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Anderson v. Berryhill

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

March 20, 2018





         On May 29, 2013, the claimant protectively applied for disability and disability insurance benefits under Title II of the Social Security Act. The claimant alleged disability beginning March 18, 2013, because of arthritis in her left leg, hip pain, restless leg syndrome, migraine headaches, depression, anxiety, carpel tunnel syndrome, anemia, high cholesterol, and acid reflux. The Commissioner denied these claims on August 21, 2013. (R. 70-76, 124-29, 163-70). On September 19, 2013, the claimant filed a written request for a hearing before an Administrative Law Judge, and he held a video hearing on April 27, 2015. (R. 8-39).

         In a decision dated July 7, 2015, the ALJ found the claimant was not disabled as defined by the Social Security Act and was, therefore, ineligible for disability benefits. (R. 51-67). On October 24, 2016, the Appeals Council denied the claimant's request for review; consequently, the ALJ's decision became the final decision of the Commissioner of the Social Security Administration. (R. 3-5). The claimant has exhausted her administrative remedies, and this court has jurisdiction pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons stated below, the court REVERSES and REMANDS the decision of the ALJ because substantial evidence does not support his residual functional capacity (RFC) determination.


         Whether the ALJ's RFC determination that the claimant can perform work at the medium exertion level lacks substantial evidence because he improperly discounted the limiting effects of the claimant's migraine headaches.


         The standard for reviewing the Commissioner's decision is limited. This court must affirm the ALJ's decision if he applied the correct legal standards and if substantial evidence supports his factual conclusions. See 42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997); Walker v. Bowen, 826 F.2d 996, 999 (11th Cir.1987).

         “No . . . presumption of validity attaches to the [Commissioner's] legal conclusions, including determination of the proper standards to be applied in evaluating claims.” Walker, 826 F.2d at 999. This court does not review the Commissioner's factual determinations de novo. The court will affirm those factual determinations that are supported by substantial evidence. “Substantial evidence” is “more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 402 (1971).

         The court must keep in mind that opinions such as whether a claimant is disabled, the nature and extent of a 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(d), 416.927(d). Whether the claimant 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). Thus, even if the court were to disagree with the ALJ about the significance of certain facts, the court has no power to reverse that finding as long as substantial evidence in the record supports it.

         The court must “scrutinize the record in its entirety to determine the reasonableness of the [Commissioner]'s factual findings.” Walker, 826 F.2d at 999. A reviewing court must not only look to those parts of the record that support the decision of the ALJ, but also must view the record in its entirety and take account of evidence that detracts from the evidence relied on by the ALJ. Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th Cir. 1986).


         The responsibility for determining the claimant's RFC rests with the ALJ. 20 C.F.R. '' 404.1546(c), 416.946(c). An RFC assessment involves consideration of all relevant evidence in determining the claimant's ability to do work in spite of her impairments. Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997); see also 20 C.F.R. '' 404.1545(a), 416.945(a).

         The ALJ determines the claimant's RFC only after establishing the extent of the claimant's severe impairments. 20 C.F.R. '' 404.1520(e)-(f), 416.920(e)-(f). In evaluating pain and other subjective complaints in making his RFC determination, the Commissioner must consider whether the claimant demonstrated an underlying medical condition, and either (1) objective medical evidence that confirms the severity of the alleged pain arising from that condition or (2) that the objectively determined medical condition is of such a severity that it can reasonably be expected to give rise to the alleged pain. Holt v. Sullivan, 921 F.2d 1221, 1223 (11th Cir. 1991). The ALJ may consider the claimant's daily activities in evaluating and discrediting complaints of disabling pain. Harwell v. Heckler, 735 F.2d 1292, 1293 (11th Cir. 1984).

