United States District Court, N.D. Alabama, Southern Division
OWEN BOWDRE CHIEF UNITED STATES DISTRICT JUDGE
October 29, 2012, the claimant protectively applied for
disability insurance benefits and a period of disability
under Title II of the Social Security Act. The claimant
alleged disability beginning April 26, 2011, because of
lumbar disc disease, cervical disc disease, right shoulder
impingement, obesity, and depression. The Commissioner denied
the claims on January 30, 2013. On February 8, 2013, the
claimant filed a written request for a hearing before an
administrative law judge (ALJ), and she held a video hearing
on February 26, 2014. (R. 13, 91-92, 109, 133, 244).
decision dated April 4, 2014, the ALJ found that the claimant
was not disabled as defined by the Social Security Act and
was, therefore, ineligible for disability benefits. On
November 17, 2015, the Appeals Council granted the
claimant's request for review. The Appeals Council
vacated the hearing decision and remanded the case to an ALJ
to obtain supplemental evidence from a vocational expert to
clarify the assessed limitations' effect on the
claimant's occupational base. The ALJ held a second
hearing on April 25, 2016, and again found that the claimant
was not disabled under the Social Security Act in a decision
dated August 25, 2016. (R. 7, 10-11, 106, 109, 127-28).
17, 2017, 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. 1). The claimant has exhausted
his 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.
issue before the court is whether the ALJ accorded proper
weight to the opinions of the claimant's treating
physician. The claimant raised three other issues involving
the ALJ's findings regarding the claimant's residual
functional capacity, the ALJ's assessment of the
claimant's subjective testimony, and the ALJ's
consideration of the claimant's disability pension.
Because the court finds that substantial evidence does not
support the ALJ's decision regarding the weight she gave
Dr. Savage's opinions, the court will not address these
STANDARD OF REVIEW
standard for reviewing the Commissioner's decision is
limited. This court must affirm the ALJ's decision if she
applied the correct legal standards and if her factual
conclusions are supported by substantial evidence.
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 (RFC), 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.
a good showing of cause to the contrary, the ALJ must accord
substantial or considerable weight to the opinions of
treating physicians. Lamb v. Bowen, 847 F.2d 698,
703 (11th Cir. 1988). The ALJ must credit the opinions of
treating physicians over those of consulting physicians
unless good cause exists for treating the opinions
differently. Lewis v. Callahan, 125 F.3d 1436,
1440-41 (11th Cir. 1997). The ALJ may discount a treating
physician's report when it is not accompanied by
objective medical evidence or is wholly conclusory.
Crawford v. Commissioner, 363 F.3d at 1159. Where
the ALJ articulated specific reasons for failing to give the
opinion of a treating physician controlling weight but
substantial evidence does not support those reasons, the ALJ
commits reversible error. See Moore v. Barnhart, 405
F.3d 1208, 1212 (11th Cir. 2005).
claimant was forty-five years old at the time of the
ALJ's final decision. The claimant has a college
education and past relevant work for the State of
Alabama as a youth service counselor. The claimant alleged
disability beginning on April 26, 2011 because of lumbar disc
disease, cervical disc disease, right shoulder impingement,
obesity, and depression. (R. 13, 25, 38).
and Mental Impairments
April 26, 2011, the claimant sought treatment with Dr. P.
Lauren Savage, Jr., an orthopedic surgeon at Alabama
Orthopedic, Spine and Sports Medicine Associates, for pain in
his right shoulder and neck, with his neck pain radiating
down to the right arm. The claimant's pain resulted from
a car accident on September 7, 2010. He assessed his right
side pain as severe with a ranking of eight out of ten on the
pain scale, and his neck pain as moderate with a rating of
four. The claimant denied feeling depressed or anxious, and
reported that his pain increased with lifting, twisting,
driving, lying on his back, and rising from sitting.
