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Williams v. Berryhill

United States District Court, N.D. Alabama

September 24, 2018

JONATHAN WILLIAMS, Claimant,
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY, Respondent.

          MEMORANDUM OPINION

          KARON OWEN BOWDRE, CHIEF UNITED STATES DISTRICT JUDGE

         I. INTRODUCTION

         On August 1, 2013, the claimant, Jonathan Williams, protectively applied for disability and disability insurance benefits under Title II of the Social Security Act and for supplemental security income under Title XVI. In both applications, the claimant alleged disability commencing on November 13, 2011, because of bipolar disorder, manic depression, suicidal ideation, ulcerative colitis, neck and back impairments, and a wrist injury. The Commissioner denied the claims on December 5, 2013. The claimant filed a timely request for a hearing before an Administrative Law Judge (ALJ) on December 10, 2013, and the ALJ held a hearing on April 22, 2015. (R. 12, 155, 172).

         In a decision dated September 17, 2015, the ALJ found that the claimant was not disabled as defined by the Social Security Act, rendering him ineligible for Social Security benefits. On January 18, 2017, the Appeals Council denied the claimant's requests for review. Consequently, the ALJ's decision became the final decision of the Commissioner of the Social Security Administration. 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, this court REVERSES and REMANDS the decision of the Commissioner to the ALJ for reconsideration.

         II. ISSUES PRESENTED

         The issue before the court is whether the ALJ accorded proper weight to the opinions of the claimant's treating physician Dr. James Yates. Although the claimant raised other issues on appeal, the court does not reach those issues because it will reverse on this issue.

         III. STANDARD OF REVIEW

         The standard for reviewing the Commissioner's decision is limited. This court must affirm the Commissioner's decision if the Commissioner applied the correct legal standards and if his 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).

         “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, 401 (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).

         IV. LEGAL STANDARD

         The ALJ must state with particularity the weight he gave different medical opinions and the reasons for that weight, and the failure to do so is reversible error. Sharfarz v. Bowen, 825 F.2d 278, 279 (11th Cir. 1987); see also MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986). The ALJ must give the testimony of a treating physician substantial or considerable weight unless the ALJ shows “good cause” to the contrary. Sryock v. Heckler, 764 F.2d 834, 835 (11th Cir. 1985). As the Eleventh Circuit explained:

[G]ood cause exists when: (1) the treating physician's opinion was not bolstered by the evidence; (2) evidence supported a contrary finding; or (3) treating physician's opinion was conclusory or inconsistent with the doctor's own medical records. Id. When electing to disregard the opinion of a treating physician, the ALJ must clearly articulate its reasons.

Phillips v. Barnhart, 357 F.3d 1232, 1240 (11th Cir. 2003) (citing Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997).

         When the ALJ fails to state specific reasons for not giving a treating physician substantial weight or if his articulated reasons lack substantial evidence, he has committed reversible error. See Moore v. Barnhart, 405 F.3d 1208, 1212 (11th Cir. 2005).

         V. FACTS

         The claimant was thirty-seven years old at the time of the ALJ's final decision; has a 10th grade education; has past relevant work as a data clerk and janitor; and alleges disability based on bipolar disorder, manic depression, suicidal ideation, ulcerative colitis, neck and back impairments, and a wrist injury. (R. 23, 155, 172, 183).

         Physical and Mental Impairments

         On January 18, 2006, the claimant went to the Northeast Alabama Regional Medical Center complaining of neck and left shoulder pain. Dr. David Bodne ordered a cervical x-ray that showed normal results. Later that year, the claimant once again went to Northeast Alabama Regional Medical Center on June 4 seeking treatment for bloody stools and abdominal pain and was admitted until June 9. The claimant informed Dr. Vishwanath Reddy that he has a past medical history of “opiate abuse, ” and “subsequent chronic methadone dependence, followed by a methadone clinic.” Dr. Reddy ordered a colonoscopy that showed an acutely inflamed large bowel. Dr. Reddy diagnosed the claimant with ulcerative colitis, anxiety, depression, and a history of chronic narcotic dependence. Dr. Reddy prescribed the claimant Levaquin 500 mg IV, Flagyl 500 mg t.i.d., and Azulfidine. (R.404-410, 421, 434).

