DOUGLAS N. FRAZIER, Magistrate Judge.
This cause is before the Court on Plaintiff's Complaint (Doc. 1) filed on June 5, 2013. Plaintiff, Steven K. Brown, II seeks judicial review of the final decision of the Commissioner of the Social Security Administration ("SSA") denying his claim for a period of disability and disability insurance benefits. The Commissioner filed the Transcript of the proceedings (hereinafter referred to as "Tr." followed by the appropriate page number), and the parties filed legal memoranda in support of their positions. For the reasons set out herein, the decision of the Commissioner is
The law defines disability 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 months. 42 U.S.C. §§ 416(i), 423(d)(1)(A), 1382(a)(3)(A); 20 C.F.R. §§ 404.1505, 416.905. The impairment must be severe, making the claimant unable to do his previous work, or any other substantial gainful activity which exists in the national economy. 42 U.S.C. §§ 423(d)(2), 1382(a)(3); 20 C.F.R. §§ 404.1505-404.1511, 416.905-416.911. Plaintiff bears the burden of persuasion through step four, while at step five the burden shifts to the Commissioner. Bowen v. Yuckert, 482 U.S. 137, 146, n.5 (1987).
On October 28, 2010, Plaintiff filed an application for disability insurance benefits and supplemental security income asserting a disability onset date of June 1, 2009. (Tr. p. 87, 88). Plaintiff's applications were denied initially on December 10, 2010, and upon reconsideration on February 25, 2011. (Tr. p. 94, 98, 106, 109). A hearing was held before Administrative Law Donald G. Smith ("ALJ") on December 11, 2012. (Tr. p. 38-86). The ALJ issued an unfavorable decision on January 14, 2013 (Tr. p. 18-29. On April 15, 2013, the Appeals Council denied Plaintiff's request for review. (Tr. p. 1-6). The Plaintiff filed a Complaint (Doc. 1) in the United States District Court on June 5, 2013. This case is now ripe for review. The parties consented to proceed before a United States Magistrate Judge for all proceedings. (See, Doc. 18).
An ALJ must follow a five-step sequential evaluation process to determine if a claimant has proven that he is disabled. Packer v. Commissioner of Social Security, 542 F. App'x 890, 891 (11
The ALJ determined that Plaintiff met the Social Security Act's insured status requirements through September 30, 2014. (Tr. p. 20). At step one of the sequential evaluation, the ALJ found that Plaintiff had not engaged in substantial gainful activity since June 1, 2009, the alleged onset date. (Tr. p. 20). At step two, the ALJ found that the Plaintiff suffered from the following severe impairments: scoliosis, obesity, flat feet, hearing loss, major depressive disorder, bipolar disorder, learning disorder, borderline intellectual functioning, and personality disorder citing 20 C.F.R. § 404.1520(c) and 416.920(c). (Tr. p. 20-21). At step three, the ALJ determined that Plaintiff did not have an impairment or combination of impairments that meets or medically equals the severity of any of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925, and 416.926). (Tr. p. 21). At step 4, the ALJ determined that the Plaintiff has the residual functional capacity ("RFC") to perform light work except that Plaintiff can lift 20 pounds occasionally and 10 pounds frequently; can sit 6 hours per workday; can stand/walk 5 hours per workday, but only 2 hours at a time; can perform simple, routine, repetitive tasks; can handle ordinary and routine changes in work setting or duties; can frequently interact with the public, coworkers and supervisors; and can maintain attention/concentration for 2 hours and then needs a 10 minute break. (Tr. p. 23). The ALJ determined that Plaintiff could not return to his past relevant work as a fast food worker, kitchen helper or stock clerk. (Tr. p. 27). The ALJ determined that Plaintiff is a younger individual with at least a high school education, and that transferability of job skills is not material. (Tr. p. 27). The ALJ found that considering Plaintiff's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that Plaintiff can perform. (Tr. p. 27). Relying on the vocational expert's testimony, the ALJ determined that Plaintiff could perform the occupations of cafe' attendant, (DOT 311.677-010), light unskilled work; merchandise marker (DOT 209.587-034) light unskilled work; and cleaner, housekeeper (DOT 323.687-014), light unskilled work. The ALJ concluded that Plaintiff was not under a disability from June 1, 2009 through the date of the decision. (Tr. p. 28).
