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Davis v. Berryhill

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

March 20, 2017





         On July 12, 2012, the claimant, Anita Davis, protectively applied for disability benefits under Titles II and XVI of the Social Security Act. (R. 132-147). The claimant alleged disability beginning on June 7, 2012, because of chronic moderately severe hip and back pain. (R. 33, 50). The Commissioner denied the claims on September 7, 2012. The claimant filed a timely request for a hearing before an Administrative Law Judge, and the ALJ held a video hearing on November 30, 2013. (R. 27-49).

         In a decision dated January 23, 2014, the ALJ found that the claimant was not disabled as defined by the Social Security Act and was, therefore, ineligible for social security benefits. (R. 11-20). On June 21, 2015, the Appeals Council denied the claimant's requests for review. (R. 1-5). Consequently, the ALJ's decision became the final decision of the Commissioner of the Social Security Administration. The claimant has 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.


         Whether the ALJ erred in evaluating the claimant's allegations of the limiting effects of her symptoms because substantial evidence does not support her findings regarding the claimant's need for a cane and her ability to frequently balance, stoop, kneel, crouch, crawl, and climb stairs.


         The standard for reviewing the Commissioner's decision is limited. This court must affirm the ALJ's decision if she applied the correct legal standards and if substantial evidence supports her 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); 20 C.F.R. §§ 404.1520, 416.920.

         V. FACTS

         The claimant was fifty-four years old at the time of the ALJ's final decision (R. 29); has a high school education (R. 73); has past relevant work as a bus attendant, sewing machine operator, sales clerk, and day care worker (R. 45); and alleges disability based on chronic moderately severe hip and back pain (R. 33, 50).

         Physical Impairments

         The claimant sought treatment on April 6, 2010 with Dr. Joshua Miller at Cooper Green Health Center, complaining of lower back pain that radiated into her left leg and calf. She reported to Dr. Miller that the Ultram and Parafon Forte that she was taking for pain was not working. He prescribed 500 mg of Naproxen and Tylenol 3 for pain and ordered an MRI of her lumbar spine. The claimant underwent an MRI of her lumbar spine on May 11, 2010 that showed shallow lordosis or curvature of the spine; normal disc heights with no gross desiccation; no disc bulge or herniation; a well-preserved central canal; “mild ligamentous hypertrophy at the lower of two levels with earliest of facet changes resulting [in] mild foraminal compromise bilaterally”; and otherwise unremarkable findings considering the claimant's age. (R. 316, 332).

         On June 8, 2010, the claimant returned to Dr. Miller complaining of back pain. Dr. Miller noted that the claimant was involved in a car accident in 2006 and that litigation was pending based on that accident. Regarding whether the pending litigation contributed to the claimant's complaints of continued pain, he noted “? factor in lack of improvement.” Dr. Miller noted the findings on the MRI the previous month and referred the claimant to physical therapy. (R. 269).

         The claimant began physical therapy at Cooper Green on June 28, 2010, and returned on July 9, 16, and 30. On July 9, she reported constant pain and numbness in her lower extremities, but the therapist reported that “despite constant complaints of pain/numbness, [the claimant] tolerate[d] exercises with no signs of discomfort.” The claimant stated on July 16 that she had “on and off days with pain, ” but she again tolerated the session with no complaints of pain or discomfort. On July 30, the claimant reported that she continued to do her exercise at home, but she continued to experience pain and had swelling in her ankles. The therapist noted that the claimant had reached the “maximum benefit” of physical therapy; encouraged her to continue her maintenance program at home; and discharged her from physical therapy. (R. 264-267).

         In a physical therapy evaluation form dated September 21, 2010, the therapist reported that the claimant reported improvement in her pain, but listed her pain level as a “7/10” on the pain scale. The therapist also noted that the claimant had weakened strength of “4/5” in her lower extremities; had difficulty with her “household activities” and “standing activities”; was able to tolerate prolonged standing and walking with some pain; could participate in her activities of daily living; and should continue her maintenance program at home. (R. 268).

         On September 21, 2010, the claimant returned to Dr. Miller complaining of constant pain in her back and legs when standing and swelling in both feet and ankles. Dr. Miller noted that the claimant completed physical therapy and was to complete a home exercise program. He continued the claimant's ...

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