United States District Court, N.D. Alabama, Northeastern Division
KARON OWEN BOWDRE, Chief District Judge.
On April 5, 2010, the claimant protectively filed a Title II application for a period of disability and disability insurance benefits, alleging disability beginning May 21, 2009. She claimed inability to work because of her right foot because of a work-related injury, nerve damage in her foot, heart problems, congestive heart failure, removal of one kidney following cancer, hypertension, depression, and severe irritable bowel syndrome. (R. 208). The Commissioner denied the claim on August 3, 2010. After filing a request for a hearing, the ALJ conducted a video hearing on August 19, 2011. (R. 20).
On February 16, 2012, the ALJ determined that the claimant was not disabled, as defined by the Social Security Act, from May 21, 2009, her alleged onset date, to the time of the hearing. (R. 26). On September 16, 2013, the Appeals Council denied the claimant's request for review; consequently the ALJ's decision became the final decision of the Commissioner of the Social Security Administration. (R. 1). The claimant exhausted her administrative remedies, and this court has jurisdiction pursuant to 42 U.S.C. § § 405 (g) and 1383(c)(3). For the reasons stated below, this court REVERSES and REMANDS the decision of the Commissioner.
II. ISSUE PRESENTED
The issue before the court is whether substantial evidence supports the ALJ's discrediting of the opinion of the claimant's treating physician Dr. Crouch.
III. STANDARD OF REVIEW
The standard for reviewing the Commissioner's decision is limited. This court must affirm the Commissioner's decision if the Commissioner applied the correct legal standards and if substantial evidence supports his factual conclusions. See 42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997); Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
"No... presumption of validity attaches to the [Commissioner's] legal conclusions, including determination of the proper standards to be applied in evaluating claims." Walker, 826 F.2d at 999. This court does not review the Commissioner's factual determinations de novo. The court will affirm those factual determinations that are supported by substantial evidence. "Substantial evidence" is "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 402 (1971).
The court must keep in mind that opinions such as whether a claimant is disabled, the nature and extent of a claimant's residual functional capacity, and the application of vocational factors "are not medical opinions, ... but are, instead, opinions on issues reserved to the Commissioner because they are administrative findings that are dispositive of a case; i.e., that would direct the determination or decision of disability." 20 C.F.R. §§ 404.1527(d), 416.927(d). Whether the Plaintiff meets the listing and is qualified for Social Security disability benefits is a question reserved for the ALJ, and the court "may not decide facts anew, reweigh the evidence, or substitute [its] judgment for that of the Commissioner." Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005). Thus, even if the court were to disagree with the ALJ about the significance of certain facts, the court has no power to reverse that finding as long as substantial evidence exists in the record to support it.
The court must "scrutinize the record in its entirety to determine the reasonableness of the [Commissioner]'s factual findings." Walker, 826 F.2d at 999. A reviewing court must not look only to those parts of the record that support the decision of the ALJ, but also must view the record in its entirety and take account of evidence that detracts from the evidence on which the ALJ relied. Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th Cir. 1986).
IV. LEGAL STANDARD
Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when the person cannot "engage in 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 result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A). To make this determination, the Commissioner employs a five-step, sequential evaluation process:
(1) Is the person presently unemployed?
(2) Is the person's impairment severe?
(3) Does the person's impairment meet or equal one of the specific impairments set forth in 20 C.F.R. Pt. 404, Subpt. P, App. 1?
(4) Is the person unable to perform his or her former occupation?
(5) Is the person unable to perform any other work within the economy? An affirmative answer to any of the above questions leads either to the next question, or, on steps three and five, to a finding of disability. A negative answer to any question, other than step three, leads to a determination of "not disabled.
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986); 20 C.F.R. §§ 404.1520, 416.920.
Absent a good showing of cause to the contrary, the ALJ must accord substantial or considerable weight to the opinions of treating physicians. Lamb v. Bowen, 847 F.2d 698, 703 (11th Cir. 1988). The ALJ must credit the opinions of treating physicians over those of consulting physicians unless good cause exists for treating the opinions differently. Lewis v. Callahan, 125 F.3d 1436, 1440-41 (11th Cir. 1997). The ALJ may discount a treating physician's report when it is not accompanied by objective medical evidence or is wholly conclusory. Crawford v. Commissioner, 363 F.3d at 1159. Where the ALJ articulated specific reasons for failing to give the opinion of a treating physician controlling weight and those reasons are supported by substantial evidence, the ALJ commits no reversible error. Moore v. Barnhart, 405 F.3d 1208, 1212 (11th Cir. 2005).
The claimant was age 48 at the time of the administrative hearing and had achieved a high school education. She previously worked at Delphi Automotive where, in 2005, an accident degloved her right foot. After her injury, she continued working, but in 2007 she ended her full-time employment because of her foot condition. (R. 210-11). The claimant alleged in 2010 that she could not work because of her right foot injury, neuropathy in her right foot, hypertension, congestive heart failure, renal cancer, depression, and irritable bowel syndrome. (R. 203).
Although the record in this case contains numerous medical records relating to the claimant's alleged mental impairments, the sole issue upon which the court bases its reversal does not deal with those mental impairments. As such, the court will not discuss all the specific facts in the record regarding the mental impairments. Moreover, although the claimant presented medical evidence regarding her foot injury and alleged pain resulting from it, the court will focus the fact section on those facts in the record relating to Dr. Crouch and other doctor's treatment of the claimant's heart conditions and hypertension that do relate to the court's reasons for reversing the ALJ's decision.
On May 4, 2009, during a visit to her treating physician, Dr. Will Crouch, in Hartselle, the claimant's blood pressure registered high at 160/90.
Dr. David Drenning at the Heart Center in Huntsville evaluated the claimant on July 6, 2009 and determined that she had uncontrolled hypertension, kidney cancer, and an aortic aneurysm. He admitted her to the hospital the following day for care of her aneurysm. (R. 503-506).
On July 6, 2009, Dr. Drenning treated the claimant's aortic aneurysm at the Huntsville Hospital. A chest scan showed an aortic aneurysm of 6.4 centimeters; her blood pressure was initially 144/80 at the office visit on July 6 and then spiked to 170/70 on July 7 at the hospital; her pulse was in the 50s; and she had a murmur in the right and left mid sternal borders. Dr. Drenning continued her medications in the hospital and gave her Labetalol intravenously to lower her systolic blood pressure to less than 140. He also ordered a cardiac catherization that showed that the claimant had a large, aortic aneurysm; mildly depressed left ventricular systolic function that slowed pumping of blood; moderate pulmonary hypertension without evidence of left-to-right shunt; mild mitral regurgitation causing the heart valve to not close properly. (R. 436-38)
On July 17, 2009 Dr. Drenning referred the claimant to Drs. Richard Clay, LeRoy Harris, Murthy Vuppala, Paul Taberaux, and Steven Cowart at the Huntsville Hospital to replace the ascending aortic aneurysm. After her surgery, the claimant became hypotensive and suffered ventricular tachycardia. Her doctors prescribed her Vicodin, Aspirin, Coreg, Amiodarone, Lisinopril, Norvasc, Levaquin, Nexium, Lorazepam, and Prozac upon discharge; placed her on an ambulation program for exercise with an ultimate goal of two miles per day; mandated a low sodium diet; and gave her instructions to use five pound upper extremity weights. The claimant could ...