JOHN E. OTT, Chief Magistrate Judge.
Plaintiff Jacqueline Deloris McKeller brings this action pursuant to 42 U.S.C. § 405(g), seeking review of the final decision of the Acting Commissioner of Social Security ("Commissioner") denying her applications for disability insurance benefits and Supplemental Security Income ("SSI"). (Doc. 1).
In January 2011, McKeller filed applications for disability insurance benefits and SSI, alleging disability beginning December 10, 2010. (R. 180-88).
McKeller requested the Appeals Council to review the ALJ's decision. (R. 30). The Appeals Council denied McKeller's request for review on May 7, 2014. (R. 1-5). On that date, the ALJ's decision became the final decision of the Commissioner. McKeller then filed this action for judicial review under 42 U.S.C. § 405(g). (Doc. 1).
The court's review of the Commissioner's decision is narrowly circumscribed. The function of the 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, 91 S.Ct. 1420, 1422 (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.
The 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. See Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991).
To qualify for disability benefits and SSI under the Social Security Act, a claimant must show the inability to engage in "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 12 months." 42 U.S.C. § 423(d)(1)(A); 42 U.S.C. § 1382c(a)(3)(A). A physical or mental impairment is "an impairment that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques." 42 U.S.C. § 423(d)(3); 42 U.S.C. § 1382c(a)(3)(D).
Determination of disability under the Social Security Act requires a five step analysis. 20 C.F.R. §§ 404.1520(a)(4) and 416.920(a)(4). Specifically, the Commissioner must determine in sequence:
Evans v. Comm'r of Soc. Sec., 551 F. App'x 521, 524 (11th Cir. 2014)
McKeller was 36 years old at the time of her hearing before the ALJ. (R. 66). She has a high school equivalency degree and past relevant work experience as a server and waitress, counter attendant, fast food worker, housekeeper, and kitchen helper. (R. 67, 90-91). She alleges in her disability report that she has been unable to work since December 10, 2010, due to carpal tunnel syndrome in both wrists and grogginess from her medications. (R. 232).
The ALJ found that McKeller had severe impairments of carpal tunnel syndrome and arthritis, but that her impairments, alone and in combination, did not meet or medically equal the severity of one of the listed impairments in the Listings.
The ALJ then found that McKeller had the residual functional capacity
Premised on the testimony of the VE, the ALJ determined that McKeller could perform her past relevant work as a server, counter attendant, fast food worker, and housekeeper. (R. 52, 90-92). Alternatively, the ALJ found that there are other jobs in the national economy that McKeller is capable of performing. (R. 52-53, 92-93). The ALJ thus concluded that McKeller was not disabled. (R. 53-54).
McKeller argues that the Commissioner's decision is not supported by substantial evidence and should be reversed or remanded for two reasons. First, McKeller argues that the ALJ failed to give adequate weight to the opinion of one of her treating physicians, Dr. Cynthia Mouton, who stated in a treatment note that McKeller had many reasons to be depressed and is disabled due to carpal tunnel syndrome. (Doc. 10 at 9-10). Second, McKeller argues that the ALJ failed to properly evaluate the opinions of Dr. John Goff, a consultative psychologist who examined her in April 2012. (Doc. 10 at 10-12). The Commissioner responds that the ALJ properly considered the opinions of the medical sources who treated and examined McKeller and that substantial evidence supports the ALJ's decision. (Doc. 11 at 4-16).
Dr. Mouton examined McKeller on November 23, 2011.
"Absent good cause, an ALJ is to give the medical opinions of treating physicians substantial or considerable weight."
