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Hernandez v. Commissioner Social Security Administration

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

March 26, 2018




         Plaintiff Karen Hernandez seeks judicial review pursuant to 42 U.S.C. § 405(g) of an adverse, final decision of the Commissioner of the Social Security Administration ("Commissioner" or "Secretary"), regarding her claim for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI). The undersigned has carefully considered the record, and for the reasons stated below, AFFIRMS the Commissioner's decision.[1]


         To qualify for disability benefits and establish entitlement for a period of disability, the claimant must be disabled as defined by the Social Security Act and the Regulations promulgated thereunder. The Regulations[2] define "disabled" as the "inability to do 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 twelve (12) months." 20 C.F.R § 404.1505(a). To establish an entitlement to disability benefits, a claimant must provide evidence of a "physical or mental impairment" which "must result from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques." 20 C.F.R. §404.1508.

         In determining whether a claimant suffers a disability, the Commissioner, through an Administrative Law Judge (ALJ), works through a five-step sequential evaluation process. See 20 C.F.R. § 404.1520. The burden rests upon the claimant on the first four steps of this five-step process; the Commissioner sustains the burden at step five, if the evaluation proceeds that far. Jones v. Apfel, 190 F.3d 1224, 1228 (11thCir. 1999).

         In the first step, the claimant cannot be currently engaged in substantial gainful activity. 20 C.F.R. § 404.1520(b). Second, the claimant must prove the impairment is "severe" in that it "significantly limits [the] physical or mental ability to do basic work activities. . .." Id. at § 404.1520(c).

         At step three, the evaluator must conclude the claimant is disabled if [the] impairments meet or are medically equivalent to one of the impairments listed at 20 C.F.R. Part 404, Subpart P, App. 1, §§ 1.00-114.02. Id. at § 404.1520(d). If a claimant's impairment meets the applicable criteria at this step, that claimant's impairments would prevent any person from performing substantial gainful activity. 20 C.F.R. §§ 404.1520(a)(4)(iii), 404.1525, 416.920(a)(4)(iii). That is, a claimant who satisfies steps one and two qualifies automatically for disability benefits if they suffer from a listed impairment. See Jones, 190 F.3d at 1228 ("If, at the third step, [the claimant] proves that [an] impairment or combination of impairments meets or equals a listed impairment, [the claimant] is automatically found disabled regardless of age, education, or work experience.") (citing 20 C.F.R. § 416.920).

         If the claimant's impairment or combination of impairments does not meet or medically equal a listed impairment, the evaluation proceeds to the fourth step where the claimant demonstrates an incapacity to meet the physical and mental demands of past relevant work. 20 C.F.R. § 404.1520(e). At this step, the evaluator must determine whether the plaintiff has the residual functional capacity ("RFC") to perform the requirements of his past relevant work. See Id. §§ 404.1520(a)(4) (iv), 4l6.92O(a)(4)(iv). If the claimant's impairment or combination of impairments does not prevent performance of past relevant work, the evaluator will determine the claimant is not disabled. See id.

         If the claimant is successful at the preceding step, the fifth step shifts the burden to the Commissioner to prove, considering claimant's RFC, age, education and past work experience, whether the claimant is capable of performing other work. 20 C.F.R. §§ 404.1520(f)(1). If the plaintiff can perform other work, the evaluator will not find the claimant disabled. See Id. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v); see also 20 C.F.R §§ 404.1520(g), 416.920(g). If the plaintiff cannot perform other work, the evaluator will find the claimant disabled. 20 CF.R. §§ 404.1520(a)(4)(v), 404.1520(g), 416.920(a) (4)(v), 416.920(g).

         The court reviews the ALJ's '"decision with deference to the factual findings and close scrutiny of the legal conclusions."' Parks ex rel. D.P. v. Comm'r, Social Sec. Admin., 783 F.3d 847, 850 (11th Cir. 2015) (quoting Cornelius v. Sullivan, 936 F.2d 1143, 1145 (11* Cir. 1991)). The court must determine whether substantial evidence supports the Commissioner's decision and whether the Commissioner applied the proper legal standards. Winschel v. Comm'r of Social Sec, 631 F.3d 1176, 1178 (11* Cir. 2011). Although 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 dr. 1983) (citations omitted), the court "may not decide the facts anew, reweigh the evidence, or substitute [its] judgment" for that of the ALJ. Winschel, 631 F.3d at 1178 (citations and internal quotation marks omitted). "Substantial evidence is more than a scintilla and is such relevant evidence as a reasonable person would accept as adequate to support a conclusion." Id. (citations omitted). Nonetheless, substantial evidence exists even if the evidence preponderates against the Commissioner's decision. Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005).


