United States District Court, N.D. Alabama, Northeastern Division
MICHAEL PUTNAM UNITED STATES MAGISTRATE JUDGE
plaintiff, Herbert Allen Lincoln, appeals from the decision
of the Commissioner of the Social Security Administration
(“Commissioner”) denying his application for
disability insurance benefits (“DIB”) and
supplemental security income (“SSI”). Mr. Lincoln
timely pursued and exhausted his administrative remedies, and
the decision of the Commissioner is ripe for review pursuant
to 42 U.S.C. Â§' 405(g), 1383(c)(3). The parties have
consented to the jurisdiction of the undersigned magistrate
judge in accordance with 28 U.S.C. § 636(c) and Federal
Rule of Civil Procedure 73; accordingly, the court enters
this memorandum opinion. Based upon 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
Lincon was 56 years old at the time of the Administrative Law
Judge's (“ALJ”) decision, and he has a high
school education. (Tr. at 21, 114). He worked as a
self-employed contractor for about 15 years, and he continued
to do some work as a painter or carpenter in 2012 and 2013.
(Tr. at 29). Mr. Lincoln claims that he became disabled on
January 1, 2011, due to hypertension, dysautonomia,
migraine headaches. (Tr. at 136).
evaluating the disability of individuals over the age of
eighteen, the regulations prescribe a five-step sequential
evaluation process. See 20 C.F.R. §§
404.1520, 416.920; see also Doughty v. Apfel, 245
F.3d 1274, 1278 (11th Cir. 2001). The first step requires a
determination of whether the claimant is “doing
substantial gainful activity.” 20 C.F.R. §§
404.1520(a)(4)(i), 416.920(a)(4)(i). If he is, the claimant
is not disabled and the evaluation stops. Id. If he
is not, the Commissioner next considers the effect of all of
the claimant's physical and mental impairments combined.
20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii).
These impairments must be severe and must meet the durational
requirements before a claimant will be found to be disabled.
Id. The decision depends upon the medical evidence
in the record. See Hart v. Finch, 440 F.2d 1340,
1341 (5th Cir. 1971). If the claimant's impairments are
not severe, the analysis stops. 20 C.F.R. §§
404.1520(a)(4)(ii), 416.920(a)(4)(ii). Otherwise, the
analysis continues to step three, which is a determination of
whether the claimant's impairments meet or equal the
severity of an impairment listed in 20 C.F.R. pt. 404,
Subpart P, Appendix 1. 20 C.F.R. §§
404.1520(a)(4)(iii), 416.920(a)(4)(iii). If the
claimant's impairments fall within this category, he will
be found disabled without further consideration. Id.
If they do not, a determination of the claimant's
residual functional capacity (“RFC”) will be
made, and the analysis proceeds to the fourth step. 20 C.F.R.
§§ 404.1520(e), 416.920(e). Residual functional
capacity is an assessment, based on all relevant evidence, of
a claimant's remaining ability to do work despite his or
her impairments. 20 C.F.R.§404.1545(a).
fourth step requires a determination of whether the
claimant's impairments prevent him from returning to past
relevant work. 20 C.F.R. §§ 404.1520(a)(4)(iv),
416.920(a)(4)(iv). If the claimant can still do his past
relevant work, the claimant is not disabled and the
evaluation stops. Id. If the claimant cannot do past
relevant work, then the analysis proceeds to the fifth step.
Id. Step five requires the court to consider the
claimant's RFC, as well as the claimant's age,
education, and past work experience, in order to determine if
he can do other work. 20 C.F.R. §§
404.1520(a)(4)(v), 416.920(a)(4)(v). If the claimant can do
other work, the claimant is not disabled. Id. The
burden of demonstrating that other jobs exist which the
claimant can perform is on the Commissioner; and, once that
burden is met, the claimant must prove her inability to
perform those jobs in order to be found to be disabled.
Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir.
the sequential evaluation process, the ALJ found that Mr.
Lincoln has not been under a disability within the meaning of
the Social Security Act from the date of onset through the
date of his decision. (Tr. at 21). He first determined that
Mr. Lincoln has not engaged in substantial gainful activity
since the alleged onset of his disability. (Tr. at 16).
According to the ALJ, plaintiff has a medically determinable
impairment of hypertension, but which is non-severe. (Tr. at
16-17). The ALJ next found the allegations that the plaintiff
suffers from dysautonomia were not supported by any medical
records of objective testings, signs, or diagnoses, and that
Mr. Lincoln's dysautonomia is not a medically
determinable impairment within the meaning of the Social
Security Act. (Tr. at 17). The ALJ found Mr. Lincoln's
allegations to be “not entirely credible, ”
citing both the plaintiff's lack of medical treatment and
the lack of objective evidence that confirmed the severity of
the conditions or that the conditions could reasonably be
expected to give rise to the symptoms alleged. (Tr. at 18).
Because there was no objective medical evidence that the
claimant had a severe impairment, the ALJ's analysis
stopped after the second step. 20 C.F.R. §§
404.1520(a)(4)(ii), 416.920(a)(4)(ii). The ALJ concluded his
findings by stating that Plaintiff is not disabled under
section 1614(a)(3)(A) of the Social Security Act. (Tr. at
Standard of Review
court's role in reviewing claims brought under the Social
Security Act is a narrow one. The scope of its review is
limited to determining (1) whether there is substantial
evidence in the record as a whole to support the findings of
the Commissioner, and (2) whether the correct legal standards
were applied. See Richardson v. Perales, 402 U.S.
