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Wrenn v. Saul

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

September 20, 2019




         On September 19, 2014, the claimant, Sandra Wrenn, applied for a period of disability, disability insurance benefits, and supplemental security income, alleging that she became disabled on April 22, 2014, because of glaucoma, diabetes, back pain, carpal tunnel syndrome, high blood pressure, anxiety, depression, and drowsiness from medication. (R. 39-50, 57-58, 80, 193). The commissioner denied the claimant’s claims on December 24, 2014. (R. 101-105). The claimant timely filed a request for a hearing before an Administrative Law Judge, and the ALJ held a video hearing on October 24, 2016. (R. 85-86).

         In a decision dated April 18, 2017, the ALJ found that the claimant was not disabled and, therefore, ineligible for the requested benefits. (R. 16-33). On appeal, the Appeals Council denied the claimant’s request for review on March 8, 2018. (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 REVERSES and REMANDS the decision of the Commissioner.


         Whether the ALJ’s residual functional capacity finding regarding the claimant’s vision limitations lacks substantial evidence.[1]


         The 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).

         “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, 402 (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 [ALJ]’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).


         Pursuant to 20 C.F.R. § 404.1520, an ALJ must follow a five-step sequential process for determining disability. At step four, the ALJ must assess the claimant’s residual functional capacity. The RFC is an ALJ’s assessment, “based on all the relevant medical and other evidence, of a claimant’s remaining ability despite [her] impairment.” Castle v. Colvin, 557 Fed.Appx. 849, 852 (11th Cir. 2014). In determining the claimant’s RFC, the ALJ is required to consider the claimant’s descriptions and observations of her limitations resulting from her severe impairments. See 20 C.F.R. § 404.1545(a)(3).

         To support his RFC determination with substantial evidence, the ALJ must “provide a sufficient rationale to link substantial record evidence to the legal conclusions reached.” Dennison v. Saul, CA 18-0532-MU, 2019 WL 3468180 *3 (S.D. Ala. July 31, 2019). The ALJ must “link the RFC assessment to specific evidence in the record bearing upon the claimant’s ability to perform the physical, mental, sensory, and other requirements of work.” Packer v. Astrue, 2013 WL 593497, *4 (S.D. Ala. Feb. 14, 2013), aff’d, 542 Fed.Appx. 890 (11th Cir. Oct. 29, 2013).

         V. FACTS

         The claimant was fifty-one-years old with a high school education[2] when the ALJ rendered his decision. (R. 16, 193, 281). The claimant has past relevant work experience as a machine packager and as a fish cleaner, machine tender. (R. 68). The claimant alleged she was disabled beginning April 22, 2014, from glaucoma, diabetes, back pain, carpal tunnel syndrome, high blood pressure, anxiety, depression, and drowsiness from medication. (R. 39-50, 57-58, 80, 193).

         Physical and Mental Impairments

         On March 25, 2011, the claimant sought treatment at the York Health Clinic for back and wrist pain. The claimant’s hand and fingers were swollen from using her hands at work. Dr. Houston diagnosed the claimant with carpal tunnel syndrome. (R. 312, 313).

         Dr. Leroy Maxwell at the Eye Max Vision Center treated the claimant on February 27 and March 6, 2014 for blurry vision associated with glaucoma. Dr. Maxwell prescribed Alphagan and Azopt eye drops to treat the increased eye pressure caused by her glaucoma. (R. 328, 334).

         The claimant saw Dr. Colie Crutcher on April 24, 2014, at Colie Crutcher, Jr., M.D. & Associates, complaining of lower abdominal and back pain after twisting her back carrying boxes at work. After a physical examination, Dr. Crutcher noted the claimant’s lumbosacral spasms. Further, Dr. Crutcher noted that the claimant’s neurological examination was within normal limits. (R. 344, 345, 347, 349).

         She returned to Dr. Crutcher on May 7 and 21, 2014, both times complaining of back pain. Dr. Crutcher noted that the claimant had back spasms during both physical examinations; that her pain was a little better when she was lying down or slightly bent over; that the claimant was unable to drive and planned to take a leave of absence from work; that she could not keep her shoes on long because of pain; that none of the claimant’s medications were working; and that she could not sit down for thirty minutes because of her pain. (R. 345-50).

         The claimant went to Keen Health and Wellness Center on June 2, 2014 for back pain. The claimant reported to Nurse Practitioner Terre Moore that on April 22, 2014, while carrying boxes at work, she twisted her back. The claimant explained to NP Moore that Dr. Crutcher gave her two injections for her back pain, and that he ordered an MRI that insurance would not approve. She described her lower back pain at this visit as throbbing, sharp pain that radiated down both legs. During the physical examination, NP Moore indicated that the claimant “jumps when I touch her” back, and that her straight leg raises were positive. (R. 320-21).

