GREGORY A. PRESNELL, District Judge.
This cause comes before the Court on the Complaint (Doc. No. 1) filed by Plaintiff on November 22, 2010, to appeal the final decision of the Commissioner of Social
On February 10, 2012, the United States Magistrate Judge issued a report (Doc. No. 22) recommending that the decision of the Commissioner be reversed and the case be remanded. No objections have been filed. Therefore, it is
1. The Report and Recommendation is
2. The decision of the Commissioner is
3. The Clerk of Court is directed to enter judgment in accordance with this order and thereafter close the file.
GREGORY J. KELLY, United States Magistrate Judge.
Yvette Lynna Kahle (the "Claimant") appeals to the District Court from a final decision of the Commissioner of Social Security (the "Commissioner") denying Claimant's claim for benefits. See Doc. No. 1. On July 12, 2006, Claimant applied for disability benefits, alleging an onset of disability as of November 2, 2005, due to peripheral neuropathy and high blood pressure. R. 244-52, 286, 293-95, 316-18. Claimant also has a significant history of alcohol dependence. R. 362-726. On February 11, 2010, the Administrative Law Judge (the "ALJ") determined that Claimant is not disabled. R. 12-26. After the Appeals Council denied Claimant's request for review, Claimant appealed the Commissioner's final decision to the District Court. R. 1-4; Doc. No. 1.
On appeal, Claimant argues that the final decision should be reversed and remanded pursuant to sentence four of 42 U.S.C. § 405(g) because the ALJ: 1) lack good cause to reject significant portions of Dr. Barber's opinion regarding Claimant's physical limitations; 2) erred by giving controlling weight to the opinion of a non-examining physician; 3) failed to include all of Claimant's functional limitations in the ALJ's residual functional capacity assessment (the "RFC") and in the hypothetical question to the vocational expert (the "VE"); 4) impermissibly accepted the requirements of certain the jobs described by the VE, which conflict with their corresponding definitions in the Dictionary of Occupational Titles; and 5) failed to consider the side-effects of Claimant's medications on her ability to work. Doc. No. 18 at 2, 8-18. For the reasons more fully discussed below, it is recommended that the Commissioner's decision be
The dispositive issue in this case is whether the ALJ erred by rejecting a portion of Dr. Barber's opinion and, therefore, the Court will tailor the medical and administrative history to that issue. Claimant was born on May 2, 1968, and attended one year of college. R. 69, 244. Claimant has past relevant work experience as a restaurant cashier and waitress. R. 279.
The record does not contain any medical opinion regarding Claimant's functional limitations from a treating physician, but it does contain three such opinions from consultative
On May 30, 2007, Claimant was examined by Dr. Alvan Barber. R. 483-89. Dr. Barber is only examining physician to offer an opinion regarding Claimant's physical limitations. Physical examination revealed "[p]ositive upper extremity numbness and tingling in the hands," and "[d]eep tendon reflexes [of] 0 in upper extremities bilaterally." R. 485. However, muscle and grip strength in the upper extremities were normal. R. 485. Numbness and tingling were also present in the lower extremities with abnormal deep tendon reflexes. R. 485. Claimant's fine and gross motor skills were intact. R. 485. Dr. Barber's impressions were as follows:
R. 486. Dr. Barber opined that:
R. 486. Thus, Dr. Barber opined that Claimant's impairments could limit her in walking and standing for long periods, lifting and carrying heavy objections, in activities that require the use of upper body movements, and in coordinated activities with hands. R. 486.
On April 19, 2007, Dr. Malcolm J. Graham, III, a clinical psychologist, conducted a consultative mental examination of Claimant. R. 465-68. Mental status examination revealed no indication of depression or anxious mood, appropriate affect, coherent thought process, proper orientation, and intact memory. R. 466-67. Dr. Graham notes that Claimant continues to work part-time as a waitress. R. 467. Dr. Graham's diagnosed Claimant with the following:
R. 467. Dr. Graham opined that there "were no problems ... in attention or concentration and there were no problems noted in recent or remote memory. There were also no behavioral indications of anxiety, depression or of thought disorder." R. 468. Thus, Dr. Graham did not provide any mental functional limitations resulting from Claimant's impairments. R. 467-68.
On September 10, 2009, Claimant was examined by Dr. Julie L. Parker, a clinical psychologist. R. 636-43.
R. 640. Dr. Parker opined that:
R. 640. Thus, Dr. Parker opined that there are no physical or cognitive barriers to Claimant's activities of daily living, but Claimant's concentration, persistence, and pace are disrupted by pain symptoms and the effects of medication. R. 640. Dr. Parker also completed a Medical Source Statement of Ability to Do Work-Related Activities (Mental) wherein she opined that Claimant's ability to understand, remember, and carry out instructions are not affected by her impairments, but that symptoms related to bipolar disorder and substance abuse would affect her ability to interact appropriately with supervisors, co-workers, and the public, as well as responding to changes in routine work settings. R. 641-42.
