United States District Court, N.D. Alabama, Western Division
OWEN BOWDRE, CHIEF UNITED STATES DISTRICT JUDGE.
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).
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
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.
STANDARD OF REVIEW
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).
. . . 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).
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.
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.
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).
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.
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).
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).
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.”
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,
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.
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).
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).
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).
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.
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).
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,
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).
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).
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).
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,
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).
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).
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