VIRGINIA EMERSON HOPKINS, District Judge.
Plaintiff Teresa Hunter ("Hunter") 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 a period of disability, disability insurance benefits ("DIB"), and Supplemental Security Income ("SSI").
Hunter was forty-eight years old on her alleged onset date. (Tr. 173). She graduated from high school and attended college for two years (Tr. 71-72, 195). She previously worked as a home health aide. (Tr. 24, 59). After undergoing back surgery in July 2010, Hunter used donated leave and Family and Medical Leave Act from August 2010 to May 2011, and then leave without pay from May to September 2011, and resigned on September 21, 2011. (Tr. 225). Hunter alleged disability due to spinal fusion surgery and kidney stones. (Tr. 195). She alleged that she became disabled on July 13, 2010. (Tr. 175).
Hunter protectively filed applications for a period of disability, DIB, and SSI on September 17, 2010. (Tr. 9, 76-77). The Social Security Administration denied these applications on November 24, 2010. (Tr. 76-77). She timely requested and appeared at two hearings before an administrative law judge ("ALJ"), on March 12, 2012, and September 4, 2012. (Tr. 19, 48). The ALJ issued a decision, dated September 28, 2012, denying her application. (Tr. 6). The Appeals Council ("AC") denied Hunter's request for review on October 9, 2013. (Tr. 1-4).
Hunter filed a complaint with this court on November 25, 2013, seeking review of the Commissioner's determination. (Doc. 1). The Commissioner answered on March 21, 2014. (Doc. 9). Hunter filed a supporting brief (Doc. 12) on April 30, 2014, and the Commissioner responded with her own (Doc. 13) on June 4, 2014. Hunter then filed a reply brief on June 12, 2014. (Doc. 14).
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 define "disabled" as "the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve (12) months." 20 C.F.R. § 404.1505(a). To establish an entitlement to disability benefits, a claimant must provide evidence about a "physical or mental impairment" which "must result from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques." 20 C.F.R. § 404.1508.
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. Id.
After consideration of the entire record, the ALJ made the following findings:
(Tr. 15-21).
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)).
Hunter objects to the ALJ's findings on her RFC for two reasons. First, she argues that the ALJ failed to give proper weight to the opinion of her treating physician, Dr. Judy Travis. (Doc. 12 at 19). Second, she contends that the ALJ's decision to discredit her self-reported limitations was not supported by substantial evidence and incorrectly applied the Eleventh Circuit's pain standard. (Id. at 22).In its review, this court finds that the ALJ's decision was not supported by substantial evidence. Accordingly, the court remands the case for further development and consideration.
Hunter argues that the ALJ erred by giving little weight to the opinion of Dr. Travis, her treating physician. In March of 2012, Dr. Travis filled out a Physical Capacities Evaluation ("PCE"), where she opined that Hunter could sit for only two hours at a time and for a total of four hours per day,
The opinion of a treating physician "must be given substantial or considerable weight unless good cause is shown to the contrary." Phillips v. Barnhard, 357 F.3d 1232, 1240 (11th Cir. 2004) (quoting Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997)) (internal quotation marks omitted). "Good cause" exists when:
Id. at 1241 (citation omitted). When the ALJ adequately states specific reasons for disregarding a treating physician's opinion, and those reasons are supported by substantial evidence, there is no error. Moore v. Barnhart, 405 F.3d 1208, 1212-13 (11th Cir. 2005) (per curiam).