Activities and sleeping made his symptoms worse. On
examination, the claimant's neck and shoulder showed no
instability. Dr. Savage prescribed the claimant Mobic and
ordered MRIs of the claimant's right shoulder and
cervical spine. (R. 433-35).
of the claimant's cervical spine showed posterior
broad-based disc bulging; bilateral severe neural foraminal
stenosis at ¶ 3-4; mild central canal stenosis at ¶
3-4; mild concentric disc bulging and mild central canal and
left neural foraminal stenosis at ¶ 4-5; concentric disc
bulging and a right posterior protrusion at ¶ 5-6;
bilateral moderate neural foraminal stenosis; mild right
central canal stenosis; and a small broad-based central
protrusion at ¶ 6-7, with mild impression on the thecal
sac. The impression was degenerative changes and disc disease
and stenosis. At a follow-up appointment on May 3, 2011, Dr.
Savage gave the claimant injections of numbing and steroid
medications and recommended a course of physical therapy. (R.
1, 2011, the claimant returned to Dr. Savage with continuing
pain and numbness in his right shoulder and pain in his mid
and lower back. The claimant complained that he woke at night
with pain three nights during the week. X-ray imaging of the
claimant's lumbosacral spine and thoracic spine showed no
disc space narrowing, acute osseous lesions, or any
significant degenerative arthritis. Dr. Savage discussed
treatment options with the claimant, and recommended an
arthroscopy of his right shoulder. Dr. Savage performed an
acromioplasty, an arthroscopic surgery to remove a small
piece of the acromion that is causing friction between the
bone and the tendon, and a Mumford procedure, an operation to
remove the end of the clavicle to ameliorate shoulder pain,
on the claimant's right shoulder on July 8, 2011. (R.
420, 422, 441).
July 15 and September 2, 2011, the claimant saw Dr. Savage
four times for follow-up appointments. Following his surgery,
the claimant had superficial abscesses in axilla, which
cleared, and he reported an improved range of motion in his
shoulder but with mild tenderness. Dr. Savage prescribed
Percocet and further physical therapy. (R. 415-419).
October 14, 2011, the claimant saw Dr. Savage for persistent
back, leg, neck, arm, and upper back pain. The claimant's
leg pain and tingling and numbness were “worse  than
right after [the] wreck.” The claimant denied a history
of depression, anxiety, bipolar or schizophrenia. Dr.
Savage's bilateral lumbar examination revealed that the
claimant had limited lumbar flexion, extension, and rotation,
and his muscle strength was “grossly normal” and
equal bilaterally. He had moderate subacromial tenderness and
good range of motion in his right shoulder, although he had
pain with flexion over the head, horizontal adduction, and
internal rotation. A new MRI of the claimant's cervical
spine showed formal protrusion on the right and moderate to
severe right and mild left neural foraminal stenosis at
¶ 5-6, as well as mild central canal stenosis. A new MRI
of his lumbar spine showed central protrusion and moderate
right neural foraminal stenosis at ¶ 5-S1 and herniation
with annular tear. The impression was nerve root impingement
syndrome and herniated nucleus pulp/lumbar. Dr. Savage
ordered a lumbar epidural injection and recommended further
physical therapy. (R. 409-11, 442-43).
December 27, 2011, the claimant saw Dr. Savage for pain in
his shoulder and back. The claimant noted that when he was
able to rest and not do too much his pain was a four or a
five on a ten-point pain scale. But, when he had a
“pain-out” his pain was a ten and
“stop[ped] him in his tracks.” Additional
symptoms included radiation of pain on his right side, sleep
disturbances, stiffness, range of motion limitation, and
weakness. The claimant denied a history of depression,
anxiety, bipolar, or schizophrenia. In his bilateral lumbar
spine, he had good alignment but generalized tenderness.
X-ray imaging showed no acute changes, and Dr. Savage gave
the claimant injections of numbing and steroid medications.
claimant saw Dr. Savage on February 21, 2012 for severe lower
back pain, which the claimant rated as an eight on a
ten-point scale. Dr. Savage noted that the claimant's
current condition prohibited him from working in his previous
profession. (R. 399, 401).
17, 2012, Dr. Savage completed a Report of Disability on
behalf of the claimant for the Retirement Systems of Alabama
(RSA). Dr. Savage stated that the claimant's job required
“a lot of monitoring” and “excessive
walking, ” as well as daily physical confrontations
with students. He stated that the claimant would not be able
to participate in control force tactics training because of
his conditions, and maintaining a safe physical environment
would require too much demanding physical work for the
claimant. Dr. Savage further noted that, ...