GRAY M. BORDEN, Magistrate Judge.
Plaintiff David L. Spivey filed this action on August 19, 2016, seeking judicial review of a final decision of the Commissioner of Social Security (the "Commissioner")
With briefing complete, this case is now ripe for review pursuant to 42 U.S.C. § 405(g). The parties have consented to the entry of a final judgment by the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(b), Rule 73 of the Federal Rules of Civil Procedure, and Rule 73.1 of the Local Rules for the United States District Court for the Middle District of Alabama. Docs. 9 & 10. Based upon a review of the evidentiary record, the parties' briefs, and the relevant authority, the court finds that the Commissioner's decision is due to be REVERSED and REMANDED, as set forth below.
This court's review of the Commissioner's decision "is narrowly circumscribed." Richardson v. Comm'r of Soc. Sec., 2017 WL 4366730, at *1 (N.D. Ala. Sept. 29, 2017). Its function "is to determine whether the decision of the Commissioner is supported by substantial evidence and whether proper legal standards were applied." Id. (citing Richardson v. Perales, 402 U.S. 389, 390 (1971); Wilson v. Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002)). To perform this review, the court must "scrutinize the record as a whole" to "determine if the decision reached is reasonable and supported by substantial evidence." Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983); see also Johnson v. Astrue, 2009 WL 1955305, at *3 (M.D. Ala. July 6, 2009) (citing Hillsman v. Bowen, 804 F.2d 1179 (11th Cir. 1986)) ("A reviewing court may not look only to those parts of the record which support the decision of the ALJ, but instead must view the record in its entirety and take account of evidence which detracts from the evidence relied on by the ALJ.").
"Substantial evidence is more than a scintilla, but less than a preponderance. It is such relevant evidence as a reasonable person would accept as adequate to support a conclusion." Perales, 402 U.S. at 401. Even if the evidence preponderates against the Commissioner's findings, the court "must affirm if the decision reached is supported by substantial evidence." Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004). "However, the Court reviews the ALJ's legal conclusions de novo because no presumption of validity attaches to the ALJ's determination of the proper legal standards to be applied." Richardson, 2017 WL 4366730, at *2. "If the court finds an error in the ALJ's application of the law, or if the ALJ fails to provide the court with sufficient reasoning for determining the proper legal analysis has been conducted, it must reverse the ALJ's decision." Id. (citing Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991)).
The continued receipt of social security benefits is subject to mandatory periodic review. 20 C.F.R. § 404.1594(a) ("There is a statutory requirement that, if you are entitled to disability benefits, your continued entitlement to such benefits must be reviewed periodically."). A claimant's disability benefits may be terminated based upon, among other things, "a finding that there has been medical improvement in the claimant's impairment or combination of impairments
To make this determination, the Commissioner employs a multi-step sequential evaluation process:
20 C.F.R. § 404.1594(f); see also Pitre, 2014 WL 3417688, at *3; Johnson, 2009 WL 1955305, at *1-2.
"To perform steps three through six, the ALJ must first determine whether the claimant has experienced medical improvement." Johnson, 2009 WL 1955305, at *2 (internal quotation marks omitted). Medical improvement is defined as "any decrease in the medical severity of [the claimant's] impairment(s) which was present at the time of the most recent favorable medical decision that [the claimant was] disabled or continued to be disabled." 20 C.F.R. § 404.1594(b)(1). "A determination that there has been a decrease in medical severity must be based on improvements in the symptoms, signs, and/or laboratory findings
In addition to evaluating medical improvement, to complete the multi-sequential process, "the ALJ must also determine the claimant's RFC." Id. at *3. "RFC is what the claimant is still able to do despite his impairments and is based on all relevant medical and other evidence." Id. (citing Phillips v. Barnhart, 357 F.3d 1232, 1238-39 (11th Cir. 2004)).
"To terminate benefits, the Commissioner may not focus only on current evidence of disability, but must also evaluate the medical evidence upon which [the claimant] was originally found to be disabled." Richardson, 2017 WL 4366730, at *3 (internal quotation marks omitted). "To that end, `[a] comparison of the original medical evidence and the new medical evidence is necessary to make a finding of improvement.'" Id. (quoting McAulay v. Heckler, 749 F.2d 1500, 1500 (11th Cir. 1985)). Indeed, "[w]ithout a comparison of the old and new evidence, there can be no adequate finding of improvement." Pitre, 2014 WL 3417688, at *3.
