VIRGINIA EMERSON HOPKINS, District Judge.
Plaintiff Tommy Tucker ("Mr. Tucker") brings this action under 42 U.S.C. § 405(g), Section 205(g) of the Social Security Act. Mr. Tucker seeks review of a final adverse decision of the Commissioner of the Social Security Administration ("Commissioner"), who denied his application for Disability Insurance Benefits ("DIB"). Mr. Tucker timely pursued and exhausted his administrative remedies available before the Commissioner. The case is thus ripe for review under 42 U.S.C. § 405(g).
Mr. Tucker was 49 years old at the time of his hearing before the Administrative Law Judge ("ALJ"). (Tr. 29, 133). He has completed the 9th grade. (Tr.153). His past work experience includes employment as a tree trimmer and supervisor of tree trimming. (Tr. 49, 153). Mr. Tucker maintains that he became disabled on March 1, 2008, due to a fall from a tree in the course of his employment as a tree trimmer. (Tr. 149, 217-19).
On February 14, 2012, Mr. Tucker protectively filed a Title II application for a period of disability and DIB. (Tr. 54). On May 3, 2012, the Commissioner initially denied this claim. (Tr. 63). Mr. Tucker timely filed a written request for a hearing on May 15, 2012. (Tr. 73). The ALJ conducted a hearing on the matter on June 6, 2013. (Tr. 21). On August 15, 2013, she issued her opinion concluding Mr. Tucker was not disabled and denying him benefits. (Tr. 29). Mr. Tucker timely petitioned the Appeals Council to review the decision on October 15, 2013. (Tr. 16-17). On February 26, 2015, the Appeals Council denied review. (Tr. 1-6). Accordingly, the ALJ's denial of Mr. Tucker's DIB claim became the Commissioner's final decision.
Mr. Tucker filed a Complaint with this court on April 14, 2015, seeking review of the Commissioner's determination. (Doc. 1). The Commissioner answered on September 24, 2015. (Doc. 9). Mr. Tucker filed a supporting brief (Doc. 12) on November 2, 2015, and the Commissioner responded with her own (Doc. 13) on December 1, 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. 23-29).
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)).
Mr. Tucker urges the court to reverse the Commissioner's decision to deny his benefits, claiming that the ALJ committed reversible error by not applying the proper legal standards and not supporting her decision with substantial evidence. (Doc. 12 at 7). More specifically, Mr. Tucker argues that the ALJ failed to correctly address his venous insufficiency
On March 17, 2012, Dr. Mali conducted a consultative examination of Mr. Tucker at the request of the Social Security Administration. (Tr. 223-28). In the post-examination written report provided by Dr. Mali, he opined multiple times that Mr. Tucker suffered from moderate to severe venous insufficiency.
In addition to the consultative examination conducted by Dr. Mali, Mr. Tucker's medical file was reviewed by Robert Mogul, M.D. ("Dr. Mogul"), a State agency physician. (Tr. 26). Based upon his paper review, Dr. Mogul completed a physical residual functional capacity assessment of Mr. Tucker on July 18, 2012. (Tr. 238-244). Within this report, Dr. Mogul specifically noted Mr. Tucker's moderate to severe venous insufficiency diagnosed by Dr. Mali. (Tr. 240). The ALJ assigned "significant weight" to Dr. Mogul's opinion as "consistent with the objective medical evidence." (Tr. 26).
Mr. Tucker maintains that the ALJ committed legal error when she omitted any discussion of Dr. Mali's diagnosis of Mr. Tucker's venous insufficiency as a severe (or non-severe) impairment from her disability decision. (Doc. 12 at 7-11); (see also Tr. 23 (listing Mr. Tucker's severe impairments without including venous insufficiency)). Instead, the ALJ only expressly mentioned this condition in her summary of Dr. Mali's medical findings. (See Tr. 26 ("He had `fairly significant venous insufficiency.'")).