At the hearing before the ALJ on January 20, 2010, Dr. Carlos Kronberger, a clinical psychologist, testified based upon a medical records review. R. 36-63. Dr. Kronberger opined that Claimant should have a Global Assessment of Functioning Score of 55, which is lower than the score provided by Dr. Graham and higher than the score provided by Dr. Parker. R. 42. Dr. Kronberger opined that Claimant does not meet a listing, she can perform simple, routine tasks, and she has marked difficulties maintaining concentration, persistence, and pace if consuming alcohol, and moderate limitations in that area if not consuming alcohol. R. 53-54. Dr. Kronberger testified that such limitations are a factor in reaching his opinion that Claimant can perform simple, routine tasks. R. 53. Dr. Kronberger disagreed with Dr. Parker's diagnosis of bi-polar disorder because "it's too soon to tell if the [C]laimant is able to maintain sobriety, whether she does have a significant mood disorder." R. 54. Dr. Kronberger agreed with Dr. Graham that Claimant suffers from a personality disorder. R. 55. Dr. Kronberger did not provide a function-by-functional analysis of Claimant's limitations.
At the January 20, 2010 hearing, Claimant testified that while she is able to write, it depends on how her hands are doing at the time. R. 69. Claimant stated that the primary reason that she cannot work is that she cannot stand on her feet and
On February 11, 2010, the ALJ issued a decision finding that Claimant is not disabled. R. 15-26. The ALJ made the following significant findings:
R. 30-37. In his decision, the ALJ thoroughly reviewed the medical record, including the opinion evidence. R. 18-23. The ALJ gives "controlling weight" to Dr. Kronberger's opinion because it "is supported by objective medical findings," and "is consistent with the evidence of record when considered in its entirety." R. 24. Regarding Dr. Barber's opinion, the ALJ gives it "great weight," but states:
R. 24 (emphasis added). Thus, although the ALJ gives Dr. Barber's opinion great weight, he rejects that portion of Dr. Barber's opinion regarding Claimant's upper body limitations. R. 24.
Regarding Dr. Parker, although the ALJ accepted her opinion that Claimant
As mentioned above, the dispositive issue in this case is whether the ALJ erred by rejecting a portion of Dr. Barber's opinion regarding Claimant's upper body limitations. Claimant maintains that the ALJ failed to give "explicit and adequate" reasons for rejecting that portion of Dr. Barber's opinion. Doc. No. 18 at 12-13. Claimant also asserts that the opinion is actually consistent with both the medical record and Claimant's testimony. Doc. No. 18 at 13. Claimant requests that the case be reversed and remanded for further proceedings pursuant to sentence four of Section 405(g). Doc. No. 18 at 18.
The Commissioner maintains that the ALJ articulated good reasons for rejecting his opinion that Claimant has limitations regarding the use of her upper body. Doc. No. 19 at 12. The Commissioner suggests that by stating that the opinion is "`inconsistent with the evidence or [sic] the record, including medical records and statements/testimony from the [C]laimant regarding activities of daily living,'" the ALJ complied with the Eleventh Circuit's requirement that an ALJ give explicit, well articulated reasons for rejecting an opinion. Doc. No. 19 at 12. The Commissioner then provides post hoc details in the record which support the ALJ's finding. Doc. No. 19 at 12-13. The Commissioner requests that the case be affirmed.
Under the authority of the Social Security Act, the Social Security Administration has established a five-step sequential evaluation process for determining whether an individual is disabled. See 20 CFR §§ 404.1520(a), 416.920(a). In Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir.2001), the Eleventh Circuit explained the five-step sequential evaluation process as follows:
Id. (citations omitted). The steps are followed in order. If it is determined that
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, 91 S.Ct. 1420, 28 L.Ed.2d 842 (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. 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, 67 F.3d at 1560; accord, Lowery v. Sullivan, 979 F.2d 835, 837 (11th Cir.1992) (court must scrutinize the entire record to determine reasonableness of factual findings); Parker v. Bowen, 793 F.2d 1177 (11th Cir.1986) (court also must consider evidence detracting from evidence on which Commissioner relied). 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).
