United States District Court, N.D. Alabama, Middle Division
MEMORANDUM OF DECISION
AVID PROCTOR UNITED STATES DISTRICT JUDGE.
Thomas Harris (“Plaintiff” or
“Harris”) brings this action pursuant to Sections
205(g) and 1631(c)(3) of the Social Security Act (the
“Act”), seeking review of the decision of the
Commissioner of Social Security (“Commissioner”)
to deny his claim for disability insurance benefits
(“DIB”) and Supplemental Security Income
(“SSI”). See 42 U.S.C.
§§405(g) and 1383(c). Based on the court's
review of the record and the briefs submitted by the parties,
the court finds that the decision of the Commissioner is due
to be affirmed.
filed his applications for DIB and SSI on January 24, 2014,
alleging disability beginning March 24, 2012. (Tr. 10, 77). The
claim was initially denied on April 9, 2014. (Tr. 10, 99).
After his application was denied, Plaintiff filed a written
request for a hearing. (Tr. 10, 104). On July 22, 2015,
Plaintiff received a hearing before Administrative Law Judge
(“ALJ”) Patrick R. Digby. (Tr. 25-47). On
November 4, 2015, the ALJ determined that Plaintiff was not
disabled under Sections 216(i) and 223(d) of the Act. (Tr.
September 17, 2016, the Appeals Council denied
Plaintiff's request for review of the ALJ decision. (Tr.
1-3). Following that denial, the final decision of the
Commissioner became a proper subject of this court's
appellate review. See Chester v. Bowen, 792 F.2d
129, 131 (11th Cir. 1986) (finding the ALJ decision final for
purposes of judicial review when the Appeals Council denied
Thomas Harris was forty-four years old both at the time of
his hearing before the ALJ, and when the ALJ's decision
was rendered. (Tr. 18, 29, 150). Prior to his alleged
injuries, Harris earned a GED and worked on an oil rig, on a
cable pole crew, at a tire plant, and at a Wal-Mart. (Tr.
40-41). These jobs included work as a machine operator,
material handler, construction worker, and welder. (Tr. 42).
In July 2010, Harris underwent triple bypass surgery
performed by Dr. Athanasuleas at Brookwood Medical Center.
(Tr. 252). Despite being cleared by his doctor to return to
work after the bypass, Plaintiff has not sought employment
since his surgery. (Tr. 32- 33). During a neurologic exam in
December 2013, Dr. Drummond of Vascular Associations of
Birmingham found that Harris had no focal
weakness. (Tr. 304). He rated Harris' strength
as a “B” and found minimal Internal Carotid
Artery (“ICA”) stenosis. (Id.) Dr. Drummond
recommended annual carotid ultrasounds for Harris.
sought medical care from his current primary care physician,
Dr. Martin, for the first time in January 2012, two years
before filing the current request for SSI and DIB. (Tr. 309).
In May 2012, Harris complained of back pain to Dr. Martin;
however, Harris described his pain as being a “1”
on a pain scale. (Tr. 327-28). Harris informed Dr. Martin
that pain in the lower part of his back and neck had been
going on “for a while” and was getting worse.
(Tr. 327). Dr. Martin diagnosed Harris with chronic back pain
in May 2012. (Tr. 330). To treat the chronic back pain, Dr.
Martin prescribed physical therapy. (Tr. 331).
attending physical therapy, Harris returned to Dr. Martin in
February 2013 with complaints of worsening back pain. (Tr.
342). In May 2013, Harris described “his back pain [as]
getting unbearable.” (Tr. 348). Despite these and other
complaints to Dr. Martin, upon examination Harris was found
to be grossly intact, non-focal, and not in any acute
distress. (Tr.342-44, 347- 50). Dr. Martin prescribed pain
injections from Dr. Howell of North Alabama Bone & Joint
for the back pain. (Tr. 342). SI joint injections were done
in the fall of 2014. (Tr. 623). The injections gave Harris
40% to 50% relief for months and led Harris to believe he was
April 2015, Harris visited Dr. Martin again. At this visit,
Harris denied any muscle weakness, back pain, or joint pain.
