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Evans v. Berryhill

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

March 21, 2017





         On September 21, 2012, the claimant, Bennett Evans, protectively applied for disability and disability insurance benefits under Title II and part A of Title XVIII of the Social Security Act. (R. 145). The claimant initially alleged disability commencing on June 16, 2012 because of coronary artery disease, cervical spine disease, depression, acid reflux, insomnia, glaucoma, and cataracts. (R. 145, 184). The Commissioner denied the claim on December 26, 2012. (R. 87). The claimant filed a timely request for a hearing before an Administrative Law Judge, and the ALJ held a hearing on January 22, 2013. (R. 95).

         In a decision dated May 1, 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. 7-28). On October 6, 2015 the Appeals Council denied the claimant's requests for review. (R. 1-4). Consequently, the ALJ's decision became the final decision of the Commissioner of the Social Security Administration. The claimant has exhausted his 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 AFFIRMS the decision of the Commissioner.


         The issue before the court is whether, under the Eleventh Circuit's pain standard, the ALJ properly assessed the claimant's subjective complaints of disabling pain.


         The standard for reviewing the Commissioner's decision is limited. This court must affirm the ALJ's decision if the ALJ applied the correct legal standards and if substantial evidence supports the ALJ's 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 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 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 fifty-four years old at the time of the ALJ's final decision. (R. 34). The claimant has a twelfth grade education and past relevant work as a shredder, delivery driver, produce clerk, and material handler. (R. 62, 185). The claimant alleges disability based on coronary artery disease, cervical spine disease, depression, acid reflux, insomnia, glaucoma, and cataracts. (R. 184).

         Physical and Mental Impairments

         On September 6, 2005, the claimant visited the University of Alabama at Birmingham emergency room because a heavy tire fell while the claimant was working, hitting him in the chest. On the same day, Dr. Tom McElderry, a cardiologist, diagnosed the claimant with a chest wall contusion and hypertension. Dr. McElderry referred the claimant to the Kirklin Clinic for further hypertension evaluation after discharge.[2] (R 269-74, 279).

         At the recommendation of his emergency room doctors, the claimant visited the Birmingham Veteran's Association Medical Clinic to establish primary care on November 30, 2005. During this initial visit, nurse practitioner Jennifer Dardy-Bonner determined that the claimant still suffered from hypertension and diagnosed the claimant with gastroesophageal reflux disease (gerd). She prescribed a blood pressure regimen consisting of Ramipril, Felodipine, and HCTZ to stabilize his hypertension, and Omeprazole for his gerd. (R. 1108-1112).

         During his yearly follow-up at the VA on August 24, 2006 with Dr. Felicia R. Noerager, the claimant's hypertension and gerd were both controlled. Similarly, on January 4, 2007, the claimant's hypertension and gerd were stable; however, Dr. Noerager sent the claimant to the emergency room because of an abnormal EKG. Ultimately, all emergency room tests and evaluations were normal. (R. 1095-97, 1102).

         The claimant continued to see Dr. Noerager for two yearly follow-up appointments, and the claimant's hypertension and gerd remained controlled until 2009. On February 27, 2009, Dr. Noerager reported that the claimant's hypertension was poorly controlled because of his failure to consistently take prescribed medications. Dr. Noerager also prescribed Ibprofin for claimant's new hip and back pain complaints. Similarly, during a September 15, 2009 follow-up, the claimant stated that he no longer took hypertension and gerd medication, but continued to experience chest pain. (R. 1025, 1029).

         On April 27, 2010, the claimant received a Kenalog shot and a Lortab perscription for back pain, and Dr. Noerager ordered an MRI of the claimant's back. Dr. Noerager also reported that the claimant's hypertension and gerd were again stabilized with medication. An MRI of the claimant's back taken on May 18, 2010 showed narrowing of the claimant's spinal column. (R. 1003-05, 1011).

         The claimant called the VA on October 13, 2011 to renew his hypertension, gerd, and pain medications; however, the medical clinic, not having seen the claimant in over a year, did not have authorization to renew. Subsequently, on December 8, 2011, the claimant visited Dr. Noerager for his yearly follow-up. During this appointment, Dr. Noerager ordered x-rays and a stress test, and prescribed tramadol for the claimant's chest pain. The claimant's hypertension and gerd both continued to remain stable. (R. 989-90, 1102).

         In a letter dated December 13, 2011, Dr. Noerager notified the claimant that the x-rays showed no abnormalities. Similarly, after a nuclear cardiac stress test conducted on January 20, 2012, Dr. Noerager sent another letter notifying the claimant that the stress test was also normal. (R. 981-86).

         On April 18, 2012, the claimant called the VA hospital complaining of chronic pain. Dr. Noerager scheduled a follow-up appointment to address this pain on April 24, 2012. During the appointment, Dr. Noerager diagnosed the claimant with hematuria and lipoma, ordered an MRI, and prescribed Roboxin, Tramadol, and Gabapentin for lower back pain. (R. 976-980)

         The claimant underwent the MRI on June 1, 2012. During the MRI follow-up on June 5, 2012, Dr. Noerager diagnosed the claimant with spinal stenosis and lipomatosis caused by mild central canal narrowing and cord compression at ¶ 6-C7, and referred the claimant to the VA neurosurgeon. Before the neurology consultation, however, the claimant was admitted to the intensive care unit and diagnosed with angina on June 17, 2012. (R. 943, 972-73).

         The claimant remained in the hospital for three days. On June 18, 2012, the claimant underwent an angiography and cardiac catheterization surgery to place a heart catheter and stent in the claimant's coronary artery. Although the angina was ultimately unresolved, the treating physician prescribed Plaviz and Lisinopril and discharged the claimant on June 19, 2012. During the claimant's June 28, 2012 emergency room follow-up, Dr. Noerager reported no substantial changes regarding his hypertension, gerd, chest pain, lower back pain, hematuria, or lipoma. (R. 877-78, 906, 925).

         Upon Dr. Noerager's referral, the claimant also visited Dr. Carin Eubanks at the VA the mental health department on June 28, 2012. Dr. Eubanks diagnosed the claimant with moderate psychological distress and recommended future treatment, but the claimant refused further treatment. (R. 876-77).

         On July 17, 2012, the claimant visited Dr. Gilbert J. Perry at the VA Cardiology Clinic to follow-up on his cardiac surgery. Dr. Perry reported that the claimant's hypertension was controlled, and referred the claimant to cardiac rehab. (R. 862-64).

         During his yearly follow-up on August 7, 2012, Dr. Noerager stated that the claimant's hypertension was controlled; however, his gerd was not improving because he no longer took his medication. She noted that the claimant needed to stop any activity causing chest pain, and that he should not return to work until early September 2012 after cardiac rehab. On the same day, the ...

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