United States District Court, N.D. Alabama, Northwestern Division
MADELINE HUGHES HAIKALA, UNITED STATES DISTRICT JUDGE
to 42 U.S.C. §§ 405(g) and 1383(c), plaintiff Cord
Lee Benson seeks judicial review of a final adverse decision
of the Commissioner of Social Security. The Commissioner
denied Mr. Benson's claims for a period of disability,
disability insurance benefits, and supplemental security
income. After careful review, the Court affirms the
Benson applied for a period of disability and disability
insurance benefits and supplemental security income on
January 23, 2012. (Doc. 7-4, pp. 2-3). Mr. Benson alleges
that his disability began on June 10, 2009. (Doc. 7-6, pp. 2,
8). The Commissioner initially denied Mr. Benson's claims
on May 7, 2012. (Doc. 7-5, pp. 2, 7). Mr. Benson requested a
hearing before an Administrative Law Judge (ALJ). (Doc. 7-5,
pp. 16-17). The ALJ issued an unfavorable decision on April
22, 2014. (Doc. 7-3, pp. 43-58). On February 25, 2016, the
Appeals Council declined Mr. Benson's request for review
(Doc. 7-3, p. 2), making the Commissioner's decision
final and a proper candidate for this Court's judicial
review. See 42 U.S.C. §§ 405(g) and
STANDARD OF REVIEW
scope of review in this matter is limited. “When, as in
this case, the ALJ denies benefits and the Appeals Council
denies review, ” the Court “review[s] the
ALJ's ‘factual findings with deference' and
[his] ‘legal conclusions with close
scrutiny.'” Riggs v. Comm'r of Soc.
Sec., 522 Fed.Appx. 509, 510-11 (11th Cir. 2013)
(quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th
Court must determine whether there is substantial evidence in
the record to support the ALJ's factual findings.
“Substantial evidence is more than a scintilla and is
such relevant evidence as a reasonable person would accept as
adequate to support a conclusion.” Crawford v.
Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir.
2004). In evaluating the administrative record, the Court may
not “decide the facts anew, reweigh the evidence,
” or substitute its judgment for that of the ALJ.
Winschel v. Comm'r of Soc. Sec. Admin., 631 F.3d
1176, 1178 (11th Cir. 2011) (internal quotations and citation
omitted). If substantial evidence supports the ALJ's
factual findings, then the Court “must affirm even if
the evidence preponderates against the Commissioner's
findings.” Costigan v. Comm'r, Soc. Sec.
Admin., 603 Fed.Appx. 783, 786 (11th Cir. 2015) (citing
Crawford, 363 F.3d at 1158).
respect to the ALJ's legal conclusions, the Court must
determine whether the ALJ applied the correct legal
standards. If the Court finds an error in the ALJ's
application of the law, or if the Court finds that the ALJ
failed to provide sufficient reasoning to demonstrate that
the ALJ conducted a proper legal analysis, then the Court
must reverse the ALJ's decision. Cornelius v.
Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991).
SUMMARY OF THE ALJ'S DECISION
determine whether a claimant has proven that he is disabled,
an ALJ follows a five-step sequential evaluation process. The
(1) whether the claimant is currently engaged in substantial
gainful activity; (2) whether the claimant has a severe
impairment or combination of impairments; (3) whether the
impairment meets or equals the severity of the specified
impairments in the Listing of Impairments; (4) based on a
residual functional capacity (“RFC”) assessment,
whether the claimant can perform any of his or her past
relevant work despite the impairment; and (5) whether there
are significant numbers of jobs in the national economy that
the claimant can perform given the claimant's RFC, age,
education, and work experience.
Winschel, 631 F.3d at 1178.
case, the ALJ found that Mr. Benson has not engaged in
substantial gainful activity since June 15, 2009, the alleged
onset date. (Doc. 7-3, p. 45). The ALJ determined that Mr.
