United States District Court, N.D. Alabama, Middle Division
G. CORNELIUS U.S. MAGISTRATE JUDGE.
Wesley Cotton appeals from the decision of the Commissioner
of the Social Security Administration
("Commissioner") denying his application for
disability and disability insurance benefits. (Doc. 1).
Plaintiff timely pursued and exhausted his administrative
remedies, and the decision of the Commissioner is ripe for
review pursuant to 42 U.S.C. § 405(g). For the reasons
stated below, the Commissioner's decision is due to be
reversed and remanded.
FACTS, FRAMEWORK, AND PROCEDURAL HISTORY
was thirty-six years old at the time he filed his
application; he was thirty-eight at the time of the
Administrative Law Judge's (“ALJ's”)
decision. (See R. 14, 25). Plaintiff has a ninth
grade education and speaks English. (R. 18, 25). His past
work experience includes employment as an auto mechanic,
brick layer, heavy equipment operator, and caulker. (R. 24).
Plaintiff claims he became disabled on October 3, 2013, due
to back problems, COPD, and fibromyalgia. (R. 14, 209).
evaluating the disability of individuals over the age of
eighteen, the regulations prescribe a five-step sequential
evaluation process. See 20 C.F.R. §§
404.1520, 416.920; Doughty v. Apfel, 245 F.3d 1274,
1278 (11th Cir. 2001). The first step requires a
determination of whether the claimant is performing
substantial gainful activity (“SGA”). 20 C.F.R.
§ 404.1520(a)(4)(i). If the claimant is engaged in
substantial gainful activity, he or she is not disabled and
the evaluation stops. Id. If the claimant is not
engaged in substantial gainful activity, the Commissioner
proceeds to consider the combined effects of all the
claimant's physical and mental impairments. 20 C.F.R.
§§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). These
impairments must be severe and must meet certain durational
requirements before a claimant will be found disabled.
Id. The decision depends on the medical evidence in
the record. See Hart v. Finch, 440 F.2d 1340, 1341
(5th Cir. 1971). If the claimant's impairments are not
severe, the analysis stops. 20 C.F.R. §§
404.1520(a)(4)(ii), 416.920(a)(4)(ii). Otherwise, the
analysis continues to step three, at which the Commissioner
determines whether the claimant's impairments meet the
severity of an impairment listed in 20 C.F.R. Part 404,
Subpart P, Appendix 1. 20 C.F.R. §§
404.1520(a)(4)(iii), 416.920(a)(4)(iii). If the impairments
fall within this category, the claimant will be found
disabled without further consideration. Id. If the
impairments do not fall within the listings, the Commissioner
determines the claimant's residual functional capacity
(“RFC”). 20 C.F.R. §§ 404.1520(e),
four the Commissioner determines whether the impairments
prevent the claimant from returning to past relevant work. 20
C.F.R. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). If
the claimant is capable of performing past relevant work, he
or she is not disabled and the evaluation stops. Id.
If the claimant cannot perform past relevant work, the
analysis proceeds to the fifth step, at which the
Commissioner considers the claimant's RFC, as well as the
claimant's age, education, and past work experience, to
determine whether he or she can perform other work.
Id.; 20 C.F.R. §§ 404.1520(a)(4)(v),
416.920(a)(4)(v). If the claimant can do other work, he or
she is not disabled. Id.
the sequential evaluation process, the ALJ found Plaintiff
had not engaged in SGA since the alleged onset date. (R. 16).
At step two, the ALJ found Plaintiff suffered from the
following severe impairments: (1) status post modified
microdiscectomy secondary to herniated disc, lumbar spine at
¶ 5-S1; (2) status post anterior interbody fusion
secondary to disc disease, spinal stenosis, radiculopathy,
and instability, lumbar spine at ¶ 5-S1; and (3)
degenerative changes of the lumbar spine. (Id.).
three, the ALJ found Plaintiff did not have an impairment or
combination of impairments meeting or medically equaling any
of the impairments listed in 20 C.F.R. Part 404, Subpart P,
Appendix 1. (R. 17). Before proceeding to step four, the ALJ
determined Plaintiff had the RFC to perform medium work as
defined in 20 C.F.R. § 404.1567(c) with the following
limitations: (1) he can sit for one hour without interruption
and for a total of at least six hours in an eight-hour
workday; (2) he can stand and/or walk for at least one hour
without interruption and for a total of at least six hours in
an eight-hour workday; (3) he cannot climb ropes, poles, or
scaffolds; (3) he can occasionally climb ramps, stairs, and
ladders; (4) he can frequently balance, stoop, kneel, and
crouch; (5) he can occasionally crawl; (6) he can frequently
use his upper extremities for reaching overhead and
frequently use his lower extremities for the operation of
foot controls; (7) he can frequently work in humidity,
wetness, and extreme heat and can occasionally work in
extreme cold; (8) he cannot work in poorly ventilated areas
or at unprotected heights; and (9) he can frequently operate
hazardous machinery, drive, and be exposed to vibration. (R.
the ALJ determined Plaintiff was unable to perform past
relevant work at step four, the ALJ relied on the testimony
of a vocational expert (“VE”) in finding a
significant number of jobs in the national economy Plaintiff
can perform. (R. 24-25). Thus, the ALJ determined Plaintiff
was not disabled. (R. 26).
