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Collier v. Saul

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

September 6, 2019





         On May 25, 2016, the claimant, Vanessa Collier, protectively applied for disability and disability insurance benefits under Titles II and XVI of the Social Security Act. (R. 60). The claimant initially alleged disability commencing on December 1, 2004 because of multiple sclerosis, fibromyalgia, back problems, celiac disease, varicose veins, swelling of her hands and feet, numbness in her hands and feet, and a ruptured disc in her neck. (R. 60). The claimant later amended her alleged onset date to April 30, 2015. (R. 40). The Commissioner denied the claim on September 9, 2016. (R. 96). The claimant filed a timely request for a hearing before an Administrative Law Judge, and the ALJ held a hearing on November 6, 2017. (R. 37).

         In a decision dated January 24, 2018, the ALJ found that the claimant was not disabled as defined by the Social Security Act and was, therefore, ineligible for social security benefits. (R. 24). On May 16, 2018, 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. (R. 1-3). 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 reverses and remands the decision of the Commissioner to the ALJ for reconsideration.


         Whether the ALJ erred in evaluating the claimant's allegations of pain and other limiting effects of her symptoms under the Eleventh Circuit's pain standard


         The standard for reviewing the Commissioner's decision is limited. This court must affirm the Commissioner's decision if the Commissioner applied the correct legal standards and if his factual conclusions are supported by substantial evidence. 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, 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. 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).


         In evaluating pain and other subjective complaints, the Commissioner must consider whether the claimant presented “‘evidence of an underlying medical condition' and either ‘objective medical evidence that confirms the severity of the alleged pain [or other subjective symptoms] arising from that condition' or ‘that the objectively determined medical condition is of such severity that it can be reasonably expected to give rise to the alleged pain [or other subjective symptoms].'” Taylor v. Acting Comm'r of Soc. Sec. Admin., No. 18-11978, 2019 WL 581548, at *2 (11th Cir. Feb. 13, 2019) (quoting Dyer, 395 F.3d at 1210); see also 20 C.F.R. § 404.1529; SSR 16-3p.[1] When evaluating a claimant's subjective symptoms, the ALJ considers all available evidence, including objective medical evidence; the claimant's daily activities; the type, dosage, and effectiveness of medications taken to alleviate the symptoms; and factors that precipitate and aggravate the symptoms. 20 C.F.R. § 404.1529(c)(3); SSR 16-3p. “Subjective pain testimony that is supported by objective medical evidence of a condition that can reasonably be expected to produce the symptoms of which the claimant complains is itself sufficient to sustain a finding of disability.” Taylor v. Colvin, No. 2:15-CV-1925-VEH, 2016 WL 6610442, at *4 (N.D. Ala. Nov. 9, 2016) (quoting Hale v. Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987). And the claimant's statements about intensity, persistence, or limiting effects of symptoms will not be rejected solely because objective medical evidence does not substantiate those statements. 20 C.F.R. § 416.929(c)(2); SSR 16-3p.

         If the ALJ decides to discredit the claimant's testimony as to her pain, he must “‘clearly articulate explicit and adequate reasons' for doing so.” Taylor, 2019 WL 581548, at *2 (quoting Dyer, 395 F.3d at 1210). The ALJ's failure to articulate reasons for discrediting the claimant's testimony is reversible error. Ellis v. Soc. Sec. Admin., Comm'r, No. 4:18-cv-00010-SGC, 2019 WL 1776805, at *5 (N.D. Ala. Apr. 23, 2019).

         Also, substantial evidence must support the ALJ's findings regarding the limiting effects of the claimant's symptoms. Meehan v. Comm'r of Soc. Sec., No. 18-14924, 2019 WL 2417642, at *3 (11th Cir. Jun. 10, 2019); Hale v. Bowen, 831 F.2d 1007, 1012 (11th Cir. 1987). Therefore, the ALJ's determination must contain explicit reasons for the weight given to a claimant's individual symptoms, be consistent with and supported by the evidence, and be clearly articulated so the claimant and any subsequent reviewer can assess how the adjudicator evaluated the individual's symptoms. SSR 16-3p. A reviewing court will not disturb a clearly articulated credibility finding that has supporting substantial evidence in the record. Rose v. Berryhill, No. 6:18-cv-00030-LCB, 2019 WL 2514936, at *9 (N.D. Ala. Jun. 18, 2019) (citing Foote v. Chater, 67 F.3d 1553, 1562 (11th Cir. 1995).

         V. FACTS

         The claimant was fifty-six years old at the time of the ALJ's final decision. The claimant has a high school education and past relevant work as a housekeeper and waitress/cashier. The claimant alleges disability based on multiple sclerosis, fibromyalgia, back problems, celiac disease, varicose veins, swelling of legs and feet, numbness in her hands and legs, and a ruptured disc in her neck. (R. 24, 45-46, 60).

