United States District Court, N.D. Alabama, Middle Division
OWEN BOWDRE, CHIEF UNITED STATES DISTRICT JUDGE.
4, 2014, the claimant, Alisha Stone, protectively applied for
disability insurance benefits and supplemental security
income under Titles II and XVI of the Social Security Act.
She alleged disability beginning December 3, 2012, because of
Chronic Obstructive Pulmonary Disease, asthma, rheumatoid
arthritis, seizures, memory loss, manic depression, Post
Traumatic Stress Disorder (PTSD), anxiety, muscle spasms,
migraines, Latent Positive TB (not active), restless leg
syndrome, fibromyalgia, problems with her left side neck
vertebrae, and herniated discs. The Commissioner denied the
claimant's applications on September 14, 2014. The
claimant filed a timely request for a hearing before an
Administrative Law Judge, and the ALJ held a video hearing on
November 5, 2015. (R. 83-84, 19).
decision dated January 11, 2016, the ALJ found that the
claimant was not disabled as defined by the Social Security
Act and was, therefore, ineligible for social security
benefits. On March 10, 2016, the Appeals Council denied the
claimant's request for review. Consequently, the
ALJ's decision became the final decision 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 will reverse and remand
the decision of the Commissioner. (R. 16-35, 1-6).
the ALJ's decision to give the opinion of the
claimant's treating psychiatrist Dr. Grant little weight
lacks substantial evidence.
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).
... 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).
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.
a showing of good cause to the contrary, the ALJ must accord
substantial or considerable weight to the opinions of
treating physicians. Lamb v. Bowen, 847 F.2d 698,
703 (11th Cir. 1988). The ALJ must credit the opinions of
treating physicians over those of consulting physicians
unless good cause exists for treating the opinions
differently. Lewis v. Callahan, 125 F.3d 1436,
1440-41 (11th Cir. 1997). The ALJ may discount a treating
physician's report when it is not accompanied by
objective medical evidence or is wholly conclusory.
Crawford v. Commissioner, 363 F.3d at 1159. Where
substantial evidence does not support the ALJ articulated
specific reasons for failing to give the opinion of a
treating physician controlling weight, the ALJ commits
reversible error. See Perez v. Comm'r of Soc.
Sec., 625 F. App'x 408, 417-18 (11th Cir. 2015);
see also Moore v. Barnhart, 405 F.3d 1208, 1212
(11th Cir. 2005).
claimant was thirty-seven years old at the time of the
ALJ's final decision. She had an eighth-grade education
and had not completed her GED. She has past relevant work as
a certified nursing assistant (CNA), a cook, and a shift
manager at a fast food restaurant. She alleges disability
based on COPD, asthma, rheumatoid arthritis, seizures, memory
loss, manic depression, PTSD, anxiety, muscle spasms,
migraines, Latent Positive TB (not active), restless leg
syndrome, fibromyalgia, problems with her left side neck
vertebrae, and herniated discs. (R. 221).
and Mental Impairments
April 28, 2011, and November 14, 2013, the claimant sought
treatment with Dr. Danny Salisbury, D.O. with Holistic Pain
Management, about once every month for anxiety and constant
sharp aches and pains all over her body, but typically
centered in her lower back. Each visit, she reported limited
activity and range of motion because of her pain and usually
ranked her pain between a 3/10 and a 6/10. Activity
reportedly worsened her symptoms, while medications and rest
diminished her symptoms. Dr. Salisbury treated her pain with
Roxicodone and Lortab, and her anxiety with Xanax, which the
claimant reported were usually effective to manage her pain.
September 28, 2012, while driving, the claimant briefly lost
consciousness, possibly because of a seizure, drove off an
embankment, and collided with a tree head-on. She was
emergency airlifted to the Huntsville Hospital emergency room
and was “in and out of responsiveness” during the
transport to the hospital. Dr. Daniel Spangler indicated that
the claimant was “nearly unintelligible”; that
her right pupil was dilated; and that she suffered from
tenderness in her head, a scalp contusion, a neck strain,
chest wall contusion, and a lip laceration. Dr. Spangler also
noted the claimant has a “known seizure
disorder.” He prescribed Dilaudid for pain, Phenergan
for nausea, and Cilaucid for breakthrough pain. After her CT
scans of her head and back showed no significant
abnormalities, Dr. Spangler discharged the claimant the next
day. He instructed her not to drive until she was cleared by
another doctor because of her seizure risk and to continue
taking her current pain medications. (R. 433-506).
