United States District Court, N.D. Alabama, Middle Division
OWEN BOWDRE CHIEF UNITED STATES DISTRICT JUDGE.
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).
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. (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.
the ALJ failed to accord proper weight to the claimant's
treating physician Dr. Ayres.
STANDARD OF REVIEW
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
. . . 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).
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.
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 (11th Cir.
2015); Martinez v. Acting Comm'r of Soc. Sec.,
660 Fed.Appx. 787 (11th 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 (11th Cir. 2003) (citing Lewis v.
Callahan, 125 F.3d 1436, 1440 (11th 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).
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).
October 2008, the claimant presented to Vein and Vascular of
Hoover on referral from Dr. Muratta for swelling in his
feet. (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. The claimant
underwent an endovenous laser ablation of the great saphenous
vein. (R. 425-31).
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).
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).
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).
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).
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.
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.
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).
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).
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).
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).
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).
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).
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.
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 ...