First, as the ALJ noted in her decision, an opinion from a physician that a claimant is "disabled" is not a medical opinion; it is an opinion on an issue reserved to the Commissioner. (R. 51); see 20 C.F.R. §§ 404.1527(d), 416.927(d); Eyre v. Comm'r, Soc. Sec. Admin., 586 F. App'x 521, 523 (11th Cir. 2014) ("[T]he ALJ, not a claimant's physician, is responsible for determining whether a claimant is statutorily disabled."). Such an opinion is not entitled to "any special significance." 20 C.F.R. §§ 404.1527(d), 416.927(d); see Social Security Ruling (SSR) 96-5p, 1996 WL 374183, *5 (July 2, 1996) ("Medical sources often offer opinions about whether an individual who has applied for . . . disability benefits is `disabled' or `unable to work,' or make similar statements or opinions. . . . Such opinions on these issues must not be disregarded. However, even when offered by a treating source, they can never be entitled to controlling weight or given special significance."). Therefore, as the ALJ correctly observed, Dr. Mouton's statement that McKeller is "disabled" was not entitled to any special significance.
Second, "[d]isability is determined by the effect an impairment has on the claimant's ability to work, rather than the diagnosis of an impairment itself." Davis v. Barnhart, 153 F. App'x 569, 572 (11th Cir. 2005); see 42 U.S.C. § 423(d)(1)(A) ("The term `disability' means inability to engage in substantial gainful activity by reason of any medically determinable physical or mental impairment. . . ."). Here, Dr. Mouton stated that McKeller is disabled due to carpal tunnel syndrome, but did not explain how the carpal tunnel syndrome affects or limits McKeller's ability to work. In fact, nowhere in Dr. Mouton's treatment notes did she offer any opinion on what McKeller can and cannot in light of her carpal tunnel syndrome. Dr. Mouton's mere diagnosis that McKeller suffers from carpal tunnel syndrome, without any corresponding assessment of how the impairment impacts her ability to work, is insufficient to establish that McKeller is disabled.
Third, Dr. Mouton provided no explanation for her statement that McKeller is disabled due to carpal tunnel syndrome and failed to cite the medical evidence supporting her statement. "A treating physician's report may be discounted when it is not accompanied by objective medical evidence or is wholly conclusory." Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1159 (11th Cir. 2004) (citation and internal quotation marks omitted); see also 20 C.F.R. §§ 404.1527(c)(3), 416.927(c)(3) ("The more a medical source presents relevant evidence to support an opinion, particularly medical signs and laboratory findings, the more weight we will give that opinion. The better an explanation a source provides for an opinion, the more weight we will give that opinion."). Here, as noted, Dr. Mouton made the conclusory statement that McKeller is "disabled due to CTS" in her comments on why McKeller had reasons to be depressed, not in her separate comments on McKeller's carpal tunnel syndrome. (R. 707-08). Nowhere in her notes on McKeller's carpal tunnel syndrome did Dr. Mouton opine that McKeller is disabled from that ailment or unable to perform any work-related activities. Moreover, Dr. Mouton made the statement that McKeller is "disabled due to CTS" without any further explanation. She did not explain how her medical findings established that McKeller is disabled, particularly her findings that McKeller had "weakness" and "moderately reduced" range of motion in her right hand and "weakness" and "decreased" range of motion in her left hand. (R. 707). Dr. Mouton also failed to explain how McKeller's "resistan[ce] to non-medical or surgical options presented" impacted her opinion. Given the absence of any explanation for her statement that McKeller is disabled due to carpal tunnel syndrome, and given that Dr. Mouton made the statement in the context of her comments on McKeller's depression, the ALJ was more than warranted in discounting Dr. Mouton's opinion.
Fourth, an ALJ has good cause for discounting a treating physician's opinion when the opinion is not bolstered by the evidence or when the evidence supports a contrary finding. Eyre, 586 F. App'x at 523; Winschel v. Comm'r of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011). Dr. Mouton's statement that McKeller is disabled due to carpal tunnel syndrome is not bolstered by the evidence in the record, which the ALJ thoroughly discussed in her decision. (R. 47-52). Rather, the evidence, including Dr. Mouton's own medical findings, supports the contrary finding made by the ALJ. As the ALJ noted, neither Dr. Bryan Givhan, McKeller's neorosurgeon, nor Dr. Thomas Patton, McKeller's neurologist, placed any restrictions on McKeller's ability to work. (R. 51). As the ALJ further noted:
(R. 48 (exhibit citations omitted)).
