JOHN E. OTT, Chief Magistrate Judge.
Plaintiff Vickie D. Wallace 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 the continuation of her disability benefits. (Doc. 1).
Plaintiff was determined on June 16, 2006, to be disabled beginning April 5, 2005, based on severe impairments of depression and status post left shoulder injury. (R. 26, 28, 141). The Social Security Administration sent Plaintiff for psychological and physical examinations in June and July 2012 (R. 375, 379) and concluded on October 2, 2012, that she was no longer disabled as of October 2012. (R. 138-39, 141). This determination was upheld on reconsideration after a disability hearing by a State agency Disability Hearing Officer. (R. 142-66).
Plaintiff requested a hearing before an Administrative Law Judge (ALJ). (R. 167, 238). An ALJ held hearings in May 2014 and June 2015 and issued a decision on June 18, 2015, finding Plaintiff's disability ended effective October 2012. (R. 23-70, 96-119). The Appeals Council denied Plaintiff's request for review on December 23, 2016. (R. 1-6). The Commissioner's final decision is ripe for judicial review. See 42 U.S.C. § 405(g).
Plaintiff was 46 years old at the time of the ALJ's decision. She previously obtained her Associate of Arts degree. (R. 114-15, 529). She has worked in the past as a receiving clerk, motel housekeeper, office cleaner, and assistant manager of a pizza shop and truck deli. (R. 42, 377). As noted above, she was previously found to be disabled as of April 2005 based on the severe impairments of depression and status post left shoulder injury. (R. 28). Plaintiff now alleges that she is disabled due to her dislocated left shoulder, depression, panic attacks, type 2 diabetes, congestive heart failure, tinnitus, and arthritis in her hands. (R. 167, 238).
Following administrative hearings, the ALJ considered Plaintiff's disability claim in accordance with the eight-step sequential evaluation process to determine whether her disability had ceased.
The ALJ also found that as of October 2012, Plaintiff had the residual functional capacity ("RFC") to perform a modified range of light work. (R. 37). Specifically, Plaintiff could lift and carry 10 pounds frequently and 20 pounds occasionally; sit and stand/walk a total of six hours each in an eight-hour workday; frequently reach in all directions, handle, finger, feel, and push/pull, bilaterally; and occasionally balance, stoop, kneel, crouch, crawl, and climb ramps and stairs (Id.) She could not, however, climb ladders, ropes, or scaffolds. (Id.) Plaintiff needed to avoid exposure to unprotected heights and moving or dangerous machinery, and she required an environment free of concentrated exposure to temperature extremes, wetness, humidity, noise, vibration, fumes, odors, gases, dust, and poor ventilation. (Id.)
The ALJ further found, based in part on the testimony of a vocational expert ("VE"), that Plaintiff could perform other work that exists in significant numbers in the national economy, including cashier, parking lot attendant, and toll collector. (R. 42, 62-63). Therefore, the ALJ determined that Plaintiff's disability ended in October 2012 and she has not become disabled since that date. (R. 43).
The court's review of the Commissioner's decision is narrowly circumscribed. The function of the court is to determine whether the Commissioner's decision 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). The 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).
