United States District Court, N.D. Alabama, Jasper Division
OWEN BOWDRE CHIEF UNITED STATES DISTRICT JUDGE
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).
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.
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.
STANDARD OF REVIEW
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).
. . . 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).
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.
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.
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).
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.
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.
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).
September 16, 2008, the claimant sought treatment at the Hope
Clinic in Jasper for a migraine, and the doctor prescribed
Maxalt. 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.
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).
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).
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).
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).
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).
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”;