Knight v. Saul

          MEMORANDUM OPINION

          KARON OWEN BOWDRE CHIEF UNITED STATES DISTRICT JUDGE.

         I. INTRODUCTION

         On September 3, 2014 the claimant, Phillip Trey Knight, filed a Title II application for a period of disability and disability insurance benefits, alleging disability onset of March 3, 2014. (R. 27). The claimant alleges disability resulting from peripheral edema secondary to peripheral vascular insufficiency, sleep apnea, hypertension, congestive heart failure, lumbar degenerative disc disease with radiculopathy, left knee degenerative joint disease, diabetes mellitus, and obesity. (R. 29). The Commissioner denied the claim on October 31, 2014. (R. 84). The claimant filed a timely request for a hearing before an Administrative Law Judge, and the ALJ held a hearing on July 25, 2016. (R. 45).

         In a decision dated October 14, 2016, the ALJ found that the claimant was not disabled as defined by the Social Security Act and was, therefore, ineligible for social security benefits.^[1] (R. 27-40). On October 5, 2017, the Appeals Council denied the claimant's request for review. (R. 1 3). Consequently, the ALJ's decision became the final decision of the Commissioner of the Social Security Administration. The claimant has exhausted his 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.

         II. ISSUE PRESENTED

         Whether the ALJ failed to accord proper weight to the claimant's treating physician Dr. Ayres.

         III. STANDARD OF REVIEW

         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 reCir. 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).

         IV. LEGAL STANDARD

         The ALJ must state with particularity the weight he gave different medical opinions and his reasons, and the failure to do so is reversible error. Sharfarz v. Bowen, 825 F.2d 278, 279 (11th Cir. 1987); see also Perez v. Comm'r of Soc. Sec., 625 Fed.Appx. 408 (11^th Cir. 2015); Martinez v. Acting Comm'r of Soc. Sec., 660 Fed.Appx. 787 (11^th Cir. 2016). The ALJ must give the testimony of a treating physician substantial or considerable weight unless “good cause” is shown to the contrary. Crawford v. Comm'r, 363 F.3d 1155, 1159 (11th Cir. 2004). Good cause “exists when the: (1) treating physician's opinion was not bolstered by the evidence; (2) evidence supported a contrary finding; or (3) treating physician's opinion was conclusory or inconsistent with the doctor's own medical records.” Phillips v. Barnhart, 357 F.3d 1232, 1240 (11^th Cir. 2003) (citing Lewis v. Callahan, 125 F.3d 1436, 1440 (11^th Cir. 1997)). The Commissioner may reject any medical opinion if the evidence supports a contrary finding. Sryock v. Heckler, 764 F.2d 834, 835 (11th Cir. 1985). If the ALJ articulates specific reasons for failing to give the opinion of a treating physician controlling weight and substantial evidence supports those reasons, the ALJ does not commit reversible error. Moore v. Barnhart, 405 F.3d 1208, 1212 (11th Cir. 2005).^[2]

         V. FACTS

         The claimant was 49 years old at the time of the ALJ's final decision. (R. 53). The claimant has a high school education, with one year of college. (R. 53). The claimant served in the Air Force for 20 years, and worked at Honda as a quality inspector for 15 years until his alleged onset of disability on March 3, 2014. (R. 48, 49). The claimant has not engaged in substantial gainful activity since his onset date. (R. 29). The claimant alleges disability resulting from peripheral edema secondary to peripheral vascular insufficiency, sleep apnea, hypertension, congestive heart failure, lumbar degenerative disc disease with radiculopathy, left knee degenerative joint disease, diabetes mellitus, and obesity. (R. 29).

         Physical Impairments

         In October 2008, the claimant presented to Vein and Vascular of Hoover on referral from Dr. Muratta for swelling in his feet.^[3] (R. 430). Surgeon James Isobe noted a pre-op diagnosis of venous insufficiency of the left leg because of great saphenous vein incompetence, causing leg pain, swelling, and ropy varicose veins.^[4] The claimant underwent an endovenous laser ablation of the great saphenous vein. (R. 425-31).

         On January 9, 2012, the claimant presented to Southern Pain Management for a follow-up on his bilateral foot neuralgia and degenerative arthritis in his left knee. The claimant rated his pain as a three out of ten, and described the pain as a constant, dull ache. The claimant also rated the effectiveness of his medication at 90%. The claimant stated that his pain interfered with his sleep and limited his physical activities, and that any increase in activity would aggravate his symptoms. Finally, the claimant stated that his last procedure was a knee injection two years prior and that he did not feel like he needed another knee injection yet. Nurse Practitioner (NP) Karina Crosen noted that the claimant moved from the chair to the exam table with ease; that he had a normal gait; and that the claimant had no lower extremity swelling that day. NP Crosen also noted that the claimant had crepitus with motion in his knees, but his knees showed no effusion or gross instability. NP Crosen consulted with Dr. Muratta and continued the claimant's pain medication prescriptions: 8 mg of Suboxone daily and 300 mg of Neurontin every eight hours. (R. 349).

         On February 3, 2012, NP Crosen completed a Medical Source Statement for Honda stating that, because of the claimant's “[p]eripheral neuropathy in both of his legs with ganglions to both feet” and “varicose/spider veins in both legs, ” he was incapacitated from work four times a month, for a duration of two days. (R. 432).