October 25, 2012, the claimant followed-up with Nurse
Practitioner Mary Kathryn Lauderdale with Quality of Life
Health Services, Inc. NP Lauderdale diagnosed the claimant
with chronic seizures/convulsions, chronic low back pain,
chronic fibromyalgia/myositis, chronic anthropathy, and
chronic asthma. She specifically noted under the
“Neuro/Psychiatric” section that the
claimant's seizures caused an “altered level of
consciousness”; drooling; focal neurological deficit;
memory impairment; headaches; poor insight; poor judgment;
poor attention span and concentration, characterized as
“concentration disjointed”; and tongue biting and
unresponsiveness. Nurse Practitioner Lauderdale prescribed
Fioricet, Lortab, and oxycodone for pain; Soma as a muscle
relaxer; Symbicort for asthma and COPD; Tegretol for
seizures; and Xanax for anxiety. (R. 601-603).
December 14, 2012, the claimant sought treatment with CED
Mental Health Center. Licensed Professional Counselor Brooke
Bowen initially examined the claimant during intake. The
claimant complained of depression (no appetite, no energy,
lack of sleep, crying spells), anxiety, panic attacks, mood
swings, and seizures. The claimant noted impairments in daily
living and reported that, when she was 15 years old, her
step-father raped and abused her. Ms. Bowen assessed the
claimant with a 31 on the Global Assessment of Functioning
(GAF) Scale, indicating major impairment in work or school,
family relations, judgment, thinking, and mood. Ms. Bowen
noted that the claimant had difficulty with acknowledging
problems and blamed them on others or on circumstances. Ms.
Bowen recommended individual therapy and a physician's
Richard Grant, a psychiatrist, assessed the claimant that
same day and diagnosed her with major depression, severe
without psychosis; post-traumatic stress disorder; seizures;
and bulging/herniated discs. (R. 540-47).
January 4, 2013, the claimant returned to CED for individual
therapy with Ms. Brooks and reported an increase in her
depression symptoms. The claimant's GAF Score remained at
31. Ms. Bowen worked with the claimant to establish goals to
decrease depression, learn coping strategies, and reduce her
dependence on prescription medications. Ms. Bowen recommended
that the claimant undergo a medical assessment by a
psychiatrist every six months and have individual therapy
every six weeks. Dr. Grant concurred with Ms. Bowen's
recommendation. (R. 536-39).
December 14, 2012 and June 24, 2015, the claimant visited CED
ten times for therapy and three times for consultations with
Dr. Grant. Several therapists with different
qualifications counseled the patient during this time in
addition to Ms. Bowen. During these sessions, the claimant
presented mostly for major depression, PTSD, seizure
disorder, panic attacks, anxiety, and diminished memory. The
severity of the claimant's symptoms fluctuated during
this period. By March 8, 2013, the claimant reported that her
depression and seizures had worsened tremendously and that
she had made no progress toward her treatment goals. The
record reflects that the claimant missed several therapy
appointments because “seizures messed up [her]
memory.” (R. 5 28-30, 534-36, 540-47, 570-78, 629-33,
April 19, 2013, Dr. Salisbury examined the claimant for
depression and chronic pain. Dr. Salisbury noted that the
claimant's mood was dysphoric and that she was tearful.
Dr. Salisbury prescribed Zoloft for depression and anxiety.
(R. 531-33). On July 8, 2013, Dr. Grant refilled the
claimant's Zoloft prescription. (R. 530).
November 14, 2013, Dr. Salisbury sent a letter to the
claimant, informing her that as of that day, Holistic Pain
Management could no longer treat her. Dr. Salisbury gave the
claimant thirty days to find a new pain management doctor,
during which time the claimant could rely on Holistic Pain
Management for emergency care only. The letter did not
specify a reason for refusing to treat the claimant further;
however, the claimant ...