The ALJ gave little weight to Dr. Travis's opinion for two reasons. First, he focused on Dr. Travis's remark on the PCE that Hunter was reinjured in a motor vehicle accident in 2011. (Tr.13, 347). The ALJ wrote, "Where is the objective evidence of any motor vehicle accident? Where is the evidence as regards her injuries from said accident?" (Tr. 13). As a threshold matter, the court finds such a series of rhetorical questions to be a distinctly unclear way to critique Dr. Travis's opinion. More importantly, the
The second reason articulated by the ALJ is that Dr. Travis's opinion "is inconsistent with Dr. Travis's examinations of the claimant, which do not show any abnormalities." (Tr. 13). This reason is supported by the evidence of Dr. Travis's examinations. Her only extensive examination notes on record come from a DDS examination in November of 2010, approximately sixteen months before she filled out the CAP and PCE. (Tr. 320, 346, 348). The physical examination findings were all normal, save only for a "mildly reduced range of motion" in Hunter's neck. (Tr. 320-21). She diagnosed Hunter with "back pain with history of lumbar disk disease," and "renal calculi with intermittent flank pain." (Tr. 321). Dr. Travis's Opinion from this examination simply states, "Ms. Hunter is still recovering from surgery to her lumbar spine. She is not getting physical therapy. She complains of intermittent episodes of flank pain consistent with renal calculi." (Id.). Dr. Travis's later treatment records, from August of 2011 to March of 2012, are only bare-bones charts, with descriptions of her condition no longer than"neck and lower back discomfort." (Tr. 350-352). There are no findings from Dr. Travis on record that lend much support to her opinions in the CAP and PCE about Hunter's extensive limitations, and so the ALJ's decision to assign little weight to her opinions is supported by substantial evidence.
However, although the ALJ's decision to give little weight to the assessments of Dr. Travis was proper, his ultimate findings on Hunter's RFC are not supported by substantial evidence. Dr. Travis was the only physician to provide a medical source statement
The court finds McCright v. Colvin, 2014 WL 1513290 (N.D. Ala Aug. 6, 2014) persuasive on this issue. In McCright, the court reversed an ALJ who had assigned little weight to the only physician who had both evaluated the claimant and prepared a medical source statement. Id. at *3. To reach his RFC finding, the ALJ relied only upon the opinion of a reviewing physician, who had never examined the claimant. Id. The court held that opinion not to be substantial evidence for an RFC determination, particularly because it was contrary to the opinion of the treating physician. Id. (citing Shafarz v. Bowen, 825 F.2d 278 (11th Cir.1987) ("The opinions of nonexamining, reviewing physicians . . . when contrary to those of the examining physicians, are entitled to little weight, and standing alone do not constitute substantial evidence.")). Here, too, the ALJ was not justified in relying only on a nonexamining physician's opinion to arrive at an RFC finding.
Furthermore, the court in McCright concluded that the case was not one of the rare instances where the RFC is so apparent that the ALJ is justified in making a determination without support from a medical source statement. 2014 WL 1513290 at *6. Another case from this district has explained this rule, "An ALJ is allowed to make some judgments as to residual physical functional capacity where so little physical impairment is involved that the effect would be apparent to a lay person." Rogers v. Barnhart, No. 3:06-CV-0153-JFG, (Doc. 13 at 5) (N.D.Ala. Oct. 16, 2006); see also Manso-Pizarro v. Secretary of Health and Human Services, 76 F.3d 15, 17 (1st Cir. 1996) ("[W]here the medical evidence shows relatively little physical impairment, an ALJ permissibly can render a commonsense judgment about functional capacity even without a physician's assessment.").
In McCright, the court distinguished the case from an unpublished
Likewise, this case lacks facts like those that enabled the ALJ in Castle to make an RFC assessment on the basis of common sense, without a medical source statement. The record contains evidence that Hunter had received medical treatment for her back pain dating back to 2005, five years before her alleged onset date. (Tr. 278). Her reports of her daily activities state extensive limitations; they do not clearly indicate that she is able to do a light range of work. (Tr. 33-38, 41-43, 201-08). Nor is there any other evidence, such as a doctor's work release or a denial of symptoms that would normally accompany the alleged disability as in Castle, giving support for the ALJ's inference that she is capable of light work. Finally, having undergone surgery and years of medical treatment, Hunter's condition is not a simple one that an ALJ can evaluate without the benefit of a medical source statement.
In this case, the ALJ's disability determination is not supported by substantial evidence because there is not a medical opinion by an examining physician in support of the ALJ's RFC determination, nor other facts permitting a determination on the basis of his common sense. Without a proper basis in the record for the ALJ's opinion, the ALJ substituted his own opinion in making the RFC determination. Accordingly, under the circumstances of this case, the ALJ committed reversible error.
Based upon the court's evaluation of the evidence in the record and the parties' submissions, the court finds that the decision of the Commissioner is not supported by substantial evidence and that she did not apply proper legal standards in arriving at it. Accordingly, the decision will be reversed and remanded by separate order.
