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Bush v. Berryhill

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

September 21, 2018





         On May 28, 2014, the claimant, Lutisha Irene Bush, applied for Supplemental Security Income benefits under Title XVI of the Social Security Act. The claimant alleged disability commencing on May 30, 2011, because of asthma, manic depression, tachycardia, post-traumatic stress disorder (PTSD), panic attacks, and a back injury. The Commissioner denied the claim on August 14, 2014, and the claimant filed a timely request for a hearing before an Administrative Law Judge (ALJ) on October 3, 2014. The ALJ held a video hearing on May 16, 2016. (R. 43, 148-53, 188).

         In a decision dated August 23, 2016, the ALJ held that the claimant was not disabled, as defined by the Social Security Act, and was, therefore, ineligible for Social Security benefits. On June 29, 2017, the Appeals Council declined to grant review of the ALJ's decision, and the claimant has now appealed her decision to this court, which has jurisdiction pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). (R. 40). For the reasons stated below, this court AFFIRMS the decision of the Commissioner.


         The claimant presents the following issues for review:

1. whether the ALJ properly evaluated the opinion of examining psychological consultant Dr. Hampton;
2. whether substantial evidence supports the claimant's testimony regarding her symptoms;
3. whether substantial evidence supports the ALJ's residual functional capacity finding that the claimant could perform light work;
4. whether the ALJ properly did not apply Grid Rule 201.14, and properly relied on vocational expert testimony to support her finding that the claimant can perform light work; and
5. whether the ALJ drew proper inferences from the claimant's lack of medical treatment.


         The 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 substantial evidence supports her 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).

         “No…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).

         The 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.

         The 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. 1986).


         The ALJ must consider all medical opinions, but she is not required to give special deference to an opinion from a single consultation. Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). However, refusal by the ALJ to accord proper weight to the opinion of a consultative examining physician is cause for reversal. Henry v. Comm'r of Soc. Sec., 802 F.3d 1264, 1268 (11th Cir. 2015).

         In evaluating pain and other subjective complaints, 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). After the claimant has established an underlying medical condition, her disability determination must be based on evidence of the intensity, persistence, and functionally limiting effects of her pain or other symptoms, and the medical record. Foote v. Chater, 67 F.3d 1553, 1561 (11th Cir. 1995). If the claimant testifies as to her subjective complaints of severe pain and other symptoms, the ALJ must articulate explicit and adequate reasons for discrediting the claimant's allegations of completely disabling symptoms. Dyer, 395 F.3d at 1210.

         In making a disability determination, the ALJ is required to evaluate the claimant's residual functional capacity, which is an assessment based on all relevant evidence of the claimant's ability to work, despite her impairments. See Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). The ALJ makes a proper residual functional capacity determination if she adequately considers the claimant's ability to “meet the physical, mental, sensory, and other requirements of work.” 20 C.F.R. § 416.945(a)(4).

         If the findings of fact correspond with one of the grid rules, as set out in Appendix 2 of 20 C.F.R. part 404, subpart P, the Commissioner must find the claimant “disabled” or “not disabled” based upon a grid rule. See 20 C.F.R. Pt. 404 subpt. P, app. 2, § 200.00; 20 C.F.R. § 416.969. However, if the claimant has exertional and non-exertional limitations, the Commissioner should use the grids as merely a framework in the decision-making process. See 20 C.F.R. § 416.969a(d). When the claimant's RFC does not exactly correspond with one of the grid rules, the ALJ may obtain the assistance of a vocational expert to determine any jobs the claimant could perform. See Wolfe v. Chater, 86 F.3d 1072, 1077-78 (11th Cir. 1996). “The ALJ must pose a hypothetical question which comprises all of the claimant's impairments.” Williams v. Barnhart, 140 F. App'x, 932, 936 (11th Cir. 2005). The ALJ commits harmless error if she omits a factor from the hypothetical that would not change the testimony of the vocational expert. Id.

         Refusal by a claimant to follow prescribed medical treatment without good cause will preclude a finding of disability. 20 C.F.R. § 404.1530(b). But Poverty may excuse failure to follow prescribed medical treatment. Ellison v. Barnhart, 355 F.3d 1272, 1275 (11th Cir. 2003). If the ALJ relies solely on a claimant's noncompliance as grounds to deny disability benefits, and the record indicates that the claimant could not afford prescribed medical treatment, the ALJ must make a determination regarding the claimant's ability to afford treatment. However, if the ALJ does not substantially or solely base her finding of nondisability on the claimant's noncompliance, she does not commit a reversible error by failing to consider the claimant's financial situation. Id.

         V. FACTS

         The claimant was fifty-two years old at the time of the ALJ's decision; obtained a GED and completed a certified nursing assistant (CNA) program; has past work experience as a CNA and a bonding agent; and alleges disability based on asthma, manic depression, tachycardia, PTSD, panic attacks, and a back injury. (R. 51, 62, 148, 179, 188-89).

         Physical and Mental Impairments

         The record includes extensive medical details regarding the claimant's back pain and migraines between 1991 and 1996. Although migraines were not listed on the claimant's social security benefits application, migraine-related complaints comprised the majority of the claimant's medical record until 2005. The claimant visited Dr. Kenneth Pilgreen and Dr. James White more than thirty times regarding migraines and back pain during this time. Dr. Pilgreen diagnosed the claimant with a common migraine with tension components in June of 1991, and he proscribed Corgard, Amitriptyline, and Midrin. The amount and type of medication that the claimant took, and the frequency of her migraines, fluctuated through the years. Dr. White also wrote the claimant's prescription for Midrin; gave the claimant a shot of Imitrex for her migraine headaches in 1993; and also conducted x-rays and CT scans at Gadsden Regional Medical Center of the claimant's lumbar spine that showed desiccation of the L5 intervertebral disc, early interspace narrowing, and mild bulging at ¶ 5. (R. 273-334).

         The record indicates that the claimant visited Dr. Lisa Oestreich of Northeast Alabama Neurological Services once in 1999 complaining of migraines; and she visited Etowah Free Community Clinic once in 2002 and again in 2005 complaining of migraines. The record included no medical entries between 2005 and 2010, and the ALJ did not ...

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