GREGORY J. KELLY, Magistrate Judge.
Javier Estrella (the "Claimant") appeals to the District Court from a final decision of the Commissioner of Social Security (the "Commissioner") denying Claimant's claim for reinstatement of benefits. See Doc. No. 1. The Commissioner previously determined Claimant to be disabled as of August 11, 2004, due to lumbar radiculopathy with chronic low back pain. R. 26, 28. On February 1, 2011, the Commissioner determined that Claimant demonstrated medical improvement and was no longer disabled beginning April 1, 2011. R. 26, 56-57, 63-65, 81-85.
Claimant challenged the Commissioner's decision to terminate Claimant's benefits, and on January 4, 2012, a hearing was held before Administrative Law Judge Janet Mahon (the "ALJ"). R. 41-54, 86. On January 24, 2012, the ALJ issued a decision finding that, as of April 1, 2011, Claimant was no longer disabled. R. 26-35.
Claimant argues that the final decision of the Commissioner is not supported by substantial evidence and should be reversed for further proceedings because the ALJ failed to order a consultative mental health evaluation. Doc. No. 15 at 16 (citing McCall v. Bowen, 846 F.2d 1317, 1320 (11th Cir. 1988)). For the reasons more fully discussed below, the Commissioner's final decision is
The Commissioner's findings of fact are conclusive if supported by substantial evidence. 42 U.S.C. § 405(g). Substantial evidence is more than a scintilla — i.e., the evidence must do more than merely create a suspicion of the existence of a fact, and must include such relevant evidence as a reasonable person would accept as adequate to support the conclusion. Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995) (citing Walden v. Schweiker, 672 F.2d 835, 838 (11th Cir. 1982) and Richardson v. Perales, 402 U.S. 389, 401 (1971)); accord Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991).
Where the Commissioner's decision is supported by substantial evidence, the District Court will affirm, even if the reviewer would have reached a contrary result as finder of fact, and even if the reviewer finds that the evidence preponderates against the Commissioner's decision. The District Court "`may not decide the facts anew, reweigh the evidence, or substitute [its] judgment for that of the [Commissioner].'" See Phillips v. Barnhart, 357 F.3d 1232, 1240 n.8 (11th Cir. 2004) (quoting Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983)).
42 U.S.C. 421(h) provides that "in any case where there is evidence which indicates the existence of a mental impairment," a determination that a claimant is not disabled "shall be made only if the Commissioner . . . has made every reasonable effort to ensure that a qualified psychiatrist or psychologist" has offered an opinion or reviewed the record. Id. In McCall v. Bowen, 846 F.2d 1317, 1320 (11th Cir. 1988), the Eleventh Circuit stated that where there is evidence indicating the existence of a mental impairment, the Commissioner may determine that the claimant is not under a disability only if the Commissioner has made "every reasonable effort to obtain the opinion of a qualified psychiatrist or psychologist." Id. (quoting 42 U.S.C. § 421(h)). In Sneed v. Barnhart, 214 F. App'x 883, 886 (11th Cir. 2006) (unpublished), the Eleventh Circuit stated that McCall "interprets § 421(h) [to] require an ALJ to order a psychological consultation where there is evidence of a mental impairment." Id.
Relying upon McCall, Claimant argues that the ALJ erred because there is evidence of mental impairment, including Claimant's testimony (R. 48-49) and the opinion of Claimant's treating psychiatrist (R. 320), but ALJ did not order a consultative mental health examination nor does the record contain any other evidence concerning Claimant's alleged mental impairment. Doc. No. 15 at 16. The Commissioner does not directly address Claimant's argument, utterly fails to address McCall, and simply argues that the ALJ properly rejected the opinion of Claimant's treating psychiatrist and substantial evidence supports the ALJ's findings. Doc. No. 18 at 9-11.
In his October 31, 2011 Disability Report, Claimant alleged that he is suffering from "more depression." R. 176. On November 4, 2011, Dr. M. Roy Kremberg, a board certified psychiatrist, provided the following opinion:
R. 320. Thus, the record contains the opinion of a board certified psychiatrist that Claimant suffers from three severe mental impairments. R. 320.
The ALJ did not order a consultative mental health exam nor did a psychologist or psychiatrist provide a non-examining opinion based upon a records review. R. 1-335. In short, the record contains no other evidence from a mental health professional, psychologist or psychiatrist. In the decision, the ALJ found that Claimant's medically determinable impairment of depression is not severe. R. 28. The ALJ based that finding solely on Claimant's activities of daily living, his ability to socialize, and the treatment records of an internist that Claimant has no memory disturbances. R. 28. The ALJ gave "limited weight" to Dr. Kremberg's opinion because: 1) it is not consistent with the medical evidence of record; 2) there are no treatment records from Dr. Kremberg in the record; 3) an opinion that a claimant is disabled is an opinion reserved for the Commissioner; and 4) Claimant did not report taking any psychotropic medications to the physical consultative examiner. R. 29.
The Court finds that the ALJ erred by failing to order a consultative mental health examination or otherwise obtain an opinion from a psychologist or psychiatrist regarding Claimant's mental health impairment. In McCall, 846 F.2d at 1320, the Eleventh Circuit indicated that a claimant's testimony plus evaluations from her treating physical physicians indicating the existence of a mental impairment may trigger the duty under 42 U.S.C. § 421(h) to obtain a consultative psychological or psychiatric examination. Here, Claimant's statements in his Disability Function Report (R. 176), his testimony (R. 48-49), and the opinion of his treating psychiatrist (R. 320) clearly indicate the presence of mental impairment(s), which warrant further inquiry. In this case, without a consultative mental health examination or other evidence from a qualified psychologist or psychiatrist, the final decision is not supported by substantial evidence. Accordingly, the final decision must be remanded for further proceedings.
Based on the forgoing, it is
See 20 C.F.R. § 404.1594(f); Chereza v. Commissioner of Social Security, 379 F. App'x. 934, 938 (11th Cir. May 21, 2010) (unpublished). "To determine if there has been medical improvement, the ALJ must compare the medical evidence supporting the most recent final decision holding that the claimant is disabled with new medical evidence." Chereza, 379 F. App'x. at 938 (citing McAulay v. Heckler, 749 F.2d 1500 (11th Cir. 1985)).