The regulations provide an eight-step sequential evaluation process for determining whether a claimant's disability continues. See 20 C.F.R. § 404.1594(f). The steps require an ALJ to determine:
20 C.F.R. § 404.1594(f)(1)-(8); see also Martz v. Comm'r Soc. Sec., 649 F. App'x 948, 954 & n.4 (11th Cir. 2016); Klaes v. Comm'r Soc. Sec., 499 F. App'x 895, 896 (11th Cir. 2012). "Medical improvement" is defined as any decrease in the severity of a claimant's impairments that were present at the time of the CPD as shown by signs, symptoms, and laboratory findings. See 20 C.F.R. § 404.1594(b)(1); see also 20 C.F.R. § 404.1528 (defining signs, symptoms, and laboratory findings) and Klaes, 499 F. App'x at 896 and Simone v. Comm'r Soc. Sec., 465 F. App'x 905, 908 (11th Cir. 2012). Medical improvement is related to a claimant's ability to work if there has been a decrease in the severity of the impairment or impairments present at the time of the CPD and an increase in her functional capacity to do basic work activities. See 20 C.F.R. §§ 404.1594(b)(3)-(4), (c)(1)-(2); see also Simone, 465 F. App'x 909. In determining whether a claimant's disability continues, the ALJ does so on a "neutral basis without any initial inference as to the presence or absence of disability being drawn from the fact that [the claimant had] previously been determined to be disabled." 20 C.F.R. § 404.1594(b)(6). "The ALJ must `actually compare' the previous and current medical evidence to show that an improvement occurred." Klaes, 499 F. App'x at 896 (citing Freeman v. Heckler, 739 F.2d 565, 566 (11th Cir. 1984)).
Plaintiff argues that the ALJ's RFC findings lack any support from an examining physician. (Doc. 10 at 8-11). A claimant's RFC is the most she can still do despite her limitations and is based on all the relevant evidence in the case record, including her medical history, medical signs and laboratory findings, the effects of treatment, daily activities, medical opinions, and any medical source statements. 20 C.F.R. § 404.1545; Social Security Ruling (SSR) 96-8p, 1996 WL 374184, at *5 (S.S.A. 1996). At the hearing level, the ALJ has the responsibility of assessing the claimant's RFC. See 20 C.F.R. §§ 404.1527(d)(2), 404.1546(c); see also Robinson v. Astrue, 365 F. App'x 993, 999 (11th Cir. 2010) (noting "the task of determining a claimant's [RFC] and ability to work is within the province of the ALJ, not of doctors"). In assessing the RFC of a claimant, the ALJ may ask for additional opinions from medical experts. See 20 C.F.R. § 404.1529(b).
In reviewing this issue, it is important to begin with the evidence supporting the ALJ's determination that Plaintiff had medical improvements as of October 2012 and that she had an RFC increase concerning her shoulder impairment and depression.
With regard to the ALJ's determination that Plaintiff had no work-related mental limitations, the evidence demonstrates Plaintiff engaged in a broad range of activities of daily living, including driving, shopping, exercising, socializing, and doing crafts. (R. 29-30, 35, 39-41, 255-56, 259-60, 262-63, 267-71, 378, 381). Overall, she had positive responses to minimal mental health treatment. For instance, she learned to respond to her panic attacks using breathing techniques, working on projects, and listening to music. (R. 30-31, 35, 38, 58-59, 357, 359, 376, 495, 528, 550-53). She failed to complain about her alleged mental health symptoms during various medical visits. (R. 30-31, 503, 554-56). She had essentially unremarkable findings on mental status examinations. (R. 30-31, 35, 41, 377, 489-90, 528-31, 550-53). Other evidence demonstrates that Plaintiff's mental health symptoms were tied to situational factors, such as her boyfriend's heart surgery, her son's vehicle accident, and court appearances. (R. 30, 34-35, 38-39, 354, 359-60, 362, 378, 494-95). Additionally, psychological consultant Dr. Sally Gordon opined that Plaintiff could learn, remember, and complete work instructions and maintain relationships with coworkers and supervisors. (R. 35-36, 40, 378). Still further, State agency psychiatric consultant Dr. Lee Blackman opined that Plaintiff's mental impairments did not significantly limit her ability to perform mental work activities. (R. 40, 392-404). This medical and non-medical evidence constitutes substantial evidence supporting the ALJ's RFC finding. (R. 37).
The thrust of Plaintiff's arguments is that the ALJ gave inadequate weight to the consultative examinations conducted in August 2014 despite the fact that he requested them. (Doc. 10 at 9). As will be discussed further below, the court finds that the ALJ properly considered the consultative examinations and afforded them appropriate weight.