By written decision dated September 10, 2007, Spivey was found disabled within the meaning of the Social Security Act as of June 27, 2003. R. 80-87. Spivey's disability was based on a seizure disorder that began when he was an infant, became inactive at an early age, and was exacerbated by head trauma in 1991. R. 25. Following a mandatory periodic review, the Commissioner found that Spivey was no longer disabled and terminated his benefits as of June 1, 2013. R. 20, 88-89. Spivey challenged this determination, and on January 26, 2013 the ALJ issued a written decision upholding the termination of his disability benefits. R. 20-33. When the Appeals Council denied Spivey's request for review, the ALJ's decision became the final decision of the Commissioner for purposes of this appeal.
After considering the entire administrative record and applying the multi-step sequential evaluation process for the review of cessation cases, the ALJ made the following findings:
The ALJ identified the September 10, 2007 decision as the "comparison point decision" ("CPD"), which is the most recent favorable medical decision finding Spivey disabled. R. 21. At the time of the CPD, the ALJ determined that Spivey had the medically determinable impairment of "seizure disorder," that he was unable to perform any past relevant work, that he had the RFC to perform less than sedentary work, and that the occupational base was so severely eroded that no other jobs existed in significant numbers in the local or national economies that he could perform. R. 22 & 25. The ALJ further determined that, after the CPD through June 1, 2013, Spivey developed an additional non-severe impairment of "history of seizures."
Employing the sequential evaluation process, at step one, the ALJ found that, through June 1, 2013—the date Spivey's disability was found to have ended—Spivey had not engaged in substantial gainful activity. R. 22. At step two, the ALJ found that Spivey does not have an impairment or a combination of impairments of listing-level severity. R. 23-25. At step three, the ALJ determined that Spivey has experienced medical improvement. R. 25-26.
Before proceeding to step four, the ALJ found that, as of June 1, 2013, Spivey has the RFC to perform medium work as defined in 20 C.F.R. § 404.1567(c), except that
R. 26. The ALJ then proceeded to step four, finding that Spivey's medical improvement is related to his ability to work because it resulted in an increase in his RFC.
Because the ALJ found that Spivey has experienced medical improvement related to his ability to work, he proceeded to step six
Spivey presents two issues
Doc. 16. The Government argues that the Commissioner's decision is supported by substantial evidence and should be affirmed. Doc. 17. Having carefully considered the parties' arguments, the record, and the applicable legal authority, and for the reasons set forth below, the undersigned finds that the Commissioner's decision is due to be REVERSED and REMANDED for failure to apply the medical improvement standard properly.
Spivey argues that the ALJ erred as a matter of law in failing to apply the medical improvement standard properly. Specifically, Spivey argues that the ALJ's decision was made in error because he "failed to describe and compare Mr. Spivey's seizures before and after his most recent favorable decision and ignored the consistent medical and nonmedical evidence of the frequency and severity of Mr. Spivey's seizures in reaching his decision."
In the Eleventh Circuit, unless an exception applies, "there can be no termination of benefits unless there is substantial evidence of [medical] improvement to the point of no disability." McAulay, 749 F.2d at 1500; see also 20 C.F.R. §§ 404.1594(a), 416.994(b). "[W]hether medical severity has decreased is determined by a comparison of prior and current medical evidence which must show that there have been changes (improvement) in the symptoms, signs or laboratory findings associated with that impairment(s)." Klaes v. Comm'r, Soc. Sec. Admin., 499 F. App'x 895, 896 (11th Cir. 2012) (internal quotation marks omitted); see also Freeman v. Heckler, 739 F.2d 565, 566 (11th Cir. 1984); Vaughn v. Heckler, 727 F.2d 1040, 1043 (11th Cir. 1984). "The ALJ must `actually compare' the previous and current medical evidence to show that an improvement occurred." Klaes, 499 F. App'x at 896 (quoting Freeman, 739 F.2d at 566). If the ALJ "fails to evaluate the prior medical evidence and make such a comparison," the court "must `reverse and remand for application of the proper legal standard.'" Id. (quoting Vaughn, 727 F.2d at 1043).
The court finds that the ALJ did not adequately compare the prior medical evidence to the current medical evidence in Spivey's case.
The ALJ's discussion of Spivey's prior medical evidence is generalized at best. The ALJ does not discuss Spivey's medical records from Crenshaw Community Hospital or his consultative examination with Dr. Mark Ellis, both of which occurred in 2005. R. 25-26. Nor does the ALJ discuss or even mention the types of seizures Spivey was having during the time period leading up to the CPD, the frequency of those seizures (the ALJ only references "60 episodes"), the symptoms Spivey experiences with each type of seizure, or the effects of and recovery needed after Spivey experiences a seizure.
