DANIEL C. IRICK, Magistrate Judge.
Michael Wayne Montgomery (Claimant) appeals the Commissioner of Social Security's final decision denying his applications for disability benefits. Doc. 1. Claimant argues that the Administrative Law Judge (ALJ) erred by: 1) assigning little weight to Dr. Nila Desai's opinion; and 2) failing to properly consider Claimant's exertional and nonexertional limitations. Doc. 13 at 5-11. Claimant requests that the matter be reversed and remanded for an award of benefits. Id. at 11. For the reasons set forth below, the Commissioner's final decision is
This case stems from Claimant's applications for disability insurance benefits and supplemental security income. R. 258-67. Claimant alleged a disability onset date of August 1, 2010. R. 258, 260. On May 8, 2012, the ALJ originally assigned to this case entered a decision finding that Claimant was capable of performing light work and could perform his past relevant work. R. 126-31. Thus, the ALJ concluded that Claimant was not disabled. R. 132. The Appeals Council entered a decision on April 22, 2013, finding that the ALJ erred in determining that Claimant could perform his past relevant work, and, thus, vacated the ALJ's decision and remanded the matter to another ALJ for further consideration consistent with Appeals Council's decision. R. 138-39. Claimant, subsequently, amended his disability applications to a closed period of disability from August 1, 2010 to January 1, 2014. R. 47-48.
The ALJ issued the operative decision on November 25, 2014. R. 18-30. The ALJ found that Claimant had the following severe impairments during the closed period: a history of human immunodeficiency virus (HIV) without neuropathy; depression; anxiety; and a history of obesity. R. 21. The ALJ found that Claimant does not have an impairment or combination of impairments that meets or medically equals any listed impairment. R. 21-22
The ALJ found that Claimant has the following residual functional capacity (RFC):
R. 22-23.
"In Social Security appeals, [the court] must determine whether the Commissioner's decision is supported by substantial evidence and based on proper legal standards." Winschel v. Comm'r of Soc. Sec., 631 F.3d 1176, 1178 (11th Cir. 2011) (quotations omitted). 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)). 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. Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991); Barnes v. Sullivan, 932 F.2d 1356, 1358 (11th Cir. 1991). The Court must view the evidence as a whole, taking into account evidence favorable as well as unfavorable to the decision. Foote, 67 F.3d at 1560. The District Court "`may not decide the facts anew, reweigh the evidence, or substitute [its] judgment for that of the [Commissioner].'" 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)).
Claimant maintains that the ALJ's reasons for assigning little weight to Dr. Desai's opinion are not supported by substantial evidence. Doc. 13 at 5-7. Thus, Claimant argues that ALJ erred by assigning little weight to Dr. Desai's opinion. Id. The Commissioner maintains that the ALJ provided good cause reasons for assigning Dr. Desai's opinion little weight, each of which are supported by substantial evidence. Doc. 15 at 6-13. Thus, the Commissioner argues that the ALJ did not err by assigning little weight to Dr. Desai's opinion. Id.
The ALJ assesses the claimant's RFC and ability to perform past relevant work at step four of the sequential evaluation process. Phillips, 357 F.3d at 1238. The RFC "is an assessment, based upon all of the relevant evidence, of a claimant's remaining ability to do work despite his impairments." Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). The ALJ is responsible for determining the claimant's RFC. 20 C.F.R. §§ 404.1546(c), 416.946(c).
The consideration and weighing of medical opinions is an integral part in determining the claimant's RFC. The ALJ must consider a number of factors in determining how much weight to give each medical opinion, including: 1) whether the physician has examined the claimant; 2) the length, nature, and extent of the physician's relationship with the claimant; 3) the medical evidence and explanation supporting the physician's opinion; 4) how consistent the physician's opinion is with the record as a whole; and 5) the physician's specialization. 20 C.F.R. §§ 404.1527(c), 416.927(c).
A treating physician's opinion must be given controlling weight, unless good cause is shown to the contrary. See 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2) (giving controlling weight to the treating physician's opinion unless it is inconsistent with other substantial evidence); see also Winschel, 631 F.3d at 1179. There is good cause to assign a treating physician's opinion less than substantial or considerable weight, where: 1) the treating physician's opinion is not bolstered by the evidence; 2) the evidence supports a contrary finding; or 3) the treating physician's opinion is conclusory or inconsistent with the physician's own medical records. Winschel, 631 F.3d at 1179.