         In his June 21, 2016, decision, the ALJ first determined that Ms. Hernandez met the Social Security Act's insured status requirements through September 30, 2017. The ALJ further found that Hernandez had not engaged in substantial gainful activity since February 28, 2011, the alleged onset date. At step two, the ALJ identified the following severe impairments: hypermobility disorder; temporomandibular joint (TMJ); anxiety; osteoarthritis; depression; post-traumatic stress disorder (PTSD); insomnia; and chronic obstructive pulmonary disease (COPD). (Tr. 25).

         The ALJ concluded at step three that Hernandez's combination of severe impairments did not meet or medically equal any impairment for presumptive disability listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 26). At step four, the ALJ determined Hernandez exhibited no past relevant work. The ALJ proceeded to step five, finding Hernandez's RFC allows her to perform light unskilled work as defined in 20 C.F.R. §§ 404.1567(b), with certain limitations.[3] (Tr. 28). The ALJ relied on the VE's testimony that Hernandez could perform such jobs as garment sorter, inspector/hand packager, or laundry folder. (Tr. 32).

         On November 8, 2016, the Appeals Council denied review, which deems the ALJ's decision as the Commissioner's final decision. (Tr. 1). Ms. Hernandez filed her complaint with the court seeking review of the ALJ's decision. (Doc. 1).


         In this appeal, Ms. Hernandez contends substantial evidence does not support the ALJ's decision. Specifically, she faults the ALJ for assigning no weight to the opinion of Hernandez's treating physician; substituting his own opinion for that of the Commissioner's examining psychiatrist; concluding that Hernandez does not meet Listings 12.04 and 12.06; and providing inadequate reasoning for discounting Hernandez's credibility regarding the severity of her pain symptoms. After consideration of the record and the ALJ's decision, the court finds substantial evidence supports the ALJ's determination.

         A. The ALJ Assigned Proper Weight to the Treating Physician's Opinion

         The ALJ must give "substantial or considerable weight" to the opinion of a treating physician "unless 'good cause' is shown." Phillips v. Barnhart, 357 F.3d 1232, 1240 (11th dr. 2003) (citing Lewis v. Callahan, 125 F.3d 1436, 1440 (11* Cir. 1997)). Good cause exists when: (1) the evidence did not bolster the treating physician's opinion; (2) evidence supported a contrary finding; or (3) a treating physician's opinion was conclusory or inconsistent with the doctor's own medical records. Id. An ALJ must clearly articulate the reasons for affording less weight to a treating physician's opinions. Id. An ALJ does not commit reversible error when (1) he articulates specific reasons for declining to give the treating physician's opinion controlling weight, and (2) substantial evidence supports these findings. Moore v. Barnhart, 405 F.3d 1208, 1212 (11* Cir. 2005) (percuriam).

         Hernandez contends the ALJ erred in giving no weight to the opinion of her treating physician, Dr. Larry Johnston. After examining Hernandez in April 2013, Dr. Johnston opined that Hernandez's chronic medical conditions render her "totally and permanently unable to carry out gainful employment." (Tr. 575). The ALJ found Dr. Johnston's opinion inconsistent with and unsupported by Hernandez's treatment records, which the ALJ stated provided no evidence of functional limitations other than her list of symptoms and diagnoses. Furthermore, the ALJ declared that Dr. Johnston's opinion invades the Commissioner's province.

         The court finds the ALJ possessed good cause to give no weight to Dr. Johnston's opinion for several reasons. Evidence in the record fails to support Dr. Johnston's opinion, including his own treatment notes. Hernandez first reported to Dr. Johnston in March 2010 with complaints of right hip pain that caused tingling in her right leg. (Tr. 447). She indicated that Lortab made the pain tolerable. From 2010 to 2013, she visited Dr. Johnson nearly every month. Throughout these visits, she consistently reported that her pain medication helped her TMJ and anxiety. (Tr. 442, 444, 445). With medication, her TMJ and joint pain ranged from a 2/10 to 3/10. (Tr. 419, 438, 442). Hernandez reported that she maintained adequate pain control and could better cope with daily stressors. (Tr. 438). Throughout 2011, Dr. Johnston reported that Hernandez presented a calm mood and stable nerves. (Tr. 413, 420, 423). In August 2011, Hernandez began complaining of plantar fasciitis, but she indicated that her pain decreased to a 3/10 with medication. (Tr. 426). She reported concerns about joint pain and possible arthritis, but she also stated that medication helped control it and enabled her to rest. (Tr. 413, 423).

