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Smith v. Berryhill

United States District Court, N.D. Alabama, Southern Division

March 14, 2017

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration Defendant.




         On September 14, 2012, the claimant, Joy Streetman Smith, applied for disability insurance benefits and supplemental security income under Title XVI of the Social Security Act. (R. 64). The claimant alleges disability commencing on August 20, 2012 because of lumbar and cervical degenerative disc diseases and chronic pain syndrome. She also listed anxiety and depression as contributing to her inability to work. Id. at 64, 66, & 168. The Commissioner denied the claim both initially and on reconsideration. Id. The claimant filed a timely request for a hearing before an Administrative Law Judge, and the ALJ held a hearing on April 14, 2014. (R. 9).

         In a decision dated June 6, 2014, the ALJ found that the claimant was not disabled as defined by the Social Security Act. (R. 72). On September 18, 2015, 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 has exhausted her administrative remedies, and this court has jurisdiction pursuant to 42 U.S.C. §§ 405(g) and 1631(c)(3). For the reasons stated below, this court AFFIRMS the decision of the Commissioner


         Whether the ALJ properly applied the Eleventh Circuit's pain standard.[1]


         The standard for reviewing the Commissioner's decision is limited. This court must affirm the ALJ's decision if he 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 claimant meets a 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 in the record supports 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 only look 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 relied on by the ALJ. Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th Cir. 1986).


         Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when the person is unable to “ 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 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).[2]

         V. FACTS

         Medical Records Regarding Physical Impairments (Back and Neck Pain) Pre-2012 Medical Records

         The claimant's medical records indicated that she had a history of back and neck pain that dated back to the 1990's, including neck surgery years ago for herniated discs resulting in cervical fusion. (R. 247, 328). A 1999 MRI report reflected that she had a L4-5 disc protrusion on the left of her spine with the remaining disc spaces satisfactory and no spinal stenosis. (R. 326-27). The Brookwood orthopedic practice treated her in the 1990's, giving her a series of epidural blocks that gave her relief, and then saw her sporadically in 2006 for back pain, when x-rays on her spine showed only minimal change. Her doctors again ordered pain blocks, and she appeared to receive relief, as another lengthy treatment gap ensued. (R. 327). The orthopedic group resumed treating her regularly six years later in 2012. (R. 328).

         In 2009, records from Cooper Green Hospital and Dr. Adrienne Carter, a primary care/internal medicine physician, indicated that the claimant received treatment for the following conditions: 1. Depression/anxiety; 2. Bipolar; 3. PTSD; and 4. Chronic pain in lower back and neck. Dr. Carter's records contain an alert for prescription drug overuse/abuse and also detailed a history of overuse of opioids. (R. 238-39). The mention of drug misuse/abuse dating back to 2008 occurred in other charts as well, such as Cooper Green Hospital charts. (R. 238-39; 244, 246). However, for the last several years, the claimant has been on a pain management plan at the pain clinic with regular testing to check for drug misuse, and she is complying with the plan with no current record of drug misuse. (R. 488-510 & 527-552).

         Brookwood Orthopedics Records beginning in 2012

         On February 2, 2012, treating orthopedist Dr. Dewey Jones noted that a gap of a number of years had occurred between his last treatment of claimant and her visit that day. He stated that straight leg raisings produced discomfort and that the claimant had some sensory deficit on the lateral left calf compared to the right, but that range of motion of both hips was normal. Dr. Jones reviewed the 1999 MRI showing a 4-5 disc protrusion on the left lumbar spine and ordered follow-up x-rays. Dr. Jones interpreted these x-rays of her lumbar spine as showing that the “lateral” of the spine was within normal limits and that the L5 area, from where her pain apparently emanated, showed no changes in the sacroiliac joint, intact pedicles of the vertebral arch, and “a little equivocal narrowing of the L5-SI [joint] but not remarkable.” Dr. Jones also stated that an anteroposterior xray view showed no changes in the SI joints. The doctor planned to proceed with epidural blocks with Dr. Sovic, which had given her relief in the past, and if blocks did not work, to consider a lumbar MRI to ensure that “we are not overlooking anything.” (R. 328).

         March 2012 MRI

         The medical records from the pain clinic described the March 2012 MRI results as follows: “The lumbar vertebral bodies are normal in height and signal intensity. There is normal lumbar lordosis. Degenerative disc disease and minimal [changes].” (R. 497). Dr. Marion Sovic of Pain Management Service, P.C. sent a letter to Dr. Dewey Jones ...

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