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Chancy v. Berryhill

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

January 18, 2018

NANCY BERRYHILL, Acting Commissioner of Social Security, Defendant.


          John E. Ott, Chief United States Magistrate Judge.

         Plaintiff Stephen Phillip Chancy brings this action pursuant to 28 U.S.C. § 405(g), seeking review of the final decision of the Acting Commissioner of the Social Security Administration denying his application for Disability Insurance Benefits (“DIB”). The case has been assigned to the court per the general order of reference of this district. After thorough review, the court finds the Commissioner's decision is due to be remanded.


         On September 10, 2013, Chancy filed an application for DIB with the Social Security Administration. (R. 12).[1] The Regional Commissioner denied his claim on January 9, 2014. (Id.) Chancy filed a Request for Hearing with an Administrative Law Judge (“ALJ”) on February 18, 2014. (Id.) On September 3, 2014, ALJ Cynthia G. Weaver conducted a hearing, which Chancy, his attorney, and a vocational expert (“VE”) attended. (Id.) The ALJ issued a decision denying Chancy's DIB claim on November 14, 2014. (R. 12-21).

         Chancy requested the Appeals Council review the ALJ's decision. The Appeals Council denied Chancy's request for review on March 26, 2016. (R. 1-4). On that date, the ALJ's decision became the final decision of the Commissioner. Chancy then filed this action for judicial review under 42 U.S.C. § 405(g) on May 5, 2016.


         The court's review of the Commissioner's decision is narrowly tailored. The court must determine whether the Commissioner's decision is supported by substantial evidence and whether the Commissioner applied the proper legal standards. Wilson v. Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002). The court must “scrutinize the record as a whole to determine if the decision reached is reasonable and supported by substantial evidence.” Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983). “Substantial evidence is more than a scintilla, but less than a preponderance.” Id. It means the decision is supported by “relevant evidence a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971).

         Applying the foregoing standard, the court must defer to the ALJ's factual findings. See Cornelius v. Sullivan, 936 F.2d 1143, 1145 (11th Cir. 1991). The court may not “decide the facts anew, reweigh the evidence, or substitute [its] judgment for that of the Commissioner.” Mitchell v. Comm'r of Soc. Sec., 771 F.3d 780, 782 (11th Cir. 2014) (citing Winchel v. Comm'r of Soc. Sec., 631 F.3d 1176, 1178 (11th Cir. 2011)). In contrast, the court reviews questions of law de novo. See Cornelius, 936 F.2d at 1145. Accordingly, no presumption of validity attaches to the ALJ's conclusions of law. Wiggins v. Schweiker, 679 F.2d 1387, 1389 (11th Cir. 1982). If the court finds the ALJ improperly applied the law, or failed to provide the court with sufficient reasoning for determining that the proper legal analysis has been conducted, the court must reverse the ALJ's decision. See Cornelius, 936 F.2d at 1145-46.


         To qualify for disability benefits, a claimant must show he or she is disabled. Being disabled is “the inability 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); 42 U.S.C. § 416(i). A physical or mental impairment is “an impairment that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C. § 423(d)(3). The plaintiff bears the burden of proving that he or she is disabled and is responsible for producing evidence in support of such a claim. Ellison v. Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003).

         Determination of disability under the Social Security Act requires a five step analysis. 20 C.F.R. § 404.1520(a). Specifically, the Commissioner must determine in sequence whether the claimant: “(1) is unable to engage in substantial gainful activity; (2) has a severe medically determinable physical or mental impairment; (3) has such an impairment that meets or equals a Listing and meets the duration requirements; (4) can perform his past relevant work, in light of his residual functional capacity; and (5) can make an adjustment to other work, in light of his residual functional capacity, age, education, and work experience.” Evans v. Comm'r of Soc. Sec., 551 F. App'x 521, 524 (11th Cir. 2014)[2] (citing 20 C.F.R. § 404.1520(a)(4)). “Once a finding is made that a claimant cannot return to prior work the burden shifts to the [Commissioner] to show other work the claimant can do.” Foote v. Chater, 67 F.3d 1553, 1559 (11th Cir. 1995) (citation omitted). The Commissioner must further show that such work exists in the national economy in significant numbers. Id.; Evans, 551 F. App'x at 524.


         Chancy was 52 years old at the time of the final decision by the Commissioner. (R. 12, 21, 110). He has a high school education and past relevant work as a furniture delivery driver, delivery route driver, and truck driver. (R. 19, 50, 157). He was injured in an on-the-job 18-wheeler accident on January 2, 2012. (R. 290). He required helicopter transportation to Huntsville Hospital because of trauma. He sustained a T11-12 compression fracture as a consequence of the accident. (R. 293).

