VIRGINIA EMERSON HOPKINS, District Judge.
Plaintiff Veronica G. Coleman ("Ms. Coleman") 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. Coleman 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. Coleman was 50 years old at the time of her hearing before the Administrative Law Judge ("ALJ"). (Tr. 45). She has completed the twelfth grade. (Tr. 45). Her past work experience includes employment as a nurse assistant. (Tr. 70). She claims she became disabled on April 16, 2010 due to status post rotator cuff repair of the left shoulder, rotator cuff tear of the right shoulder, degenerative disc disease of the cervical spine, type II diabetes mellitus, and arterial hypertension. (Tr. 23). Her last period of work ended on April 15, 2010. (Tr. 195).
On July 10, 2011, Ms. Coleman protectively filed a Title II application for a period of disability and DIB. (Tr. 20). On September 13, 2011, the Commissioner initially denied these claims. Id. Ms. Coleman timely filed a written request for a hearing on September 21, 2011. Id. The ALJ conducted a hearing on the matter on January 23, 2013. Id. On April 24, 2013, he issued his opinion concluding Ms. Coleman was not disabled and denying her benefits. (Tr. 17). She timely petitioned the Appeals Council to review the decision on May 14, 2013. (Tr. 14-16). On August 5, 2014, the Appeals Council issued a denial of review on her claim. (Tr. 1-5).
Ms. Coleman filed a Complaint with this court on October 6, 2014, seeking review of the Commissioner's determination. (Doc. 1). The Commissioner answered on January 14, 2015. (Doc. 8). Ms. Coleman filed a supporting brief (Doc. 10) on February 27, 2015, and the Commissioner responded with her own (Doc. 11) on March 12, 2015. With the parties having fully briefed the matter, the court has carefully considered the record and affirms the decision of the Commissioner.
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. Id.
After consideration of the entire record, the ALJ made the following findings:
(Tr. 23-35).
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. Coleman objects to the ALJ's conclusion that she retains the residual functional capacity ("RFC") to perform work-related activities at the light level of exertion. She urges this court to reverse the Commissioner's decision to deny her benefits on the grounds that the ALJ's decision is not supported by substantial evidence because he did not properly evaluate the medical source opinions of Dr. Jeffrey Davis and Dr. Richard Rex Harris. (Doc. 10 at 8, 10). In the alternative, she requests that "her case be remanded for a full and proper consideration of the medical evidence of record, including the opinions of [her] treating physician, Dr. Davis, and the consultative physician, Dr. Harris." (Doc. 10 at 15).
Ms. Coleman argues that the evidence of record supports a more limited RFC based upon the severity of her pain and other subjective limitations, and that she would have been found disabled had the ALJ evaluated the examining physicians' opinions correctly. Id. at 9, 11. She also asserts that the ALJ had a duty to recontact the examining physicians. (Doc. 10 at 15). In its review, this court finds that the ALJ applied the correct legal standard and afforded the appropriate weight to the medical source opinions of Ms. Coleman's examining physicians. Substantial evidence supports the ALJ's conclusion that Ms. Coleman has a RFC to perform light work activity, and that she is not disabled given this RFC finding.
Ms. Coleman contends that the ALJ's decision is not based on substantial evidence because he failed to accord adequate weight to the opinion of treating physician, Dr. Jeffrey Davis. (Doc. 10 at 10). Ms. Coleman's argument triggers the treating physician's rule, requiring the opinions of Dr. Davis to "be given substantial or considerable weight unless `good cause' is shown to the contrary." Phillips v. Barnhart, 357 F.3d 1232, 1240 (11th Cir. 2003). Against this backdrop, the court sees no reversible error committed by the ALJ and finds the ALJ's RFC finding is consistent with the work-related limitations that Dr. Davis imposed taken as a whole.
Dr. Davis treated Ms. Coleman for a period between October 2010 and December 2011, during which he would assess Ms. Coleman's complaints, conduct physical examinations, and make recommendations about her functional capacity based upon his observations and objective medical evidence. On January 25, 2011, Dr. Davis placed Ms. Coleman at maximum medical improvement ("MMI") with a permanent partial impairment of "12% of the upper extremity, [and] 7% of the whole person." (Tr. 282). He then released Ms. Coleman to work "as per functional capacity evaluation done," referring to the limitations of her December 2010 functional capacity evaluation ("FCE").
Almost a year passed before Ms. Coleman returned to Dr. Davis's office on November 27, 2012. (Tr. 455-57). During that visit, he noted she experienced "left shoulder pain" and "cervical pain referred to [her] left shoulder." (Tr.455). He recommended "no change in date of [Ms. Coleman's] maximum medical improvement and permanent partial impairment." Id. Dr. Davis also recommended "no change in her work restrictions for her functional capacity evaluation," which was last assessed in October 2012 and reflected the ability to perform work at the light activity level.