Benson suffers from the following severe impairments:
degenerative disc disease, degenerative joint disease with
chronic low back pain/lumbago, spondylosis, sacroiliitis,
osteoarthritis at multiple sites with musculoskeletal pain,
arthralgias, hepatitis, coronary arterial disease, history of
venous insufficiency, gout diagnosed on one occasion, episode
of acute bronchitis, obesity, and depression/mood disorder.
(Doc. 7-3, p. 45). Mr. Benson also has the non-severe
impairment of hyperlipidemia. (Doc. 7-3, p. 46). Based on a
review of the medical evidence, the ALJ concluded that Mr.
Benson does not have an impairment or combination of
impairments that meets or medically equals the severity of
any of the listed impairments in 20 C.F.R. Part 404, Subpart
P, Appendix 1. (Doc. 7-3, p. 46).
light of Mr. Benson's impairments, the ALJ evaluated Mr.
Benson's residual functional capacity. The ALJ determined
that Mr. Benson has the RFC to perform:
light work as defined in 20 CFR 404.1567(b) and 416.967(b)
except for the following limitations: the claimant can
interact appropriately with supervisors but this should be
casual non-confrontational and with supportive feedback; can
interact appropriately with coworkers, customers, and members
of the general public but this should be casual
non-confrontational and infrequent; can respond appropriately
to work pressures in usual work setting; can respond
appropriately to changes in a routine work setting but
changes should be infrequent and gradually introduced; can
use judgment for simple 1-2 step work related decisions;
cannot use judgment in detailed or complex work related
decisions; can understand, remember, carry out simple 1-2
step instructions; cannot understand remember and carry out
detailed or complex instructions; and can maintain attention,
concentration and pace for at least 2 hours and concentrate
and persist at tasks at an appropriate pace throughout an 8
hour day with customary work breaks. In addition, the
claimant can occasionally lift and/or carry 20 pounds, and
frequently up to 10 pounds. He can stand and/or walk with
normal breaks for a total of 3 hours, and sit with normal
breaks for a total of more than 6 hours on a sustained basis
in an 8 hour workday. The claimant is limited in the
bilateral lower extremities to occasional pushing and/or
pulling. The claimant can occasionally climb ramps and
stairs, balance, stoop, kneel, crouch, and crawl, but never
climb ladders, ropes, or scaffolds. The claimant has no
manipulative limitations, visual limitations, or
communicative limitations. The claimant should avoid
concentrated exposure to extreme cold. He is unlimited in
exposure to extreme heat, wetness, humidity, noise, fumes,
odors, dusts, gases, poor ventilation, etc. He should avoid
concentrated exposure to vibration, and all exposure to
hazards. He must avoid all unprotected heights and hazardous
machinery. . . . In addition, out of an abundance of caution
and giving the claimant the benefit of all doubt, the
claimant will require a sit/stand option all day at the
(Doc. 7-3, pp. 48-49) (internal citation omitted).
on this RFC, the ALJ concluded that Mr. Benson is not able to
perform his past relevant work as a sand blaster, machine
packager, cook/kitchen manager, or truss builder. (Doc. 7-3,
p. 56). Relying on testimony from a vocational expert, the
ALJ found that jobs exist in the national economy that Mr.
Benson can perform, including assembler, hand packer, and
call out wire worker. (Doc. 7-3, p. 57). Accordingly, the ALJ
determined that Mr. Benson has not been under a disability
within the meaning of the Social Security Act. (Doc. 7-3, p.
SUMMARY OF THE MEDICAL EVIDENCE
Record Before the ALJ
March 9, 2006, Dr. Michael Herndon at Alexandria Medical
Clinic diagnosed Mr. Benson with varicose veins and leg pain
and noted that Mr. Benson was obese. (Doc. 7-9, p. 28). On
September 4, 2009, Dr. Herndon diagnosed Mr. Benson with
acute gouty arthritis. (Doc. 7-9, p. 24). On January 7, 2010,
Mr. Benson asked Dr. Herndon to refer him to a vascular
surgeon. (Doc. 7-9, p. 23). During this visit, Dr. Herndon
diagnosed varicose veins on Mr. Benson's legs and noted
that Mr. Benson was obese. (Doc. 7-9, p. 23).