         On March 9, 2009, the claimant saw Dr. James Yates, an internist, at the Jacksonville Medical Center, seeking to establish himself as a patient. The claimant reported to Dr. Yates that he was diagnosed with ulcerative colitis and has bouts of upper abdominal cramping and “mucous-like stools.” Dr. Yates noted the claimant was an “alert, ” “well-developed, well-nourished white male in no acute distress.” Dr. Yates further noted that the claimant's depression questionnaire was “positive on all the questions.”[1] Dr. Yates diagnosed the claimant with ulcerative colitis, inguinal lymphadenopathy, and depression. (R. 460).

         From that point, the record contains no relevant medical evidence until December 16, 2010, when the claimant again saw Dr. Yates, complaining of “back pain into his shoulders and [legs].” During his physical examination of the claimant, Dr. Yates noted the claimant had “tenderness in the lower cervical and lower lumbar area, ” and that the claimant straight leg testing was “negative.” He diagnosed the claimant with degenerative disc disease of the cervical and lumbar area and prescribed Vicoprofen and Klonopin. (R. 459).

         The claimant returned to Dr. Yates on March 31, 2011, when Dr. Yates noted “no change in [the claimant's] examination.” He additionally noted that the claimant continued to have “slight upper lumbar tenderness.” Dr. Yates prescribed acetaminophen and hydrocodone and refilled his Klonopin prescription. (R. 459).

         Then on November 13, 2011, the claimant returned to the Northeast Alabama Medical Center following a suicide attempt. The attempt resulted in a laceration of his flexor tendons, ulnar artery, median nerve, and ulnar nerve on his left wrist. Dr. Dewayne Clark and Dr. Duane Tippets performed an operation on the claimant's left wrist, repairing most of the injuries. At a follow-up visit on January 10, 2012, Dr. Tippets noted that the claimant has diffuse contracture of the fingers and that the claimant's recovery would likely be very limited. (R. 439-449, 454).

         On August 6, 2012, the claimant again saw Dr. Yates, following another suicide attempt. Dr. Yates noted that the claimant “has quite a bit of problem with depression including the suicide attempt” and that he “needs to get back on some medications.” Dr. Yates noted the claimant continued to have degenerative disc disease and chronic pain syndrome and prescribed the claimant Lortab as needed for pain and Klonopin for his depression. (R. 457).

         On October 16, 2012, the claimant met again with Dr. Yates for a follow-up appointment. Dr. Yates noted the claimant's pain symptoms were “about the same.” Dr. Yates refilled the claimant's previous medications. (R. 457).

         The claimant returned to Dr. Yates for another follow-up appointment on March 27, 2013. Dr. Yates noted that the claimant was “overall doing fairly well, ” and made an assessment of generalized anxiety disorder classified as “slightly symptomatic.” Dr. Yates additionally noted that the claimant's chronic pain syndrome from the degenerative disc disease was stable and prescribed the claimant Klonopin, Lortab, and Cymbalta. (R. 456).

         On August 9, 2013, the claimant again saw Dr. Yates. Dr. Yates noted that the claimant informed him that he was going out of town and needed his prescriptions for Klonopin and Lortab refilled that same day. (R. 455).

         One month later, on September 9, 2013, the claimant had another appointment with Dr. Yates, where he complained of pain in a specific area of his back. Dr. Yates found a “localized spasm at about L1 on the right.” Dr. Yates noted the claimant's chronic pain syndrome was the “same, ” and diagnosed him with a “localized muscle spasm in [his] upper lumbar area.” Dr. ...


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