CHARLES S. COODY, Magistrate Judge.
The plaintiff applied for disability insurance benefits pursuant to Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq., alleging that she was unable to work because of a disability beginning on January 31, 2009.
Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when the person is unable to
To make this determination
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986).
The standard of review of the Commissioner's decision is a limited one. This court must find the Commissioner's decision conclusive if it is supported by substantial evidence. 42 U.S.C. § 405(g); Ingram v. Comm'r of Soc. Sec. Admin., 496 F.3d 1253, 1260 (11th Cir. 2007). "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." Richardson v. Perales, 402 U.S. 389, 401 (1971); Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158-59 (11th Cir. 2004). A reviewing court may not look only to those parts of the record which supports 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. Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th Cir. 1986). The 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) (alteration in original) (quotation marks omitted).
Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
(Doc. # 13, Pl's Br. at 2).
A disability claimant bears the initial burden of demonstrating an inability to return to her past work. Lucas v. Sullivan, 918 F.2d 1567 (11th Cir. 1990). In determining whether the claimant has satisfied this burden, the Commissioner is guided by four factors: (1) objective medical facts or clinical findings, (2) diagnoses of examining physicians, (3) subjective evidence of pain and disability, e.g., the testimony of the claimant and her family or friends, and (4) the claimant's age, education, and work history. Tieniber v. Heckler, 720 F.2d 1251 (11th Cir. 1983). The court must scrutinize the record in its entirety to determine the reasonableness of the ALJ's decision. See Walker, 826 F.2d at 999. The ALJ must conscientiously probe into, inquire of and explore all relevant facts to elicit both favorable and unfavorable facts for review. Cowart v. Schweiker, 662 F.2d 731, 735-36 (11th Cir. 1981). The ALJ must also state, with sufficient specificity, the reasons for her decision referencing the plaintiff's impairments.
42 U.S.C. § 405(b)(1) (emphases added). Within this analytical framework, the court will address the plaintiff's claims.
See 20 C.F.R. Pt. 220, App. 1, Listing 12.05C. Consequently, a claimant meets the strictures of 12.05(C) by presenting evidence of (1) a sub-average general intellectual functioning initially manifested prior to age of twenty-two; (2) valid IQ score of 60 to 70 inclusive; and (3) evidence of an additional mental or physical impairment that has more than a "minimal effect" on the claimant's ability to perform basic work activities. Lowery v. Sullivan, 979 F.2d 835 (11th Cir. 1992); Edwards v. Heckler, 755 F.2d 1513, 1517 (11th Cir. 1985).
At the administrative hearing in January 2012, her counsel asserted that Thomas' primary severe impairment was anxiety, not intellectual disability.
(R. 37).
However, in June 2012, at another administrative hearing, counsel raised the issue of Thomas' intellectual functioning.
(R. 47).
The ALJ considered whether Thomas's intellectual functioning constituted mental retardation without explicitly referencing Listing 12.05C.
(R.16).
The ALJ also described in detail the evidence related to Thomas' intellectual functioning.
(R. 20-21).
After reviewing the medical evidence, the ALJ evaluated Thomas' intellectual abilities and determined that she suffers from borderline intellectual functioning, and not mental retardation. (R.14). Thus, the ALJ implicitly considered whether Thomas met Listing 12.05C and concluded that she did not. The ALJ's determination is supported by substantial evidence. Thomas admitted that she completed the paperwork to apply for disability. (R. 50). Thomas did not raise intellectual functioning as a severe impairment in her first application for disability for the closed period from March 1, 2005 through January 28, 2008, (R. 82). In her disability report, Thomas reported that she could read, understand and write English. (R.235). She did not allege an intellectual disability as a mental impairment when she applied for disability. (R. 236). It was not until her second administrative hearing that she argued that she might meet Listing 12.05C. (R. 47)
Thomas relies on her school records to demonstrate that she meets Listing 12.05C.
The record is unclear precisely how much education Thomas possesses. At the administrative hearing, the plaintiff testified that she did not have a G.E.D. (R. 49-50). However, on her disability application, she indicated that she completed tenth grade, and had not taken special education classes. (R. 237). Dr. Jordan indicated in a consultative evaluation report done at the request of the Commissioner, that Thomas had completed the tenth grade, attended regular classes, and has a GED. (R. 379). Spectracare's intake form also indicates that Thomas finished the 10th grade and she had a GED. (R. 522). Dr. Barbara Traenkner, on the other hand, noted in her consultative evaluation report done at the request of the Commissioner, that Thomas
(R. 560).
