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Robertson v. Berryhill

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

February 15, 2019

WILMA ROBERTSON, Claimant,
v.
NANCY BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY, Respondent.

          MEMORANDUM OPINION

          KARON OWEN BOWDRE, CHIEF UNITED STATES DISTRICT JUDGE.

         I. INTRODUCTION

         On May 16, 2014, the claimant, Wilma Robertson, applied for disability insurance benefits and Supplemental Security Income on June 23, 2014, alleging that she became disabled on March 11, 2014, because of pain associated with her degenerative disc disease, degenerative joint disease, scoliosis, hypertension, obesity, anemia, epistaxis, bradycardia, and fibroid tumors. (R. 138-39, 142-47). The commissioner denied the claimant's claims on September 2, 2014. (R. 78, 79, 80-84). The claimant timely filed a written request for a hearing before an Administrative Law Judge, and the ALJ held a video hearing on March 2, 2016. (R. 85-86).

         In a decision dated July 14, 2016, the ALJ found the claimant was not disabled and was, therefore, ineligible for the requested benefits. (R. 7-26, 37-57). After the claimant requested review of the hearing decision, the Appeals Counsel denied the claimant's request for review on July 27, 2017. (R. 1-6, 134-37). Consequently, the ALJ's July 2016 decision became the final decision of the Commissioner of the Social Security Administration. (R. 1-6). The claimant has exhausted her 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 AFFIRMS the decision of the Commissioner.

         II. ISSUES PRESENTED

         The claimant presents the following issues for review:

1. whether the ALJ erred in failing to properly apply the pain standard. Specifically, whether the ALJ failed to take into account any level of pain caused by the ten severe impairments, specifically degenerative disc disease, degenerative joint disease, scoliosis and fibroid tumors;
2. whether the ALJ erred in failing to link the residual functional capacity to the evidence; and
3. whether the ALJ failed to fully and fairly develop the record by failing to obtain the opinion of a treating, examining or non-examining physician regarding Ms. Robertson's functional capacity.

         III. STANDARD OF REVIEW

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

         IV. LEGAL STANDARD

         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). The ALJ may consider the claimant's daily activities in evaluating and discrediting complaints of disabling pain. Harwell v. Heckler, 735 F.2d 1292, 1293 (11th Cir. 1984).

         If the ALJ decides to discredit the claimant's testimony as to her pain, he must articulate explicit and adequate reasons for that decision; failure to articulate reasons for discrediting the claimant's testimony is reversible error. Foote v. Chater, 67 F.3d 1553, 1561-62 (11th Cir. 1995). A reviewing court will not disturb a clearly articulated credibility finding supported by substantial evidence in the record. Id. at 1562.

         The ALJ must also complete a residual functional capacity (“RFC”) assessment of each claimant. The responsibility for determining the claimant's RFC rests with the ALJ. 20 C.F.R. 404.1546(c), 416.946(c). An RFC assessment involves consideration of all relevant evidence in determining the claimant's ability to do work in spite of her impairments. Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997); see also 20 C.F.R. 404.1545(a), 416.945(a). However, the ALJ's decision does not have to reference every specific piece of evidence that the ALJ evaluated, as long as the decision shows that he considered the claimant's medical condition as a whole. Castel v. Comm'r of Soc. Sec., 355 Fed.Appx. 260, 263 (11th Cir. 2009).

         The ALJ must first assess the claimant's functional limitations and restrictions and then express his functional limitations in terms of exertional levels. See Castel v. Comm'r of Soc. Sec., 355 Fed.Appx. 260, 263 (11th Cir.2009); Freeman v. Barnhart, 20 Fed.Appx. 957');">220 Fed.Appx. 957, 959-60 (11th Cir.2007); see also Bailey v. Astrue, 5:11-CV-3583-LSC, 2013 WL 531075 (N.D. Ala. Feb. 11, 2013). The ALJ determines the claimant's RFC only after establishing the extent of the claimant's severe impairments. 20 C.F.R. 404.1520(e)-(f), 416.920(e)-(f).