Concerning Plaintiff's physical condition, Dr. Timothy Parish evaluated Plaintiff in July 2012. He diagnosed Plaintiff with (1) "Type I diabetes mellitus, poorly controlled, [with] associated peripheral neuropathy and chronic pain syndrome" and (2) "chronic cardiac failure, bilateral peripheral edema and decreased exercise tolerance." (R. 387). The ALJ afforded Dr. Parish's opinion that Plaintiff had chronic heart failure "little weight." (R. 41). In doing so, the ALJ noted that this diagnosis dated back to earlier care Plaintiff was receiving from Dr. Mark Richman that was "propagated" into Plaintiff's medical history when Dr. Wiley Livingston assumed her care. (Id.) The ALJ also found that Plaintiff's medical records from the pertinent period for the disability review show "no objective signs of [chronic heart failure] and no complaints from [Plaintiff] of [chronic heart failure]-related symptoms." (Id.) Additionally, the court notes that Dr. Parish's notes provide that Plaintiff's heart rate and rhythm were "regular"; her heart sounds were normal; there were no "extra sounds or murmurs"; there was no peripheral edema; and all other indicators were normal. (R. 382). Accordingly, the ALJ was correct in affording little weight to Dr. Parish's opinion.
Dr. Sally Gordon did a psychological consultation of Plaintiff in June 2012. She opined Plaintiff (1) was able to learn, remember, and complete work instructions and maintain amicable relationships with coworkers and supervisors;
The ALJ gave great weight to Dr. Gordon's first opinion about Plaintiff's ability to learn, remember, and work. (R. 40). The ALJ specifically found that it was "consistent with the mental status results recorded in her report," the level of function described by third-party informants," and Plaintiff's self reports. (Id.) The ALJ afforded little weight to Dr. Gordon's second opinion involving Plaintiff's ability to respond to work pressures and live independently. Specifically, the ALJ found these opinions to be internally inconsistent and inconsistent with other evidence of record. (Id.) In support of this finding, the ALJ stated, "Dr. Gordon appears to have credited [Plaintiff's] endorsement of frequent hypoglycemic episodes during which she was unable to process even simple information, chew, swallow, recognize her name, etc.; however, as noted, [Plaintiff's] records fail to support those reports." (Id.) Additionally, State agency psychiatric consultant Dr. Lee Blackman determined that the evidence fails to establish any medically determinable bipolar disorder and that Plaintiff's mental impairments cause no significant limitation in her ability to work. (R. 40, 392-404). The ALJ noted that Dr. Blackman's opinions were consistent with other mental health consultants.
Dr. Sharon D. Waltz conducted a second psychological evaluation of Plaintiff in August 2014. Her diagnostic impressions include a diagnosis that Plaintiff had probable borderline intellectual functioning; that Plaintiff had a "mental impairment present to a moderate degree" and "a constriction of interests due to mental health problems"; and that Plaintiff "can function primarily independently with assistance and can manage benefits in her own best interests `with assistance.'" (R. 29, 41, 530-31). The ALJ accorded little weight to Dr. Waltz's opinions because of internal inconsistencies and inconsistencies with other evidence of record. (R. 41). Specifically, the ALJ stated:
(R. 41).
Plaintiff argues that there is nothing in Dr. Waltz's "findings that could be inferred to relate only to borderline intellectual functioning rather than the Axis I mental impairment of panic disorder." (Doc. 10 at 9-10). This court finds that the ALJ properly weighed Dr. Waltz's opinions in light of the record evidence. The ALJ is correct that Dr. Waltz's findings and conclusions are internally inconsistent and inconsistent with the other evidence. By way of example, Dr. Waltz stated that Plaintiff was "moderately impaired" in her ability to work. (R. 531). This is not supported by Dr. Waltz's examination of Plaintiff, which is generally unremarkable.
