MONTE C. RICHARDSON, Magistrate Judge.
The scope of this Court's review is limited to determining whether the Commissioner applied the correct legal standards, McRoberts v. Bowen, 841 F.2d 1077, 1080 (11th Cir. 1988), and whether the Commissioner's findings are supported by substantial evidence, Richardson v. Perales, 402 U.S. 389, 390 (1971). "Substantial evidence is more than a scintilla and is such relevant evidence as a reasonable person would accept as adequate to support a conclusion." Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004). 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 district court must view the evidence as a whole, taking into account evidence favorable as well as unfavorable to the decision. Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995); accord Lowery v. Sullivan, 979 F.2d 835, 837 (11th Cir. 1992) (stating that the court must scrutinize the entire record to determine the reasonableness of the Commissioner's factual findings).
Plaintiff argues that the ALJ did not give legally sufficient reasons to reject the opinions of his pain management specialist, Dr. Scott Fuchs, from March 10 and March 21, 2016, and the opinions of his primary care physician, Dr. Francis Harrington, from July 31, 2014. Plaintiff also argues that the ALJ's credibility finding does not follow the Agency's two-step analysis. The Commissioner responds that substantial evidence and proper legal analysis support the ALJ's decision.
At step two of the five-step sequential evaluation process, the ALJ found that Plaintiff had the following severe impairments: congenital fusion of the thoracic spine with kyphosis, degenerative disc disease of the thoracic spine, sciatica, and degenerative changes of the cervical spine. (Tr. 17.) At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments. (Tr. 18.)
The ALJ then found that Plaintiff had the residual functional capacity ("RFC") to perform sedentary work, "except he [could] stand two hours in an eight-hour workday; walk one hour in an eight-hour workday; and stoop[] not more than rarely." (Id.) In making this finding, the ALJ discussed Plaintiff's complaints and daily activities, the treatment notes, the objective medical records, and the opinion evidence. (Tr. 18-23.)
The ALJ addressed Plaintiff's complaints as follows:
(Tr. 19.)
The ALJ found that although Plaintiff's medically determinable impairments could reasonably be expected to cause the alleged symptoms, Plaintiff's statements regarding the intensity, persistence, and limiting effects of these symptoms were not entirely consistent with the medical evidence and other evidence in the record. (Tr. 22.) The ALJ explained:
(Id.)
Further, the ALJ addressed the treatment records from Dr. Scott Fuchs.
(Tr. 23.)
The ALJ also addressed records from "Dr. Harrington," including the opinion from October 3, 2016 that Plaintiff was disabled from "kyphosis and scoliosis." (Tr. 21.) However, the ALJ did not seem to weigh Dr. Jane M. Harrington's opinion from October 3, 2016. Rather, the ALJ gave "little weight" to Dr. Francis Harrington's opinion that Plaintiff was unable to work. (Tr. 22.) The ALJ reasoned: "The opinion fails to outline any specific work-related limitations. Moreover, it is a conclusory statement on an issue reserved to [the] Commissioner and it is not supported by the objective medical evidence of record or the minimal clinical signs." (Id.)
The ALJ concluded that "the medical record as a whole" supported the conclusion that Plaintiff could perform the "physical requirements of work at the sedentary exertional level, with the acknowledged limitations, considering his severe impairments." (Tr. 23.) The ALJ noted that he had also considered the non-severe impairments in assessing the RFC, but found "no specific functional limitations beyond those outlined" in the decision. (Id.) Ultimately, the ALJ concluded that there were jobs existing in significant numbers in the national economy that Plaintiff could perform. (Tr. 24.)
On July 31, 2014, Dr. Francis E. Harrington, Jr., a treating physician, completed a Functional Capacity Letter, opining that Plaintiff was "[u]nable to work at this time" due to low back pain, that his impairments would be expected to last at least 12 months, that his prognosis was fair, and that he would require an accommodation for sitting/standing/shifting positions at will. (Tr. 584.)
On October 3, 2016, Dr. Jane M. Harrington, a treating physician, noted that Plaintiff was "disabled" from "kyphosis and scoliosis." (Tr. 628.) In the same note, the doctor stated that the dose of the Fentanyl Patch would be doubled to 50 mg, every three days, in order to attain pain control with long-acting medication and decrease the amount of immediate-release pain medication to 60 tablets only for breakthrough pain. (Tr. 628-29.)
On November 2, 2016, Dr. Jane M. Harrington again noted that Plaintiff was "disabled." (Tr. 630.) On that day, she again increased the dose of the Fentanyl Patch to 75 mg, every three days, and prescribed Percocet 7.5/325 mg for breakthrough pain. (Id.)
