United States District Court, S.D. Alabama, Northern Division
MEMORANDUM OPINION AND ORDER
WILLIAM E. CASSADY, Magistrate Judge.
The Plaintiff brings this action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of a final decision of the Commissioner of Social Security denying her claims for disability insurance benefits ("DIB") and supplemental security income ("SSI"). The parties have consented to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28 U.S.C. § 636(c), for all proceedings in this Court. (Doc. 18 ("In accordance with the provisions of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this case consent to have a United States Magistrate Judge conduct any and all proceedings in this case, ... order the entry of a final judgment, and conduct all post-judgment proceedings.").) Upon consideration of the administrative record ("R.") (doc. 12), the Plaintiff's brief (doc. 14), the Commissioner's brief (doc. 15), and the arguments presented at the June 27, 2014 hearing, it is determined that the Commissioner's decision denying benefits should be affirmed.
I. Procedural Background
On or around May 24, 2010, the Plaintiff filed an application for DIB and SSI (R. 130-31; see R. 9), alleging disability relating to the following ailments: back and neck pain, high blood pressure, feet pain, female problems, and nerve pain in her left hip, ( see R. 160). She stated that she became disabled on May 24, 2010. (R. 130.) Her application was initially denied on July 23, 2010, (R. 57-68). A hearing was then conducted before an Administrative Law Judge on August 31, 2011. (R. 24-46). On November 16, 2011, the ALJ issued a decision finding that the claimant was not disabled (R. 9-20), and, on January 17, 2012, the Plaintiff sought review from the Appeals Council, (R. 186-88). On March 26, 2013, the Appeals Council issued a decision declining to review the ALJ's decision. (R. 1-3.) Therefore, the ALJ's determination was the Commissioner's final decision for purposes of judicial review. See 20 C.F.R. § 404.981. The Plaintiff filed a Complaint in this Court on May 22, 2013. (Doc. 1.)
II. Standard of Review and Claims on Appeal
In all Social Security cases, the plaintiff bears the burden of proving that he or she is unable to perform his or her previous work. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir. 1986). In evaluating whether the plaintiff has met this burden, the examiner must consider the following four factors: (1) objective medical facts and clinical findings; (2) diagnoses of examining physicians; (3) evidence of pain; and (4) the plaintiff's age, education, and work history. Id. Once the plaintiff meets this burden, it becomes the Commissioner's burden to prove that the plaintiff is capable-given his or her age, education, and work history-of engaging in another kind of substantial gainful employment that exists in the national economy. Sryock v. Heckler, 764 F.2d 834, 836 (11th Cir. 1985). Although at the fourth step "the [plaintiff] bears the burden of demonstrating an inability to return to his [or her] past relevant work, the [Commissioner of Social Security] has an obligation to develop a full and fair record." Shnorr v. Bowen, 816 F.2d 578, 581 (11th Cir. 1987) (citations omitted).
The task for this Court is to determine whether the ALJ's decision to deny Plaintiff benefits is supported by substantial evidence. Substantial evidence is defined as more than a scintilla, and means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. Richardson v. Perales, 402 U.S. 389, 401 (1971). "In determining whether substantial evidence exists, [a court] must view the record as a whole, taking into account evidence favorable as well as unfavorable to the [Commissioner's] decision." Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986). Courts are precluded, however, from "deciding the facts anew or re-weighing the evidence." Davison v. Astrue, 370 F.App'x 995, 996 (11th Cir. Apr. 1, 2010) (per curiam) (citing Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005)). And, "[e]ven if the evidence preponderates against the Commissioner's findings, [a court] must affirm if the decision reached is supported by substantial evidence." Id. (citing Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158-59 (11th Cir. 2004)).
On appeal to this Court, the Plaintiff asserts three claims:
1. The Commissioner's decision should be reversed because the ALJ's residual functional capacity assessment is not supported by substantial evidence;
2. The Commissioner's decision should be reversed because the ALJ failed to complete a psychiatric review technique form and append it to his decision or incorporate it into his findings; and
3. The Commissioner's decision should be reversed because the ALJ failed to properly assess the Plaintiff's complaints of pain.
(Doc. 14 at 2; see id. at 6-9.) For the reasons discussed below, the Commissioner's decision denying the Plaintiff benefits should be affirmed.
III. Relevant Medical Evidence
Back, leg and neck pain
On May 21, 2002, the Plaintiff presented to her primary care physician with complaints of lower back pain and pain radiating down her left leg. (R. 211.) Her physician prescribed her Celebrex and scheduled her for an MRI of the lumbar spine, ( id. ), which proceeded on June 11, 2002, (R. 275). The results from the MRI indicated mild protrusion of the L5-S1 disc; however, "there was no [marked] encroachment of the existing nerve root." (R. 208, 275.) During a subsequent doctor's visit on June 14, 2002, the Plaintiff reported that the pain down her left leg had improved significantly since she began taking Celebrex. (R. 208.) By the time of her July 15, 2002 visit, her back pain had resolved with conservative treatment. (R. 206.) On November 8, 2002, a radiology examination of her lumbar spine revealed that it was normal. (R. 274.) On July 29, 2003, the Plaintiff presented to Hale County Hospital Clinic with complaints of neck pain and shortness of breath. (R. 239.) The treating physician determined that she had pharyngitis, lethargy, hypertension, shortness of breath, and a history of anemia. ( Id. ) On August 22, 2005, the Plaintiff presented to Hale County Hospital Clinic with complaints of back pain. (R. 236.) Her treating physician determined that she had myofascial spasms of the lumbar spine and prescribed Tylenol and Flexeril. ( Id. ) On December 9, 2008, while being treated at the Marion Rural Health Center for cold symptoms/chest congestion, the Plaintiff also reported complaints of back and hip pain. (R. 251-52.)