The scope of this Court's review is limited to determining whether the ALJ applied the correct legal standard, McRoberts v. Bowen, 841 F.2d 1077, 1080 (11
Where the Commissioner's decision is supported by substantial evidence, the district court will affirm, even if the reviewer would have reached a contrary result as finder of fact, and even if the reviewer finds that the evidence preponderates against the Commissioner's decision. Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11
Plaintiff raises three issues on appeal. As stated by Plaintiff they are:
Plaintiff asserts that the Appeals Council erred in failing to consider new, material, and chronologically relevant evidence concerning Plaintiff's sleep apnea. The Commissioner asserts that the record supports the ALJ's decision and the additional medical evidence does not show that it caused additional limitations as to Plaintiff's ability to work. The ALJ's Decision was dated January 14, 2013. On December 30, 2012, the Plaintiff participated in a sleep study due to indications of hypersomnolence, and obstructive sleep apnea syndrome. (Tr. p. 526). On January 15, 2013, Ferreira Gregory, M.D. signed a Documents Review Report. (Tr. p. 526). Dr. Gregory's impression was that Plaintiff has severe obstructive sleep apnea syndrome with severe hypoxemia. (Tr. p. 526). At the conclusion of the sleep study, Dr. Gregory recommended that Plaintiff obtain a CPAP plus 20 with supplemental oxygen. (Tr. p. 526).
In his Decision, the ALJ mentioned Plaintiff's sleep apnea. (Tr. p. 25). The ALJ stated, "[i]n terms of the claimant's sleep apnea, the record contains few, if any, complaints of a similar nature to a medical source. As the claimant has sought little, if any, treatment for these alleged symptoms, the undersigned finds that they are not as severe as alleged, and that the claimant's testimony is less than fully credible in this regard." (Tr. p. 25). Plaintiff mentioned his sleep apnea problems to Patricia Hough, M.D. on June 19, 2012. (Tr. p. 490). Plaintiff testified at the hearing, that he tends to fall asleep "here and there." (Tr. p. 54). Plaintiff testified that there are days when he falls asleep sitting watching the television, and will fall asleep for two to three hours. (Tr. p. 19). He falls asleep at a friend's house, and he talked about this problem with his doctors and was told it was sleep apnea. (Tr. p. 58). He indicated he was going for a sleep study on December 30, 2012. (Tr. p. 58).
The Appeals Council considered the additional records of the sleep study for Dr. Gregory. (Tr. p. 1-5). The Appeals Council stated, "[w]e found no reason under our rules to review the Administrative Law Judge's decision. Therefore, we have denied your request for review." (Tr. p. 1). One rule that the Appeals Council applied stated that if it received "new and material evidence and the decision is contrary to the weight of all the evidence now in the record" then it would have granted review. (Tr. p. 1).
A claimant is generally permitted to present new evidence at each state of his administrative process. Ingram v. Comm'r of Soc. Sec., 496 F.3d 1253, 1261 (11
In the instant case, Plaintiff's sleep study was conducted prior to the date of the ALJ's decision, and the report diagnosing Plaintiff with severe obstructive sleep apnea syndrome with severe hypoxemia was signed on January 15, 2013, one day after the ALJ's Decision. At step two of the sequential evaluation process, the ALJ determined that Plaintiff had the following severe impairments: scoliosis, obesity, flat feet, hearing loss, major depressive disorder, bipolar disorder, learning disorder, borderline intellectual functioning, and personality disorder. The ALJ did not consider sleep apnea a severe impairment.