The ALJ assigned "great weight" to Dr. Davis's opinion concerning Ms. Coleman's physical capacity, "given the nature and extent of his treating relationship." (Tr. 32). The ALJ reasoned that Dr. Davis's "opinions are well supported by, and not inconsistent with, the evidence of record as a whole." Id. However, the ALJ had "not given any weight" to Dr. Davis's assessment of Ms. Coleman's pain because he determined Dr. Davis's "opinions are based on a very intermittent treatment history, not a longitudinal history of ongoing pain problems sufficient to establish a disabling medical condition." Id. Ms. Coleman argues that the ALJ did not adequately weigh Dr. Davis's medical opinions because his treatment of Dr. Davis's assessment of her physical capacity was inconsistent with his treatment of Dr. Davis's assessment of her pain.
The court finds that any alleged error in the ALJ's assignment of weight to Dr. Davis's individual assessments constitutes harmless error, because it is evident from the ALJ's decision that he adopted Dr. Davis's opinion of Ms. Coleman's functional capacity in determining her RFC.
The ALJ's lack of clarity in his allocation of weight to Dr. Davis's opinions is cured by his analysis in determining the extent of Ms. Coleman's limitations, which was appropriately consistent with Dr. Davis's opinions. Dr. Davis recommended that Ms. Coleman return to work according to the limitations of her FCE, restricting her to light work activity.
Additionally, Ms. Coleman's allegations of pain have been accounted for through the ALJ's effective adoption of the opinions of Dr. Davis. Dr. Davis's reports note Ms. Coleman's complaints of pain, which demonstrate his consideration of her pain when making his recommendations. For example, Dr. Davis reviewed Ms. Coleman's December 2010 FCE in January of 2011 and noted in his report that "[t[he patient had some right hip and lower back pain during the testing."
Furthermore, Dr. Davis's FCEs factored in when Ms. Coleman limited herself in performing physical tasks and when she experienced pain performing these tasks.
Thus, notwithstanding the confusing language used by the ALJ about Dr. Davis's pain assessment, the ALJ properly considered Dr. Davis's medical evaluations in determining Ms. Coleman's RFC, and he applied the appropriate level of deference to these opinions. Further, in relying upon Dr. Davis's opinions, Dr. Davis's assessment of Ms. Coleman's pain was considered and credited indirectly in the ALJ's determination of her RFC. Any alleged error of the ALJ was harmless. Accordingly, consistent with the foregoing analysis, the ALJ appropriately evaluated and relied upon Dr. Davis's opinions about Ms. Coleman's functional capacity, and his disability decision is supported by substantial evidence.
Ms. Coleman also contends that the ALJ's decision is not based on substantial evidence because he failed to "properly evaluate and state the weight given to Dr. Harris'[s] significant opinion." (Doc. 10 at 12). She argues that, "[t]he ALJ's failure to provide proper analysis of how he reached his conclusion as to Dr. Harris'[s] opinion is cause for a reversal of the decision." Id.
Upon his examination of Ms. Coleman, Dr. Richard Rex Harris concluded that she had the ability to perform light to sedentary work activity. (Tr. 81) ("It is my medical opinion that this claimant is capable of light to sedentary work in the work place."). Although Dr. Harris's opinion partially supports the ALJ's RFC finding,
The Eleventh Circuit has held that the ALJ may properly discount a physician's opinion when the evidence supports a conclusion which differs from that physician's opinion. Bloodsworth v. Heckler, 703 F.2d 1233, 1240 (11th Cir. 1983) (citing Oldham v. Schweiker, 660 F.2d 1078, 1084 (5th Cir. 1981) ("[T]he Secretary may reject the opinion of any physician when the evidence supports a contrary conclusion."). However, the ALJ must "state with particularity the weight he gave the different medical opinions and the reasons therefor." Sharfarz v. Bowen, 825 F.2d 278, 279 (11th Cir. 1987) (citing MacGregor v. Bowen, 976 F.2d 1050, 1053 (11th Cir. 1986)).
In his decision, the ALJ did not afford "controlling weight" to the medical source opinion of Dr. Harris. (Tr. 33). He determined that Dr. Harris's opinions "appear to be inconsistent with his own clinical findings of record and largely based upon [Ms. Coleman's] subjective allegations, which are not credible." Id. This court finds that the ALJ's assignment of the weight attributed to Dr. Harris's medical opinion is adequate, and that his conclusion to not give Dr. Harris's opinion controlling weight was supported by substantial evidence.
The record supports the ALJ's reasoning that Dr. Harris's medical source opinion contained inconsistencies with his own clinical evidence. Dr. Harris opined that Ms. Coleman could only occasionally reach, handle, finger, feel, and push and pull. (Tr. 34). However, he notes in his report that she has full range of motion of her neck, shoulders, arms, wrists and fingers, and that she can open and close doors, and button and unbutton her clothing.