24, 2010, Mr. Benson visited the emergency room at Northeast
Alabama Regional Medical Center and complained about an
abscess located on his lower back. (Doc. 7-9, p. 60). Mr.
Benson rated the pain a 5 out of 10. (Doc. 7-9, p. 60). Mr.
Benson had a normal range of motion in his extremities. (Doc.
7-9, p. 61). Mr. Benson returned twice over the next three
days for rechecks of the abscess. (Doc. 7-9, pp. 54-59).
During both of these visits, Mr. Benson's musculoskeletal
exams were normal. (Doc. 7-9, pp. 55, 58).
November 8, 2011, Mr. Benson visited Northeast Alabama
Regional Medical Center after experiencing chest pain that he
rated an 8 out of 10. (Doc. 7-9, p. 37). When he was
admitted, Mr. Benson was not experiencing “specific
discomfort, ” and doctors explained that he did
“not appear to be in any pain” and did “not
appear to be hurting” or experiencing distress. (Doc.
7-9, p. 37). Mr. Benson's cardiac examination was normal.
Doctors noted that his extremities had no cyanosis or
swelling. Mr. Benson moved all of his extremities
“without any difficulty, ” and he had no erythema
or swelling in his joints. (Doc. 7-9, p. 38). At discharge,
Dr. Davisson Edmond diagnosed Mr. Benson with hypertension,
hyperlipidemia, and chest pain. (Doc. 7-9, p. 35). Dr. Edmond
noted that Mr. Benson was morbidly obese but was
“ambulating very well.” (Doc. 7-9, p. 35). Mr.
Benson had a negative EKG and stress test, and the rest of
his physical exam was unremarkable. (Doc. 7-9, p. 35).
February 1, 2012, Mr. Benson saw nurse practitioner Janice
Parker at Quality of Life Heatlh Services. Mr. Benson
complained of lower back pain that radiated to his right
thigh. (Doc. 7-10, p. 4). He stated that his symptoms were
aggravated by “ascending stairs, bending, changing
positions, descending stairs, lifting, sitting[, ] and
walking.” (Doc. 7-10, p. 4). Although doctors had
diagnosed degenerative disc disease five or six years
earlier, Mr. Benson told the nurse practitioner that he had
not had back problems in years. (Doc. 7-10, p. 4). Mr. Benson
had no cervical spine tenderness or thoracic spine
tenderness, and he had normal mobility and curvature. (Doc.
7-10, p. 6). Mr. Benson's hips had a full range of
motion, and he had no joint deformity, heat, swelling,
erythema, or effusion. (Doc. 7-10, p. 6). Ms. Parker noted
that Mr. Benson had a reduced range of motion due to the
severity of the pain radiating down the right thigh on
movement and palpitation of the lumbar spine area. (Doc.
7-10, p. 6). Ms. Parker also noted Mr. Benson's lumbar
spine had severe pain with motion and spasms. (Doc. 7-10, p.
6). Ms. Parker diagnosed Mr. Benson with an acute sprain in
his lumbar region and acute pain in the limb. (Doc. 7-10, p.
6). She prescribed warm compresses, topical pain cream, and
prescription pain medication. (Doc. 7-10, p. 6).
February 8, 2012, Mr. Benson saw Ms. Parker at Quality of
Life again. (Doc. 7-10, p. 8). Mr. Benson complained of
persistent low back pain and told Ms. Parker that his
prescribed medications did not provide “much
relief.” (Doc. 7-10, p. 8). Mr. Benson was positive for
back pain, joint pain, and muscle weakness, and his gait was
limp. (Doc. 7-10, pp. 9-10). A cervical and thoracic spine
examination was normal, but Mr. Benson's lumbar spine was
tender and his range of motion was moderately reduced. (Doc.
7-10, p. 10). Ms. Parker recommended an MRI of Mr.
Benson's lumbar spine, and treatment notes indicate Mr.
Benson was going to consider the procedure. (Doc. 7-10, p.