At step two, "[a]n impairment is not severe only if the abnormality is so slight and its effect so minimal that it would clearly not be expected to interfere with the individual's ability to work, irrespective of age, education or work experience." McDaniel v. Bowen, 800 F.2d 1026, 1031 (11
According to the Eleventh Circuit, "[n]othing requires that the ALJ must identify, at step two, all of the impairments that should be considered severe," but only that the ALJ considered the claimant's impairments in combination, whether severe or not. Heatly v. Comm'r of Soc. Sec., 382 F. App'x 823, 825 (11
Plaintiff's diagnosis of severe obstructive sleep apnea syndrome with severe hypoxemia is not slight and its effect not minimal on Plaintiff's ability to work. The ALJ did find other impairments or combination of impairments severe, however failed to consider Plaintiff's sleep apnea severe and failed to consider it in combination with Plaintiff's other impairments asserting that Plaintiff failed to seek treatment for the sleep apnea and that his testimony was less than fully credible regarding his somnolence. His symptoms of falling asleep during the day at various times and sleeping for two to three hours at a time would interfere with his ability to work. The diagnosis of severe sleep apnea syndrome with severe hypoxemia confirmed his impairment. The Commissioner argues that the Sleep Study showed that a CPAP provided substantial improvement, however, it was only recommended and there is no evidence showing that Plaintiff obtained a CPAP. The Appeals Council should have reviewed the ALJ's decision in light of the new medical evidence of Plaintiff's severe obstructive sleep apnea syndrome with severe hypoxemia because the evidence was new and material and related to the period of time on or before the date of the ALJ's decision. Further, the ALJ specifically commented that Plaintiff had failed to seek treatment for these impairments and that his testimony was not fully credible as to his impairments, therefore this new medical evidence conflicts with the ALJ's findings, and the findings are contrary to the weight of the evidence currently of record. The Court determines that the Appeals Council erred in failing to review the ALJ's decision in light of the new medical evidence submitted to the Appeals Council concerning Plaintiff's sleep apnea and hypoxemia.
Plaintiff argues that Plaintiff meets Listing 12.05C, and the ALJ erred in failing to find that Plaintiff met this Listing. The Commissioner argues that Plaintiff failed to meet his burden of showing that his impairments met the requirements of Listing 12.05C.
To meet the requirements of a listing, a plaintiff must "have a medically determinable impairment(s) that satisfies all of the criteria in the listing." 20 C.F.R. § 404.1525(d). The burden is on Plaintiff to show that he meets the Listings. Wilkinson on Behalf of Wilkinson v. Bowen, 847 F.2d 660, 662 (11
Listing 12.05 provides in part as follows:
20 C.F.R. pt. 404, subpt. P., app. 1, § 12.05.
The structure of Listing 12.05 differs from other mental disorder listings by containing four sets of criteria, and a plaintiff must satisfy the diagnostic description and one of the four sets of criteria. 20 C.F.R. pt. 404, subpt. P, app. 1, § 12.00. In the instant case, Plaintiff argues that he satisfies the diagnostic description and Listing 12.05, Subsection C that requires a "valid verbal, performance, or full scale IQ of 60 through 70 and a physical or other mental impairment imposing an additional and significant work-related limitation of function." 20 C.F.R. pt. 404, subpt. P., app. 1, § 12.05C.
The ALJ determined that some of Plaintiff's IQ scores do meet Listing 12.05, however, the ALJ determined that the presumption that Plaintiff manifests deficits in adaptive function were rebutted by Plaintiff's higher levels of adaptive function, and therefore, did not meet the criteria for Listing 12.05C. Specifically, the ALJ found that Plaintiff's activities of daily living including using public transportation, driving a car, and using a computer indicated that Plaintiff has a higher level of adaptive functioning than his scores manifest, and considered Plaintiff's borderline intellectual functioning to be a severe impairment rather than finding it met or equaled Listing 12.05.
A valid I.Q. score within the 60 to 70 ranges is not conclusive of mental retardation where the "`I.Q. score is inconsistent with other evidence in the record on the claimant's daily activities and behavior.'" Hickel v. Comm'r of Soc. Sec., 539 F. App'x 980, 983-84 (11
In the instant case, the ALJ did not take into consideration all of Plaintiff's limitations in daily living. For example, although Plaintiff is able to drive a car, it took him approximately 10 times to pass the written test, and four times to pass the road test before he was able to obtain a license. (Tr. p. 51-52). Plaintiff's mother completed a Function Report indicating that Plaintiff can only process no more than two commands at a time, and can only carry through with one of these. (Tr. p. 268). According to his mother, Plaintiff's family remind him to feed, give water to, and walk the dog. (Tr. p. 269). He has to be reminded to wash his hair, brush his teeth, and clean after toileting, and cannot clean himself well after toileting. (Tr. p. 269-270). The chores that he performs may take him three times as long. (Tr. p. 270). Plaintiff does socialize at church and with friends, but is unable to pay his own bills or manage money. (Tr. p. 275). The ALJ failed to reconcile these further limitations on daily living to determine if Plaintiff met the Listing 12.05C. An ALJ is not required to discuss all of the evidence in the record, "`but he may not ignore evidence that does not support his decision. . . .'" Saddler v. Astrue, 2008 WL 2824885, *3 (M.D. Fla. July 21, 2008) (quoting Briggs v. Massanari, 248 F.3d 1235, 1239 (10
Plaintiff asserts that the ALJ erred in rejecting the opinions of the State Agency Psychological Consultant, Dr. Visser and the Plaintiff's treating psychiatrist, Dr. Hough. The ALJ failed to adopt Drs. Visser and Hough's opinions that Plaintiff has some "marked" limitations. The Commissioner argues that the ALJ properly considered the records and opinions of Drs. Visser and Hough and properly determined the weight accorded to each.