When there is a conflict, inconsistency, or ambiguity in the record, the ALJ has an obligation to resolve the conflict, giving specific reasons supported by the evidence as to why she accepted or rejected a finding. When faced with this conflicting evidence, the ALJ addressed the inconsistencies, and explained why she determined that Thomas suffered from borderline intellectual functioning and not mental retardation.
(R. 25) (footnote added).
Next, under section 12.05C, a person is disabled if she has a valid verbal, performance, or full scale IQ of 60 through 70 and a physical or other mental impairment which imposes additional significant limitations of function. 20 C.F.R. Pt. 220, App. 1. Listing 12.05. Thomas argues that because she has an IQ score of 64 from Dr. Traenkner, she meets the Listing. The plaintiff was administered the Wechsler Intelligence Scale for Adults-III (WAIS-III) by Dr. Traenkner, a licensed clinical psychologist, on March 18, 2012. (R. 559-62). She obtained a full scale I.Q. score of 64. Dr. Traenkner indicated that the plaintiff was compliant and cooperative, her attention was "generally good," and the test results were "considered moderately valid." (R. 560) (emphasis added).
(Id.)
Dr. Traenkner concluded that based on Thomas' cooperation and compliance throughout the testing, the "evaluation is considered generally valid." (R. 561). Thereafter, Dr. Traenkner opined that Thomas' "ability to understand and follow simple directions is unimpaired by her psychiatric function, but due to her poor intellectual functioning and depressive symptoms, she may have a mild impairment following complex directions." (Id.) (emphasis added); see also R. 563 ("Due to poor intellectual functioning, mild impairment may be present in following complex instruction.").
The Commissioner argues that Thomas cannot demonstrate that she meets Listing 12.05 because she does not have a valid IQ score and Dr. Traenkner did not diagnose mental retardation. See Doc. # 18 at 5-6. While the Listing does not require evidence of a diagnosis of mental retardation, it does require "a valid verbal, performance, or full scale IQ of 60 through 70." The ALJ recognized that Dr. Traenkner considered Thomas' scores to be "moderately valid," and "[t]here contraindicative results in [Thomas'] use of vocabulary." (R. 21). The ALJ considered Dr. Traenkner's assessment of Thomas' mental capacity. "The claimant was assessed with mild to moderate limitations in functioning, anxiety, depression and significant history of polysubstance abuse with history of relapse." (R. 21).
I.Q. scores are not necessarily conclusive of mental retardation. See Popp v. Heckler, 779 F.2d 1497, 1499-1500 (11th Cir. 1986) (ALJ could disregard standardized I.Q. scores which were inconsistent with activities and behavior). Dr. Traenkner, and no other medical professional, has suggested that Thomas' intellectual functioning is consistent with a finding of intellectual disability within the meaning of Listing 12.05C. Finally, and perhaps more importantly, Thomas does not demonstrate, and the record does not indicate, that her intellectual deficiencies significantly impair her ability to work. Thomas admitted that she could read, write and do simple math, although she asserted that she was not a strong speller and her handwriting was very sloppy. (R. 28).
In this case, the ALJ concluded, after from a review of the evidence, that Thomas suffered from borderline intellectual functioning and thus did not meet the criteria of Listing 12.05C. Pursuant to the substantial evidence standard, this court's review is a limited one; the entire record must be scrutinized to determine the reasonableness of the ALJ's factual findings. Lowery, 979 F.2d 837. The ALJ's findings meet the reasonableness standard.
Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997) (citing 20 CFR § 404.1527 (d)(2)). The ALJ's failure to give considerable weight to the treating physician's opinion is reversible error. Broughton, 776 F.2d at 961-62.