For all of the foregoing reasons, the ALJ had good cause to discount Dr. Mouton's opinion and to give the opinion little weight. Substantial evidence supports the ALJ's decision.
Dr. Goff, a consultative psychologist, examined McKeller on April 6, 2102. (R. 695-700). Dr. Goff determined that McKeller was "functioning within the borderline to low average range of psychometric intelligence"; that she was "functionally literate"; that she was "very suspicious and paranoid and [that] there may have been a decompensation in the past"; and that her "verbal memory appears to be relatively poor." (R. 700). His diagnosis included personality disorder not otherwise specified, with borderline and paranoid features. (Id.) He commented that McKeller's personality disorder "seems to be the most obvious impediment to vocational activity in general."
Dr. Goff also completed a Medical Source Statement (Mental) on McKeller. (R. 701-03). Among other assessments, Dr. Goff determined that McKeller has a "marked" degree of impairment in her ability to interact with the general public; an "extreme" degree of impairment in her ability to get along with coworkers or peers; an "extreme" degree of impairment in her ability to maintain attention and concentration for extended periods; a "marked" degree of impairment in her ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; a "marked" degree of impairment in her ability to make simple work-related decisions; a "marked" degree of impairment in her ability to respond appropriately to supervision; and an "extreme" degree of impairment in her ability to respond to normal work pressures." (Id.) At the same time, he determined that McKeller has only a "mild" degree of impairment in her ability to ask simple questions or request assistance; a "mild" degree of impairment in her ability to understand, remember, and carry out simple instructions and a "moderate" degree of impairment in her ability to understand, remember, and carry out complex instructions and repetitive tasks; a "mild" degree of impairment in her ability to sustain a routine without special supervision; and a "mild" degree of impairment in her ability to respond appropriately to changes in the work setting. (Id.)
Because Dr. Goff was not one of McKeller's treating medical sources and examined McKeller only once, his opinions were not entitled to any deference. See Eyre, 586 F. App'x at 523 ("The ALJ owes no deference to the opinion of a physician who conducted a single examination: as such a physician is not a treating physician."). The ALJ "carefully considered but placed only minimal weight" on Dr. Goff's opinions, concluding that they were "wholly inconsistent with the evidence when considered in its entirety." (R. 44). McKeller argues that "the ALJ's conclusions do not withstand scrutiny; there are indications of mental impairment in the evidence of record, including the opinion of . . . Dr. Mouton, who concluded that [McKeller] was disabled due to depression." (Doc. 10 at 12). McKeller contends that "for failing to properly evaluate and state the weight given to Dr. Goff's opinion[s], the ALJ's decision cannot be based upon substantial evidence." (Doc. 10 at 13). Again, McKeller's contention lacks merit.
The court first notes that McKeller did not allege that her ability to work was limited by any mental impairment in her disability report. (See R. 232). In addition, as the ALJ observed in her decision, "no allegations of psychiatric and/or psychological symptoms were . . . alleged by the claimant at the hearing until [her] attorney posed a hypothetical question to the vocational expert based on Dr. Goff's report." (R. 44). Indeed, when the ALJ completed her examination of McKeller at the hearing, the ALJ specifically asked McKeller whether there were "[a]ny other problems" that were keeping her from working apart from the physical problems she had testified to, and McKeller responded, "That would be it." (R. 89-90).
Moreover, although McKeller asserts that there are "indications of mental impairment in the evidence of record," the only evidence she cites is Dr. Mouton's statement that she has "many reasons to be depressed," which McKeller mischaracterizes as a conclusion that she is "disabled due to depression." (Doc. 10 at 12). As previously noted by the court, Dr. Mouton never stated that McKeller is disabled due to depression, and McKeller herself denied being depressed. (R. 706, 708).
Finally, the ALJ provided a thorough discussion of the reasons why she accorded Dr. Goff's opinions minimal weight:
(R. 44-45 (exhibit citation omitted)).
The Commissioner determined that McKeller was not disabled under the Social Security Act. For the reasons set forth above, the undersigned concludes that the Commissioner's decision is due to be