VIRGINIA EMERSON HOPKINS, District Judge.
Plaintiff Tina K. Cook brings this action under 42 U.S.C. § 405(g), Section 205(g) of the Social Security Act. She seeks review of a final adverse decision of the Commissioner of the Social Security Administration ("Commissioner"), who denied her application for Disability Insurance Benefits ("DIB"). Ms. Cook timely pursued and exhausted her administrative remedies available before the Commissioner. The case is thus ripe for review under 42 U.S.C. § 405(g).
Ms. Cook was 44 years old at the time of her hearing before the Administrative Law Judge ("ALJ"). Tr. 117. She has a high school diploma and attended a few years of college. Tr. 130. Her past work experience includes employment as a machine operator, restaurant owner, and store manager. Tr. 149-156. She claims she became disabled on May 5, 2008, due to fibromyalgia and muscle connective tissue disorder in her legs. Tr. 125. Her last period of work ended on that same date. Id.
On February 23, 2009, Ms. Cook protectively filed a Title II application for a period of disability and DIB. Tr. 20. On April 14, 2009, the Commissioner initially denied these claims. Id. Ms. Cook timely filed a written request for a hearing on May 1, 2009. Id. The ALJ conducted a hearing on the matter on November 1, 2010. Id. On December 15, 2010, she issued her opinion concluding Ms. Cook was not disabled and denying her benefits. Tr. 20-30. Ms. Cook timely petitioned the Appeals Council to review the decision on February 1, 2011. Tr. 12. On August 8, 2012, the Appeals Council issued a denial of review on her claim. Tr. 1.
Ms. Cook filed a Complaint with this court on October 5, 2012, seeking review of the Commissioner's determination. Doc. 1. The Commissioner answered on January 9, 2013. Doc. 7. On March 25, 2013, the Commissioner filed a supporting brief. Doc. 9.
The court's review of the Commissioner's decision is narrowly circumscribed. The function of this court is to determine whether the decision of the Commissioner is supported by substantial evidence and whether proper legal standards were applied. Richardson v. Perales, 402 U.S. 389, 390 (1971); Wilson v. Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002). This court must "scrutinize the record as a whole to determine if the decision reached is reasonable and supported by substantial evidence." Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983). Substantial evidence is "such relevant evidence as a reasonable person would accept as adequate to support a conclusion." Id. It is "more than a scintilla, but less than a preponderance." Id.
This court must uphold factual findings that are supported by substantial evidence. However, it reviews the ALJ's legal conclusions de novo because no presumption of validity attaches to the ALJ's determination of the proper legal standards to be applied. Davis v. Shalala, 985 F.2d 528, 531 (11th Cir. 1993). If the court finds an error in the ALJ's application of the law, or if the ALJ fails to provide the court with sufficient reasoning for determining that the proper legal analysis has been conducted, it must reverse the ALJ's decision. Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991).
To qualify for disability benefits and establish his or her entitlement for a period of disability, a claimant must be disabled as defined by the Social Security Act and the Regulations promulgated thereunder.
The Regulations provide a five-step process for determining whether a claimant is disabled. 20 C.F.R. § 404.1520(a)(4)(i-v). The Commissioner must determine in sequence:
Pope v. Shalala, 998 F.2d 473, 477 (7th Cir. 1993) (citing to formerly applicable C.F.R. section), overruled on other grounds by Johnson v. Apfel, 189 F.3d 561, 562-63 (7th Cir. 1999); accord McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986). The sequential analysis goes as follows:
Pope, 998 F.2d at 477; accord Foote v. Chater, 67 F.3d 1553, 1559 (11th Cir. 1995). The Commissioner must further show that such work exists in the national economy in significant numbers. Foote, 67 F.3d at 1559.
After consideration of the entire record, the ALJ made the following findings:
Tr. 22-30.
The court may only reverse a finding of the Commissioner if it is not supported by substantial evidence. 42 U.S.C. § 405(g). "This does not relieve the court of its responsibility to scrutinize the record in its entirety to ascertain whether substantial evidence supports each essential administrative finding." Walden v. Schweiker, 672 F.2d 835, 838 (11th Cir. 1982) (citing Strickland v. Harris, 615 F.2d 1103, 1106 (5th Cir. 1980)).
Ms. Cook did not submit a brief outlining her arguments for reversal. Nevertheless, the court has exercised its duty to independently scrutinize the record. It finds that substantial evidence supports the Commissioner's factual findings and the Commissioner did not commit any legal errors in arriving at her conclusion that Ms. Cook was not disabled.