Ms. Parker diagnosed chronic lumbago and chronic neuralgia,
and she prescribed oral prescriptions, topical pain
medication, and warm compresses. (Doc. 7-10, p. 10).
February 15, 2012, Mr. Benson saw Dr. Carla Thomas at Quality
of Life. (Doc. 7-10, p. 12). He again complained of pain in
his lower back and gluteal area. (Doc. 7-10, p. 12). The pain
radiated to the left and right ankle, and Mr. Benson
described the pain as “burning, deep, diffuse, and
shooting.” (Doc. 7-10, p. 12). The pain was aggravated
by bending, flexing, and sneezing. (Doc. 7-10, p. 12). Dr.
Thomas noted that Mr. Benson's symptoms were
“relieved by heat.” (Doc. 7-10, p. 12). Dr.
Thomas found that Mr. Benson's left and right hips were
tender, and his lumbar spine had a muscle spasm; however, Mr.
Benson's gait was normal, and he had full range of motion
in his extremities and an otherwise normal musculoskeletal
exam. (Doc. 7-10, p. 14). Dr. Thomas explained that Mr.
Benson's neuralgia and lumbar sprain had improved, and
she encouraged Mr. Benson to exercise. (Doc. 7-10, p. 14).
February 23, 2012, Mr. Benson saw Dr. Jeffrey Pierson at
Stringfellow Memorial Hospital and complained of pain in the
lower back, right gluteus, and right hip after he tripped and
fell. (Doc. 7-9, p. 71). Mr. Benson stated that his symptoms
were of “moderate intensity.” (Doc. 7-9, p. 71).
Mr. Benson was positive for extremity pain, back pain, joint
pain, and myalgias. (Doc. 7-9, p. 71). Mr. Benson had severe
tenderness to palpation in his mid-lumbar area. (Doc. 7-9, p.
72). Mr. Benson had mild tenderness to palpitation in the
hip, but his range of motion was normal. (Doc. 7-9, p. 72). A
lumbar spine x-ray showed no acute fracture. Dr. Stringfellow
diagnosed Mr. Benson with an acute lumbar strain and
prescribed pain medication. (Doc. 7-9, p. 72).
March 9, 2012, Mr. Benson saw Dr. Emanuel Joseph at Quality
of Life and complained of worsening symptoms from his fall.
(Doc. 7-10, p. 16). Mr. Benson described the pain as
“an ache, burning, deep, piercing, shooting, stabbing,
and throbbing.” (Doc. 7-10, p. 16). The symptoms were
aggravated by resting, rolling over in bed, standing,
twisting, and walking. (Doc. 7-10, p. 16). He could not lie
on the affected side, and according to Mr. Benson, his back
was acutely painful to the touch. (Doc. 7-10, p. 16). Dr.
Joseph noted normal mobility and curvature in Mr.
Benson's cervical and thoracic spine, but he found that
Mr. Benson had antalgic gait on the right side, and Mr.
Benson's lumbar spine had a muscle spasm and severe pain
with motion. (Doc. 7-10, p. 17). Dr. Joseph diagnosed acute
lumbago and acute bursitis and prescribed pain medication.
(Doc. 7-10, p. 17).
March 23, 2012, Mr. Benson returned to Dr. Joseph at Quality
of Life and complained that there was no improvement since
his last visit and that the medication had no effect on his
pain. (Doc. 7-10, p. 19). Mr. Benson stated that he
experienced “sharp low back pain after sneezing”
that radiated down his left thigh and leg. (Doc. 7-10, p.
19). Dr. Joseph noted that Mr. Benson was positive for back
pain and that his lumbar spine was tender and had a
significantly reduced range of motion. (Doc. 7-10, p. 20).
Mr. Benson was negative for joint pain, joint swelling,
muscle weakness, and neck pain. (Doc. 7-10, p. 20). Dr.
Joseph noted normal mobility and curvature in Mr.
Benson's cervical and thoracic spine. (Doc. 7-10, p. 20).