The ALJ's discussion of the current medical evidence is even more superficial. Indeed, the ALJ notes that Spivey underwent a lobectomy in 2009 that "significantly improved" his seizure disorder, although he does not articulate precisely how. R. 26. Relying on what is identified only as "recent medical evidence," the ALJ noted that, "as long as [Spivey] remained compliant with his prescribed treatment, his seizure episodes are infrequent at best." But, again, the ALJ does not specifically identify this "recent medical evidence," the "prescribed treatment" regime to which he is referring, what specific number of seizures quantifies as "infrequent," and what evidence supports the conclusion that, as of June 1, 2013, Spivey's seizures are "infrequent" when compared to the prior medical evidence. R. 26.
The ALJ notes that, at "one point," Spivey "denied having any grand mal episodes within the previous one to two years"; that there is "no evidence that his medication caused any side effects"; that he has a valid driver's license; and that he maintains a lawn care and livestock business for both himself and his neighbor. R. 36. Again, however, this "comparison" is devoid of any specific discussion of Spivey's medical records from Dr. Lawrence Ver Hoef, his treating neurologist, or Dr. Tompkins. The ALJ also does not specifically discuss the records from Drs. Warren G. Brantley, C. Robertson, or R. Whitney. Yet these records reflect that Spivey had a generalized tonic-clonic seizure in May 2010 (R. 368), that he still experiences simple partial seizures at the rate of 2.5 per month as of July 2012 (R. 363), that Spivey reported in May 2013 to Dr. Brantley that his last seizure was in March 2013 (R. 387), that Spivey reported in May 2013 to Dr. Robertson that his last two seizures were in March and April of that year and that his April seizure was tonic-clonic with a loss of consciousness (R. 390), that Dr. Ver Hoef noted as of August 2013 that Spivey was still experiencing simple partial seizures at the rate of 2.5 per month (R. 423), and that Spivey reported to Dr. Tompkins in May 2014 that his last seizure was in February of that year (R. 264).
The ALJ did not specifically discuss any of this evidence or attempt to compare it to Spivey's prior medical evidence. To the contrary, it appears that the ALJ ignored this evidence in characterizing Spivey's "seizure episodes as infrequent at best." R. 26. And, even with the medical evidence the ALJ did discuss, he did not include citations to the specific medical evidence that support his conclusions or adequately explain how the "recent medical evidence," when compared to the prior medical evidence, suggests or indicates that Spivey has medically improved such that his disability should end. While the Commissioner contends that the ALJ did engage in a thorough and specific discussion of the current medical evidence, a review of the ALJ's decision shows that he did not do so in the context of his medical improvement finding. Rather, this discussion, which is devoid of any actual comparison with the prior medical evidence, was a compontent of the ALJ's RFC finding. R. 26-30.
Accordingly, because the ALJ did not "actually compare" the previous and prior medical evidence to show that a medical improvement has occurred, the court cannot evaluate whether the ALJ's decision is based on substantial evidence. Thus, the ALJ's decision must be reversed and this case remanded for application of the correct legal standard for finding medical improvement. See Klaes, 499 F. App'x at 896-97; Gavin v. Comm'r of Soc. Sec., 2016 WL 3226436, at *5 (M.D. Fla. June 13, 2016) (finding that, when an ALJ fails to compare prior and current medical evidence, the decision must be reversed and the case remanded for application of the proper legal standard); see also Freeman, 739 F.2d at 566; Vaughn, 727 F.2d at 1043.
The court has carefully and independently reviewed the record and concludes that, for the reasons stated above, the decision of the Commissioner is REVERSED and REMANDED with the following instructions:
1. The Commissioner shall reevaluate whether Spivey has medically improved to the point of being no longer disabled, making sure to compare the prior medical evidence with the current medical evidence and to articulate the specific findings and reasoning to support the decision reached on this issue;
2. If appropriate, reevaluate the medical opinions; and
3. Take such other action as may be necessary to resolve this claim properly.
A final judgment consistent with this opinion will be entered separately.
The second group of exceptions to medical improvement set forth in subsection (e) include: (1) any prior determination or decision was fraudulently obtained; (2) the claimant does not cooperate with the Social Security Administration; (3) the Social Security Administration is unable to find the claimant; and (4) the claimant fails to follow prescribed treatment that would be expected to restore the claimant's ability to engage in substantial gainful activity. 20 C.F.R. § 404.1594(e)(1)-(4).