United States District Court, N.D. Alabama, Western Division
OWEN BOWDRE CHIEF UNITED STATES DISTRICT JUDGE
22, 2012, the claimant, Angela Leigh Stephenson, protectively
applied for disability benefits under Title II of the Social
Security Act. (R. 121-124). The claimant alleged disability
beginning on July 15, 2010, because of anxiety, bipolar
disorder, and back pain. (R. 14). The Commissioner denied the
claims on September 19, 2012. The claimant filed a timely
request for a hearing before an Administrative Law Judge, and
the ALJ held a hearing on January 27, 2014. (R. 27-49).
decision dated May 6, 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.
11-26). On November 20, 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 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
Whether the ALJ erred in evaluating the claimant's
allegations of pain and other limiting effects of her
symptoms under the pain standard because substantial evidence
does not support his findings.
Whether the ALJ erred in giving less than significant weight
to the opinion of the claimant's treating physician Dr.
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 forty-three years old at the time of the
ALJ's final decision (R. 26, 121); has a GED (R. 37); has
past relevant work as a cashier, laborer, and daycare worker
(R. 56); and alleges disability based on anxiety, bipolar
disorder, and back pain (R. 33, 50).
claimant's medical records reveal that Dr. Harry L.
Richardson with Reform Medical Clinic treated the claimant
for back pain since at least June 25, 2010. On that date, the
claimant reported having stabbing, sharp pains in her back
that radiated down her right leg. Dr. Richardson's
physical examination of the claimant revealed tenderness in
her back with pain with range of motion, and he prescribed
Lortab for pain, Ambien for insomnia, and Seroquel for her
depression and anxiety. (R. 230-231).
return visits to Dr. Richardson on July 23 and August 30,
2010, the claimant continued to complain of chronic pain in
her back, and Dr. Richardson noted tenderness in her back and
pain with range of motion on both visits. During the August
30 visit, the claimant noted that the medications did not
control her back pain, and Dr. Richardson included a
prescription for Darvocet for pain. He also referred the
claimant to Dr. Chester Boston for an assessment of her back
claimant saw Dr. Boston at the University Orthopaedic Clinic
& Spine Center on September 22, 2010. The claimant
reported that she had pain and stiffness in her lumbar region
for about eight years; that bending, sitting, and walking
aggravated her symptoms; that the pain radiated from her back
to her right buttock and thigh; that she had numbness in her
lower extremity occasionally; and that Dr.
Graham gave her numerous epidural blocks in the
past that gave her limited relief. Dr. Boston noted that the
claimant had physical therapy in the past without relief.
Upon physical examination, Dr. Boston reported that the
claimant had a normal, non-antalgic gait, but had tenderness
and pain in the SI Joint on the right side. He ordered x-rays
of her lumbar spine that showed no evidence of spondylolysis
and ordered an MRI of her spine.
claimant underwent the MRI of her spine on October 20, 2010
at the University Orthopaedic Clinic in Tuscaloosa. (R.
353-356). The MRI revealed lumbarization of SI; a right
lateral bulge at LI-L2 that contributes to some mild
foraminal narrowing; a diffuse bulge and facet hypertrophy at
¶ 4-L5 that led to mild foraminal narrowing; and a
diffuse bulge at ¶ 5-S1 that is slightly greater toward
the left that has caused facet hypertrophy and moderate
bilateral foraminal narrowing “with crowding of the
exiting roots.” (R. 351-352).
claimant returned to Dr. Richardson on May 5, 2011, and he
noted that she had back tenderness with muscle spasms and
pain with range of motion. He also noted neck tenderness in
her “bilateral paracervical aspect” with muscle
spasms and pain with range of motion in her neck. (R
Richardson's referral, the claimant sought treatment with
Dr. Fred Graham with West Alabama Spine & Pain
Specialists in Tuscaloosa from at least 2011 until 2014.
During that time frame, the record contains notes from visits
the claimant had with Dr. Graham on July 13, 2011; February
22, June 6 and November 1, 2012; and April 8, and October 7,
2013. (R. 263-274, 324-338).
July 2011 visit with Dr. Graham, the claimant reported low
back pain that radiated into her legs and muscle spasms. She
also stated that she tried physical therapy in the past but
it “hurts me worse” and that her current
medications were not working. Dr. Graham gave her an
injection; ordered an x-ray of her lumbar spine; and added
Flexeril and SEC cream for joint stiffness. At her next visit
on February 22, 2012, she said her pain had worsened, but
that the SEC cream did help with ...