysis as it pertains to

his weighting of the various medical opinions.

       An ALJ must include “a narrative discussion describing how the evidence

supports” his “explanation of the varying degrees of weight he gave to differing opinions

concerning [the claimant’s] conditions and limitations.”       Monroe, 826 F.3d at 190

(internal quotation marks and citation omitted). In this case, the ALJ’s discussion of

certain expert opinions was at times conclusory or sparse. For example, the ALJ gave Dr.

Burgess’s opinion “some weight” because “it is rather vague and general in nature,” but

did not discuss what aspects of that opinion he found overly vague. Cf. id. at 191

                                            14
(finding insufficient the explanation that the “consultative examiner opinion is consistent

with the objective evidence and other opinions of record” even though the ALJ had

recounted various medical evidence earlier in his opinion). On remand, we caution the

ALJ to provide better explanations in support of these types of determinations.

       We are also skeptical about the ALJ’s rationale for according great weight to the

opinion of Dr. Clayton — who did not personally examine or treat Woods — while at the

same time discounting the opinions of the doctors who did examine and treat her. In

general, an ALJ should accord “more weight to medical opinions from [a claimant’s]

treating sources, since these sources are likely to be the medical professionals most able

to provide a detailed, longitudinal picture of [a claimant’s] medical impairment(s).” 20

C.F.R. § 404.1527(c)(2); id. § 404.1527(c)(1) (stating the same presumption for

examining sources). An ALJ may, however, credit the opinion of a non-treating, non-

examining source where that opinion has sufficient indicia of “supportability in the form

of a high-quality explanation for the opinion and a significant amount of substantiating

evidence, particularly medical signs and laboratory findings; consistency between the

opinion and the record as a whole; and specialization in the subject matter of the

opinion.” Brown, 873 F.3d at 268; see 20 C.F.R. § 404.1527(c).

       It is not clear to us that Dr. Clayton’s opinion satisfies this standard. For example,

Dr. Clayton concluded that Woods could lift up to 50 pounds (something none of her

treating physicians believed she was capable of), but failed to explain how he arrived at

that specific number. The same is true of his conclusion that Woods can sit or stand for

six hours in an eight-hour workday.          As the ALJ himself acknowledged, these

                                             15
conclusions conflict with the opinions of Drs. Burgess, de Wit, Aasheim, and with

Woods’s own testimony. Nor is there any evidence in the record that Dr. Clayton is a

specialist and therefore due additional deference.         The ALJ should consider these

potential shortcomings on remand in deciding what weight to accord the opinion of Dr.

Clayton, and any other non-treating, non-examining physicians.



                                           V.

      For the foregoing reasons, we vacate the judgment of the district court and remand

the case with instructions to vacate the denial of benefits and remand for further

administrative proceedings consistent with this opinion.

                                  VACATED AND REMANDED WITH INSTRUCTIONS




                                           16