         Additionally, the ALJ has a basic obligation to develop a full and fair record. Ellison v. Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003); Graham, 129 F.3d at 1422. Developing a full and fair record “may not require use of expert-testimony.” Welch v. Bowen, 854 F.2d 436, 440 (11th Cir. 1988). “The failure to include [an RFC assessment from a medical source] at the State agency level does not render the ALJ's RFC assessment invalid.” Langley v. Astrue, 777 F.Supp.2d 1250, 1261 (N.D. Ala. 2011). Furthermore, “the ALJ's duty to develop the record [does not] take away the claimant's burden of proving he is disabled.” Ellison, 355 F.3d at 1276. A full and fair record ensures that the ALJ has fulfilled his duty to explore the relevant facts and enables the reviewing court to “determine whether the ultimate decision on the merits is rational and supported by substantial evidence.” Id.

         V. FACTS

         The claimant was fifty-six years old with a tenth grade education when the ALJ rendered his decision. (R. 22, 138). The claimant reported that she was disabled because of pain associated with her degenerative disc disease, degenerative joint disease, scoliosis, hypertension, obesity, anemia, epistaxis, bradycardia, and fibroid tumors. (R. 173). The claimant had past relevant work experience as a nurse's aide and vehicle processor. (R. 54, 174). The claimant alleged she was disabled beginning March 11, 2014. (R. 41, 173).

         Physical Impairments

         The claimant visited the emergency room at DCH Regional Medical Center on April 3, 2013, complaining of vaginal bleeding. The claimant reported that her last normal menstrual cycle was 3 years prior. The claimant told ER staff that she noticed continuous spotting for two months prior to her visit, but that her bleeding became heavy about one week prior. The claimant reported lightheadedness, shortness of breath, and abdominal cramping, along with hot flashes, occasional night sweats, and mood swings. The claimant denied vaginal dryness, headache, blurry vision, chest pain, vomiting, and diarrhea. As to her general medical history, the claimant reported hypertension, but denied migraines, blood disorders, and back problems, among others.

         Dr. Angelia Woodward admitted claimant and ordered an ultrasound of the claimant's pelvis, which revealed suspected enlarged fibroid tumors in the claimant's uterus. Over the next two days, doctors performed additional scans, including a chest scan, which revealed no abnormalities, and an ultrasound of the lower extremities that revealed bilateral leg swelling, but no evidence of deep vein thrombosis. On the day of her discharge, April 5, 2013, the claimant reported that she felt better after receiving blood and also reported chronic back pain issues and possible depression. Dr. Abilash Balmuri discharged the claimant with instructions to make an appointment with Capstone Gynecology to follow up on her vaginal bleeding. Dr. Balmuri also started claimant on hormonal therapy. (R. 225-60).

         On May 15, 2013, Dr. David Smith of DCH performed an MRI of the claimant's spine after claimant complained of lower back pain. The imaging revealed a normal anatomic alignment in the claimant's lumbar vertebrae, clumped descending nerves, which did not appear to be abnormal; left lateral disc protrusion without evidence of neural impingement; a disc bulge at ¶ 4-L5; and a mild annular bulge at ¶ 5-S1 without evidence of impingement. (R. 457-58).

         The claimant visited the DCH emergency room on July 28, 2013, complaining of lower back pain and pain behind her neck that started one month prior to her visit. The claimant rated her pain as a nine on a ten-point pain scale. Dr. Jeremy Pepper evaluated the claimant, gave her pain medication, and referred her to The Spine Care Center in Tuscaloosa for a follow up visit to determine if she had degenerative disk disease. (R. 437-56).

         On August 9, 2013, claimant visited the DCH emergency room complaining of hip pain after “falling up the stairs.” The claimant also complained of back pain and reported a history of back pain. Dr. Christi Vaughn ordered several x-rays, all of which indicated bruising and lumbar strain, but no fractures or dislocation. Dr. Vaughn discharged claimant the same day with instructions to use elevation and compression to allow her bruising to heal. (R. 409-36).

         The claimant visited the DCH emergency room again on October 8, 2013, complaining of chest pain. The claimant rated her pain as a seven on a ten-point pain scale. The claimant reported that her pain was tight and sharp, lasted for a few minutes at a time, and was brought on by exertion. The claimant also reported chronic back pain and chronic abdominal pain because of a fibroid tumor for which she was supposed to have surgery. Dr. Robert Sheppard ordered a stress echocardiogram that revealed no abnormality and was negative for ischemia. Dr. Charles Brant reviewed all of claimant's systems and each system was negative for abnormalities. After being admitted to the hospital, the claimant received a transfusion and reported feeling better. Dr. Brant discharged the claimant on October 9, 2013, with recommendations to continue her medications and to follow up with her primary care physician for treatment of iron deficiency. (R. 263-323).