         From July 11, 2012, to January 7, 2014, the claimant sought treatment at Southeastern Pain Management eleven times for bilateral foot neuralgias, degenerative arthritis of the left knee, and bilateral knee and ankle pain. Nurse Practitioner Shannon Doyal saw the claimant at each visit and consulted with Dr. Muratta concerning the claimant's treatment plan. NP Doyal renewed the claimant's pain medication prescriptions, Suboxone and Neurontin, at each visit and she increased the claimant's dosage on several occasions. At each visit, the claimant consistently described his pain as constant with a dull ache and sharp at times. Additionally, the claimant stated at each visit that his pain interfered with his sleep and limited his activities. The claimant rated his pain from a three to a six out of ten, though more frequently he rated it as a five or six. The claimant reported that the effectiveness of his medications ranged from 50% to 90%, though he reported 75% most frequently throughout this time period. Additionally, NP Doyal consistently noted that the claimant reported that “rest along with the medications will help relieve his symptoms.” (R. 338-48).

         The claimant began reporting to NP Doyal that he had numbness in his feet on July 17, 2012. (R. 348). On September 11, 2012, NP Doyal increased the claimant's Neurontin prescription. NP Doyal noted that, in addition to the claimant's continued knee crepitus, he began having a mild build-up of fluid in his knees. On October 25, 2012 the claimant received injections in both knees for bilateral knee pain and osteoarthritis. (R. 346).

         The claimant's Suboxone dosage increased during another follow-up visit at Southeastern Pain Management on November 9, 2012. (R. 345). The claimant reported that he experienced numbness and tingling in his feet and ankles. NP Doyal noted the claimant had swelling in his lower extremities. And on January 10, 2013, at the claimant's next follow-up, in addition to swelling, NP Doyal noted the claimant had lower extremity varicose veins, spider veins, and hair loss. (R. 344).

         On July 11, 2013, in addition to his usual pain, the claimant described his pain as throbbing and a five out of ten; however, he began specifying that his pain was worse on most days because of work. (R. 341). NP Doyal increased the claimant's Suboxone prescription to “8 and 2 mg one every eight hours for chronic pain.” At another follow-up appointment several months later on November 5, 2013, among his usual pain and symptoms, the claimant began reporting that he had a burning sensation in his feet, and that his pain increased his irritability, and decreased his concentration and appetite. (R. 340). On December 6, 2013, NP Doyal noted filling out the claimant's medical leave paperwork. NP Doyal also noted rescheduling an appointment for the claimant to receive another round of knee injections. (R. 339).

         On March 1, 2014, the claimant went to the emergency department of Gadsden Regional Medical Center in a wheelchair, with the chief complaint of edema. Dr. Diop examined the claimant and found that he had normal blood pressure, normal gait, but had swelling and erythema in his bilateral lower extremities. The claimant stated the lower extremity swelling began to get worse within the past few weeks. Dr. Diop diagnosed the claimant with cellulitis and discharged him home with instructions to follow-up with his primary care physician, Dr. Ayres. (R. 271- 72, 307-14).

         The claimant followed up with his physician at Southside Medical Clinic on March 3, 2014. Dr. Ayres noted that the claimant was in the Gadsden ER for “what was called cellulitis.” Dr. Ayres also noted that the claimant had lower extremity swelling, hyperglycemia, and “markedly elevated” blood pressure. Dr. Ayres prescribed Tribenzor for the claimant's high blood pressure. (R. 377).

         The claimant visited Southeastern Pain Management on March 4, 2014, for a follow-up on his bilateral leg and foot neuralgia, and bilateral knee pain. The claimant stated his main pain was his back, which began about six months before and had worsened. NP Doyal noted that the claimant had intermittent bilateral leg pain. The claimant stated that he was able to work, but his particular job was “very difficult on his pain.” The claimant stated his plan of care was 70% effective in managing his pain and helping with his activities of daily living. NP Doyal noted that the claimant had little tenderness to his lumbar spine, improvement of low back pain with extension of the lumbar spine, and no change in pain with flexion of the lumbar spine. NP Doyal also noted decreased sensation to the claimant's left calf. (R. 337).

         The next day, the claimant visited Dr. Ayres for a follow-up. Dr. Ayres noted that the claimant's blood pressure had improved slightly; however, the claimant's lower extremity swelling persisted, and he had shortness of breath. Dr. Ayres referred the claimant to a cardiologist. (R. 375).

         On March 14, 2014, the claimant presented to Southern Cardiovascular Associates on referral from Dr. Ayres. Dr. Darryl Morin noted the reason for referral as further evaluation of the claimant's “uncontrolled hypertension, significant peripheral bilateral lower extremity edema with weight gain of 20-25 pounds over the past month with the patient having significant shortness of breath at rest as well as dyspnea on exertion.” The Dr. Morin noted that the claimant was on the following medications: Gabapentin for nerve pain, Lexapro for depression and anxiety, and Tribenzor. Dr. Morin did not make any changes to the claimant's medications at that time. Dr. Morin recommended a complete 2D resting transthoracic echocardiogram, a venous doppler evaluation, and a nuclear perfusion stress study. (R. 244- 47).

         Dr. Ayres completed a Medical Source Statement on March 18, 2014, for Honda on behalf of the claimant, noting that the claimant's medical condition would cause an unknown duration of continued future absence from work. (R. 446).

         On March 25, 2014, the claimant's doppler exam came back normal and his transthoracic echocardiogram was abnormal showing a mildly dilated left ventricle; mild concentric left ventricular hypertrophy; left ventricular systolic function (mildly rooted); ejection fraction about 45%; and mild aortic dilation. (R. 265-66). The claimant's nuclear cardiology study showed he had left ventricular dilation; mild reduction radioisotope uptake in the inferior wall; generalized left ventricular hypokinesis; and a severely hypokinetic septum. (R. 248).

         The claimant underwent a heart catheterization at Gadsden Regional Medical Center on March 28, 2014, which came back abnormal and indicated an intermediate risk of ischemia. Dr. Morin recommended medical therapy and/or counseling, a follow-up with the ...