There are, however, limited circumstances when the ALJ can disregard the treating physician's opinion. The requisite "good cause" for discounting a treating physician's opinion may exist where the opinion is not supported by the evidence, or where the evidence supports a contrary finding. Good cause may also exist where a doctor's opinions are merely conclusory, inconsistent with the doctor's medical records, or unsupported by objective medical evidence. See Jones v. Dep't. of Health & Human Servs., 941 F.2d 1529, 1532-33 (11th Cir. 1991); Edwards v. Sullivan, 937 F.2d 580, 584-85 (11th Cir. 1991); Johns v. Bowen, 821 F.2d 551, 555 (11th Cir. 1987). The weight afforded to a physician's conclusory statements depends upon the extent to which they are supported by clinical or laboratory findings and are consistent with other evidence of the claimant's impairment. Wheeler v. Heckler, 784 F.2d 1073, 1075 (11th Cir. 1986). The ALJ "may reject the opinion of any physician when the evidence supports a contrary conclusion." Bloodsworth v. Heckler, 703 F.2d 1233, 1240 (11th Cir. 1983). The ALJ must articulate the weight given to a treating physician's opinion and must articulate any reasons for discounting the opinion. Schnorr v. Bowen, 816 F.2d 578, 581 (11th Cir. 1987).
On May 23, 2012, Dr. Lopez completed a medical source statement assessing Thomas's ability to do work-related activities. (R. 632-38). According to Dr. Lopez, Thomas has marked limitations in four areas and moderate limitations in three areas of dealing with her ability to make occupational adjustments. (R. 632-33). She has marked limitations in two areas and moderate limitations in two areas of making personal-social adjustments. (R. 633). She has marked limitations in nine areas and moderate limitations in two areas of concentration, persistence or pace. (R. 636-37). According to Dr. Lopez, Thomas' limitations stem from her chronic mood disorder and chronic depression. (R. 634). He opined that "she can't work." (R. 635).
After reviewing the medical evidence, the ALJ concluded that Dr. Lopez's "assessment is contradicted by his own treatment notes, remains inconsistent with the full record regarding the claimant's mental capacity, and is afforded little weight." (R. 22).
(Id.)
The ALJ's decision to give Dr. Lopez's opinion little weight is supported by substantial evidence. Treatment records from Spectra Care do not support Dr. Lopez's assessment of the severity of Thomas' mental impairments. For example, Thomas presented to SpectraCare for an intake assessment on September 8, 2011. The assessment was completed by Beate Holmes ("Holmes"), a licensed social worker. (R. 512-26). Dr. Hammond, a licensed psychologist, also signed the intake assessment. (R. 516). Although Dr. Lopez prescribed Celexa and Trazodone for Thomas on October 6, 2011, there is no indication that Thomas saw Dr. Lopez, or attended individual or group therapy on that date. (R. 509). Thomas was terminated from SpectraCare on December 13, 2011 for "non-compliance with treatment." (R. 507).
Thomas returned to SpectraCare on February 16, 2012, complaining that her depression had gotten worse. (R. 609-24). Holmes conducted another assessment. (Id.) Thomas participated in group therapy on February 28, 2012. (R. 607). Her progress was described as moderate. (R. 608). On March 1, 2012, Dr. Lopez prescribed Celexa, Doxepin and Vistaril for Thomas. (R. 627-31). On March 13, 2012, Thomas participated in group therapy and it was noted that her "[p]rogess is moderate evidenced by medication compliance and report of improvement." (R. 605). Thomas also reported that she would be taking a month-long trip to "get out" of the house. (R. 606). On April 10, 2012, Thomas canceled her therapy appointment. (R. 603-04). On April 24, 2012, Thomas attended group therapy, and her progress was noted as satisfactory. (R.601-02). The last report of Thomas' attendance at group therapy was on May 8, 2012. (R. 599-600).
Although Dr. Lopez assessed Thomas with significant marked and moderate limitations there is no evidence in the treatment notes to indicate that Dr. Lopez ever evaluated or even saw Thomas. His assessment was based on four group therapy appointments over a three month period. Consequently, Dr. Lopez's treatment notes do not support the level of disability he attributes to Thomas.
The ALJ may disregard the opinion of a physician, provided that she states with particularity reasons therefor. Sharfarz v. Bowen, 825 F.2d 278 (11th Cir. 1987). The ALJ examined and evaluated the treatment records for evidence supporting Dr. Lopez's assessment of Thomas' ability to work, and she considered Thomas' own testimony. Only then did the ALJ discount Dr. Lopez's opinion that Thomas was disabled. Based on its review of the ALJ's decision and the objective medical evidence of record, the court concludes that the ALJ properly rejected Dr. Lopez's opinion regarding Thomas' mental limitations.