         Following the administrative hearing, the ALJ determined Chancy met the insured status requirements of the Act through December 31, 2016, and had not engaged in substantial gainful activity since his alleged disability onset date of January 3, 2012. (R. 14). The ALJ further found Chancy had a severe history of thoracic spine fracture, status post ACDF at ¶ 5-6, status post left shoulder arthroscopy, degenerative disk disease (“DDD”), degenerative joint disease (“DJD”), and osteoarthritis. (Id.) The ALJ then found that Chancy did not have an impairment or combination of impairments that met or medically equaled one of the impairments listed in the regulations for presumptive disability. (R. 14-15). The ALJ determined that Chancy had the residual functional capacity (“RFC”) to perform light work, except that he can occasionally balance, stoop, kneel, crouch, crawl, and climb ramps and stairs; can never climb ropes, ladders, or scaffolds; can occasionally perform overhead reaching with the right upper extremity, but no overhead reaching with the left upper extremity; and should avoid extreme hot and cold temperatures, wetness, humidity, vibration, and unprotected heights. (R. 15-19).

         The ALJ next found that Chancy's RFC precluded him from performing his past relevant work. (R. 19-20). The ALJ found, based on the vocational expert's (“VE”) testimony, that Chancy's RFC did not preclude him from performing other work that exists in significant numbers in the national economy, considering his age, education, work experience, and RFC. (R. 20-21). The ALJ concluded that Chancy was not disabled under the Social Security Act. (R. 21).

         V. DISCUSSION

         The parties agree that the primary issue is whether substantial evidence of record and application of proper legal standards supports the Commissioner's final decision that Chancy was not disabled. (See Doc. 17 at 31 & Doc. 18 1-2). Chancy argues that the ALJ's finding that he has the RFC to perform light work is not supported by substantial evidence and that the correct legal standards were not applied. (Doc. 17 at 32). In support of this position, his counsel raises three specific challenges:

(1) The ALJ failed to properly evaluate the opinions and conclusions of his treating physician, Jerry V. Mosley, M.D.;
(2) The ALJ failed to properly evaluate Chancy's credibility regarding the intensity, persistence, and limiting effects of his symptoms; and
(3) The ALJ failed to provide Chancy with a fair, unbiased hearing.

(Doc. 17 at 32-57; Doc. 18 at 2). Each will be addressed below.

         A. Dr. Mosley

         1. The Claims and the Standard of Review

         Chancy's initial argument is that the ALJ did not accord proper weight to the opinions and conclusions of his treating physician, Dr. Mosley. (Doc. 17 at 32-44). Specifically, Chancy asserts that the ALJ (1) did not accord proper weight to Dr. Mosley's “extensive involvement” with Chancy as a treating physician (id. at 34); (2) failed to appreciate that the other evidence in the record supports Dr. Mosley's opinions (id. at 36); and (3) failed to recognize that Dr. Mosley's opinions were not conclusory or inconsistent with his records (id.). The Commissioner responds that the ALJ properly weighed Dr. Mosley's testimony. (Doc. 18 at 6-8).

         In assessing the weight to be given a treating physician's testimony, the standard is clear:

         A treating physician's testimony is entitled to “substantial or

considerable weight unless ‘good cause' is shown to the contrary.” Crawford v. Commissioner of Social Security, 363 F.3d 1155, 1159 (11th Cir. 2004) (quoting Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997)) (internal quotations omitted). The weight to be afforded a medical opinion regarding the nature and severity of a claimant's impairments depends, among other things, upon the examining and treating relationship the medical source had with the claimant, the evidence the medical source presents to support the opinion, how consistent the opinion is with the record as a whole, and the specialty of the medical source. See 20 C.F.R. §§ 404.1527(d), 416.927(d). Furthermore, “good cause” exists for an ALJ not to give a treating physician's opinion substantial weight when the: “(1) treating physician's opinion was not bolstered by the evidence; (2) evidence supported a contrary finding; or (3) treating physician's opinion was conclusory or inconsistent with the doctor's own medical records.” Phillips v. Barnhart, 357 F.3d 1232, 1241 (11th Cir. 2004) (citing Lewis, 125 F.3d at 1440); see also Edwards v. Sullivan, 937 F.2d 580, 583-84 (11th Cir. 1991) (holding that “good cause” existed where the opinion was contradicted by other notations in the physician's own record).
The court must also be aware that opinions such as whether a claimant is disabled, the 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(e), 416.927(d). The court is interested in the doctors' evaluations of the claimant's “condition and the medical consequences thereof, not their opinions of the legal consequences of his [or her] condition.” Lewis, 125 F.3d at 1440. Such statements by a physician are relevant to the ALJ's findings, but they are not determinative, as it is the ALJ who bears the responsibility for assessing a claimant's residual functional capacity. See, e.g., 20 C.F.R. § 404.1546(c).

