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Moten v. Berryhill

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

August 29, 2018

NANCY BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Tiffany Sontrica Moten brings this action pursuant to 42 U.S.C. § 405(g), seeking review of the final decision of the Acting Commissioner of Social Security (“Commissioner”) denying her supplemental security income (“SSI”) benefits. (Doc. 1).[1] The case has been assigned to the undersigned United States Magistrate Judge pursuant to this court's general order of reference. The parties have consented to the jurisdiction of this court for disposition of the matter. See 28 U.S.C. § 636(c), Fed.R.Civ.P. 73(a). Upon review of the record and the relevant law, the undersigned finds that the Commissioner's decision is due to be affirmed.


         Plaintiff filed her application for SSI benefits in April 2014, alleging she became disabled beginning August 17, 2013. A hearing was conducted on June 17, 2014. Plaintiff requested at the hearing that her onset date be amended to her filing date of April 7, 2014. Her application was initially denied by an administrative law judge (“ALJ”). The Appeals Council (“AC”) denied Plaintiff's request for review. (R. 1).[2]

         II. FACTS

         Plaintiff was 33 years old at the time of the ALJ's decision. (R. 23). She has not had substantial gainful activity at any time. (R. 21, 29, 47, 156, 160). She alleges disability due to her back condition from a car wreck, osteoarthritis, degnerative joint disease in her knees and legs, bursitis in her knees and legs, and depression. (R. 159).

         Following Plaintiff's hearing, the ALJ found that she had the medically determinable severe impairments of obesity, osteoarthritis, enthesopathy of the knees, a history of pes bursitis, and heel spurs. (R. 21). He also found that Plaintiff did not have an impairment or combination of impairments that met or equaled the severity of a listed impairment. (R. 22). He further found that Plaintiff had the residual functional capacity (“RFC”) to perform sedentary[3] work with limitations. (R. 22-28). He determined that Plaintiff had no past relevant work. (R. 29). He further found that based on Plaintiff's age, education, work experience, RFC, and the testimony of a vocational expert (“VE”), Plaintiff could work as an charge account clerk, toy stuffer, and button reclaimer. (R. 29-30). The ALJ concluded that Plaintiff was not disabled. (R. 30).


         The court's review of the Commissioner's decision is narrowly circumscribed. The function of the court is to determine whether the Commissioner's decision is supported by substantial evidence and whether proper legal standards were applied. Richardson v. Perales, 402 U.S. 389, 390, 91 S.Ct. 1420, 1422 (1971); Mitchell v. Comm'r Soc. Sec., 771 F.3d 780, 782 (11th Cir. 2015, Wilson v. Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002). 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 Cir. 1983). Substantial evidence is “such relevant evidence as a reasonable person would accept as adequate to support a conclusion.” Id. It is “more than a scintilla, but less than a preponderance.” Id.

         The court must uphold factual findings that are supported by substantial evidence. However, it reviews the ALJ's legal conclusions de novo because no presumption of validity attaches to the ALJ's determination of the proper legal standards to be applied. Davis v. Shalala, 985 F.2d 528, 531 (11th Cir. 1993). If the court finds an error in the ALJ's application of the law, or if the ALJ fails to provide the court with sufficient reasoning for determining that the proper legal analysis has been conducted, it must reverse the ALJ's decision. See Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991). The court must affirm the ALJ's decision if substantial evidence supports it, even if other “evidence preponderates against the Commissioner's findings.” See Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004) (quoting Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir.1990)).


         To qualify for benefits, a claimant must show her inability to engage in “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 12 months.” 42 U.S.C. § 1382c(a)(3)(A). A physical or mental impairment is “an impairment that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C. § 1382c(a)(3)(D).

         Determination of disability under the Social Security Act requires a five step analysis. 20 C.F.R. § 416.920(a). Specifically, the Commissioner must determine in sequence:

whether the claimant: (1) is unable to engage in substantial gainful activity; (2) has a severe medically determinable physical or mental impairment; (3) has such an impairment that meets or equals a Listing and meets the duration requirements; (4) can perform his past relevant work, in light of his residual functional capacity; and (5) can make an adjustment to other work, in light of his residual functional capacity, age, education, and work experience.

Evans v. Comm'r of Soc. Sec., 551 Fed.Appx. 521, 524 (11th Cir. 2014).[4] The plaintiff bears the burden of proving that she was disabled within the meaning of the Social Security Act. Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005); see also 20 C.F.R. § 416.920(a) (“[The applicable] regulations place a very heavy burden on the claimant to demonstrate both a qualifying disability and an inability to perform past relevant work.”).

         V. DISCUSSION

         Plaintiff asserts that the ALJ erred in that he failed to (1) properly assess the medical opinion of her treating physician, Dr. Dolores Victoria; (2) properly consider her obesity pursuant to Social Security Ruling (“SSR”) 02-01; and (3) determine that she met Listing 1.02A-major joint dysfunction. (Doc. 10 at 2). The Commissioner responds that substantial evidence supports the ALJ's determinations and Plaintiff has failed to meet her burden of proving her impairments met or equaled Listing 1.02A. (Doc. 11 at 4-19).

