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Cotton v. Social Security Administration

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

September 28, 2018




         Plaintiff 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.


         Plaintiff 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).

         When 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), 416.920(e).

         At step 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.

         Applying 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.).

         At step 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. 17).

         Because 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).


         A 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).

         Nonetheless, 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).

         However, 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).


         Plaintiff 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 problems. (Id.).

         Here, 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).

         On 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).[2] 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).

         Five 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. ...

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