The ALJ must state the weight assigned to each medical opinion, and articulate the reasons supporting the weight assigned to each opinion. Winschel, 631 F.3d at 1179. The failure to state the weight with particularity or articulate the reasons in support of the weight prohibits the Court from determining whether the ultimate decision is rational and supported by substantial evidence. Id.
The record reveals that Claimant began treating with Dr. Desai for HIV in September 2010. R. 434-38. Claimant's initial physical examination was unremarkable, but his viral load
Dr. Desai treated Claimant on several occasions between September 2010 and December 2011. R. 476-79, 482-83, 485-86, 488-500. Claimant reported suffering from an array of symptoms related to his HIV, such as body aches, headaches, weakness, fatigue, insomnia, visual problems, fever, and diarrhea. R. 476, 478, 482, 485, 488, 490, 493, 495, 497. Claimant's physical examinations were unremarkable during this period, and his viral load significantly decreased while his CD4 count increased. R. 473-74, 476, 478, 482, 485, 488, 490, 493, 495, 497. Dr. Desai routinely diagnosed Claimant with HIV, and occasionally diagnosed him with neuropathy, depression, and anxiety during this period. R. 477, 479, 483, 486, 489, 491, 494, 496, 498, 500. Dr. Desai's treatment notes from this period, though, did not contain any functional limitations. See R. 476-79, 482-83, 485-86, 488-500.
Dr. Desai completed a "Medical statement regarding HIV and AIDS" in March 2012. R. 593-95. Dr. Desai checked a box indicating that Claimant is HIV positive, and checked lines indicating that Claimant has repeated episodes of severe fatigue, fever, malaise, pain, night sweats, nausea, headaches, and insomnia. R. 593-94. Dr. Desai also checked a line indicating that Claimant suffers from "[o]ther repeated severe episodes caused by HIV-AIDS, such as . . . leukoplakia, myositis, pancreatitis, hepatitis, peripheral neuropathy, glucose intolerance, muscle weakness, cognitive or other mental limitation." Id. Dr. Desai, however, did not indicate which of these symptoms and impairments affect Claimant. See id. Dr. Desai also checked lines indicating that Claimant has marked restriction of daily activities, marked difficulties in maintaining social functioning, and marked difficulties completing tasks in a timely manner due to deficiencies in concentration, persistence, or pace. Id. Dr. Desai, however, does not offer any specific details concerning the particular limitations caused by Claimant's marked restrictions in daily activities or marked difficulties in social functioning and completing tasks in a timely matter. See R. 594-95. Dr. Desai opines that Claimant does not suffer any significant side effects from medications. R. 594. Dr. Desai also did not complete sections concerning sitting, standing, lifting, and mental restrictions, and, thus, there is no indication whether Claimant's HIV caused any specific sitting, standing, lifting, or mental restrictions. R. 594-95. Dr. Desai, though, opines that Claimant cannot work. R. 594.
Dr. Desai continued to treat Claimant after rendering the foregoing opinion. R. 601-04, 606-11, 613-16. Claimant continued to report suffering from an array of symptoms related to his HIV, such as body aches, headaches, weakness, fatigue, insomnia, visual problems, fever, and diarrhea. R. 601, 606, 608, 610, 613, 615. Claimant's physical examinations were unremarkable during this period, and his viral load was almost undetectable while his CD4 count continued to increase. R. 604, 606, 608, 610, 613, 615, 620-47. Dr. Desai continued to diagnose Claimant with HIV, noting that the disease had stabilized. R. 603, 607, 609, 611, 614, 616. Dr. Desai also occasionally diagnosed Claimant with neuropathy, depression, and anxiety during this period. R. 607, 609, 611, 614, 616. Dr. Desai's treatment notes from this period, though, did not contain any functional limitations. See R. 601-04, 606-11, 613-16.
The ALJ discussed Dr. Desai's opinion, and assigned it little weight, explaining:
R. 26-27. Thus, the ALJ assigned Dr. Desai's opinion little weight because her opinion was: 1) conclusory; 2) internally inconsistent; 3) inconsistent with her examination findings, as well as her September 2013 finding that Claimant's HIV was stable; 4) inconsistent with the medical evidence of record; 5) and inconsistent with the intensity of Claimant's treatment. Id.