         A. Dr. Victoria's Medical Opinion

         1. Guiding Principles

         As noted above, Plaintiff bears the burden of proving that she is disabled within the meaning of the Social Security Act. See 20 C.F.R. § 416.920(a); Moore, 405 F.3d at 1211; Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001). Specifically, Plaintiff must provide evidence of an underlying medical condition and objective medical evidence confirming either the severity of the alleged symptoms or that the medical condition could be reasonably expected to give rise to the alleged symptoms. See 20 C.F.R. § 419.929(a); Dyer v. Barnhart, 359 F.3d 1206, 1210 (11th Cir. 2005); Wilson, 284 F.3d at 1225-26; Edwards v. Sullivan, 937 F.2d 580, 584 (11th Cir. 1991). In analyzing the evidence, the focus is on how an impairment affects Plaintiff's ability to work, and not on the impairment itself. See 20 C.F.R. § 416.929(c)(1); McCruter v. Bowen, 791 F.2d 1544, 1547 (11th Cir. 1986) (“severity of [impairments] must be measured in terms of [their] effect upon the ability to work ... not from purely medical standards of bodily perfection or normality”).

         In assessing the weight to afford a doctor's opinion, an ALJ may consider numerous factors, including whether the doctor treated or examined the claimant, the evidence presented to support her opinion, whether the doctor's opinion is consistent with the record as a whole, and the doctor's specialty. See 20 C.F.R. § 416.927(c). A treating doctor's opinion generally is entitled to more weight, and an ALJ must show “good cause” for discounting a treating doctor's opinion. See 20 C.F.R. § 416.927(c)(2); see also Phillips v. Barnhart, 357 F.3d 1232, 1240 (11th Cir. 2003); Mace v. Comm'r, Soc. Sec. Admin, 605 Fed.Appx. 837, 841 (11th Cir. 2015). However, an ALJ has discretion to give a treating physician's opinion less than controlling weight if the medical evidence does not support it or it is inconsistent with other substantial evidence in the case record. See 20 C.F.R. § 416.927(c)(2)-(4); SSR 96-2p, 1996 WL 374188, at *2; see also Mace, 605 Fed.Appx. at 641. Opinions on some issues, however, such as whether Plaintiff is unable to work, 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. § 416.927(d); see Bell v. Bowen, 796 F.2d 1350, 1353-54 (11th Cir. 1986); Lee v. Comm'r, Soc. Sec. Admin., 551 Fed.Appx. 539, 542 (11th Cir. 2014). Opinions on issues reserved to the Commissioner, even when offered by a treating physician, are not entitled to controlling weight or special significance. See 20 C.F.R. § 416.927(d)(3).

         2. Background

         Plaintiff initially argues that the ALJ failed to accord proper weight to Dr. Victoria's opinion as a treating physician and the ALJ failed to show good cause for affording her opinion only partial weight. The record demonstrates that Dr. Victoria is a treating physician with Quality of Life Health Services (“Quality of Life”). She has been treating Plaintiff since March 2010 for various issues, including low back pain, morbid obesity, knee pain, and hypertension. (R. 506-07, 626). In December 2013, Plaintiff reported hurting her left knee when she fell down stairs in June 2013. (R. 427). She also reported that she had been to the emergency room several times. X-rays were taken and showed inflammation of the left knee. Dr. Victoria treated the injury with ibuprofen and Mobic, but that did not provide Plaintiff with any relief. (Id.) She complained of swelling and difficulty walking. (Id.) Her physical examination showed left knee swelling, a reduced range of motion, and tenderness. (R. 429).

         Plaintiff had an MRI performed on her knees on January 22, 2014. The MRI showed “underlying degnerative changes in both knees, slightly more prominent on the left with minor marginal osteophytic spurring and tibial plateau sclerosis.” (R. 444). There was “[n]o distinct additional acute bony or soft tissue pathology ... evident.” (Id.)

         Plaintiff was also examined initially by Dr. Daniel R. Sparks on February 12, 2014, due to complaints of left knee pain. She reported that her pain began in February 2013, when she fell off her porch. (R. 460). Dr. Sparks's examination determined that there was no swelling, bruising, or effusion. Plaintiff had normal range of motion and no instability. (Id.) X-rays showed mild arthritis and “varus with mild narrowing and small osteophytes.” (Id.) He administered an injection of Celestone and Marcaine. (R. 461). Plaintiff was diagnosed with “arthritis- [degnerative joint disease] of the knee.” (Id.) She was seen by Dr. Sparks one week later. She complained that the injection did not relieve her pain, but made her “knee numb.” (R. 459). Dr. Sparks recommended Lodine and physical therapy. (R. 308, 459). He also recommended that she have an apartment on the ground floor for easy accessibility. (R. 376).

         Plaintiff attended physical therapy on February 26, 2014. During her initial session, Plaintiff ambulated without assistance and exhibited a limp. (R. 310). She reported pain at a level of 8/10. Her left lower extremity strength was “3” and her right strength was “4/5.” (R. 310-11). She asked the therapist if a cane would help. She was told that a rolling walker would be better because it would redistribute her weight to her hands. (R. 310, 317). She was also told that weight loss was important in decreasing her knee pain. (R. 311, 318). She participated in physical therapy on February 27. She reported a pain level of 7/10. (R. 321). Due to the death of her mother, her next therapy session was not until March 24. She reported a pain level of 6/10 during that session. (R. 323). She also stated that she intended to ask Dr. Sparks for a prescription for a cane. (Id.)

         Dr. Sparks saw Plaintiff on March 25, 2014. He wrote her a prescription for a cane. (R. 377). Plaintiff returned to Dr. Sparks on April 2, 2014, complaining that she fell at the previous appointment and hurt her left knee. Dr. Sparks's examination of Plaintiff revealed no swelling, bruising, or instability. (R. 458). He also noted a normal range of motion in her left knee. (Id.) He diagnosed ...

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