Mr. Tucker cites to several binding and persuasive authorities in support of his position that reversible error occurred. The binding opinions include Brady v. Heckler, 724 F.2d 914 (11th Cir. 1984), McDaniel v. Bowen, 800 F.2d 1026 (11th Cir. 1986), Hillsman v. Bowen, 804 F.2d 1179 (11th Cir. 1986), and Flynn v. Heckler, 768 F.2d 1273 (11th Cir. 1985). (Doc. 12 at 8). The persuasive decisions are Williams v. Barnhart, 186 F.Supp.2d 1192 (M.D. Ala. 2002) and Ashford v. Barnhart, 347 F.Supp.2d 1189 (M.D. Ala. 2004). The court discusses these authorities in more detail below.
In McDaniel, the ALJ classified none of the claimant's impairments as severe and terminated the process at step two. In reversing the district court that had affirmed the ALJ's denial of disability, the McDaniel court discussed the Brady decision (another step two appeal) and provided clarification concerning step two of the disability evaluation:
724 F.2d at 920. We concluded that, under this newly articulated standard, the Secretary's finding that Brady was not suffering from a severe impairment was not supported by substantial evidence. From representations by counsel during argument on this appeal, it appears that uncertainty persists about the Brady analysis of step two. We attempt here to clarify.
McDaniel, 800 F.2d at 1031 (emphasis added).
The McDaniel panel further explained:
McDaniel, 800 F.2d at 1031 (footnote omitted).
The other binding opinions relied upon by Mr. Tucker similarly involve disability denials that end at step two. See Hillsman, 804 F.2d at 1180 ("The Administrative Law Judge who reviewed her case determined that appellant did not have a `severe impairment' as required by 20 C.F.R. § 404.1520(c) (1986)."); Flynn, 768 F.2d at1275 ("Had the Administrative Law Judge had benefit of our opinion in Brady, we believe he would of necessity have concluded that the threshold showing of a `severe impairment' was made."). Because Mr. Tucker's disability claim proceeded past step two, his case is significantly different procedurally than these binding cases upon which he relies.
Mr. Tucker's persuasive authorities from the Middle District of Alabama, however, are more closely on point. For example, in Williams, the ALJ proceeded past step two with
Williams, 186 F. Supp. 2d at 1198 (emphasis added).
Ashford involved an appeal of a disability reevaluation in which the claimant was determined no longer to be disabled. 347 F. Supp. 2d at 1190. The ALJ found the claimant to have the severe impairments of "schizoaffective disorder, provisional; borderline intellectual functioning, degenerative joint disease, hypertension, and obesity, id. at 1192, but did not discuss the severity of her documented condition of bipolar disorder and only mentioned it as an alleged impairment. Id. at 1194. In reversing and remanding, the district court reasoned concerning this assignment of error:
Ashford, 347 F. Supp. 2d at 1194 (emphasis added).
Here, the record is comparable to Williams and Ashford, as Mr. Tucker's moderate to severe venous insufficiency is a documented condition confirmed by Drs. Mali and Mogul that the ALJ mentions in summarizing Dr. Mali's findings, but never discusses as part of her step two analysis.
In responding to these cases, the Commissioner cites to Jamison v. Bowen, 814 F.2d 585 (11th Cir. 1987), and suggests that no reversible error has occurred because the ALJ found other severe impairments and proceeded past step two. (Doc. 13 at 12) More specifically, the Commissioner indicates that, under Jamison, "the finding of any severe impairment . . . is enough to satisfy the requirement of step two." 814 F.2d at 588 (emphasis added) (citing Brady v. Heckler, 724 F.2d 914, 920 (11th Cir. 1984)).
The Commissioner also relies on the unpublished decision of Delia v. Comm'r of Soc. Sec., 433 F. App'x 885, in which a mistake made by the ALJ at step two was determined to be harmless error:
Delia, 433 F. App'x at 887 (emphasis added).