The ALJ stated several reasons for assigning Dr. Desai's opinion little weight, but Claimant argues that many of the reasons are not supported by substantial evidence. Doc. 13 at 6-7. Claimant maintains that Dr. Desai's opinion is consistent with his complaints of fatigue, fever, malaise, pain, night sweats, nausea, headaches, and insomnia, which appear in Dr. Desai's treatment notes. Id. Claimant also maintains that Dr. Desai's opinion is consistent with his testimony. Id. Thus, Claimant argues that the ALJ erred by assigning little weight to Dr. Desai's opinion. Id.
The undersigned finds that the ALJ stated good cause to assign Dr. Desai's opinion little weight. First, Dr. Desai's opinion is, as the ALJ found, conclusory, as she simply checked lines indicating that Claimant's HIV causes several severe symptoms, as well as marked restrictions in daily activities and marked difficulties in maintaining social functioning and completing tasks in a timely manner. The presence of severe symptoms, marked restrictions in daily activities, and marked difficulties in maintaining social functioning and completing tasks in a timely manner do not, in and of themselves, provide any insight as to specific limitations caused by Claimant's HIV. See Moore v. Barnhart, 405 F.3d 1208, 1213 n.6 (11th Cir. 2005) (explaining the mere existence of an impairment does not reveal the extent to which that impairment limits a claimant's ability to perform work-related functions). The form Dr. Desai used to express her opinions contained other sections that would have shed more light on the nature and severity of any functional limitations, including sections intended to provided detailed sitting, standing, lifting, and mental limitations, but Dr. Desai did not complete those sections, and, thus, failed to articulate what, if any, specific functional limitations are caused by Claimant's HIV. See R. 594-95. Thus, the ALJ's determination that Dr. Desai's opinion is conclusory is supported by substantial evidence.
Second, Dr. Desai's opinion is, as the ALJ found, internally inconsistent.
Third, Dr. Desai's opinion is, as the ALJ found, inconsistent with Dr. Desai's treatment notes, particularly her examination findings. Dr. Desai was aware of Claimant's complaints of fatigue, fever, malaise, pain, night sweats, nausea, headaches, and insomnia, but her examination findings were routinely unremarkable. See R. 476-79, 482-83, 485-86, 488-500, 601-04, 606-11, 613-16. These unremarkable examinations and the improvement in Claimant's viral load and CD4 levels ultimately lead Dr. Desai to conclude that Claimant's HIV had stabilized. This evidence stands in contrast to Claimant's reported symptoms and testimony, which the ALJ did not find entirely credible,
The ALJ, in light of the foregoing, has stated good cause to assign little weight to Dr. Desai's opinion.
Claimant argues that the ALJ failed to properly consider his exertional and nonexertional impairments, and failed to include certain limitations in his RFC determination. Doc. 13 at 7-11. The Commissioner argues that the ALJ properly considered Claimant's impairments, and that his RFC determination is supported by substantial evidence. Doc. 15 at 13-16.
The ALJ thoroughly considered the relevant medical, opinion, and testimonial evidence concerning Claimant's physical and mental impairments, and the effect those impairments have on his ability to perform work related activities. R. 23-27. Thus, the Court finds that the ALJ conducted a proper function-by-function analysis. See SSR 96-8p, 1996 WL 374184 (July 2, 1996).
The ALJ, as previously mentioned, determined that Claimant has the RFC to perform light work, with additional exertional and nonexertional limitations. R. 22-23. Claimant, though, maintains that the evidence demonstrates that he is limited to performing less than sedentary work. Doc. 13 at 9-10. Claimant, in support, points to his complaints of body aches, headaches, weakness, fatigue, insomnia, visual problems, fever, and diarrhea, his diagnoses of HIV, neuropathy, depression and anxiety, Dr. Desai's opinion, and his own testimony. Id. Claimant seemingly argues that the ALJ failed to sufficiently account for the limitations caused by his impairments in the RFC determination. Id. The ALJ, though, considered the very evidence Claimant's relies on in support of his argument, and, after considering that evidence, assigning little weight to Dr. Desai's opinion, and finding Claimant's testimony not entirely credible, determined that Claimant has the RFC to perform light work, with additional exertional and nonexertional limitations. R. 22-27.
For the reasons stated above, it is