Dr. Hashim Hakim also conducted a neurological consult of Plaintiff in August 2014. During this interview, Plaintiff complained of nerve damage from the knee down, restless leg syndrome, and seizures. Specifically, Plaintiff stated that she had three seizures over the preceding three months. (R. 511). Following Plaintiff's examination, Dr. Hakim diagnosed her with diabetes mellitus, peripheral neuropathy related to her diabetes, seizures, congestive heart failure, and arthritis. (R. 513). His diagnosis of seizures was based on Plaintiff's self-reporting. (Id.) Plaintiff's imaging work-ups were negative for evidence as to any causation for the reported seizures. (R. 511-13). In Dr. Hakim's work-related activities statement, he indicated that Plaintiff could sit at one time without interruption for two hours, stand for one hour, and walk for one hour. (R. 519). He also determined that in an 8-hour work day, Plaintiff could sit for four hours, stand for two hours, and walk for two hours. (Id.)
Plaintiff argues that the ALJ did not properly weigh Dr. Hakim's opinions and did not include an opportunity for alternative sitting and standing in his RFC analysis to accommodate Dr. Hakim's restrictions. (Doc. 10 at 9-10). She also argues that the ALJ's determination with regard to her "total lifting and standing/walking capacities do not match the requirements for light work as defined, and the total sitting capacity of four hours . . . does not even match the requirements for sedentary work (20 C.F.R. § 404.1567[
The ALJ conducted a thorough analysis of Dr. Hakim's opinions in conjunction with the other evidence concerning Plaintiff's situation. The ALJ stated as follows:
(R. 40 (record citations omitted)). The ALJ also noted in his opinion that Plaintiff has documented diabetes mellitus with chronically poor blood sugar control. (R. 39). He also found that Plaintiff "is not always compliant in using diabetes medications as prescribed, in following a diabetic diet, or in returning for follow up as scheduled." (Id.) The ALJ further found that although Plaintiff "has developed a number of diabetes-related complications, most are mild or in an early stage and improve when she is compliant in following treatment protocols." (Id.) This finding is supported by the record, which fails to show any episodes of ketoacidosis or diabetes mellitus-related hospitalizations. Additionally, the ALJ noted that the "record also fails to support [Plaintiff's] allegations of frequent falls or syncopal episodes due to hypoglycemia." (Id.) Instead, the ALJ found that "[t]he records do document evidence of peripheral neuropathy that is likely related to poor diabetes control and more symptomatic in the lower extremities than the upper extremities." (Id.) Therefore, the ALJ further found, "It is also reasonable that [Plaintiff] would experience some generalized weakness and fatigue when her blood sugar level is fluctuating." (Id.) The ALJ then concluded:
(Id.)
Plaintiff has failed to show that the ALJ erred in not obtaining additional medical expert opinions related to her physical condition. The court finds that the ALJ did not express any doubts or concerns regarding the sufficiency of the evidence. To the contrary, the record demonstrates confidence in his findings based on the record. Plaintiff's conclusory argument that further development of the record might produce additional clarifying evidence is insufficient to warrant a remand of this case. See Sarria v. Comm'r of Soc. Sec., 579 F. App'x 722, 724 (11th Cir. 2014) (ALJ not required to order additional medical examination to develop a full and fair record where claimant did not produce evidence to support her alleged disability and existing evidence supported ALJ's findings); Prince v. Comm'r, Soc. Sec. Admin., 551 F. App'x 967, 972 (11th Cir. 2014) ("An ALJ is not required to seek the independent testimony of a medical expert where the record is sufficient to determine whether the claimant is disabled and additional medical expert testimony would be unnecessary." (citing Wilson v. Apfel, 179 F.3d 1276, 1278 (11th Cir. 1999)). Additionally, Plaintiff has not shown that any purported evidentiary gaps resulted in unfairness or "clear prejudice" warranting a remand.
For the reasons set forth above, the undersigned concludes that the decision of the Commissioner is due to be affirmed. An appropriate order will be entered separately.
(R. 40 (record citation omitted)).
20 C.F.R. § 404.1567(a) & (b).