It is obvious, from her hearing testimony and from other parts of the record, that Ms. Cook disputes that she can return to work of any kind because of her fibromyalgia and associated pain in her extremities. See, e.g, Tr. 48-52. The court will thus analyze here the ALJ's conclusion that she still had the capacity to perform "light" work
Ms. Cook cites her considerable pain in supporting her disability claim. In her hearing testimony, she stated that the pain was "primarily" in her hips and legs and "occasionally" in her arms. Tr. 48. The pain allegedly manifested itself as "a burning pain all over," and it allegedly afflicted her every day. Id. She claimed she had relatively good days and bad days, however, and the bad days occurred roughly three days a week. Id. On those bad days, she stated that she lied down roughly six hours a day with a heating pad wrapped up in a blanket. Tr. 48-49. She scaled her pain during these times as "at least a seven or eight. It's like your body is on fire." Tr. 49. However, the pain was only at a four or five on the relatively "good" days. Id. The pain allegedly prevented her from many of her daily activities — like going outdoors, doing crafts, and sewing. Tr. 49-50. Also, she was unable to do household chores regularly. Tr. 50. The pain further caused her to inadvertently drop things she was holding. Id. According to Ms. Cook, she wouldn't be able to perform even a stationary job because she couldn't stand and look down for a long period of time. Id.
A claimant who seeks "to establish a disability based on testimony of pain and other symptoms" must show the following:
Wilson v. Barnhart, 284 F.3d 1219, 1225 (11th Cir. 2002) (citation omitted). An ALJ must articulate "explicit and adequate reasons" in order to discredit subjective testimony. Id. (citation omitted). Failure to do so "requires, as a matter of law, that the testimony be accepted as true." Id. (citation omitted). However, the ALJ does not need to "specifically refer to every piece of evidence in his decision," so long as the decision shows that the ALJ considered the claimant's medical condition as a whole. Dyer v. Barnhart, 395 F.3d 1206, 1211 (11th Cir. 2005) (citation omitted).
The ALJ here acknowledged that Ms. Cook had "some credible pain symptoms" from her severe impairments. Tr. 24. However, the ALJ was also explicit and persuasive in explaining why she did not find that the objective medical evidence substantiated Ms. Cook's allegations of "totally disabling" symptoms and limitations. Id. The ALJ based her conclusion on the following three foundations:
Id. The ALJ then elaborated by reviewing the medical record systematically. She highlighted a "Function Report" Ms. Cook filled out in March 2009. Tr. 25. In that report, Ms. Cook acknowledged performing personal care, doing routine household chores, driving, and shopping. Id. Ms. Cook further admitted to requiring reminders to take her pain medication, and she reported no problems paying attention or following instructions. Id.
The ALJ noted that Ms. Cook had suffered from bilateral ulnar nerve entrapment and had received treatment for it as far back as 2005. Id. In fact, she had undergone two procedures — in October 2005 and December 2007 — to address symptoms of this ailment in her right ulnar nerve and left elbow. Id. These procedures were reportedly successful, and a February 2008 EMG/NCS of Ms. Cook's upper-left extremity revealed no abnormalities. Id.
The ALJ also underscored several medical appointments Ms. Cook made after her alleged disability onset date. Id. During these visits, Ms. Cook variably complained to her physicians about fatigue, lightheadedness, foot swelling, aching/tingling in her legs, and respiratory problems. Id. The ALJ emphasized that, in each instance, physical examinations revealed Ms. Cook's condition to be unremarkable or otherwise without serious abnormalities. Tr. 25-26. On several occasions — such as in January 2009, October 2009, and December 2009 — Ms. Cook reported that she was doing well or that her medication was working. Tr. 26-27. After her physician performed a surgical procedure on her to address her cervical radiculopathy, she further reported in follow-up appointments in March, May, and June 2010 that she was doing "exceptionally well," that her physical activity was unencumbered, and that the procedure had "almost erased the neuropathic pain she had been having in her arms." Tr. 27. She did complain to her primary care physician in the spring and fall of 2010 regarding fibromyalgia-related pain in her hip and leg. Tr. 27-28. However, she reported to her rheumatologist that September that her medication was working well with her pain symptoms. Tr. 28.
The ALJ finally emphasized certain admissions Ms. Cook made in her hearing testimony. Ms. Cook acknowledged that she had no major problems with her neck since her surgery outside of "some lack of flexion." Id. She also admitted that "she was not under as much stress as she reported to her Rheumatologist in September 2010." Id. She further admitted having no issues with personal care. Id.
Altogether, the ALJ has articulated "explicit and adequate reasons" for discrediting Ms. Cook's claims of totally-disabling pain. The court further finds that substantial evidence supports the ALJ's conclusion that the objective medical evidence did not sustain the severity of Ms. Cook's alleged pain.