Dr. Joseph commented that Mr. Benson had “antalgic
gait, no weight bearing on right leg[, and] truncal
tilt.” (Doc. 7-10, p. 20). Dr. Joseph diagnosed chronic
lumbago, chronic lumbar sprain or strain, and bursitis. (Doc.
7-10, p. 21). He scheduled an MRI of Mr. Benson's spine
and refilled Mr. Benson's medication. (Doc. 7-10, p. 21).
October 9, 2012, Mr. Benson saw Dr. Thomas at Quality of Life
to follow up on his back and leg pain and arthalgias located
in his wrist. (Doc. 7-12, p. 42). Mr. Benson was positive for
decreased mobility, limping, and spasms but negative for
joint instability, joint locking, joint tenderness, popping,
and weakness. (Doc. 7-12, p. 43). Mr. Benson had a mildly
reduced range of motion in his left knee, but otherwise, he
had a normal musculoskeletal examination, and he had no other
joint problems. (Doc. 7-12, p. 45). Dr. Thomas noted that Mr.
Benson's hyperlipidemia, hepatitis C, and osteoarthrosis
had improved, and she prescribed medication to treat Mr.
Benson's symptoms and encouraged him to exercise. (Doc.
7-12, pp. 45-46).
November 9, 2012, Mr. Benson again visited Dr. Thomas at
Quality of Life and complained of lower back and leg pain
that radiated to the left ankle. (Doc. 7-12, p. 47). Mr.
Benson described the pain as “diffuse and
shooting.” (Doc. 7-12, p. 47). Dr. Thomas stated that
Mr. Benson's symptoms were relieved by heat. (Doc. 7-12,
p. 47). He had no edema in his extremities, but his gait was
compensated, and his lumbar spine had a muscle spasm and a
mildly reduced range of motion. (Doc. 7-12, p. 50). Again,
Dr. Thomas found that Mr. Benson's hyperlipidemia,
hepatitis C, and osteoarthrosis had improved. (Doc. 7-12, p.
50). She prescribed medication and encouraged aerobic
exercises. (Doc. 7-12, p. 50).
January 3, 2013, Mr. Benson visited the Calhoun-Cleburne
Mental Health Board. (Doc. 7-10, pp. 32-33). Dr. Maurice
Jeter, Jr. performed a psychiatric evaluation of Mr. Benson.
Dr. Jeter found that Mr. Benson was in no apparent distress,
he maintained good eye contact, and he responded to questions
appropriately. (Doc. 7-10, pp. 32-33). Dr. Jeter noted that
Mr. Benson had “psychomotor retardation” and a
depressed mood; however, Mr. Benson's affect was
congruent, his insight and judgment were good, and he
expressed no suicidal/homicidal ideations or psychosis. (Doc.
7-10, p. 33). Dr. Jeter diagnosed Mr. Benson with mood
disorder due to chronic pain. Dr. Jeter assessed a GAF score
of 60. (Doc. 7-10, p. 33). Dr. Jeter's report concludes
with the following recommendations:
Patient appears to be depressed today. As well he is not
sleeping well. There are significant financial stressors in
his family. Will prescribe Celexa 20 mg a day and Trazodone
100mg 1/2 to 1 at night as needed for insomnia.
Patient was counseled on risks and benefits of medications,
expressed understanding and consented to treatment. A safety
plan was reviewed.
Patient is to follow up according to therapist
(Doc. 7-10, p. 33)
an individual therapy session with a Calhoun-Cleburne Mental
Health Board therapist on January 4, 2013, Mr. Benson's
cognition was appropriate to the situation, and his speech
was appropriate. (Doc. 7-10, p. 36). Mr. Benson arrived in a
“dysphoric mood” and reported “difficulty
since his wife lost her job due to lack of work.” (Doc.
7-10, p. 36). Mr. Benson reported that he had tried to keep
himself “occupied” by “tak[ing] apart and
pu[ting] together many things in the house.” (Doc.
7-10, p. 36). The therapist noted that Mr. Benson still had
trouble sleeping, but the therapist hoped that medication
would help. (Doc. 7- 10, p. 36). The therapist noted ...