The Commissioner additionally relies upon Heatly v. Comm'r of Soc. Sec., 382 F. App'x 823 (11th Cir. 2010), another harmless error case:
Heatly v. Comm'r of Soc. Sec., 382 F. App'x at 824-25 (footnotes omitted) (emphasis added).
The Commissioner further argues that, because the ALJ indicated that her RFC determination must include consideration of both severe and non-severe impairments (Tr. 22), "[t]his is sufficient to show that, at the remaining steps of the sequential evaluation process, the ALJ considered the combined effect of Plaintiff's impairments on Plaintiff's ability to work." (Doc. 13 at 13 (citing Wilson v. Barnhart, 284 F.3d 1219, 1224 (11th Cir. 2002) ("The ALJ's determination constitutes evidence that he considered the combined effects of Wilson's impairments.")).
Against this backdrop, the court is persuaded to follow the Commissioner's collection of cases in the context of this case and conclude that any step two error committed by the ALJ concerning Mr. Tucker's diagnosis of venous insufficiency was harmless. In particular, Mr. Tucker has not shown how failing to specifically identify venous insufficiency as a severe condition at step two (or as a non-severe condition later in the process) resulted in the ALJ's arriving at a materially less restrictive RFC determination for him. Cf. Moore v. Barnhart, 405 F.3d 1208, 1213 n.6 (11th Cir. 2005) ("To a large extent, Moore questions the ALJ's RFC determination based solely on the fact that she has varus leg instability and shoulder separation."); id. ("However, the mere existence of these impairments does not reveal the extent to which they limit her ability to work or undermine the ALJ's determination in that regard. (citing McCruter v. Bowen, 791 F.2d 1544, 1547 (11th Cir. 1986))). Importantly, the ALJ primarily relied upon Dr. Mogul's physical capacity assessment when formulating Mr. Tucker's RFC and Dr. Mogul's opinion that Mr. Tucker could perform a limited range of light work expressly included moderate to severe venous insufficiency as a relevant underlying impairment.
Additionally, the ALJ ultimately determined Mr. Tucker's RFC to be sedentary with restrictions after partially crediting Mr. Tucker's subjective allegations:
Mr. Tucker also assigns error because the ALJ did not order additional medical testing. (Doc. 12 at 7). More specifically, Mr. Tucker claims that it was a reversible error not to develop the record further based on Dr. Mali's observation that Mr. Tucker "would benefit . . . [from] hav[ing] EMG nerve conduction studies of his right foot, given his history of trauma and surgery to rule out any possible nerve injury that could have occurred." (Tr. 228). However, the ALJ assessed Mr. Tucker's medical history, including opinions from several medical professionals, as well as Mr. Tucker's own, subjective assessment of his capabilities in deciding Mr. Tucker's RFC. This court finds that due to the relative simplicity of Mr. Tucker's medical record, additional medical testing was not needed and, thus, no reversible error occurred. Cf. Manso-Pizarro v. Sec'y of Health & Human Servs., 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.").
The ALJ has a duty to sufficiently develop the record when making her RFC calculation, including "when the evidence as a whole is insufficient to allow [the Commissioner] to make a determination or decision on [the] claim." 20 C.F.R § 404.1519a(b); see Reeves v. Heckler, 734 F.2d 519, 522 n.1 (11th Cir. 1984) ("It is reversible error for an ALJ not to order a consultative examination when such an evaluation is necessary for him to make an informed decision."). Whether the ALJ is obligated to order an additional medical examination depends on the circumstances of each case and the caliber of the evidence already available. See 20 C.F.R § 404.1545(a)(3) ("We will assess your [RFC] based on all of the relevant medical and other evidence").
