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Bond v. Berryhill

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

August 22, 2017

PAMELA BOND, CLAIMANT,
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY, RESPONDENT.

          MEMORANDUM OPINION

          KARON OWEN BOWDRE CHIEF UNITED STATES DISTRICT JUDGE.

         I. INTRODUCTION

         On February 22, 2012, the claimant, Pamela Bond, protectively applied for disability and disability insurance benefits under Titles II and XVI of the Social Security Act. (R. 237). In both applications, the claimant alleged disability beginning on September 10, 2009, because of sarcoidosis, atypical microbacteria, and neuropathy. (R. 273). The Commissioner denied the claims initially on September 19, 2012, and again on reconsideration on February 8, 2013. (R. 175, 184). The claimant filed a timely request for a hearing before an Administrative Law Judge, and the ALJ held a hearing on August 7, 2014. (R. 38).

         In a decision dated October 22, 2014, the ALJ found that the claimant was not disabled under the Social Security Act and thus not entitled to social security benefits. (R. 27). On February 12, 2016, the Appeals Council denied the claimant's request for review. (R. 1). The ALJ's decision thus became the final decision of the Commissioner. 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 the decision of the Commissioner and remands the case to the Commissioner for further proceedings.

         II. ISSUE PRESENTED

         The claimant presents the following issue for review:

(1) whether substantial evidence supports the ALJ's decisions to assign little weight to treating sources Dr. Jack Lichtenstein, rheumatologists; Dr. Daniel Hexter, neurologist; and Dr. Kioumarce Yazdani, internist.

         III. STANDARD OF REVIEW

         The standard for reviewing the Commissioner's decision is limited. This court must affirm the Commissioner's decision if the Commissioner applied the correct legal standards and if the factual conclusions are supported by substantial evidence. 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 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, 401 (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 look only 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).

         IV. LEGAL STANDARD

         Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when the person cannot “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 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 forty-five years old at the time of the ALJ's final decision (R. 89); had completed some college (R. 42); had past relevant work as a seal coat technician, billing manager, and medical billing specialist (R. 104); and alleges disability based on sarcoidosis, atypical microbacteria, and neuropathy. (R. 273).

         Physical and Mental Impairments

         Dr. Mark Mossey admitted the claimant to Anne Arundel Medical Center in Maryland on September 10, 2009. Examinations found a 1.7 centimeter mass in the claimant's left lung, and a biopsy showed that the mass was a non-caseating granuloma. Further exams identified large hypodense lesions in the left and right lobes of the liver. (R. 388-397).

         The claimant visited Dr. Kioumarce Yazdani on October 8, 2009 complaining of difficulty swallowing. Dr. Yazdani noted that the claimant had non-caseating granulomas and was experiencing pain after eating. (R. 645). The claimant saw Dr. Yazdani again on November 17, 2009 (complaining of incontinence and pain after eating); on December 14, 2009 (complaining of tender bowels); and on March 18, 2010 (for tests showing small colonic polyps). (R. 387, 645).

         On October 22, 2009, Dr. Stephen Cattaneo saw the claimant for a consultation. Dr. Cattaneo noted that the claimant's symptoms and objective testing could represent sarcoidosis, a disease characterized by inflammatory masses, or granulomas, in different parts of the body. On November 11, 2009, Dr. Cattaneo admitted the claimant to Anne Arundel Medical Center for surgery to remove the lung nodule, which was successful. On December 3, 2009, Dr. Cattaneo wrote to Dr. Yazdani, the claimant's internist, regarding the claimant's further treatment. Dr. Cattaneo expressed that the claimant reported intermittent back and abdominal pain; that she had not eaten well and was inactive in her daily activities; and that he encouraged the claimant increase her activity. (R. 373-78, 380-84).

         Dr. Cattaneo referred the claimant to Dr. Glen Gibson, a surgical oncologist, who examined the claimant on April 8, 2010. Dr. Gibson noted lack of increase in size of the claimant's liver masses and stated that the liver lesions were not contributing to her severe decline in general functional ability that manifested in September 2009. (R. 405).

