United States District Court, N.D. Alabama, Southern Division
OWEN BOWDRE CHIEF UNITED STATES DISTRICT JUDGE
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).
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.
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
STANDARD OF REVIEW
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).
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).
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.
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.
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
(5) Is the person unable to perform any other work within the
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
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir.
1986); 20 C.F.R. §§ 404.1520, 416.920.
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.
and Mental Impairments
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).
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.
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).
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).
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
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.
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).
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 ...