STANDARD OF REVIEW
court's role in reviewing claims brought under the Social
Security Act is a narrow one. The scope of its review is
limited to determining (1) whether there is substantial
evidence in the record as a whole to support the findings of
the Commissioner, and (2) whether the correct legal standards
were applied. See Stone v. Comm'r of Soc. Sec.,
544 Fed.Appx. 839, 841 (11th Cir. 2013) (citing Crawford
v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th
Cir. 2004)). A court gives deference to the factual findings
of the Commissioner, provided those findings are supported by
substantial evidence, but applies close scrutiny to the legal
conclusions. See Miles v. Chater, 84 F.3d 1397, 1400
(11th Cir. 1996).
a court may not decide facts, weigh evidence, or substitute
its judgment for that of the Commissioner. Dyer v.
Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005) (quoting
Phillips v. Barnhart, 357 F.3d 1232, 1240 n.8 (11th
Cir. 2004)). “The substantial evidence standard permits
administrative decision makers to act with considerable
latitude, and ‘the possibility of drawing two
inconsistent conclusions from the evidence does not prevent
an administrative agency's finding from being supported
by substantial evidence.'” Parker v.
Bowen, 793 F.2d 1177, 1181 (11th Cir. 1986) (Gibson, J.,
dissenting) (quoting Consolo v. Fed. Mar.
Comm'n, 383 U.S. 607, 620 (1966)). Indeed, even if a
court finds that the proof preponderates against the
Commissioner's decision, it must affirm if the decision
is supported by substantial evidence. Miles, 84 F.3d
at 1400 (citing Martin v. Sullivan, 894 F.2d 1520,
1529 (11th Cir. 1990).
no decision is automatic, for “despite th[e]
deferential standard [for review of claims], it is imperative
that th[is] Court scrutinize the record in its entirety to
determine the reasonableness of the decision reached.”
Bridges v. Bowen, 815 F.2d 622, 624 (11th Cir. 1987)
(citing Arnold v. Heckler, 732 F.2d 881, 883 (11th
Cir. 1984)). Moreover, failure to apply the correct legal
standards is grounds for reversal. See Bowen v.
Heckler, 748 F.2d 629, 635 (11th Cir. 1984).
asserts the ALJ's decision is not supported by
substantial evidence and should be reversed and remanded.
(Doc. 12). Specifically, Plaintiff contends the ALJ: (1)
failed to properly evaluate the credibility of
Plaintiff's testimony of pain; and (2) improperly
discounted the opinion of Plaintiff's treating physician.
(Id. at 4-13). The Plaintiff's arguments are
limited to the ALJ's findings regarding his back
Plaintiff's back problems began after a car accident on
August 5, 2013, while he was at work. (R. 18, 19). An August
9, 2013 MRI of Plaintiff's lumbar spine showed: (1) a
small lateralizing soft disc centrally and on the right at
¶ 5-S1 with mild to moderate mass effect on the right S1
nerve root; (2) a small eccentric annual tear on the right at
¶ 5-S1; and (3) mild degenerative changes at ¶
1-L2. (R. 308). During an August 14, 2013 visit to the
Alabama Comp Clinic, Plaintiff reported aching, stabbing pain
in his lower back with numbness and tingling in his legs. (R.
309). The Alabama Comp Clinic recommended a lumbar epidural
steroid injection, which was performed on September 3, 2013.
(Id.; R. 326).
September 19, 2013, Plaintiff saw Dr. Martin Jones of
Neurological Surgery Associates complaining of back and right
leg pain; he also reported having two epidural injections,
which did not help and made the pain worse. (R. 459). Dr.
Jones noted conservative treatment had been ineffective and
that Plaintiff chose to undergo a microdiscectomy. (R. 460).
Dr. Jones performed the microdiscectomy on October 4, 2013.
(R. 465). During an October 21, 2013 follow-up, Dr. Jones
noted Plaintiff was "doing well." (R. 468). On a
November 18, 2013 follow-up, Dr. Jones noted Plaintiff was
making progress and recommended physical therapy. (R.
471-72). On December 19, 2013, Dr. Jones noted the plaintiff
was still having pain and reported no improvement. (R. 473).
Dr. Jones ordered an MRI, which was performed on December 24,
2013. (R. 474, 476). The MRI revealed post-surgical changes
on the right at ¶ 5-S1 with considerable scar tissue
around the S1 nerve root but no recurrent herniation or
lesion. (R. 476). On a January 6, 2014 follow-up visit, Dr.
Jones noted the MRI "looks fine" and stated there
was no further surgical remedy and recommended a Functional
Capacity Evaluation ("FCE"). (R. 477-79). The FCE
was performed on January 14, 2014, and concluded Plaintiff
could perform work at the light to medium level. (R.
481-91). On January 27, 2014, Dr. Jones noted
Plaintiff could return to work which accommodated the FCE
analysis and opined he would be at maximum medical
improvement with a ten percent impairment rating. (R.
492-94). On February 4, 2014, Plaintiff was released from
physical therapy with a good prognosis. (R.433).
months later, on July 4, 2014, Plaintiff visited the office
of his primary treating physician, Dr. Michael Dupré,
complaining of lower back pain radiating down his right leg
and foot; Plaintiff reported the pain prevented him from
walking or sitting for extended periods. (R. 635-37).
Examination revealed tenderness and muscle spasms in
Plaintiff's lower back and paraspinal region. ...