         On April 22, 2010, Anne Arundel Medical Center admitted the claimant because of complaints of leg pain without injury. Dr. David Todd performed spinal x-rays which showed scoliosis. The claimant returned to Dr. Yazdani on April 23, 2010, complaining of leg pain and on May 2, 2010, Dr. Yazdani completed a summary of the claimant's condition to that point. He noted that the claimant exhibited degenerative disc disease, non-caseating granulomas, frequent back pain, and chronic diarrhea. (R. 496, 646).

         On June 18, 2010, the claimant visited Dr. Karenga Lemmons, an internist, for a second opinion on referral from Dr. Yazdani. Dr. Lemmons noted bilateral leg pain radiating down ankles with numbness that had been present for six months prior. Dr. Lemmons further noted that the claimant appeared stressed and lacked understanding of her treatment history. Additionally, the claimant had 5/5 motor skills and a normal gait. (R. 426-28).

         On July 28, 2010, the claimant saw Dr. Reena Thomas on referral from Dr. Lemmons for the reported numbness in her legs. Dr. Thomas stated that electrodiagnostic evidence showed chronic spinal root irritation, but no electrodiagnostic evidence of a myopathy[2] or large fiber peripheral neuropathy.[3] (R. 407, 498, 782-84).

         The claimant returned to Dr. Lemmons' office on several occasions from June 30, 2010 to October 25, 2010 for follow-up with a nurse practitioner, Sharon Cave. The claimant consistently reported chronic left leg pain and numbness, intermittent pain in her right leg and left forearm, and swelling in her left leg. (R. 429-33).

         The claimant presented for an infectious disease consultation with Dr. Rahki Krishnan on July 22, 2010, which showed caseating and noncaseating granulomas. Dr. Krishnan referred the claimant to the Johns Hopkins Sarcoidosis Clinic, and the claimant presented on November 3, 2010 for Dr. Edward Chen to evaluate her for possible sarcoidosis. The claimant reported experiencing burning pain in both legs. Dr. Chen observed significant generalized fatigue; no red, hot, or swollen joints; and normal gait and stance. Dr. Chen described the claimant's ailments and prognosis as a nodular variant of pulmonary sarcoidosis. Further, he recommended reassessment of the claimant's liver and spleen; a consultation with a gastroenterologist; repeated gadolinium MRIs to assess the claimant's leg pain; an echocardiogram to screen for pulmonary hypertension; and a sleep study. (R. 412-415, 782-83).

         The claimant again returned to NP Cave in Dr. Lemmons' office on November 8, 2010 for a follow-up. The claimant reported that she was becoming fatigued between four to five in the afternoon each day, at which time she would sleep until two in the morning; further, she stated that she was using a walker. The claimant had an MRI on November 9, 2010, which showed signs of scoliosis, disc protrusions, and a high intensity zone. (R. 434).

         The claimant followed up with Dr. Krishnan, the infectious disease consultant, on November 11, 2010. Dr. Krishnan stated that the final diagnosis was sarcoidosis and that the claimant should follow up further with Johns Hopkins. The claimant presented on November 16, 2010 for the sleep study recommended by Dr. Chen, which showed no significant sleep-related breathing disorder. (R. 504-08, 784).

         On November 19, 2010, the claimant presented to Anne Arundel Medical Center for a right ankle fracture. The hospital referred the claimant to Dr. Edward Holt, an orthopedist, for further treatment. The claimant visited Dr. Holt for a foot and ankle exam on November 26, 2010. Per the claimant, she developed pain with weight bearing and turned abruptly, causing her right fibula to fracture. Dr. Holt recommended surgery to repair the claimant's fractured ankle, and performed an open reduction and internal fixation of the ankle fracture on December 1, 2010. (R. 510-11, 514, 586).

         The claimant returned to Dr. Chen on December 7th, 2010 for test results. Dr. Chen indicated that per the MRI results the claimant's liver showed signs of hemangioma and a multicystic condition. Further, Dr. Chen indicated the claimant had clear signs of vitamin D deficiency; extensive degenerative changes in her mid-back; and disc problems in her lower back. He further recommended that the claimant visit a back specialist. (R. 416-17).

         The claimant followed up with Sharon Cave, NP on December 17, 2010. The claimant again stated that she was using a walker, and NP Cave listed sciatica[4] as a diagnosis. (R. 435). The claimant returned on January 10, 2011 complaining of ...


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