Thomas also asserts that the ALJ improperly discounted the opinion of Dr. David Arnold. On January 12, 2012, Dr. Arnold completed a Physical Residual Functional Capacity Questionnaire. (R. 527-31). According to Dr. Arnold, Thomas' depression affects her physical functional limitations. (R. 528). Dr. Arnold opined that Thomas' depression and anxiety would occasionally interfere with her attention and concentration but she was incapable of tolerating "even `low stress' jobs." (Id.) He then offered opinions on Thomas' physical functional limitations. (R.528-30).
After reviewing the medical evidence, the ALJ concluded that Dr. Arnold's "assessment is afforded no weight. The assessment listed physical limitations, based on the diagnosis of mental impairments. This assessment is internally inconsistent and remains unsupported by corresponding treatment records." (R. 24).
(R. 23-24).
The ALJ's decision to give Dr. Arnold's opinion no weight is supported by substantial evidence. Treatment records do not support Dr. Arnold's assessment of Thomas' functional capacity. For example, treatment records reveal that Dr. Arnold saw Thomas on November 30, 2006, January 12, 2012, and March 27, 2012 (R. 315-17, 532-35 & 592-93). In 2006, Thomas complained of blockage of her carotid arteries. (R. 315-17). An examination revealed no swelling, joint tenderness or other abnormalities. (R.316). On January 12, 2012, Thomas complained of headaches. (R.532). She also complained of "chronic neck and back pain,"and wanted disability forms completed. (R. 533). According to Thomas, she "can't walk but a little bit." (Id.) She "hurts all over," and "never feels good." (Id.) She also complained of shortness of breath. (Id.). A physical examination found no wheezing, and no tenderness of her back or neck. (R. 534). Dr. Arnold diagnosed her with tension headaches and depression. (Id.).
On March 27, 2012, Thomas presented to Dr. Arnold complaining of chronic headaches and pain in her back, neck and shoulders. (R. 592). In this examination, Dr. Arnold determined that Thomas' gait was antalgic but she had normal muscle strength and tone. (R.593). She had a normal left straight leg raise but a positive straight leg raise on the right leg. (Id.) While she had muscle spasms in the back, her joint stability was normal. (Id.) There was tenderness at the left sacroiliac area and pain to palpation along the lower back. (Id.) Dr. Arnold diagnosed Thomas with degenerative disc disease, lumbar, and prescribed medication. (Id.).
The ALJ was entitled to discredit Dr. Arnold's opinion on grounds that it was unsupported by his own objective observations and on grounds that it was inconsistent with the medical record and the record as a whole. See 20 C.F.R. § 416.927(d)(3)-(4). Dr. Arnold's treatment records do not support his assessment of the severity of Thomas' impairments. Dr. Arnold's assessment was based on one office visit in 2006 and two office visits in 2012. Dr. Arnold treated Thomas conservatively with medication, and his own records do not support the severity he ascribes to Thomas' physical functional limitations. Based upon its review of the ALJ's decision and the objective medical evidence of record, the court concludes that the ALJ properly rejected Dr. Arnold's opinion regarding the limitations caused by Thomas' physical impairments.
However, the ALJ only reaches the materiality question after the claimant first has been found to be disabled. Because the ALJ determined that Thomas was not disabled, the ALJ, in accordance with the regulations, did not consider whether Thomas' substance abuse was a contributing factor. See 20 C.F.R. § 404.1535. She is entitled to no relief on this basis.
20 C.F.R. Pt. 404, Subpart P, Appendix 2, MEDICAL-VOCATIONAL GUIDELINES 200.00 Introduction (emphasis added). The ALJ found that Thomas could perform her past relevant work as a Duct Maker at step four of the sequential analysis, and the plaintiff does not challenge this finding. (R.26). The Medical-Vocational Guidelines become relevant at step 5 of the sequential analysis when the ALJ must determine whether the plaintiff can perform other work in the national economy. Because the ALJ concluded at step 4 that the plaintiff could return to her past relevant work, the Medical-Vocational Guidelines are not applicable to Thomas. See Phillips, 357 F.3d at 1242 ("The general rule is that after determining the claimant's RFC and ability or inability to return to past relevant work, the ALJ may use the grids to determine whether other jobs exist in the national economy that a claimant is able to perform.")
