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Mosley v. Colvin

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

February 15, 2018

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.



         Plaintiff Christine Mosley (“Plaintiff”) brings this action pursuant to Section 205(g) of the Social Security Act (the “Act”), seeking review of the decision of the Commissioner of Social Security (the “Commissioner”) denying her claims for a period of disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Act. See 42 U.S.C. §§ 405(g) and 1383(a).

         I. Proceedings Below

         Plaintiff filed her application for Social Security Disability (SSD) benefits on September II, 2013 and for SSI on January 31, 2014. (R. 172, 174). In both applications Plaintiff alleged that her disability began on May 31, 2013. (Id.). Both Plaintiff's SSD and SSI applications were initially denied by the Social Security Administration (“SSA”) on April 10, 2014. (R. 110, 117). Plaintiff then requested and received a hearing before Administrative Law Judge (“ALJ”) J. L. Munford on November 9, 2015. (R. 36, 108, 131). In his decision, dated January 27, 2016, the ALJ determined that Plaintiff had not been under disability within the meaning of § 1614(a)(3)(A) of the Act since September 11, 2013, the date the application was filed. (R. 17-30). After the Appeals Council denied Plaintiff's request for review of the ALJ's decision, (R. 1), the ALJ's decision became the final decision of the Commissioner, and therefore a proper subject of this court's appellate review.

         II. Facts

         Plaintiff, twenty-five (25) years old at the time of the administrative hearing, has formal education consisting of a high school diploma, some college courses, and a course in “patient care assistance.” (R. 42, 51). Her previous work experience, which ended in approximately May or June 2013, includes employment characterized as “caregiver” and “patient care assistant.” (R. 52, 57 - 58). Plaintiff alleges she is unable to work because of chronic, debilitating nausea and vomiting resulting from gastroparesis[1] and migraines. (R. 42). Plaintiff's alleged onset date for disability is May 31, 2013. (R. 42). During her alleged period of disability, Plaintiff received treatment from multiple in-state and out-of-state medical facilities. (R. 278-1481, 1490-1660, 1669-2178).

         By way of background, Plaintiff is an obese female who has been seen by multiple medical doctors for treatment relating to, inter alia, gastroparesis, gastroesophageal reflux disease (GERD), [2] migraine headaches, depression, anxiety, and obesity. Plaintiff's medical history includes, inter alia, a laparoscopic fundoplication[3] (with prolonged postop nasogastric feedings[4]) and cholecystectomy[5] in 2006, and a laparoscopic placement of gastric electric stimulator in April 2015. (R. 1579). As a possible result of these operations, Plaintiff has suffered from a history of nondiabetic gastroparesis. (R. 1582). Additionally, Plaintiff weighed 225 pounds, with a body mass index (BMI) of 32.3, in January 2013 and 215 pounds, with a BMI of 31.8, in April 2015. (R. 1171, 1579). Because Plaintiff has a body mass index greater than 30, she is classified as obese. (R. 1171, 1579).

         Plaintiff was hospitalized for treatment related to her nausea and vomiting in July 2013; during which time Dr. Halama performed an esophagogastroduodenoscopy[6] (EGD) with biopsy. (R. 1563-64). Following this procedure, Dr. Halama noted, “[n]o abnormalities were seen on today's study to suggest a cause for [Plaintiff's] symptoms.” (R. 1563). During her hospital stay, Plaintiff's complaints of either nervousness, anxiety, or depression were inconsistent, as she complains of these symptoms on July 17, 2013, but denies them on the following day, July 18, 2013. (R. 1558-61). Plaintiff was hospitalized a second time in July 2013, again for chronic nausea. During that stay she underwent a CT scan of her abdomen and pelvis, which showed “a number of colonic diverticula[7] are present without evidence of diverticulitis.”[8] (R. 1547). Following her discharge on August 2, 2013, Plaintiff received treatment from a gastroenterologist. (R. 1172-1187). Plaintiff presented to the ER again on August 3, 2013, one day after being released, complaining of mental health issues and exhibited signs she had overused her medications, which she has a history of doing, and left the hospital against medical advice. (R. 1544). Plaintiff attended a follow-up appointment with Dr. Craig Philpot, a gastroenterologist, in September 2013, at which time Plaintiff reported that her symptoms were much improved, and she had not experienced any nausea, vomiting, abdominal pain, or weight loss. (R. 1474). Dr. Philpot's examination of Plaintiff showed that her bowel sounds were normal with no hepatosplenomegaly, tenderness, distention, or abdominal masses. (R. 1474).

         In October 2014, Plaintiff was referred to Dr. William Palmer, a gastroenterologist at the Mayo Clinic, again reporting nausea and gastroparesis, and stating “the only thing that she is able to tolerate are specifically foods like a fast food burger.” (R. 1889-90). Dr. Palmer's examination revealed a non-distended abdomen with positive bowel sounds and no organomegaly, and faint pain on deep palpation. (R. 1891). Dr. Palmer noted that a repeat gastric emptying study, multiple CT scans of the abdomen and pelvis, an ultrasound of the abdomen, an Endoscopic Retrograde Cholangiopancreatography[9] (ERCP), and multiple colonoscopies were all within normal limits. (R. 1891-92). Dr. Palmer ordered an esophagus x-ray with barium tablet and stomach x-ray, which returned normal results, with “no narrowings, ” “strictures, ” or “abnormalities to explain symptoms.” (R. 1893). Additionally, multiple EGD's have returned unremarkable results. (R. 1419).