At the fourth step in the evaluation process, the ALJ is required to determine a claimant's RFC and based on that determination, decide whether the plaintiff is able to return to his or her previous work. McCruter v. Bowen, 791 F.2d 1544, 1547 (11
"The Secretary must specify what weight is given to a treating physician's opinion and any reason for giving it no weight, and failure to do so is reversible error." MacGregor v. Bowen, 786 F.2d 1050, 1053 (11
"Generally, the opinions of examining or treating physicians are given more weight than non-examining or non-treating physicians unless `good cause' is shown. Poellnitz v. Astrue, 349 F. App'x 500, 502 (11
On April 11, 2012, Kenneth Visser, PhD., a Clinical Psychologist evaluated Plaintiff and reviewed Plaintiff's prior evaluations. (Tr. p. 449-460. Dr. Visser found that Plaintiff "has intellectual limitations," and that he "enjoys other people" but "has had problems in work environments, because he feels a sense of entitlement." (Tr. p. 456). Dr. Visser found Plaintiff to have marked limitations in understanding and remembering complex instruction, carrying out complex instruction, and the ability to make judgments on complex work-related decisions. (Tr. p. 458). The ALJ found Dr. Visser's reports inconsistent because Dr. Visser determined that Plaintiff enjoyed other people, yet had problems at work because he felt entitled. (Tr. p. 26)
From June 2012 through July 2012, Patricia Hough, M.D., a treating physician, also evaluated Plaintiff. (Tr. p. 487-493). Dr. Hough completed a Medical Source Statement. (Tr. p. 487-488). Dr. Hough determined that plaintiff had a history of problems with supervisors, and had marked limitation in accepting instructions and responding appropriately to criticism from supervisors, and maintaining socially appropriate behavior and emotional stability when interacting with coworkers. (Tr. p. 488). The ALJ discounted Dr. Hough's findings asserting that her opinion was entitled to little weight because it was inconsistent with the record as a whole, and because it was inconsistent with the treating and examining sources statements that Plaintiff was cooperative, with intact thought processes and normal thought content. (Doc. 26).
Dr. Visser found that Plaintiff had difficulty at work because of his sense of entitlement, and Dr. Hough determined that Plaintiff had marked limitations in accepting instructions and criticism. The ALJ noted that Dr. Kevin Ragsdale and Dr. Robert Hodes determined that Plaintiff could perform simple work tasks which is not in conflict with Dr. Visser or Dr. Hough. (Tr. p. 26). Dr. Ragsdale determined Plaintiff had moderate difficulties in maintaining concentration, persistence, or pace, and mild difficulties in maintaining social functioning. (Tr. p. 410). Dr. Ragsdale did not include any explanation as to these findings. Dr. Hodes provided a Case Analysis which affirmed Dr. Ragsdale's Psychiatric Review Technique with little explanation. (Tr. p. 414). Dr. Visser and Dr. Hough had concerns that Plaintiff was unable to function in a work environment due to his belief that he was entitled to promotions and his inability to interact with other workers appropriately. The ALJ did not reconcile these findings with the other medical records. The ALJ concluded that because Plaintiff is able to socialize with others and can act appropriately at medical examinations that he is able to act appropriately in work situation where he would be subject to criticism from supervisors. The Court determines that the ALJ failed to articulate sufficient reasons to discount Dr. Visser's and Dr. Hough's opinions as to Plaintiff's ability to function in a work environment.
Upon consideration of the submissions of the parties and the administrative record, the Court finds that the decisions of the ALJ and the Appeals Council are not supported by substantial evidence.