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Leigh v. Berryhill

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

March 23, 2017





         On June 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).

         In a 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 Commissioner.


         A. 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.

         B. Whether the ALJ erred in giving less than significant weight to the opinion of the claimant's treating physician Dr. Graham.


         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); 20 C.F.R. §§ 404.1520, 416.920.

         V. FACTS

         The 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).

         Physical Impairments

         The 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).

         At 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 pain. (230-238).

         The 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[1] 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.

         The 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).

         The 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 227-229).

         On Dr. 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).

         At the 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 ...

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