         If the ALJ decides to discredit the claimant's testimony regarding the intensity and limiting effects of her severe impairments, he must articulate explicit and adequate reasons for that decision. Foote v. Chater, 67 F.3d 1553, 1561-62 (11th Cir. 1995). If substantial evidence does not support the ALJ's findings regarding the limiting effects of her severe impairments, the ALJ commits reversible error. Foote, 67 F.3d at 1562.

         V. FACTS

         The claimant was sixty years old at the time of the ALJ's final decision. The claimant has a 12th grade education and past relevant work as a trucking detailer and in a composite job involving clerical work, dispatching, delivering, and cleaning. (R. 165). The claimant alleged disability beginning on March 18, 2013 because of arthritis in her left leg, hip pain, restless leg syndrome, migraine headaches, depression, anxiety, carpel tunnel syndrome, anemia, high cholesterol, and acid reflux. (R. 164).

         Physical Limitations

         On September 16, 2008, the claimant sought treatment at the Hope Clinic in Jasper for a migraine, and the doctor prescribed Maxalt.[1] From February 3, 2009 through February 28, 2012, the claimant sought treatment on approximately seven occasions at the Hope Clinic for her migraine headaches. Although she was still waking up with migraines, she reported in June and December 2010 that the Maxalt was working. In August 2011, she complained that she had a burning sensation in the right side of her head and then developed a migraine. (R. 251-261).

         The claimant also sought treatment for her back, leg, and joint pain at the Hope Clinic beginning in November 2006. The record contains no medical reports regarding the claimant's back or joint pain again until February 3, 2009, when she complained to a doctor at the Hope Clinic about her arthritis and tingling pain in her left arm and shin. On June 9, 2009, she complained that her legs hurt, tingled, and cramped at night, and the doctor at the Hope Clinic suspected restless leg syndrome and prescribed Requip. (R. 259, 260, 269).

         Between October 26, 2009 and July 26, 2010, the claimant sought treatment with Dr. Morton Goldfarb at ENT Associates of Alabama on four occasions for chronic external otitis and acute exacerbation in her right ear. The claimant complained of headaches, dizziness, vomiting, and feeling “off balance.” Audiograms revealed “rather significant loss in the high frequencies” and “significant nerve loss.” At the July 26 visit, Dr. Goldfarb noted that the claimant was on Prozac for depression and anxiety, Methacarbonol for arthritis, Mobic for pain and inflammation, and Crestor for balance. Dr. Goldfarb ordered a brain CT with contrast, but the record does not contain results of that CT scan. (R. 239-242).

         The claimant's next documented complaint at the Hope Clinic on December 16, 2010 involved her left hip and leg tingling “all the time.” A doctor at the Hope Clinic prescribed the claimant Neurontin for the tingling in her lower extremities. On the claimant's next visit to Hope Clinic on February 28, 2012, she complained of a burning sensation in her neck at night. A doctor at the Hope Clinic assessed the tingling as neuropathy, and continued the claimant on Neurontin. By her follow-up on June 26, 2012, the claimant indicated that she had “no complaints.” (R. 251, 253-54).

         On April 23, 2013, the claimant complained of tingling in her left arm from the elbow down to her fingertips. The doctor at Hope Clinic suspected “possible carpel tunnel” syndrome and prescribed a wrist splint. (R. 294).

         The claimant completed a “Function Report-Adult” on June 24, 2013 at the request of the Social Security Administration. In that report, she stated that she lives with her husband Royce Anderson and starts her day by straightening up her house, but she has to sit several times because her feet and legs start to hurt. She cleans and sweeps the house about one hour a day. She does a little laundry; watches television; cooks supper; cleans the kitchen; watches television again; and then goes to bed. She takes care of her husband by cooking for him and making sure he takes his medications. Her husband walks the dog because she cannot walk “a long distance.” Her restless leg syndrome makes her legs ache constantly. (R. 184-86).

         The claimant drives and goes out “several times a day.” She grocery shops with her husband twice a week for about one hour. She reads; watches television about four hours a day but has to get up and walk around because her legs ache; swims; works in the flower bed “some”; ...

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