Additionally, an ALJ is ultimately responsible for the RFC, which is an administrative finding, not a medical evaluation. See 20 C.F.R § 404.1527(e)(2) ("Although we consider opinions from medical sources on issues such as . . . your [RFC] . . . the final responsibility for deciding these issues is reserved to the Commissioner."). Although medical evaluations about a claimant's RFC are often valuable, they are not required when making an RFC finding. See Langley v. Astrue, 777 F.Supp.2d 1250, 1258 (N.D. Ala. 2011) ("[T]he court concludes that the law of this circuit does not required [sic] an RFC from a physician."); see also Green v. Social Security Admin. 223 F. App'x 915, 922-24 (11th Cir. 2007) (ruling that an ALJ's RFC can be substantially supported when it disregards the only medical evaluation made by a doctor); Castle v. Colvin, 557 F. App'x 849, 853 (11th Cir. 2014) ("The ALJ discredited [claimant's subjective complaints of pain] by explaining that this pain had not require[d] routine or consistent treatment, and [the claimant] often went for months or years between complaining of this pain to his physicians.") (citing Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005))).
The Eleventh Circuit has afforded significant latitude to the ALJ in determining whether additional medical evidence is needed to make an informed RFC determination: the ALJ "has a duty to develop the record where appropriate but is not required to order a consultative examination as long as the record contains sufficient evidence for the [ALJ] to make an informed decision." Ingram v. Comm'r of Soc. Sec. Admin., 496 F.3d 1253, 1269 (11th Cir. 2007) (citing Doughty v. Apfel, 245 F.3d 1274, 1281 (11th Cir. 2001) (citation omitted))). The ALJ is thus expected to interpret the totality of the record, including any available medical information, and may use her judgment as to whether an additional medical examination is required.
It is clear from this record that the ALJ did not engage in reversible error here because she sufficiently looked at the totality of the evidence in making her RFC determination. The ALJ relied heavily upon Dr. Mogul's physical capacities assessment of Mr. Tucker. Dr. Mogul reviewed Mr. Tucker's medical record, including his right foot impairment and determined that Mr. Tucker was capable of performing a reduced range of light work. (Tr. 238-44). The ALJ gave partial credence to Mr. Tucker's complaints of right foot pain in further reducing his vocational capabilities to sedentary work. (Tr. 24, 27). In addition, the ALJ took note of Mr. Tucker's assessment of his own abilities (such as washing dishes, bathing, mopping, vacuuming, driving, and managing personal care as reported to Dr. Mali) in discounting the degree of debilitating pain and other subjective symptoms claimed by Mr. Tucker elsewhere in the record. (Tr. 27, 225); (see also Tr. 167 (describing daily activities as "go to store, pick up around the house, ride around in my truck, go to my mother's."); (Tr. 169 (listing household chores including laundry, picking up around the house, picking up trash, and riding on lawn mower); (Tr. 171 (listing fishing as an interest done "a few times")). The fact that Mr. Tucker's pain symptoms were alleviated by over-the-counter pain medications also indicated that his symptoms were not as debilitating as he made out. (Tr. 25); (see also Tr. 42 ("Aleve helps ease [the pain] up a little bit. It don't stop it, but it helps, the Aleve eases it up.")).
An ALJ must consider a claimant's subjective reports of symptoms. If the ALJ decides not to fully credit a claimant's subjective testimony, "he must articulate explicit and adequate reasons for doing so." Holt v. Sullivan, 921 F.2d 1221,1223 (11th Cir. 1991). Further, these reasons must "take into account and evaluate the record as a whole." McCruter v. Bowen, 791 F.2d 1544, 1548 (11th Cir. 1986). Here, the ALJ articulated her reasons, including the important fact that Mr. Tucker self-reported being independent with a large number of daily activities as described above. Dr. Mogul's assessment, Mr. Tucker's daily activities and his own testimony that use of over-the-counter pain medication eases some of his symptoms provide substantial evidence to support the ALJ's conclusion that Mr. Tucker's condition was not disabling to the extent that he was unable to perform a reduced range of sedentary work, and further development of the record through additional testing by another consultative examiner was unnecessary under the circumstances of this case.
Based upon the its evaluation of the administrative record and the parties' submissions, the court finds that the decision of the Commissioner is due to be affirmed. The court will enter a final judgment order consistent with this memorandum opinion.
20 C.F.R. § 404.1567(b).