Furthermore, Social Security regulations specifically direct the ALJ to consider the extent to which a medical opinion is consistent with other evidence in the record. 20 C.F.R. § 404.1527(c)(4) ("Generally, the more consistent an opinion is with the record as a whole, the more weight we will give to that opinion."). The ALJ's conclusion that Ms. Coleman had the RFC to perform light work activity was supported by the opinion of Ms. Coleman's treating physician, Dr. Davis. As discussed previously, Dr. Davis's opinion is consistent with the objective medical evidence provided by the FCEs Ms. Coleman participated in as well as diagnostic medical imaging.
On the other hand, Dr. Harris came to the conclusion that Ms. Coleman had a more restrictive ability to perform work-related activity based upon his single examination of her on August 24, 2012.
Thus, the ALJ afforded proper weight and provided adequate analysis of consulting physician Dr. Harris's medical opinion, and his conclusions regarding Dr. Harris's opinion are supported by substantial evidence. Therefore, a reversal of the ALJ's decision as requested by Ms. Coleman is not in order and remand for further consideration of Dr. Harris's medical opinion is unnecessary.
Ms. Coleman also requests that her case be remanded for further development of the record and consideration because, she contends, the ALJ had a duty to recontact Dr. Davis and Dr. Harris to clarify their medical source opinions. Ms. Coleman argues that the ALJ was required under SSR 96-5p
Under Social Security Regulations, the ALJ makes a disability determination based on what the record shows, and will consider the consistency and sufficiency of the evidence in doing so. If evidence is inconsistent, the ALJ will "weigh the relevant evidence" to reach a disability decision using the information contained in the record. 20 C.F.R. § 404.1520b(b). If the evidence in the record is insufficient, or after weighing inconsistent evidence the ALJ "determine[s] [h]e cannot reach a conclusion about whether [the claimant is] disabled," the ALJ may recontact a physician for additional information. 20 C.F.R. § 404.1520b(c).
In the Eleventh Circuit, a court determining whether a duty to recontact a medical source arises is guided by "whether the record reveals evidentiary gaps which result in unfairness or clear prejudice." Couch v. Astrue, 267 F. App'x 853, 855 (11th Cir. 2008) (quoting Brown v. Shalala, 44 F.3d 931, 935 (11th Cir. 1995). "The likelihood of unfair prejudice may arise if there is an evidentiary gap that `the claimant contends supports [his] allegations of disability.'" Couch, 267 F. App'x at 855 (quoting Brown, 44 F.3d at 936 n.9).
The record reflects that the duty to recontact did not arise here. While the record may contain some inconsistent information, in particular between the opinions provided by Drs. Davis and Harris, and within Dr. Harris's report and clinical notes, the record does not indicate that the medical sources were in control of additional records that would clarify any inconsistencies. Overall, the record contained substantial evidence supporting the ALJ's disability determination.
It appears that the ALJ was in possession of all of Dr. Davis's medical records, and the information contained therein was adequate to enable the ALJ to determine that Ms. Coleman was not disabled. Any inconsistencies the ALJ would have found in the evidence from Dr. Davis would have been cured by the ALJ's adoption of Dr. Davis's conclusions regarding Ms. Coleman's functional capacity. The ALJ did not simply "dismiss this opinion," but factored in any of Dr. Davis's determinations pertaining to Ms. Coleman's physical abilities and pain through his acceptance of Dr. Davis's recommendations for Ms. Coleman's work restrictions. Therefore, there was no need for additional information or clarification from Dr. Davis.
Furthermore, the ALJ applied the proper weight to Dr. Harris's medical opinion, and made his disability determination accordingly. As explained above, the ALJ adopted Dr. Davis's opinion, and Dr. Harris's statements actually partially corroborated this opinion. Dr. Harris indicated Ms. Coleman could perform light to sedentary work activity, while Dr. Davis indicated she could perform light work activity. The ALJ applied the appropriate relative weight between these two physicians, given that Dr. Davis was Ms. Coleman's treating physician and Dr. Harris was simply a consulting physician. Additionally, the record contained Dr. Harris's clinical notes. These notes provided the necessary information for the ALJ to find that Ms. Coleman could perform light work activity, the less restrictive level of work activity Dr. Harris stated Ms. Coleman could perform.
After properly weighing the relevant evidence from Ms. Coleman's medical sources, the ALJ found that he could make a disability determination despite these inconsistencies. Therefore, remand for further development of the record is not necessary. The record contains sufficient evidence for the ALJ to make an informed determination as to whether Ms. Coleman is disabled.
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 supported by substantial evidence and that she applied proper legal standards in arriving at it. Accordingly, the decision will be affirmed by separated order.