         In January 2012, Hernandez complained of joint pain to Dr. Robert Hunt. She reported slight swelling in her hands, difficulties with cramping in her hands and feet, and snapping in peripheral joints. Dr. Hunt diagnosed Hernandez with joint hypermobility and arthralgias, but he also stated that the symptoms could indicate evolving inflammatory arthritis. (Tr. 330-31). A few weeks later, Hernandez returned to Dr. Johnston chiefly with complaints of TMJ, anxiety, and insomnia. However, she stated that the pain medication alleviated her symptoms. (Tr. 410). Her return to Dr. Hunt in February 2012 demonstrated a "completely unremarkable lab" with x-rays exhibiting no obvious abnormalities of significance. (Tr. 329). During her remaining visits in 2012, Hernandez indicated that medication controlled her TMJ, hypermobility syndrome, and anxiety. (Tr. 390-407). She also reported she was sleeping through the night without any side effects from medication. (Tr. 391, 401). Dr. Johnston continued her on Ambien, Baclofen, Celexia, Lortab, Xanax, and Lodine. (Tr. 393, 395, 402).

         Hernandez's visits to Dr. Johnston in January and February 2013 portray that she retained control over her anxiety, TMJ, and hypermobility syndrome with medication. She stated she improved her ability to cope with daily stressors and that Ambien helped her insomnia. (Tr. 376, 378). These notes manifest an inconsistency with Dr. Johnston's April 2013 medical opinion, where he stated that Hernandez's chronic medical conditions render her "totally and permanently unable to carry out gainful employment" (Tr. 575). During her remaining visits to Dr. Johnston in 2013, Hernandez confirmed that her pain was doing "very well" with medication and was averaging around 4/10. (Tr. 355, 359, 367).

         Plaintiffs treatment records, most of which related to jaw pain, contained some abnormal findings, but they consistently noted Plaintiff displayed "adequate pain control and . . . [was] able to function and do . . . [activities of daily living] without difficulty." (Tr. 355, 359, 367, 375, 378, 382, 386, 394, 398, 401, 404, 407, 410). She exhibited no acute distress (Tr. 345, 364, 372, 376, 379, 383, 390 - 91, 399, 402, 405, 408, 411), and she noted she was feeling "well." (Tr. 581, 584, 578, 587). She possessed a full range of motion in her extremities, (Tr. 605) or a full range of musculoskeletal motion and a negative straight leg raise test. (Tr. 369, 384, 387). She demonstrated normal (2/4) deep tendon reflexes of the lower extremities that were neurovascularly intact. (Tr. 360, 3 84, 387). She displayed normal (5/5) grip strength. (Tr. 369). A right shoulder and cervical x - ray both exhibited no acute osseous abnormality. (Tr. 610 -11). She had a normal gait and station. (579, 584).

         In 2014, Hernandez began visiting Dr. Wendy Gomez. (Tr. 578). In May 2014, Hernandez reported to Dr. Gomez with complaints of chest pain, heart palpitations, and pain located in the substernal area. (Id.) Dr. Gomez assessed her symptoms as acute bronchitis, allergic rhinitis, tobacco abuse, and wheezing, and prescribed Singulair and ProAir HFA. (Tr. 580). She reported back to Dr. Gomez in June 2014 with complaints of moderate chest pain that was worsening, and Dr. Gomez prescribed Robaxin, Tramadol HCI, and Clindamycin HCI (Tr. 581-82). Dr. Gomez took x-rays of Hernandez's right shoulder and cervical spine, noting the images revealed "no acute osseous abnormalities]." (Tr. 610-11).

         During her visits to Dr. Gomez in September and October 2014, Hernandez complained of moderate joint pain, but she reported improvements in her pain over time. (Tr. 583, 586-88). During the most recently-reported medical visit in January 2015, Hernandez complained of chest pain in the central and right areas that manifested after a possible altercation with her son and daughter-in-law. (Tr. 600). She described her pain as moderate, and the chest x-ray indicated no acute cardiopulmonary abnormality. (Tr. 603).