Routine office visits to the Plaintiff's primary care physician at Marion Clinic in 2002-06 indicated findings of obesity and hypertension, as well as ongoing treatment for her hypertension with Hydrochlorothiazide (HCTZ). (R. 194-205.)
On April 5, 2011, the Plaintiff was seen by a nurse practitioner at Taylor Internal Medicine of Selma ("Taylor Internal Medicine") for her hypertension. (R. 283, 285.) The Plaintiff reported that she "[has] pain all over [her] body, that is worse in the mornings, and [she is] out of [her] blood pressure medicine." (R. 283.) The Plaintiff's blood pressure was elevated at the time of the visit. ( Id. ) The Plaintiff reported that she had not taken her blood pressure medication for one month. ( Id. ) She also reported "that she has an occasional headache at times, [and] they usually resolve on their own." ( Id. ) It was determined that the Plaintiff had "benign essential hypertension" and "pain in joint involving multiple sites." ( Id. ) She was prescribed HCTZ, Meloxicam and Ibuprofen, and she was told to return to the office in one week to have her blood pressure rechecked. ( Id. ) However, there is no evidence that she ever returned for a follow-up visit, as directed. ( See R. 281-85.) The April 5, 2011 visit was her only visit to Taylor Internal Medicine. ( Id. )
On June 23, 2011, the Plaintiff was seen in the emergency room for chest pains. (R. 288.) Her blood pressure at that time was 138/88. ( Id. )
In March and April of 2002, the Plaintiff was treated for left hand pain. (R. 238, 240-41.) Her treating physician determined that she had tendinitis of the small finger of her left hand and possible arthritis of her left hand and wrist; she was prescribed Tylenol and Indocin, an anti-inflammatory. (R. 238.) On June 13, 2010, the Plaintiff was treated in the emergency room at Hale County Hospital for arthritis in her right hand. (R. 258-67.) She was given Toradol for her pain. (R. 263.)
On September 5, 2002, after being diagnosed with "[d]ysfunctional uterine bleeding and cramping, " the Plaintiff underwent a "diagnostic laparoscopy with bilateral tubal ligation, " as well as a cervical curettage, an endometrial curettage, and uterine ablation. (R. 277-78.) On December 11, 2009, the Plaintiff was seen for complaints of having an irregular menstrual cycle and excessive bleeding. (R. 249.) On June 23, 2011, while being treated for complaints of chest pain, the Plaintiff reported a history of uterine fibroids. (R. 287-88.)
Testimony of Dr. James Anderson
Dr. Anderson testified as a medical expert witness at the time of the August 31, 2011 hearing before the ALJ. (R. 35-42.) Dr. Anderson opined that
[The Plaintiff is] morbidly obese - 61 inches, 295 pounds - [and] she has obesity related lower back pain treated symptomatically. She has hypertension which is asymptomatic, and she has chronic pelvic pain due to benign gynecological problems with iron deficiency anemia. Anemia is treated successfully with iron replacement tablets. She also has several episodes of generalized pain treated with anti-inflammatory medications. The records that we have, includ[ing] those submitted today, in my view would not meet or equal... disability.
With regard to the protrusion of the L5-S1 disc, indicated in the 2002 MRI, Dr. Anderson testified that such protrusion "is a disc pathology that may or may not be symptomatic." (R. 37.) Furthermore, Dr. Anderson discounted the finding of disc protrusion on the 2002 MRI because of the age of the MRI. (R. 40.) He stated that "something almost a decade old is not really of clinical significance" because, over time, "abnormal disc disease can get better [or] worse." (R. 40-41.) For example, he stated that "[d]iscs that protrude... can grind down and become asymptomatic." (R. 41.) He explained that a determination as to whether disc protrusion is symptomatic is based on the "longitudinal treating record." ( Id. )
Additionally, Dr. Anderson testified that the diagnosis of tendinitis in the Plaintiff's hands is "a reasonable clinical explanation for her hand pain. (R. 39.) He stated that tendinitis "is a clinical diagnosis and it's treated symptomatically." ( Id. )
IV. ALJ's Decision
On November 16, 2011, the ALJ issued a decision finding that the Plaintiff is not disabled. (R. 9-17.) In reaching his decision, the ALJ found that the Plaintiff has not engaged in substantial gainful activity since the alleged onset date of May 24, 2010. (R. 11.) The ALJ found that the Plaintiff "has the following severe impairments: morbid obesity; arthritis; and occasional myofascial spasms of the spine." ( Id. ...