Cagle v. Comm'r. Soc. Sec., 2015 WL 5719180, *3 (N.D. Ala. Sept. 30, 2015).

         2. Background

         The ALJ's opinion in this case includes an extensive review of Chancy's medical records and other evidence. It provides:

The claimant alleges disability due to injuries sustained in an accident on January 3, 2012; however hospital records show the entire workup at the time of the accident was negative for more than a chest wall contusion and Tl 1-12 compression fracture which was demonstrated on an MRI of the thoracic spine. There was no significant central canal stenosis. He was given a back brace for comfort and was ambulating well. At discharge, he was instructed to perform activities as tolerated, while avoiding any bending, stooping, or heavy lifting (Exhibit 3F). Thereafter, a February 22, 2012 MRI of the cervical spine showed no significant nerve compression or spinal cord compression, and he returned to Dr. Banks in April 2012 feeling much better. Notably, he continued to wear the back brace despite Dr. Banks recommending he wean off the brace. Neurological examinations continued to be completely normal, with no significant tenderness to palpation of his back and the motor, reflex, and sensory exams were normal. X-rays continued show a stable fracture without any changes. These findings are consistent with Dr. Mosley's progress note of July 16, 2012 indicating the claimant denied arthralgia, joint swelling and exhibited no abnormalities of gait (Exhibit 2F). In September 2012, Dr. Banks opined the claimant was at maximum medical improvement with regard to the thoracic spine fracture and released the claimant to return to work with medium duty restrictions (Exhibit 3F).
As for the cervical spine, there were no significant findings on a September 2012 MRI. Although it showed cervical spondylotic disease at ¶ 5-6 and C6-7, there was “absolutely” no cord compression and no signal change, and Dr. Banks noted satisfactory range of motion of the neck (Exhibit 3F). Then in March 2013, a myelogram and CT of the cervical spine revealed evidence of bony osteophytic disease and disk herniation on left at ¶ 5-6 causing a C6 radiculopathy, and Dr. Banks recommended and then perform[ed] an ACDF on April 26, 2013 (Exhibit 3F). The claimant did well following the surgery, and May 2013 x-rays showed good alignment of the screws and hardware without evidence of complication. Dr. Banks recommended that he remain off work and return in 3 months (Exhibit 4F). In August 2013, Dr. Banks opined the claimant had reached maximum medical improvement from a cervical standpoint, [ ] and opined he should continue the restriction to the medium work category until it is readdressed by Dr. Ca1ter (sic) on the left shoulder (Exhibit 4F).
Regarding the claimant's shoulder pain, the claimant saw Dr. Cantrell in March 2013 when he was given an injection in the shoulder. At that time, Dr. Cantrell noted some degenerative changes, but there was no evidence of a rotator cuff tear (Exhibit IF). After the ACDF in April 2013, he continued to complain of shoulder pain even though Dr. Cantrell noted no swelling, deformity, or instability of the left shoulder with only slight limitation of internal rotation behind the back. However, the claimant underwent a left shoulder arthroscopy on June 25, 2013 and followed with some physical therapy. In August 2013, x-rays continued to show stabilization with no complicating factors or other obvious bony abnormalities identified (Exhibit 4F). He was progressing nicely and range of motion had improved with minimal discomfort. Dr. Cantrell released the claimant on September 16, 2013 (Exhibits 6F, 7F).
Thereafter, the claimant has been managed conservatively with medication and injections for hip and SI joint pain by Dr. Sovic and has done well. When last treated, June 19, 2014, he reported that his last block had helped, and he was the “Best he's felt in 2 yrs” (Exhibit 14F). His return visit on July 8, 2014, was only for a medication check, which suggests his symptoms were controlled with medication and were not especially troublesome (Exhibit 14F). He has also been followed by Dr. Mosley on three occasions, primarily for hypertension (Exhibit 13F). Dr. Mosley observed the claimant to be well developed/nourished in no acute distress and noted essentially normal examinations. At the most recent visit, April 9, 2014, the claimant complained of constant pain with decreased range of motion, yet there is no evidence of a musculoskeletal examination in the office notes (Exhibit 13F), which would lead one to conclude the findings, if there were any, were insignificant or normal.
A July 18, 2014 MRI of the lumbar spine showed the old compression fractures and multilevel degenerative disk disease. MRI of the thoracic spine showed mild to moderate central canal stenosis in addition to the multilevel disk disease (Exhibit 17F). However, he has not returned to a physician, which suggests he is not experiencing any significant symptoms and limitations which would require medical treatment.