         In addition to the medical records' contrast with Dr. Johnston's assessment, Dr. Johnston's opinion that Hernandez is "totally and permanently unable to carry out gainful employment" invades the province of the ALJ and sustains no dispositive weight.

According to 20 C.F.R. § 404.1527(d), the determination of whether an individual is disabled is reserved to the Commissioner, and no special significance will be given to an opinion on issues reserved to the Commissioner. Section (d)(2) provides that although the Commissioner will consider opinions from medical sources on issues such as the RFC and the application of vocational factors, the final responsibility for deciding those issues is reserved to the Commissioner.

Pate v. Comm'r, Soc. Sec. Admin., 678 Fed.Appx.. 833, 834 (11th Cir. 2017). That is, "the task of determining a claimant's .. . ability to work is within the province of the ALJ, not of doctors." Robinson v. Astrue, 365 Fed.Appx. 993, 999 (11* Cir. 2010).

         Based on this review, the ALJ properly articulated that Dr. Johnston's opinion was not consistent with or supported by Hernandez's treatment records, and thus substantial evidence buttresses the ALJ's accordance of no weight for the physician's opinion regarding Hernandez's alleged disability.

         B. The ALJ Assigned Proper Weight to the Examining Psychiatrist's Opinion

         To determine the weight given to a medical opinion, an ALJ must consider several factors, including the examining relationship, the treatment relationship, the evidence presented to support the opinion, the consistency of the opinion with other evidence, and the specialization of the medical professional 20 C.F.R. §404.1527(c); see Davis v. Comm'r of Soc. Sec, 449 Fed.Appx. 828, 832 (11* Cir. 201 l)(statmg that the ALJ will give more weight to the medical opinions of a source who has examined the plaintiff and opinions that are supported by medical signs and findings and are consistent with the overall "record as a whole"). The ALJ may reject the opinion of any physician when the evidence supports a contrary conclusion. Hearn v. Comm'r of Soc. Sec, 619 F. App's 892, 895 (11* Cir. 2Ol5)(citing P, hodsworth v. Heckler, 703 F.2d 1233, 1240 (11* Cir. 1983)).

         Hernandez contends the ALJ improperly substituted his own opinion for that of Dr. Christopher Randolph, the Commissioner's examining psychiatrist, as he afford Dr. Randolph's opinion little weight.[4] The ALJ stated that the record evidence and Hernandez's testimony did not support more than moderate difficulties in social functioning. (Tr. 27). Contrary to Hernandez's arguments, the ALJ afforded proper weight to Dr. Randolph's opinion, and substantial evidence supports the ALJ's finding that Dr. Randolph's opinion concerning Hernandez's limitations and ability to work did not accord with his own evaluations or the record.

         After examining Hernandez in November 2015, Dr. Randolph completed a Medical Source Statement of Ability to do Work-Related Activities (Mental) that concluded: (1) Hernandez's impairments affected her ability to understand, remember, and carry out instructions; (2) Hernandez faced extreme[5] restrictions in the ability to understand and remember complex instructions, to carry out complex instructions, and to make judgments on complex work-related decisions; (3) Hernandez faced marked[6] limitations in the ability to make judgments on simple work-related decisions; and (4) Hernandez faced moderate[7] limitations in the ability to understand, remember, and carry out simple instructions. (Tr. 647). In addition, Dr. Randolph referred to Hernandez's self-described issues with social avoidance and withdrawal as support for his opinion. (Tr. 646).

         However, for each set of limitations, the form instructs the physician to identify the particular medical or clinical findings supporting the claimed limitation. Utilizing a partially-completed SLUMS examination, Dr. Randolph opined that Hernandez possesses "significant" cognitive impairments that underlie the limitations. (Tr. 647.) Dr. Randolph also opined that Hernandez faced "extreme" impairments in (1) her ability to respond appropriately to usual work situations and to changes in a routine work setting, and (2) her ability to interact appropriately with the public, supervisors), and coworkers. (Tr. 648). Dr. Randolph stated that Hernandez's impairments would also affect her social interactions and interpersonal relationships. (Id.) However, Dr. Randolph failed to depict any clinical findings on the form to offer support for these limitations.

         The ALJ properly assigned little weight to Dr. Randolph's medical source opinion, and substantial evidence supports his decision. The ALJ stated that nothing in the claimant's treatment records supported Dr. Randolph's findings and that his conclusions appeared to be based solely on the claimant's report. (Tr. 27). Furthermore, the ALJ discussed in detail the ...

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