Congress has empowered the District Court to reverse the decision of the Commissioner without remanding the cause. 42 U.S.C. § 405(g)(Sentence Four). To remand under sentence four, the District Court must either find that the Commissioner's decision applied the incorrect law, fails to provide the court with sufficient reasoning to determine whether the proper law was applied, or is not supported by substantial evidence. Keeton v. Dep't of Health & Human Serv., 21 F.3d 1064, 1066 (11th Cir.1994) (reversal and remand appropriate where ALJ failed to apply correct law or the ALJ failed to provide sufficient reasoning to determine where proper legal analysis was conducted) (citing Cornelius v. Sullivan, 936 F.2d 1143, 1146 (11th Cir.1991); Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir.1990)); Jackson v. Chater, 99 F.3d 1086, 1090-91 (11th Cir.1996) (remand appropriate where ALJ failed to develop a full and fair record of claimant's RFC); accord Brenem v. Harris, 621 F.2d 688, 690 (5th Cir.1980) (remand appropriate where record was insufficient to affirm, but also was insufficient for District Court to find claimant disabled).
This Court may reverse the decision of the Commissioner and order an award of disability benefits where the Commissioner has already considered the essential evidence and it is clear that the cumulative effect of the evidence establishes disability without any doubt. Davis v. Shalala, 985 F.2d 528, 534 (11th Cir. 1993); accord, Bowen v. Heckler, 748 F.2d 629, 631, 636-37 (11th Cir.1984). A claimant may also be entitled to an immediate award of benefits where the claimant has suffered an injustice, Walden v. Schweiker, 672 F.2d 835, 840 (11th Cir.1982), or where
Weighing the opinions and findings of treating, examining, and non-examining physicians is an integral part of the process for determining disability. The ALJ may reject any medical opinion if the evidence supports a contrary finding. Sryock v. Heckler, 764 F.2d 834, 835 (11th Cir.1985). Nonetheless, the ALJ must state with particularity the weight given different medical opinions and the reasons therefore, and the failure to do so is reversible error. Sharfarz v. Bowen, 825 F.2d 278, 279 (11th Cir.1987). Without the ALJ stating the specific weight given to different medical opinions and the reasons therefore, it is impossible for a reviewing court to determine whether the ultimate decision is supported by substantial evidence. See e.g. Hudson v. Heckler, 755 F.2d 781, 786 (11th Cir.1985).
Johnson v. Barnhart, 138 Fed.Appx. 266, 269 (11th Cir.2005). "The opinion of a non-examining physician does not establish the good cause necessary to reject the opinion of a treating physician." Johnson, 138 Fed.Appx. at 269. Moreover, the opinions of a non-examining physician do not constitute substantial evidence when standing alone. Spencer ex rel. Spencer v. Heckler, 765 F.2d 1090, 1094 (11th Cir. 1985).
While the opinion of a one-time examining physician may not be entitled to deference, especially when it contradicts the opinion of a treating physician, the opinion of an examining physician is generally entitled to more weight than the opinion of a non-examining physician.
In this case, Dr. Barber was the only examining physician to offer an opinion regarding Claimant's physical limitations. Dr. Barber examined Claimant and found positive numbness and tingling in the upper and lower extremities and poor reflexes. R. 485-486. Based upon his examination, Dr. Barber opined that Claimant's impairments could limit the use of upper body movements and coordinated activities with the hands. R. 486. In rejecting that portion of Dr. Barber's opinion, the ALJ offers only the conclusory statement that Dr. Barber's opinion is "inconsistent with the evidence of record, including medical records and statements/testimony from the [C]laimant regarding activities of daily living." R. 24. The ALJ does not articulate how the opinion is inconsistent the medical record or with which particular statements regarding Claimant's activities of daily living. R. 24.
In Monte v. Astrue, Case No. 5:08-cv-101-Oc-GRJ, 2009 WL 210720 at *6 (M.D.Fla. Jan. 28, 2009), the Court held:
Id. (quoting Walker v. Bowen, 826 F.2d 996, 1001 (11th Cir.1987)). Therefore, reversal is required where an ALJ fails to sufficiently articulate the reasons supporting his decision to reject portions of a medical opinion while accepting others. In this case, the ALJ failed to sufficiently articulate the reasons supporting his decision to reject portions of Dr. Barber's opinion. See Poplardo, 2008 WL 68593 at *11 (failure to specifically articulate evidence contrary to doctor's opinion requires remand); Paltan, 2008 WL 1848342 at *5 (failure to explain how opinion was inconsistent with medical evidence requires remand); Venette v. Apfel, 14 F.Supp.2d 1307, 1314 (S.D.Fla.1998) (a claimant's testimony that she can do some housework, light cooking, and light grocery shopping
The Court has considered whether the ALJ's error is harmless. Given that there are no opinions from treating physicians, Dr. Barber was the only examining physician to offer an opinion regarding Claimant's physical functional limitations, and that he offered an opinion which, if accepted, would necessarily reduce Claimant's RFC, the Court cannot find that the ALJ's error was harmless.
Based on the forgoing, the undersigned recommends that the Court:
Failure to file written objections to the proposed findings and recommendations contained in this report within
Recommended in Orlando, Florida on February 10, 2012.