(Tr. 655). Dr. Martin did not find Harris to be in any acute
distress, and found him to be neurologically intact and
non-focal. (Id.) At another appointment in June
2015, Harris had 5/5 motor strength in his upper extremities,
despite claims of muscle weakness in May 2015. (Tr. 660,
addition to treatment by Dr. Martin and Dr. Howell, Harris
was also seen by Dr. Kast of North Alabama Neuro Services
during 2014 and 2015. (Tr. 483, 498). Dr. Martin referred
Harris to Dr. Kast in April 2014. (Tr. 483). During an
appointment with Harris in July of 2014, Dr. Kast stated that
Harris' degenerative lumbar disc disease was “age
appropriate” as there was no “evidence of gross
bony abnormalities or alignment issues.” (Tr. 499-500).
Harris was not in any obvious distress during the visit and
his “neurologic exam [was] absolutely normal in both
lower extremities.” (Tr. 499). After reviewing
Harris' CT scan, Dr. Kast concluded that the
“minimal amount of degenerative changes are absolutely
typical for anyone over the age of 35.” (Tr. 500).
later, in June 2015, Dr. Kast saw Harris again regarding
Harris' complaints of back pain. The records from the
appointment note that Harris had “no obvious cranial
nerve deficits” and had a “normal motor, sensory
and tendon reflex exam in both upper extremities.” (Tr.
679). There was also no Hoffman sign and in the lower extremities
there were no long tract findings.(Id.). Dr. Kast
concluded that Harris' condition did not warrant surgery,
and referred Harris back to Dr. Howell for injection
therapies. (Tr. 678-680).
uses a five-step sequential evaluation process to determine a
claimant's disability. 20 C.F.R. §404.1520(a) and
416.920(a). First, the ALJ must determine whether the
claimant is engaging in substantial gainful activity. 20
C.F.R. §404.1520(b) and 416.920(b). Substantial gainful
activity is work done for pay or profit that requires
significant physical or mental activities. 20 C.F.R.
§404.1572(a-b) and 416.972(a-b). If the claimant has
employment earnings above a certain threshold, the ability to
engage in substantial gainful activity is generally presumed.
20 C.F.R. §404.1574, 404.1575, 416.974, and 416.975. If
the ALJ finds that the claimant engages in substantial
gainful activity, then the claimant cannot claim disability,
regardless of a medical condition or age, education, and work
experience. 20 C.F.R. §414.1520(b) and 416.920(b).
the ALJ must determine whether the claimant has a
medically-determinable impairment that significantly limits
the claimant's ability to perform basic work activities.
20 C.F.R. §404.1420(c) and 416.920(a)(4)(ii). Absent
such impairment, the claimant may not claim disability.
Id. Third, the ALJ must determine whether the
claimant's impairment meets or functionally equals an
impairment listed in 20 C.F.R. §404, Subpart P, Appendix
1. If the criteria for impairment is met or functionally
equal, the claimant is disabled. 20 C.F.R.
§404.1520(a)(4)(iii) and 416.920(a)(4)(iii).
impairment is not met or is not functionally equivalent, the
ALJ will assess the claimant's residual functional
capacity (“RFC”) to perform, given their
impairment, in a work setting. 20 C.F.R.
§§404.15245(a)(1) and 416.920(a)(1). The RFC is
based on medical and other evidence in the record. 20 C.F.R.
§§404.1520(a)(4)(iv) and 416.920(a)(4)(iv). The ALJ
makes an assessment about a claimant's RFC using a
two-step process that determines: (1) whether there is an
underlying medically-determinable impairment that could
reasonably be expected to produce the claimant's pain;
and (2) the extent to which the claimant's symptoms would
limit claimant's functioning. 20 C.F.R.
§§404.1545(e) and 416.920(e). To determine the