(R. 16-17).

         In his challenge to the ALJ's determination, Chancy provides a detailed chronological summary of his medical history since the accident. (Doc. 17 at 13-30). When that rendition is compared with the ALJ's decision and the record, it is evident Chancy's medical history is complicated. Accordingly, the court will begin its review of the matter with a comprehensive review of Chancy's medical history.

         Dr. Banks first saw Chancy at Huntsville Hospital shortly after the 18-wheeler accident. His notes reflect that Chancy's neck was “tender in the posterior midline around the C6-7 region” and his movement was limited because of back pain. (R. 291). Dr. Banks diagnosed Chancy with a T12 fracture compression. (R. 292). He saw Chancy about one month later on February 8, 2012, due to numbness and tingling in his left arm and “significant” pain in his back. (R. 244). Chancy was prescribed Norco 10 every four hours, along with Skelaxin. (R. 244). Chancy's February 13, 2012, MRI showed (1) post surgical changes related to a prior fusion at ¶ 6-7; (2) moderate cervical degenerative change above and below the level of fusion at ¶ 5-6 and C7-T1 and main level cervical degenerative change; (3) borderline versus mild canal narrowing at ¶ 5-6 and C7-T1; (4) moderate left foraminal narrowing at ¶ 5-6 and moderate right foraminal narrowing at ¶ 7-T1, mild to moderate left foraminal narrowing suggested at ¶ 7-T1 and mild right foraminal narrowing suggested at ¶ 5-6; and (5) mild facet arthropathy at ¶ 1-2. (R. 273). There was no significant nerve or spinal cord compression specified. (Id.) During his February 20, 2012 visit with Dr. Banks, Chancy's self-reported symptoms included the following: fatigue, blurred or double vision, sleep apnea, nausea or vomiting, constipation, joint pain, joint stiffness or swelling, joint weakness, muscle pain or cramps, difficulty walking, headaches, dizziness, balance problems, numbness, memory loss or confusion, sleep problems, depression, pain in his left hip, falling three times from losing his balance, trouble sleeping, suicidal thoughts, and mood changes. (R. 248). After reviewing the MRI, Dr. Banks noted the following: “prior 6-7 fusion with adjacent level disease at ¶ 5 and C6, worse towards the left, and also some broad based disk bulging at ¶ 7 and T1, no significant nerve or spinal cord compression seen, ” and “numbness and tingling in [Chancy's] left arm could be related to the 5-6 disk herniation.” (R. 243).

         On Chancy's March 7, 2012 visit, Dr. Banks noted Chancy's continued complaints of pain in his left arm with numbness and tingling. Dr. Banks then noted that the MRI revealed “adjacent level disease above his prior C6-C7 cervical fusion.” (R. 242). He also noted that Chancy had “an area of palpable tenderness of his kyphotic deformity related to his fracture.” (Id.) He further noted that Chancy was “able to ambulate with a walker and, overall, appears [to be] feeling better.” (Id.) Dr. Banks prescribed Mobic, a Medrol Dosepak, pain medications, and muscle relaxers. (Id.)

         During Chancy's April 9, 2012 visit with Dr. Banks concerning a follow-up for his “T11-12 burst fractures, ” Chancy reported experiencing pain. (R. 241). Dr. Banks noted that “[o]verall he appears that he is feeling much better.” (Id.). Dr. Banks recommended that Chancy continue pain management. He also refilled Chancy's Norco #45 prescription. Finally, he noted that Chancy was experiencing gastritis and stomach pain caused by his medications. (Id.) He recommended that Chancy try to decrease his Mobic intake.

         On May 21, 2012, Dr. Banks documented that Chancy was still suffering from back pain, as well as numbness and tingling in his left arm. (R. 240). Chancy denied “any significant pain or weakness in his legs.” (Id.) Chancy reported that he was not able to ambulate outside “for more than five minutes without excruciating back pain.” (Id.) However, Dr. Banks noted that Chancy was able to ambulate with a cane and that Chancy did not require a cane as he independently ambulated in the room during the examination. (Id.) Dr. Banks also noted that Chancy could not bend forward without pain. (Id.) However, he further noted that Chancy was still wearing his brace ‚Äúdespite the fact that [he] recommended [Chancy] wean himself out of his brace the last ...

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