United States District Court, N.D. Alabama, Middle Division
N. JOHNSON, JR. UNITED STATES MAGISTRATE JUDGE.
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
AND STANDARD OF REVIEW
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 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.
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).
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).
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).
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.
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)
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).
AND PROCEDURAL HISTORY
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).
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. (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).
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).
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.
The ALJ Assigned Proper Weight to the Treating
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).
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
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).
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).
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).
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).
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).
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).
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
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.
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
The ALJ Assigned Proper Weight to the Examining
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*
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. 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.
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 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 limitations in the ability
to make judgments on simple work-related decisions; and (4)
Hernandez faced moderate 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).
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
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 ...