389, 390, 401 (1971); Wilson v. Barnhart, 284 F.3d
1219, 1221 (11th Cir. 2002). 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. Commissioner of Soc.
Sec., 363 F.3d 1155, 1158 (11th Cir. 2004), quoting
Lewis v. Callahan, 125 F.3d 1436, 1439-40 (11th Cir.
1997). The Court approaches the factual findings of the
Commissioner with deference, but applies close scrutiny to
the legal conclusions. See Miles v. Chater, 84 F.3d
1397, 1400 (11th Cir. 1996). The Court may not decide facts,
weigh evidence, or substitute its judgment for that of the
Commissioner. Id. “The substantial evidence
standard permits administrative decision makers to act with
considerable latitude, and ‘the possibility of drawing
two inconsistent conclusions from the evidence does not
prevent an administrative agency's finding from being
supported by substantial evidence.'” Parker v.
Bowen, 793 F.2d 1177, 1181 (11th Cir. 1986) (Gibson, J.,
dissenting) (quoting Consolo v. Federal Mar.
Comm'n, 383 U.S. 607, 620 (1966)). Indeed, even if
this Court finds that the evidence preponderates against the
Commissioner's decision, the Court must affirm if the
decision is supported by substantial evidence.
Miles, 84 F.3d at 1400. No decision is automatic,
however, for “despite this deferential standard [for
review of claims] it is imperative that the Court scrutinize
the record in its entirety to determine the reasonableness of
the decision reached.” Bridges v. Bowen, 815
F.2d 622, 624 (11th Cir. 1987). Moreover, failure to apply
the correct legal standards is grounds for reversal. See
Bowen v. Heckler, 748 F.2d 629, 635 (11th Cir. 1984).
well established that the burden of showing an entitlement to
benefits is on the claimant. An ALJ has a duty to develop the
record beyond the evidence presented by the claimant in some
instances, but “is not required to order a consultative
examination as long as the record contains sufficient
evidence for the ALJ to make an informed decision.”
Ingram v. Commissioner of Soc. Sec. Admin., 496 F.3d
1253, 1269 (11th Cir. 2001) (finding no duty to order testing
where the record contained “ample evidence”),
citing Doughty v. Apfel, 245 F.3d 1274, 1281 (11th
Cir. 2001). “It is only where a consultative
examination is necessary for the ALJ to make a decision due
to some conflict, ambiguity, or other insufficiency” in
the evidence that an ALJ must order an additional
consultative examination. Hollis v. Colvin, No.
12-00659-N, 2013 WL 5567067, at * 4 (S.D. Ala. Oct. 9, 2013).
Remand for further development of the record is necessary
only when “the record reveals evidentiary gaps which
result in unfairness or clear prejudice.” Id.
Even then, it is up to the claimant to “show that the
lack of records created an evidentiary gap, resulting in
unfairness or clear prejudice.” Id., quoting
Edwards v. Sullivan, 939 F.2d 580, 586 (11th Cir.
1991). The ALJ has no duty to order additional examinations
where the plaintiff “did not satisfy his duty to put
any alleged  impairments into controversy by adducing
competent evidence of the same.” McCray v.
Massanari, 175 F.Supp.2d 1329, 1339 (M.D. Ala. 2001).
Finally, Social Security Ruling 96-4P mandates that A[n]o
symptom or combination of symptoms can be the basis for a
finding of disability, no matter how genuine the
individual's complaints may appear to be, unless there
are medical signs and laboratory findings demonstrating the
existence of a medically determinable physical or mental
impairment.” SSR 96-4P, see also SSR
Lincoln was, at the time of his hearing, living with his
mother and stepfather. He testified that he helped with
household chores, performed yardwork, did his own laundry,
and prepared his meals. (Tr. at 35). Mr. Lincoln alleges that
the ALJ's decision should be reversed and remanded
because the ALJ erred in failing to find that the
plaintiff's dysautonomia was a medically determinable
impairment. (Doc. 11, pp. 3-4). He further alleges that the ALJ
erred in not stating the weight given to the treating
physician's opinion, and in failing to properly develop
the record. (Doc. 11, pp. 4-6).
Court must be aware of the fact 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). Whether the Plaintiff 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).
considering the plaintiff's claims that he suffers from
disabling dysautonomia, the ALJ noted that Mr. Lincoln had
failed to produce any “objective medical records
documenting such condition and no diagnosis by an acceptable
medical source [is contained] in the records.” (Tr. at
17). A review of all of the medical records that have been
produced demonstrate that the only references to dysautonomia
are Dr. Brian James's listing of that condition in the
medical history, with the notation “known to Dr.
Norwood.” (Tr. at 183). Such notations are records
of what the patient told the doctor and do not serve as
evidence of any medical testing or diagnosis. Moreover, the
same doctor's record from that visit describes the
plaintiff's “dysautonomia symptoms” as
“stable on Elavil.” No diagnosis of dysautonomia, and
no laboratory findings that would support such a diagnosis,
have been noted by any medical professional. In fact, the only
medical records referred to by the plaintiff are the
treatment records of Dr. James, who apparently first saw the
plaintiff in October of 2012, which was 22 months after the
alleged onset date. At that visit, the doctor noted that Mr.
Lincoln “feels well today with no questions,
complaints, or symptoms noted.” When Mr. Lincoln
returned to Dr. James ninety days later for a comprehensive
exam, his complaint was for “foot pain.” (Tr. at
185). The doctor noted that ...