Pennington v. Berryhill

          MEMORANDUM OPINION

          KARON OWEN BOWDRE CHIEF UNITED STATES DISTRICT JUDGE.

         I. INTRODUCTION

         On December 30, 2014, the claimant protectively applied for disability and disability insurance benefits under Title II of the Social Security Act. The claimant initially alleged disability beginning December 28, 2014, because of depression, anxiety, obsessive-compulsive disorder, panic attacks, eating disorder, complex regional pain syndrome, chronic migraines, social anxiety, and several suicide attempts. The Commissioner denied the claims on April 2, 2015. The claimant filed a timely request for a hearing before an Administrative Law Judge, and the ALJ held a hearing on August 31, 2016. (R. 17, 2071).

         In a decision dated January 24, 2017, the ALJ found that the claimant was not disabled as defined by the Social Security Act, rendering her ineligible for Social Security benefits. On October 5, 2017, the Appeals Council denied the claimant's request for review. Consequently, the ALJ's decision became the final decision of the Commissioner of the Social Security Administration. The claimant has exhausted her administrative remedies, and this court has jurisdiction pursuant to 42 U.S.C. §§405(g) and 1383(c)(3). (R. 1, 14).

         Because substantial evidence does not support the ALJ's findings regarding the weight he gave the claimant's treating physician and a consulting examiner, this court REVERSES and REMANDS the decision of the Commissioner to the ALJ for reconsideration.

         II. ISSUE PRESENTED

         Whether the ALJ erred in failing to state the weight he gave to the opinion of the consultative examiner Dr. Susan Corbin and in his description of the substance of Dr. Corbin's opinion.

         III. STANDARD OF REVIEW

         The standard for reviewing the Commissioner's decision is limited. This court must affirm the Commissioner's decision if he applied the correct legal standards and 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. But 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. And 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 given to different medical opinions” and the reasons for his finding; the failure to do so is reversible error. Romeo v. Comm'r of Social Security, 686 Fed.Appx. 731, 732 (11th Cir. 2017) (citing Winschel v. Comm'r of Social Security, 631 F.3d 1176, 1179 (11th Cir. 2011)). The ALJ's stated reasons must be legitimate and supported by the substantial evidence in the record. See Tavarez v. Commissioner of Social Security, 638 Fed.Appx. 841, 847 (11th Cir. Jan. 7, 2016) (finding that the “ALJ did not express a legitimate reason supported by the record for giving [the consulting physician's] assessment little weight.”).

         V. FACTS

         The claimant was forty-eight years old at the time of the ALJ's final decision; has a high school education; has past relevant work as a physical therapy assistant; and alleges disability based on major depressive disorder, anxiety, complex regional pain syndrome, fibromyalgia, migraine headaches, and chronic and severe pain. (R. 20, 25).

         Physical and Mental Impairments

         In November 2007, the claimant was involved in an automobile accident and suffered a broken right hand. Consequently, the claimant underwent surgery at Alabama Outpatient Surgery, in which Dr. Gary Russell placed two pins in her hand and casted it. Between January 3 and January 30, 2008, the claimant had follow-up appointments with Dr. Russell at Southern Orthopedics and Sports Medicine Associates. At each visit, Dr. Russell noted that the claimant's hand was stiff and weak, eventually diagnosing her with reflex sympathetic dystrophy (RSD) and referring her to physical therapy. On January 21, Dr. Russell removed the pins in the claimant's hands and scheduled an anesthetic injection into the nerves in her neck on February 5 to prevent pain. (R. 47, 241-43).

         From that point, the record contains no relevant medical evidence until February 1, 2011, when the claimant presented to the Northwest Alabama Mental Health Center. She noted she had been a client over 20 years prior and sought to re-establish herself as a patient. The claimant told therapist Sondra Wightman that her symptoms of depression, anxiety, and panic attacks had increased; that simple activities such as walking down the sidewalk or stopping at a red light cause her to have panic attacks because she “thinks people are staring at her”; that she previously attempted suicide in 1990 and was hospitalized as a result; and that she thought of suicide again “two months ago, after a really bad day at work.” (R. 260).

         Regarding her interests, the claimant told Ms. Wightman that she “does not have a lot of interest or energy, ” aside from watching television at home. Ms. Wightman noted that the claimant's current depressive state, along with her anxiety and panic attacks, cause emotional discomfort and impairs her ability to “enjoy daily activities to the fullest and perform appropriately at work.” (R. 260).

         Between August 26, 2011 and September 24, 2013, the claimant continued her therapy sessions with Ms. Wightman at the Northwest Alabama Mental Health Center. Based on Ms. Wightman's notes, the psychiatrist diagnosed the claimant with “severe” major depressive disorder and prescribed her Paroxetine and Bupropion for depression and anxiety.^[1] (R. 254-94, 348-50).

         The claimant visited Dr. Arthur Patton, an internal medicine doctor at Norwood Clinic, for the first time on September 24, 2013, complaining of a severe migraine headache “like her usual migraines, only worse.” During his physical examination of the claimant, Dr. Patton noted that the claimant demonstrated “moderate pain behavior with vomiting.” Dr. Patton diagnosed the claimant with a migraine headache and ordered injections of Phenergan and Toradol, and prescribed acetaminophen. (R. 246-47).

         Between September 24, 2013 and December 3, 2014, the claimant continued meeting with Ms. Wightman who noted that her conditions remained the same. The claimant repeatedly stated that she was depressed and lacked energy. (R. 252, 269, 299, 301-02, 304, 306-07, 309, 311-12, 314-19, 321-22, 324, 326, 330).

         On December 3, 2014, the claimant saw Dr. John Cantrell, an internal medicine doctor at St. Vincent's Gardendale Clinic, seeking to become a patient. She explained her history with depression and anxiety and stated that her migraines had worsened in the past two months. Dr. Cantrell noted the claimant's anxiety and depression as “abnormal, ” and further noted a finding of pain and RPS in her right hand. Dr. Cantrell diagnosed the claimant with obsessive compulsive disorder (OCD), migraines, joint pain, insomnia, chronic pain syndrome, and depression. He prescribed acetaminophen for her migraines, Lyrica and Zanaflex for chronic pain, and Paxil and Wellbutrin for depression and OCD. (R 404-07).

         One month later, on January 2, 2015, the claimant returned to Dr. Cantrell. She stated that she could not afford Lyrica; had an eating disorder, chronic pain syndrome, and depression; and wanted to know if she could be tested for fibromyalgia. She further informed Dr. Cantrell that she was filing for disability because she could not work. During his physical examination, Dr. Cantrell noted the same findings as the prior appointment. Dr. Cantrell advised the claimant to stop taking Lyrica and continue taking Zanaflex for chronic pain. (R. 400-02, 508-10).

         At the request of the Social Security Administration, the claimant completed a “Function Report-Adult” on January 8, 2015. In that report, the claimant stated that, because of her pain and OCD, she “takes longer” to dress and bathe. The claimant further stated that the “pain and stiffness” of her right hand does not allow her to use utensils while eating and causes difficulty when shaving. She never cooks; she just prepares “easy microwave meals and sandwiches”; can clean the house; can do laundry once a week with the help of her mother; cannot do yard work because of “anxiety and panic attacks, severe fatigue and pain”; can drive alone, but only for ...