         Physical Impairments

         In December of 2009, the claimant first saw Dr. Elson at the Kirklin Clinic as a consultation for her celiac disease that had been diagnosed in September 2009. Dr. Elson noted that the claimant complained of constant pain in her abdomen, intermittent nausea and vomiting, and alternating days of diarrhea and constipation. The claimant reported that she had “been trying very hard to stay on a gluten-free diet” to alleviate her celiac disease symptoms but felt as though the gluten-free diet had worsened her pain, constipation, and diarrhea. Dr. Elson determined that a repeat colonoscopy with biopsies was appropriate given the severity of the claimant's symptoms despite her gluten-free diet; the colonoscopy showed normal results. (R. 257-58, 260).

         On June 23, 2010, the claimant saw Dr. Brockington at the Kirklin Clinic after an initial evaluation of her paresthesias in May 2010, which resulted in a diagnosis of underlying peripheral neuropathy because of her celiac disease. The claimant reported pain at a level of seven out of ten. Her physical exam indicated a marked loss of vibratory sensation in her upper and lower extremities, decreased deep tendon reflexes, mild weakness in her hand grips, and subtle atrophy of her thenar muscle regions. On July 12, 2010, doctors at the University of Alabama at Birmingham admitted the claimant for an IVIG infusion to alleviate her peripheral neuropathy symptoms; however, the claimant reported the IVIG did not improve her symptoms. (R. 262, 265, 268).

         On July 30, 2012, the claimant saw Dr. Brockington again because her balance had not improved and she could not work because of risk of falling and injury. Additionally, the claimant stated that her celiac disease had not improved despite her strict adherence to a gluten-free diet. Dr. Brockington noted that the claimant's gait was ataxic and she could not tandem walk. On October 19, 2013, Dr. Brockington wrote a letter “To Whom It May Concern” stating that the claimant's neurological symptoms of peripheral neuropathy had persisted despite treatment and consequently resulted in significant impairments including pain, weakness, and impaired balance. In this letter, Dr. Brockington stated that he believed the claimant qualified for long term disability. (R. 254, 268-69).

         The claimant returned to Dr. Brockington on May 15, 2014 with complaints of limb pain and paresthesia. Dr. Brockington noted that the claimant's paresthesia worsened with increased activity and affected the claimant's balance. Dr. Brockington also noted the claimant's joint pain, muscle pain, decreased range of motion, abnormal balance, numbness, and tingling. Dr. Brockington then diagnosed the claimant with unspecified idiopathic peripheral neuropathy. (R. 275-77).

         From January 2015 to October 2017, the claimant regularly visited Dr. Wiley Livingston at the Medical West Bessemer Clinic for treatment of her impairments. On January 8, 2015, Dr. Livingston noted the claimant had a history of multiple sclerosis, fibromyalgia, and celiac disease, and the claimant described symptoms of back pain, joint pain, joint stiffness, muscle aches, and sleep disturbances. The physical examination of the claimant was normal except mild diffuse tenderness of her abdomen. Dr. Livingston also mentioned that the claimant took Percocet and received epidural blocks for pain. (R. 328, 330-31).

         On April 30, 2015, the claimant visited Dr. Livingston with complaints of chronic pain “all over, ” numbness in her hands and feet, sleep disturbances, depressed mood, and anxiety. The physical examination of the claimant was normal. Dr. Livingston renewed the claimant's prescription for Percocet and increased her Cymbalta dose. Two months later, the claimant visited Dr. Livingston with complaints of pain in both of her legs because of her varicose veins, which had been occurring constantly for two weeks. The claimant rated her pain at a level of nine out of ten. Although the claimant lacked tenderness of her skin upon examination, Dr. Livingston still recommended the claimant wear support stockings. The claimant's physical examination was normal, but the doctor did not examine the claimant's extremities, back, or spine. Dr. Livingston renewed the claimant's prescription for Percocet. (R. 308, 310-11, 313, 315-17).

         Approximately a month later, on August 6, 2015, the claimant again sought treatment from Dr. Livingston with complaints of neck pain and back pain that radiated down her right leg. The claimant had received a cervical epidural block in June 2015 at Brookwood Medical Center, but the block only “helped some.” Dr. Livingston noted that the claimant had to push her husband's wheelchair, which aggravated her symptoms, but the claimant's physical examination was normal. Consequently, Dr. Livingston injected the claimant's sacroiliac joints with 120 milligrams of depo-medrol to decrease her inflammation and prescribed alendronate to treat her osteoporosis. Additionally, Dr. Livingston continued to prescribe Percocet for the claimant. (R. 302, 304-06).

         After a previous visit on October 27, 2015 to see Dr. Livingston for problems related to her gastrointestinal issues, the claimant saw Dr. Livingston on November 23, 2015 with complaints of tailbone pain after falling down her steps six days prior. The physical examination only reviewed the claimant's vital signs, but Dr. Livingston noted she moved stiffly and diagnosed her with sacral back pain. Dr. Livingston continued to prescribe Percocet for the claimant. (R. 292-295).

         Months later on May 23, 2016, the claimant visited Dr. Livingston with complaints of aching, burning sharp pain and tenderness of her left breast which started a month prior, occurred three to four times a day, and lasted anywhere from thirty minutes to three to four hours. Likewise, the claimant reported that she has had multiple breakdowns since her husband's death on May 1, 2016, coupled with panic attacks, anxiety, trouble sleeping, and blood in her stool. The physical examination was normal except tenderness with palpation of the claimant's left breast, but no ...

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