         On October 31, 2013, the claimant visited University Medical Center complaining of abnormal bleeding and an abnormal pap smear. Dr. John McDonald reviewed the claimant's systems, which were negative for abnormalities aside from the abnormal pap smear and bleeding. Dr. John McDonald performed an endometrial biopsy and advised claimant to follow up in one week. The laboratory report for this biopsy indicated atypical squamous cells of undetermined significance, benign endometrial polyps, and no indication of HPV. (R. 328-31, 334-38).

         On January 3, 2014, the claimant saw Dr. Toya Burton at Whatley Health Services because of back pain. She stated her pain began fifteen years ago, but was improving. After a review of claimant's systems and a physical exam, Dr. Burton scheduled the claimant for chiropractic manipulation and massage therapy and recommended that the claimant get an update MRI of her back. (R. 922-925).

         The claimant visited University Medical Center on January 8, 2014, to follow up on her previously reported abnormal bleeding and an abnormal pap smear. Dr. John McDonald performed a cervical biopsy that indicated no diagnostic histopathologic alteration and benign epithelium, blood, and mucus. (R. 325-27, 332-33).

         The claimant sought medical treatment at DCH Regional Medical Center on February 7, 2014, following a motor vehicle accident that occurred the previous day. The claimant complained to Dr. Christi Vaughn of pain from the accident, including low back pain and neck pain. A CT scan of claimant's cervical spine revealed no fractures or subluxation, moderate multilevel degenerative changes, mild posterior disc bulging at ¶ 2-C3 and C3-C4, mild posterior spondylotic spurring at ¶ 4-C5 with moderate posterior disc bulging centrally to the right, and mild central posterior disc bulge or protrusion at ¶ 5-C6. A CT scan of claimant's thoracic spine revealed mild scoliotic curvature, no acute fracture, and appropriate bone density. A CT scan of the claimant's lumbar spine revealed degenerative endplate sclerosis and osteophyte formation at ¶ 5-S1. (R. 504-06).

         Later that day, claimant checked herself into North Harbor Pavillion, a mental health facility for older adults. The claimant complained to Dr. Sanjay Singh that she was suffering from depression and chronic back pain and reported that her recent car accident had increased her back pain and caused neck pain. She also reported that she had been sleeping poorly because of her pain and that her pain rendered her unable to work. The claimant rated her back pain as a seven on a ten-point pain scale. The claimant told Dr. Singh she felt useless because she can no longer do the things she used to do and that she heard voices telling her to kill herself, but would never attempt suicide because her sister had attempted suicide. Dr. Singh observed the claimant overnight and recommended that she visit Indian Rivers Mental Health Facility the next week for an evaluation. Dr. Singh discharged the claimant on February 8, 2014. (R. 496-97, 715-739).

         The claimant visited Whatley Health Services on February 17, 2014, complaining of back pain. She reported to Dr. Toya Burton that her back pain began around twenty years prior and was worsening. The claimant stated that the pain was in her lower back, legs, neck, and thighs and radiated to her back, ankles, arms, calves, and feet. After a physical exam, Dr. Burton scheduled the claimant for electric stimulation therapy and chiropractic manipulation. (R. 807-09).

         On February 20, 2014, the claimant visited Whatley Health Services to follow up on her reported hypertension, back pain, and anemia. The claimant reported to Dr. Aalia Al Barwani that she had not been taking her iron pills because they irritate her stomach and also reported lower back and neck pain. The claimant stated that she had not seen a specialist for her back pain because she wanted to get health insurance first. Dr. Al Barwani recommended a follow-up visit in two weeks. (R. 803-06).

         The claimant again visited Whatley Health Services on March 6, 2014, to follow up on her hypertension, back pain, and anemia. Claimant reported to Dr. Aalia Al Barwani that she was experiencing headaches, chest pain, and nausea related to her anemia. Claimant also reported lower back and neck pain, which occurred intermittently. Dr. Al Barwani reviewed claimant's systems and conducted a physical exam, which revealed no abnormalities. Dr. Al Barwani prescribed ...


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