In response to hypothetical questions at the administrative hearing in this case, the VE testified that there were no jobs available in the national economy for someone with Thomas' functional limitations if her limitations also included functional limitations involving attendance problems or reflected in Dr. Lopez's opinion. (R. 70-73). In essence, Thomas argues that the ALJ erred by failing to credit Dr. Lopez's opinion in determining her functional capacity. It is clear from the context of the ALJ's opinion, and from the record as a whole, that the ALJ reviewed and considered all the medical evidence in the record in determining Thomas' RFC. To the extent that the plaintiff is arguing that the ALJ should have accepted her treating physicians' opinions regarding her psychiatric and attendance issues, as the court explained, the ALJ had good cause to discount their opinions. Thus, the ALJ was not required to include those limitations in her questions to the vocational expert. This court must accept the factual findings of the Commissioner if they are supported by substantial evidence and based upon the proper legal standards. Bridges v. Bowen, 815 F.2d 622 (11th Cir. 1987). The court has independently considered the record as a whole and finds that the record provides substantial support for the ALJ's conclusions. Consequently, the court concludes there was sufficient medical evidence before the ALJ from which she properly could made a residual functional capacity assessment.
(Doc. # 13 at 8). Thomas alleges no facts and points to no evidence in the record in support of her position that she became disabled between April 1, 2011 and September 30, 2011. The burden is on the plaintiff to demonstrate that the Commissioner's decision is not supported by substantial evidence, and the argument of counsel is insufficient to meet this burden. More importantly, however, the court has scoured the record for any evidence that might suggest that Thomas' condition worsened between April and September 2011, and has found none. She is entitled to no relief on this basis.
The existence of a Title XVI application for SSI benefits would not alter the analysis or the result in this case. See Sullivan v. Zebley, 493 U.S. 521, 525 n.3 (1990) ("The regulations implementing the Title II disability standard, 42 U.S.C. § 423(d) . . . and those implementing the identical Title XVI standard, § 1382c(a)(3) . . . are the same in all relevant respects. Compare 20 CFR §§ 404.1520-1530 with §§ 416.920-930 (1989)); Ware v. Schweiker, 651 F.2d 408 (5th Cir. 1981) (Unit A) ("To be entitled either to Social Security disability insurance benefits, 42 U.S.C.§ 423, or supplemental income benefits, 42 U.S.C. § 1382, a claimant must establish that she is disabled. The statutory test for each of these benefits is the same.").
At this juncture, any error was harmless because the ALJ considered the record as a whole, including all medical evidence, and determined that Thomas was not disabled. See Diorio v. Heckler, 721 F.2d 726, 728 (11th Cir. 1983) (applying harmless error analysis in the Social Security case context). See also Howard v. Soc. Sec. Admin., Comm'r., 566 F. App'x 784, 787 (11th Cir. 2014) ("even if the AC improperly failed to consider some of [the plaintiff's] additional evidence, any error was harmless because we have independently reviewed all submitted evidence.") The court is not required "to remand for express findings when doing so would be a "wasteful corrective exercise" in light of the evidence of record and when no further findings could be made that would alter the ALJ's decision." Sanchez v. Comm'r of Soc. Sec., 507 F. App'x 855, 856 (11th Cir. 2013). Because the ALJ concluded that Thomas was not entitled to disability benefits pursuant to Title II, she is also not eligible for supplemental social security income benefits under Title XVI.
"Even though Social Security courts are inquisitorial, not adversarial, in nature, claimants must establish that they are eligible for benefits." Ingram, 496 F.3d at 1269 (citing Doughty v. Apfel, 245 F.3d 1274, 1281 (11th Cir. 2001)). See also Holladay v. Bowen, 848 F.2d 1206, 1209 (11th Cir. 1988). This the plaintiff has failed to do. The court has carefully and independently reviewed the record and concludes that substantial evidence supports the ALJ's conclusion that plaintiff is not disabled.
Accordingly, it is the RECOMMENDATION of the Magistrate Judge that the decision of the Commissioner denying benefits to Thomas be AFFIRMED and that this case be DISMISSED with prejudice. Further, it is
Failure to file written objections to the proposed findings and recommendations in the Magistrate Judge's report shall bar the party from a de novo determination by the District Court of issues covered in the report and shall bar the party from attacking on appeal factual findings in the report accepted or adopted by the District Court except upon grounds of plain error or manifest injustice. Nettles v. Wainwright, 677 F.2d 404 (5th Cir. 1982). See Stein v. Reynolds Securities, Inc., 667 F.2d 33 (11th Cir. 1982). See also Bonner v. City of Prichard, 661 F.2d 1206 (11th Cir. 1981, en banc), adopting as binding precedent all of the decisions of the former Fifth Circuit handed down prior to the close of business on September 30, 1981.