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Mwangi v. Berryhill

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

March 20, 2017





         On August 1, 2012, the claimant, Christy Annette Mwangi, protectively applied for disability and disability insurance benefits under Titles II and XVI of the Social Security Act. (R. 148, 274). In both applications, the claimant alleged disability beginning on July 1, 2012, because of fibromyalgia, depression, anxiety, chronic back pain caused by a bulging disc, nerve pain in her legs, and arthritis in her knee. (R. 38-39, 161). The Commissioner denied the claims on October 3, 2012. The claimant filed a timely request for a hearing before an Administrative Law Judge, and the ALJ held a hearing on January 13, 2014. (R. 37).

         In a decision dated March 21, 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. 15). On August 28, 2015, the Appeals Council denied the claimant's requests for review. (R. 1-6). 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 to the ALJ for reconsideration.


         Whether the ALJ erred in the weight he gave to the opinions of the claimant's treating physician Dr. Toumah Sahawneh and examining, consulting physicians Dr. Alan Blotcky and Dr. Rex Harris because substantial evidence did not support the ALJ's findings.


         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)[1]; 20 C.F.R. §§ 404.1520, 416.920.

         V. FACTS

         The claimant was thirty-eight years old at the time of the ALJ's final decision (R. 44); had completed sixth grade, but did not obtain her GED (R. 46-57); has past relevant work as a certified nurse's assistant, fast food worker, and waitress (R. 26); and alleges disability based on fibromyalgia, depression, anxiety, chronic back pain, nerve pain in her legs, and arthritis in her knee.

         Physical and Mental Impairments

         The claimant presented to the Emergency Department at Trinity Medical Center on November 10, 2009 after falling down stairs in her home and injuring her right knee, describing her pain as “constant, sharp, [and] throbbing” and assessing her pain as an eight out of ten on the pain scale. Dr. Jeremy Rogers ordered an x-ray of claimant's knee, which showed no acute facture or dislocation. Dr. Rogers diagnosed the claimant with acute tendonitis in the right knee and prescribed Ibuprofen 800 mg and Darvocet as needed for pain. (R. 496-507).

         On February 1, 2010, the claimant returned to the Emergency Department at Trinity Medical Center complaining of a severe, sharp pain in her lower back. The claimant, who was thirteen weeks pregnant, stated that she lifted a heavy man off the floor at work and felt a sharp pain in her lower back about ten minutes later. She assessed her pain as a nine out of ten on the pain scale. Dr. Samuel Flowers prescribed the claimant Acetaminophen/Oxycodone as needed for severe pain and Cyclobenzaprine for muscle spasms.

         The claimant again sought treatment on November 18, 2010 at the Emergency Department at Trinity Medical Center for intense pain in her left buttock, radiating to her left leg, side of her foot, and toes. She had given birth eleven weeks prior via a C-section and an epidural. At this visit, she complained of numbness and tingling on her left side that intensified with standing, and stated that nothing relieved her pain. Dr. Flowers noted that the claimant's back had “tenderness to palpation over lumbar spine, ” and that she experienced pain while flexing and extending her back and while laterally bending to her left side. Dr. Flowers ordered an MRI that revealed no acute fractures but showed a bulge at ¶ 5-SI that did not cause any “significant mass effect.” Dr. Flowers prescribed the claimant Acetaminophen/Oxycodone as needed for pain and Norflex as needed for muscular pain. (R. 401-411).

         On February 8, 2011, the claimant presented to Trinity Medical Center for physical therapy, complaining of muscle spasms and back pain and assessing her daily pain as an eight out of ten on the pain scale. The claimant stated that she had pain standing and rolling over onto her back, and that she could stand less than five minutes, sit less than fifteen minutes, and walk less than five minutes. Physical Therapist Debbie King noted that the claimant had abnormal muscle tone; decreased range of motion; and limitations in her activities of daily living. Although Ms. King scheduled physical therapy for the claimant two to three times a week through April 8, 2011, the claimant did not show up for several sessions, and the February 8, 2011 notes are the only ones for physical therapy in the record. (R. 382-396).

         The claimant sought treatment with Dr. Toumah Sahawneh at the Baptist Health Center in Oneonta on October 3, 2011 for back and leg pain. Dr. Sahawneh noted tenderness and muscle spasms in the claimant's lower back. The claimant reported that her medications make her sleepy and she cannot work.[2]

         From December 22, 2011 through May 8, 2012, the claimant saw Dr. Sahawneh six times, each time complaining of chronic back, leg, knee, and foot pain, along with muscle spasms. The claimant reported on February 2 and May 8, 2012 that her pain was getting worse, despite taking Lortab for pain. (R. 553-566).

         The claimant saw Dr. John Smith at Baptist Health Center on June 27, 2012, complaining of back pain. Dr. Smith noted that the claimant had back pain for the past two years, and that a 2010 MRI showed a bulging disk in her back. The claimant's medications at the time of this visit were Neurontin, Mobic, Lortab, and SOMA. Dr. Smith noted tenderness in the claimant's back at the sacrum and both “SI joints” and prescribed Dexa and Medrol, both anti-inflammatory medications. He also told the claimant to continue the Lortab as needed for pain. Dr. Smith ordered another MRI of the lumbar spine if the claimant was not better in one week. (R. 549).

         On July 6, 2012, the clamant returned to Dr. Sahawneh for a follow-up complaining of back, knee, and ankle pain, in addition to swelling; she reported tenderness in her legs and back, along with muscle spasms. Dr. Sahawneh's clinical impression included chronic pain in her back and knees. The claimant underwent an MRI later that afternoon that showed no abnormalities in her ...

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