On March 10, 2016, Dr. Scott Fuchs, a treating physician, completed an RFC Questionnaire, opining that in an eight-hour workday, Plaintiff could sit for three hours, stand for two hours, walk for one hour, and work for three hours. (Tr. 618.) He further opined that due to spine fusion and degeneration, Plaintiff could occasionally lift and/or carry up to ten pounds; that he could occasionally bend, climb, and reach above; that he could never squat, crawl, stoop, crouch, and kneel; that due to his narcotic pain medications, he could not tolerate any exposure to unprotected heights, marked temperature changes, noise, moving machinery, or driving automotive equipment, but he could be continuously exposed to dust, fumes, and gases. (Tr. 618-19.) Dr. Scott Fuchs opined that Plaintiff's pain was moderate to severe, and it was objectively shown by joint and spinal deformity, muscle spasms, and X-rays. (Tr. 619.)
On March 10, 2016, Dr. Scott Fuchs also completed a Medical Statement Regarding Low Back Pain for Social Security Disability Claim. (Tr. 621.) He reaffirmed that Plaintiff's pain was moderate to severe, and opined that Plaintiff could stand/sit for 15 minutes at one time, work for two to three hours per day, lift 10 pounds occasionally and none frequently, and never bend or stoop. (Id.) Dr. Scott Fuchs noted that examination or testing revealed the following: neuro-anatomic distribution of pain, limitation of motion of the spine, need to change position more than once every two hours, and chronic non-radicular pain and weakness. (Id.)
On March 21, 2016, Dr. Scott Fuchs wrote a letter, stating in relevant part: "Bret Brockus has been under my care for an ongoing chronic spinal condition. This condition is permanent and has had limited progress. He cannot participate in the work program requested by [the] Department of Children and Families." (Tr. 623.)
On March 4, 2017, Dr. Louis Fuchs, an impartial medical expert contracted by the Social Security Administration ("SSA"), responded to the ALJ's interrogatories based on a review of the evidence. (Tr. 732-36.) Under impairments, Dr. Louis Fuchs listed chronic LS myofascitis and cervical myofascitis, noting "multiple neuro exams [within normal limits] while spinal motions decreased somewhat." (Tr. 733.) The doctor supported his opinion by citing to records from August 19, 2013; January 16, 2014; May 21, 2014; September 6, 2014; March 17, 2015; September 22, 2015; May 31, 2016; and August 26, 2016. (Id.) Dr. Louis Fuchs opined that Plaintiff's impairments, either separately or in combination, did not meet or equal any impairment described in the Listings, because multiple exams, neuro-wise, were within normal limits. (Tr. 734.)
Dr. Louis Fuchs was also asked to identify any functional limitations or restrictions resulting from Plaintiff's impairments. (Tr. 735.) He responded that Plaintiff could sit, stand, and/or walk at one time at least 1-2 hours; lift and/or carry 10 pounds continuously and 20 pounds occasionally; stoop, crouch, bend, and kneel occasionally; climb stairs or ramps without limitation, but never scaffolds; and could be exposed to severe heat/cold occasionally, but never to vibrations. (Id.)
The Court agrees with Plaintiff that the ALJ's evaluation of the medical opinion evidence warrants a remand. As stated previously, in an RFC Questionnaire completed on March 10, 2016, Dr. Scott Fuchs opined, in part, that in an eight-hour workday, Plaintiff could only sit for three hours, stand for two hours, walk for one hour, work for three hours, and lift and/or carry up to ten pounds occasionally. (Tr. 618.) In a Medical Statement completed the same day, Dr. Scott Fuchs opined, in part, that Plaintiff could sit/stand for 15 minutes at a time, work for two to three hours per day, and lift 10 pounds occasionally. (Tr. 621.) He stated that Plaintiff's pain was moderate to severe and was objectively supported by examinations and testing, which revealed joint and spinal deformity, muscle spasms, limitation of motion of the spine, chronic non-radicular pain and weakness, and anatomic distribution of pain, among others. (Tr. 619, 621.)
The ALJ assigned "little weight" to the March 10, 2016 opinions from Dr. Scott Fuchs and explained that Dr. Fuchs overestimated Plaintiff's limitations in light of the limited examination findings. (Tr. 23.) Also, the ALJ gave "no weight" to Dr. Fuchs's opinion from March 21, 2016 that Plaintiff could not participate in the work program requested by the Department of Children and Families due to his permanent condition and limited progress (Tr. 623), because the opinion did not provide a function-by-function analysis of Plaintiff's abilities and was not supported by the objective medical evidence of record as a whole (Tr. 23).
Even if the ALJ was correct that Dr. Fuchs's opinion from March 21, 2016 did not provide a function-by-function analysis of Plaintiff's abilities, the ALJ improperly rejected Dr. Fuchs's opinions from March 10, 2016 and March 21, 2016 based on allegedly limited examination findings and other objective medical evidence. First, the ALJ's statement that Plaintiff's examination findings were limited is not supported by substantial evidence.