         Plaintiff also testified to having migraines which prevent her from working. (R. 42). Medical records show that early in 2014 Plaintiff consulted a neurologist at Norwood Neurology for her headaches and was prescribed Topamax during her first visit. (R. 1480-81). During a follow-up visit in March 2014, Plaintiff reported improvement in the frequency of her headaches, and the neurologist increased her dosage of Topamax and planned to see Plaintiff for a follow-up in one month. (R. 1479). However, Plaintiff's records from Norwood Neurology indicate she did not follow-up as directed. (R. 1478-1481). Further, although Plaintiff has seen her gastroenterologist multiple times since her last appointment with her neurologist in March 2014, Plaintiff has not reported headaches at any of these appointments. (R. 1584-1643).

         In support of Plaintiff's condition, her mother Adrienne Mosley (“Mrs. Mosley”) submitted a “Function Report - Adult Third Party.” (R. 228-35). In this report, Mrs. Mosley states that “most of [Plaintiff's] day is spent in bed. She suffers from chronic nausea, abdominal pain as well as anxiety, depression, and migraines. Some of the medicine she takes makes her unable to function.” (R. 228). However, the ALJ found Mrs. Moseley's testimony not entirely credible because it is contradicted by the medical evidence. (R. 27).

         Additionally, Plaintiff was evaluated by a state agency medical consultant. (R. 86-107). This evaluation included both a physical examination and a psychological examination. (Id.). The ALJ found that the consultant's physical assessment was “consistent with the claimant's treatment history, imaging reports, and physical examination findings.” (R. 27). However, the ALJ discounted the consultant's psychological assessment because the ALJ found “it was unsupported by the claimant's treatment history, mental status examinations findings, and reported activities of daily living.” (Id.).

         The ALJ concluded, “[b]ased on the claimant's reported activities of daily living, treatment history, imaging reports, and physical and mental status examinations findings . . . that the claimant can perform medium work with [the] additional nonexertional limitations” described in the residual functional capacity (“RFC”) assessment. (Id.). Following this conclusion, the ALJ determined that based on “the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform.” (R. 28).

         III. ALJ Decision

         The ALJ applied the five-step test. He first determined that Plaintiff had not engaged in substantial gainful activity during the period from her alleged onset date of May 31, 2013, through her date last insured of March 31, 2015. (R. 20). Second, the ALJ determined that Plaintiff had the following “severe, ” medically determinable impairments: gastroparesis, gastroesophageal reflux disease (GERD), obesity, and migraine headaches. (R. 20). However, the ALJ determined Plaintiff's pulmonary embolism, leukocytosis, [10] anemia, and dysmenorrhea[11] were not “severe” disabling impairments. (R. 20). Additionally, although Plaintiff testified to suffering from anxiety and depression, the ALJ determined these mental impairments did not cause more than minimal limitations in Plaintiff's ability to perform basic mental work activities. (R. 21, 50). The ALJ evaluated the evidence while considering the four broad functional areas set out in section 11.00(G)(3)(b), i.e. daily activities, social functioning, concentration, persistence or pace, and adapting and managing; and what evidence is needed to evaluate a Plaintiff's mental disorder set out in section 12.00C of the Listing of Impairment (20 C.F.R., Part 404, Subpart P, Appendix 1, Part A2.). (R. 21).

         Having found at least one severe impairment, the ALJ correctly proceeded to the third step in the five-step analysis. Based on his analysis at step three, the ALJ determined Plaintiff “does not have an impairment or combination of impairments that meets or equals the severity of one of the listed impairments” found in 20 C.F.R. § 404, Subpart P, Appendix 1. (R. 23). Because the ALJ determined that none of Plaintiff's impairments meet or medically equal the criteria of any listed impairment, the ALJ continued to step four.

         At step four, the ALJ determined that Plaintiff has a RFC to perform medium work, “except that she cannot drive a motor vehicle or operate hazardous machinery and should avoid all exposure to unprotected heights.” (R. 23-24). Analyzing Plaintiff's RFC in conjunction with her prior work history, the ALJ determined that she did not have the RFC necessary to perform any past relevant work. (R. 28). Thus, the ALJ correctly proceeded to the fifth and final step. Relying on the testimony of a vocational expert (VE), and considering Plaintiff's age, education, work experience, and RFC, the ALJ determined that there are jobs in significant numbers in the national economy which Plaintiff can perform. (R. 28). Based on these determinations, the ALJ concluded that Plaintiff is “capable of making a successful adjustment to other work that exists in significant numbers in the national economy, ” and therefore, is not disabled.

         IV. Plaintiff's Argument for Remand or Reversal

         Plaintiff alleges that the ALJ failed to “follow the ‘slight abnormality' standard in finding that Plaintiff's depression and anxiety are non-severe” and failed to properly apply the Eleventh Circuit pain ...

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