Social Security proceedings "are inquisitorial rather than adversarial." Sims v. Apfel, 530 U.S. 103, 110-11 (2000) (plurality opinion). The ALJ thus has the duty "to investigate the facts and develop the arguments both for and against granting benefits." Id. at 111 (citing Richardson v. Perales, 402 U.S. 389, 400-01 (1971)). The ALJ's "basic obligation to develop a full and fair record," Coward v. Schweiker, 662 F.2d 731, 735 (11th Cir. 1981), exists whether or not the applicant is represented. Brown v. Shalala, 44 F.3d 931, 934 (11th Cir. 1995) (citation omitted). When the claimant is unrepresented, however, the ALJ's duty is heightened. See Smith v. Schweiker, 677 F.2d 826, 829 (11th Cir. 1982). As the Commissioner notes, Ms. Cook was legally represented in his hearing below. Doc. 9 at 14 (citing Tr. 48). Thus, the ALJ had no special duty to "scrupulously and conscientiously probe into, inquire of, and explore for all relevant facts." Id. (quotation omitted).
The ALJ must specifically "develop the claimant's complete medical history for at least the 12 months preceding the month in which the application was filed, and to make every reasonable effort to help a claimant get medical reports from the claimant's own medical sources when permission is given." Robinson v. Astrue, 235 F. App'x 725, 727 (11th Cir. 2007) (unpublished) (citing 20 C.F.R. § 416.912(d)). The ALJ should re-contact medical sources when the evidence received from that source is inadequate to determine whether the claimant is disabled. See 20 C.F.R. §§ 404.1512(e), 416.912(e). "Nevertheless, the claimant bears the burden of proving that he is disabled, and, consequently, he is responsible for producing evidence in support of his claim." Ellison v. Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003) (per curiam) (citations omitted).
In arriving at her conclusion that Ms. Cook had the RFC to perform light work, the ALJ did not examine a medical source statement ("MSS") from either a treating or examining physician. Nor did the ALJ independently solicit a consultative examination from a qualified physician.
Neither omission was reversible error. An ALJ should order an MSS or a consultative examination "when such an evaluation is necessary for him to make an informed decision." Reeves v. Heckler, 734 F.2d 519, 522 n.1 (11th Cir. 1984) (citation omitted)). That is, such an assessment is essential when the record is otherwise underdeveloped. The court has already reviewed the meticulous analysis performed by the ALJ in this case. The ALJ did not encounter a claimant with an unexamined (or inadequately examined) collection of impairments. Rather, the ALJ confronted a "record contain[ing] sufficient evidence . . . to make an informed decision." Ingram v. Comm'r of Soc. Sec. Admin., 496 F.3d 1253, 1269 (11th Cir. 2007) (citation omitted). Ms. Cook — through her counsel — notably did not petition the ALJ for an MSS or a consultative examination. The ALJ therefore did not err in failing to obtain one unrequested by this represented claimant.
Neither did the ALJ reversibly err in the questions she directed to the vocational expert ("VE") who testified at Ms. Cook's hearing. In order for the testimony of a VE "to constitute substantial evidence, the ALJ must pose a hypothetical question which comprises all of the claimant's impairments." Wilson v. Barnhart, 284 F.3d 1219, 1227 (11th Cir. 2002) (per curiam) (citation omitted). In this case, the ALJ posed four hypothetical scenarios to the VE. She described the first scenario in the following way:
Tr. 53. In response to the VE's question concerning what she meant by "head movements," the ALJ elaborated, "Like having, having to do frequent up, down sort of as the claimant testified. She's not supposed to do looking up and looking down." Id. After the VE responded to that clarification, the ALJ then described the second hypothetical:
Id. After the VE responded to that hypothetical, the ALJ described the following scenario:
Tr. 54. Finally, the ALJ concluded with this scenario:
Tr. 55.
These hypothetical questions more than adequately spanned Ms. Cook's impairments. The ALJ progressively adjusted her various scenarios to accommodate the full range of Ms. Cook's possible restrictions. In fact, when asked by the VE to clarify her comment regarding head movement restrictions, the ALJ specified precisely how Ms. Cook's circumscribed neck flexion limited her functional capabilities. The ALJ also permitted Ms. Cook's attorney to ask a further hypothetical to the VE that reflected certain alleged limitations of Ms. Cook's that he evidently wanted to highlight. Altogether, the ALJ satisfied her duty to fully and fairly develop the record in this respect.
Based upon the court's evaluation of the evidence in the record and the parties' submissions, the court finds that the Commissioner's decision is supported by substantial evidence and that she applied proper legal standards in arriving at it. Accordingly, the court will affirm the decision by separate order.
20 C.F.R. § 404.1567(b).