Even prior to Plaintiff's alleged disability onset date, his examinations were positive for, inter alia, tenderness in the lumbar and thoracic areas, decreased range of motion, and joint pain. (See, e.g., Tr. 425.) After the onset date, Plaintiff's posture was kyphotic and leaning forward. (Tr. 343-44.) He continued to have thoracic and lumbar tenderness and pain, as well as moderate cervical tenderness and spasm, and a positive Quadrant Test. (Id.) There was a large sacral bone marrow change on an MRI, a large myofascial component of the thoracic spine, likely secondary to kyphosis and congential fusion at T10-11, and an increase in Plaintiff's pain/symptoms with spinal extension. (Id.) On October 2, 2012, there was numbness/tingling in Plaintiff's extremities and pain with straight leg raising test bilaterally. (Tr. 441-42.) In June 2013, Plaintiff underwent a surgical repair of his left biceps tendon, which had been ruptured. (Tr. 547, 553; see also Tr. 479 (noting a swollen and painful left elbow with no palpable biceps tendon, pain and weakness with pronation, sprains and strains of the shoulder and upper arm, rotator cuff, and joint pain).)
In January 2014, there was a paraspinal muscle spasm, lumbar tenderness, thoracic pain, and mild left straight leg raising on examination, prompting a referral to pain management. (Tr. 473-74.) A number of physical examinations, including those from February-March 2014, November-December 2015,
During multiple office visits, Dr. Scott Fuchs noted that Plaintiff's sciatica, degeneration of thoracic disc, and shoulder pain, among others, were contributing to Plaintiff's complaints. (See, e.g., Tr. 635-36, 641-42.) Plaintiff's worst pain was in his lower back, which was reported as an 8 or 9, was radiating to his legs, and was "always exacerbated with over [sic] activities like standing and walking for too long." (Tr. 637.) It was noted that Plaintiff had a "known abnormal fusion in the lower thoracic spine leading to secondary kyphosis" and that he could "be very uncomfortable at times from pain." (Id.)
Further, the results of the diagnostic testing were not inconsistent with the treatment notes.
The records also show that Plaintiff had failed conservative treatment, such as non-opiate medications, adjuvant therapy, interventional pain assessment, and physical therapy
Based on the foregoing, the Court cannot conclude that the ALJ's evaluation of Dr. Scott Fuchs's opinion is supported by substantial evidence. Similar to his evaluation of Dr. Scott Fuchs's opinion, the ALJ accorded "little weight" to Dr. Francis Harrington's opinion that Plaintiff was unable to work, partly because it was "not supported by the objective medical evidence of record or the minimal clinical signs." (Tr. 22.) However, as shown above, it seems that the ALJ did not adequately consider the medical evidence as a whole.
In addition, there was an opinion by Dr. Jane M. Harrington from October 3, 2016, which the ALJ mentioned (Tr. 21), but never weighed, and another opinion by the same doctor from November 2, 2016, stating that Plaintiff was "disabled," which the ALJ never mentioned. Notably, there were two treating physicians with the last name "Harrington" and two other physicians (one treating and one non-examining) with the last name "Fuchs"; yet, it is unclear whether the ALJ adequately considered each of these doctors' opinions separately, as well as in combination, when determining the RFC. To the extent the opinions were consistent with one another, the ALJ was required to take that into consideration in weighing them. See 20 C.F.R. §§ 404.1527(c)(4), 416.927(c)(4). However, on this record, the Court is left to speculate whether that happened here.
As such, this case will be remanded with instructions to the ALJ to re-consider the medical opinions of record. In light of this conclusion and the possible change in the RFC assessment, it is unnecessary to address Plaintiff's argument regarding the ALJ's credibility findings. See Jackson v. Bowen, 801 F.2d 1291, 1294 n.2 (11th Cir. 1986) (per curiam); Freese v. Astrue, 2008 WL 1777722, at *3 (M.D. Fla. Apr. 18, 2008); see also Demenech v. Sec'y of the Dep't of Health & Human Servs., 913 F.2d 882, 884 (11th Cir. 1990) (per curiam).
Accordingly, it is
1. The Commissioner's decision is
2. The Clerk of Court is directed to enter judgment accordingly, terminate any pending motions, and close the file.
3. In the event that benefits are awarded on remand, any § 406(b) or § 1383(d)(2) fee application shall be filed within the parameters set forth by the Order entered in In re: Procedures for Applying for Attorney's Fees Under 42 U.S.C. §§ 406(b) & 1383(d)(2), Case No.: 6:12-mc-124-Orl-22 (M.D. Fla. Nov. 13, 2012). This Order does not extend the time limits for filing a motion for attorney's fees under the Equal Access to Justice Act, 28 U.S.C. § 2412.
(Tr. 23.)
Although between December 2014 and September 2015 some of Plaintiff's examinations were noted to be generally unremarkable, he was nevertheless continued on pain management, with Percocet and other narcotic pain medications being refilled on a monthly basis. (Tr. 596-610, 625-27 (noting that Plaintiff was taking Oxycodone-Acetaminophen 10-325 mg every four hours and MS Contin 30 mg twice a day, among other medications).)