         NP Moore ordered an MRI of the thoracic spine that revealed mild multilevel degenerative disc changes with a minimal disc bulging at the lower thoracic level, with no focal disc protrusion, cord impingement, or canal stenosis. An MRI of the lumbar spine revealed a small central focal disc protrusion at ¶ 5-S1 that mildly deformed the anterior margin of the thecal sac without central canal narrowing or nerve root displacement. The MRI records indicate a mild disc bulging at ¶ 4-L5 and mild disc bulging and narrowing of the neural foramina at ¶ 3-L4, slightly more on the left. (R. 320, 325, 326).

         When the claimant returned to Dr. Crutcher for a follow-up visit on June 18, 2014, he again noted that the claimant had back spasms and had “months of pain.” During the July 23, 2014 follow-up, the claimant indicated she was in “a great deal of discomfort.” Dr. Crutcher noted the claimant’s back, leg and foot pain, and noted that she had muscle spasms in her back upon physical examination. He noted the claimant’s recent MRI that revealed minimal disc bulging and referred her to neurosurgery “ASAP.” During the August 25, 2014 follow-up, Dr. Crutcher noted the claimant’s continued back pain and spasms and noted “spinal injection approval.” When the claimant returned to Keen Health & Wellness Clinic on July 28, 2014 for a follow-up for her back pain, the doctor noted that the claimant’s lower back was tender upon physical examination; that the claimant’s back pain persisted but was a “tiny bit better”; and that he was referring her to a neurosurgeon. (R. 328).

         At the follow-up visits with Dr. Maxwell on September 4 and 18, 2014, the claimant’s vision was blurry even on the prescription eye drops and her glaucoma was “still uncontrolled.” Dr. Maxwell noted “progression of advanced glaucoma.” (R. 330-334).

         On September 24, 2014, Dr. Jason Swanner with the UAB Ophthamology Service Glaucoma Center examined the claimant at Dr. Maxwell’s referral and diagnosed the claimant with glaucoma in both of her eyes. Dr. Swanner reported that the claimant had advanced open-angle glaucoma and was on the maximum tolerated medication, including Timolol, Simbrinza, and Travatan. Dr. Swanner indicated that the claimant’s “posterior segment examination shows significant optic nerve cupping in both eyes.” He recommended dong a SLT laser surgery on her right eye first to see if it would lower her eye pressure and treat her glaucoma. If it was successful, he would do the same procedure on the left eye. If the SLT surgery was not effective, Dr. Swanner recommended trabeculectomy surgery. (R. 519).[3]

         At the request of the Disability Determination Service, the Health Department screened the claimant’s vision on October 12, 2014, and she had visual acuity without correction of 20/70 in both eyes and with correction 20/50 in both eyes, indicating visual impairment. (R. 363).

         On December 9, 2014 and January 13, 2015, the claimant returned to Dr. Cutcher complaining that she had back spasms and was “hurting all over.” She reported that she wakes at night because of her pain and has bilateral leg swelling. At the January 13 visit, Dr. Cutcher noted the claimant’s “loss of vision” as an “Additional Problem.” (R. 404-405).

         During her follow-up visits with Dr. Maxwell on February 19, April 30, and May 4, 2015, the claimant still complained of blurry vision and itchy eyes. Her medications listed to treat her glaucoma included Simbrinza, Timolol, and Travz.

         On April 9, 2015, the claimant initially visited Hill Hospital Physicians Clinic complaining of elevated blood pressure, headaches, and back pain. Dr. Paul Marlo examined the patient and diagnosed her with unspecified essential hypertension, lumbago, anemia, glaucoma, and diabetes mellitus without mention of complication. Dr. Marlo prescribed medication for her hypertension. At her follow-up on May 4, 2015, her blood pressure was elevated, but the claimant did not have acute distress. Dr. Marlo continued the claimant on her blood pressure medication. Dr. Marlo’s notes also indicate that the claimant “states that she is having eye surgery this month for glaucoma.”[4] (R. 416, 419).

         When the claimant returned to Dr. Crutcher on May 12, 2015, he noted her back pain, back spasms, and vision loss. He indicated that she could lift 15 pounds occasionally, sit for ten minutes, and stand for thirty minutes. (R. 402).

         At a follow-up with Dr. Maxwell on August 6, 2015, the claimant continued to have blurry vision even on her medications and complained that the ...

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